Send Me Up the River

“NEW YORK CITY’S BOLDEST.” Without context, the sign welcoming us to America’s most notorious jail confuses me. Who are the boldest? The incarcerated? The guards? Us?

Definitely not us. Our van bumps along over the girder bridge, shuttling our team from Queens to Rikers Island. We’re a small group of young psychiatrists, here to learn about mental healthcare in the criminal justice system. The East River roars below us as planes roar overhead; to our right I see the tarmacs of LaGuardia Airport. The day before our visit, a passenger plane had collided with a firetruck, killing both pilots. The wreckage is walled off from the public but plain as day from this angle.

As our van reaches the next checkpoint, we seem to leave civilization. The buildings are utilitarian fortresses, boasting concrete facades and chain-link fencing. Once spanning a modest hundred acres, the facility now covers more than four hundred acres, anchored to a bed of convict-hauled landfill. Though Rikers currently houses seven or eight thousand incarcerated people, at its peak it could host over 20,000. In some years, as many as 80% of these folks hadn’t even gone to trial yet, being unable to afford bail and thus stuck on bureaucratic timetables. Some have waited as long as three years to stand trial, all without a conviction, unable to leave.

Our team, on the other hand, is in and out quickly. We stow our belongings in the van before navigating a maze of metal detectors. Once through, we pass between lines of men wearing beige jumpsuits, flanked by guards on either side. I think of a sermon I heard on Genesis 15, about how God passed between halved animals in Abraham’s place; it’s not that these men are atoning sacrifices but that seeing their bleak situation, usually hidden from our public conscience, scandalizes my own sense of innocence.

We first meet with healthcare workers who conduct medical and psychiatric screening exams, aimed at detecting anyone too ill or intoxicated to come in. Some folks are started on medications for withdrawals right away, whereas those who mask their symptoms or simply haven’t entered withdrawal yet slip through.

Eventually we’re led to a large room where men of all ages seem to roam about aimlessly, some wearing smocks. A guard explains that the smock indicates that the man was assessed to be at high risk of suicide, reminding others to watch for self-harm. A man experiencing intense psychosis engages me in conversation about the microchips implanted in his brain by the CIA, who actually work for the Nazis. “But I love Jewish people!” he exclaims. He says that he’s a victim of an experiment, and though we disagree on the forces at play, I can’t say that his conclusion is entirely wrong; conspiracies aside, his situation is indeed a result of haphazard trial and error on a systemic level.

Working in an inpatient psychiatric unit, I regularly feel conflicted about participating in a system that often holds people against their will and even treats them over their objection. Standing here in Rikers, though, our unit back in Manhattan seems like a hotel. Yes, many of these men have committed (or at least, allegedly committed) terrible crimes. But many others are here for less serious charges, and many may be innocent. This whole system is well outside my wheelhouse, but from talking with folks who wrestle with these systemic problems day in and day out, it seems there is no easy solution. Or, at least, not one that we’re willing to pay for.

If convicted, many of these people, men and women alike, will continue “up the river” to Sing-Sing, a state prison whose reputation rivals that of its jail counterpart at Rikers. I used to tutor incarcerated men at various prisons throughout New Jersey in college, where the conditions, not unlike those of Rikers, contorted my perception of the criminal justice system. Many of these men were sharp and able to get their GED relatively quickly. But, whatever their crime and whatever their sentence, their identity as a “convict” would probably stick with them.

I think back to when my dad was asked to step down from being the flag football coach at my elementary school after the principal learned about his prison record. He’d been convicted for playing doctor (the irony), writing fake prescriptions for narcotics. His stint in jail was actually the worst part. He tried to hang himself with his shoelaces while going through opioid withdrawal; when they broke, the guard enthusiastically announced, “We got another swinger!” He fared better in prison, where a low-security facility allowed for outings to go bowling and get ice cream, though I imagine this is a rarity today. And as far as some of our public record systems are concerned, he’ll always be a convict.

The reality is that American jails and prisons house far more “psychiatric patients” than all our state psychiatric hospitals combined. At the time of my writing, as many as 1 in 5 Americans in jail or prison meet diagnostic criteria for a serious mental illness (SMI), including schizophrenia and other psychotic disorders. There are believed to be about ten times as many folks with SMI in our jails and prisons as there are in our state mental hospitals, a phenomenon known as the “Penrose effect”—the hypothesis that when there are fewer psychiatric hospital beds, more people with SMI end up incarcerated. In terms of addiction, nearly two-thirds of people sentenced to jail meet criteria for a substance use disorder, yet fewer than 1 in 7 U.S. jails offer medications for opioid use disorder. The tragic effect is that, in the first two weeks after release, the risk of fatal overdose may be roughly 40 to 50 times than that of the general population.

This problem is both new and old. Historically, many folks with SMI have been ostracized as demon-possessed or simply chained up and locked away. The late 18th and early 19th centuries saw the rise of “humane treatment” for mental illness, spurring the construction of “insane asylums” that, for all their problems, often allowed folks with SMI to live with a greater degree of autonomy and freedom. By the 1950s and ‘60s, the advent of psychiatric medications alongside the era’s broader civil liberties litigation accelerated the shift away from asylums, a move now known as “deinstitutionalization.” But where did these people go? JFK’s administration planned to build 1,500 federally and state-funded outpatient centers for people with mental illness—only about half of which were ever built, chronically underfunded in the wake of his assassination and then gutted during the Reagan administration. By this time, the main thesis of the War on Drugs—the idea that it’s just the drug (as opposed to the life conditions that make the drug so appealing) that caused addiction—was still riding high. A few decades and more than a million overdose-related deaths later, we can see how well that hypothesis held up.

Driving back across the bridge from Rikers, now in the opposite lane, it’s harder to see the debris from yesterday’s plane crash. The accident wasn’t the fault of any single person; several mistakes had to line up in exactly the wrong way to enable the catastrophic outcome. It’s a new day in the 24-hour news cycle, and the rest of the world has moved on. But here on the bridge, it’s at the top of my mind. Seeing things up close changes the way we think about them—in that we do, in fact, think about them.