Jail, America’s Psych Ward

In America, people with mental illness have a remarkably disproportionate involvement in the criminal justice system. Men in jail are four times more likely to suffer from serious mental illness than their non-incarcerated counterparts while women are almost six times more likely. There are ten times more people with a mental illness behind bars than in state funded psychiatric beds. Put another way, there is not a single county in the United States in which the psychiatric facility serving the community has as many individuals with severe psychiatric disorders as does the county jail. A serious mental illness is defined as persons over the age of 18, who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration, resulting in a functional impairment that substantially interferes with or limits one or more major life activities.

The disparity between mentally ill individuals in society versus behind bars stems in part from the get-tough-on-crime policies that have permeated our criminal justice system for decades. These policies forced jails to morph into ill-equipped, large-scale, mental health facilities. If you follow the news, it is more apparent than ever that jail is not an appropriate place for the mentally ill. At the Los Angeles County Jail, a mentally ill inmate was beaten to death by his cellmates after they became irritated with him because he was “mumbling to himself.” In August 2015, a 31 year-old mentally ill detainee serving a five-day sentence for petty theft at Santa Clara County Jail was beaten to death by three correction deputies while he was waiting for a bed to free up in a mental health facility. He was allegedly beaten for pocketing his medication. These incidents illustrate that jail inmates with mental health issues are not getting the care they need and the results are devastating.

But are jails even required to provide mental health care to inmates? Absolutely. Jails are constitutionally required to provide adequate medical care to pretrial detainees under the Due Process Clause. In City of Revere v. Massachusetts General Hospital, the Supreme Court explicitly stated that pretrial detainees are entitled to be free of punishment, thus requiring the government to provide medical care to inmates and receive protections “at least as great as the Eight Amendment protections available to a convicted prisoner.” Under this obligation, the government must provide medical care necessary to maintain the health and safety of people they place behind bars. In Bowring v. Godwin, the Fourth Circuit concluded that the constitutional right to medical care extends to mental illness treatment, stating there is “no underlying distinction between the right to medical care for physical ills and its psychological or psychiatrist counterpart.” Because inmates are the only group of Americans with a constitutional right to health care it has been reported by some county officials that mentally ill individuals often commit crimes simply to receive treatment.

So what kind of mental health care are pretrial detainees (remember, these are individuals who have yet to be found guilty of any crime) actually receiving while incarcerated? Despite the large number of mentally ill people involved in the criminal justice system, police officers and jail staff receive very little training about interacting and managing inmates with mental disabilities. This lack of training can have deadly effects in the field and in jail. Mentally ill inmates are often locked in solitary confinement because jail staff doesn’t know how to manage them. Solitary confinement is thought to be the most severe and cruel punishment for anyone suffering from mental illness and is known to lead to suicide. Jails are often understaffed and thus many mentally ill inmates go untreated. Until recently, the Santa Clara County Main Jail had a grand total of three psychiatrists for the approximately 1,500 mentally ill inmates behind bars. This lack of staff has irreversible effects for Santa Clara jail inmates. For example, inmates experiencing adverse side effects from prescribed medication often go unnoticed. Inmates are often forced to stop taking their medication in preparation for a doctor’s appointment resulting in extreme drug withdrawal that leads to psychosis. This inadequate treatment results in a vastly higher number of mentally ill individuals re-entering the criminal justice system. In sum, “[t]he lack of treatment for seriously ill inmates is inhumane and should not be allowed in a civilized society.” – Dr. E. Fuller Torrey, founder of the Treatment Advocacy Center.

There are a number of additional factors contributing to the insufficient mental health care that inmates receive in jail. First, inmates with serious mental illnesses are four times more likely to be incarcerated for less serious charges such as disorderly conduct and threats than non-ill inmates. Second, jail exacerbates psychiatric symptoms because inmates are often placed in solitary confinement, and can be subjected to violence and sexual abuse from fellow inmates or jail staff. Third, people suffering from mental health disorders that don’t cause a radical change in behavior, like depression or PTSD, may go untreated because unless recognized by staff, an inmate’s mental health is self-reported. Fourth, pretrial detainees who were in therapy or comprehensive treatment before an arrest do not continue to receive these services while incarcerated, making mental health issues significantly worse. And remember, all these devastating affects of incarceration on mentally ill pretrial detainees occur before the individual is even found guilty.

Not only can the results of jails becoming de facto mental hospitals be detrimental to mentally ill inmates, but we actually spend more money by investing in incarceration instead of preventative care. Frequent flyers in the criminal justice system cost taxpayers twice as much as assertive community treatment programs because inmates tend to continually cycle in and out of jails and hospitals. According to a special report published in 2016 by USA Today, a community can pay for an entire year of intensive treatment for the cost of one incarceration (94 days) or one hospital stay (19 days) for a person with mental illness. The numbers prove that investing upfront in preventative mental healthcare actually reduces costs in the aggregate. A jail diversion program for the mentally ill in Massachusetts saved $1.3 million in emergency health services and jail costs. Georgia found that providing comprehensive mental health services to mentally ill people involved in the criminal justice system cut the number of days these people spent in the hospital by 89%, and the number of days spent in jail by 78%. In all, the program saved Georgians $1 million in its first year.

Mentally ill people are much more likely to be arrested and charged for minor offenses. These individuals are then placed in jail, an environment that exacerbates mental health issues, even before being convicted. They receive less than adequate mental health care for two times the cost of community treatment programs and when eventually released are significantly more likely to recidivate then their non-ill counterparts. My next post will be about the specific challenges mentally ill inmates are faced with right here in Santa Clara County, followed by a discussion of possible solutions to this great economic and social catastrophe.