Before I worked behind the wire, I figured the people prowling our jails and prisons were the kind of sociopaths you see in films, like Tony Montana and Hannibal Lecter. But that changed with my first correctional psychiatry job back in 2015. I learned I was all wrong about the makeup of America’s correctional population and quickly realized the correctional system has largely assumed medical care of our country’s seriously mentally ill.
The steel bars and razor-sharp fences of our jails and prisons keep inmates from escaping, but they also keep the public from learning more about the 2.3 million people locked up behind them. Most people probably don’t know that more than half of our nation’s prisoners have serious mental illness or that two-thirds are dealing with addiction.
Many of the correctional officers I worked alongside showed very little awareness or understanding of the mental illness experienced by inmates under their watch, but not all. A few told me they were shocked to be put in charge of prisoners who were clearly unfit for the brutality of prison life.
“Doc, he shouldn’t be here,” a CO once told me while I evaluated an inmate whose psychosis was so severe he couldn’t make his own words ― the man just repeated some of mine over and over. He couldn’t move on his own either; he was catatonic.
“He’s not right,” the CO added, gesturing to the prisoner’s head ― a crude observation but an accurate one. I couldn’t believe the man wasn’t in a hospital.
I’ve heard inmates argue with their hallucinations. I’ve seen them cower in their cells, scared to death of the evil forces they believe are pursuing them.
State psychiatric facilities have shuttered in increasing numbers over the past decade, leaving people with mental illness struggling to procure services from a mental health care system that is underfunded, is impossibly difficult to navigate and is built upon discriminatory insurer tactics. There are now 10 times as many seriously mentally ill people in jails and prisons as in state hospitals, and our country’s three largest psychiatric facilities are actually jails.
A recent case in New Hampshire shows what can happen when mental health care isn’t readily available to those who need it. Andrew Butler, a 21-year-old living with schizophrenia, was committed to the state’s only inpatient psychiatric facility in the fall of 2017. However, because the state hospital doesn’t have a high-security unit for patients with behavioral challenges, Butler was transferred to a prison. He was held in an area called the “secure psychiatric unit” for almost a year, despite the fact he hadn’t even been accused of committing a crime.
The SPU is not an accredited psychiatric facility, contrary to what its name suggests, and patients can find themselves imprisoned there for years. Though he was supposedly sent to the prison for psychiatric care, Butler reported being tasered and pepper-sprayed by staff. He filed a federal lawsuit, arguing that his prison transfer violated the Emergency Medical Treatment and Labor Act, and he was transferred back to the state hospital last week following public outrage. His lawsuit has shed a light on our society’s poor treatment of the mentally ill.
Though the SPU and units like it employ medical personnel, they’re ultimately run by COs, which makes delivering care a real challenge. Many times, the COs I worked with in a similar facility in another state said they believed prisoners were making up psychotic symptoms and acting bizarrely in order to manipulate the situation and gain an undeserved trip to come see me. They couldn’t have been more wrong.
Though he was supposedly sent to the prison for psychiatric care, Butler reported being tasered and pepper-sprayed by staff.
I’ve cared for many ill patients in my career, but inmates with mental illness tend to experience far more severe illness than psychiatrically hospitalized patients. I’ve heard inmates argue with their hallucinations. I’ve seen them cower in their cells, scared to death of the evil forces they believe are pursuing them. Some inmates I’ve treated are convinced the devil has possessed their souls; others are tormented by delusions of FBI implants in their brains. Sometimes their words and thoughts are so disorganized they make no sense at all.
All of this is terrifying not only for the ill individual but also for other inmates, who often have little understanding of the complexities of mental illness.
Instead of receiving the treatment they need, many inmates with mental illness are held in solitary confinement, sometimes for years, to punish the behaviors that stem from their illnesses. It’s little surprise suicide is the most common cause of death in local jails and is rising sharply among prison populations.
And I can’t talk about inmates with mental illness without also mentioning those who have intellectual disabilities. One-fifth of U.S. prisoners have a cognitive disability (which includes intellectual disabilities along with learning disorders, autism and other conditions). We provide special education services to people with intellectual disabilities when they are children. However, it seems we would rather watch them fall through society’s frayed safety net into prison after they finish school than continue paying for the services they need as adults. I’d never felt as sick to my stomach as when I observed inmates serving serious prison time who could barely get dressed on their own.
We can’t wait any longer to address these injustices. Congress is currently considering federal sentencing reform, which is a step in the right direction. However, our criminal justice system needs a complete redesign that appropriately considers those with mental illness and intellectual disabilities. This will require educating our police officers and court personnel about mental illness and intellectual disability, increasing funding for and increasing the use of mental health evaluations for defendants, and updating criminal responsibility legal standards so they more accurately account for the contribution of mental illness and intellectual disability when crimes are committed. Perhaps most important, efforts must focus on district attorneys ― the true gatekeepers of our correctional system. More than 90 percent of criminal cases never go to trial because they are resolved through plea bargains in a process that often exploits those with reduced mental capacity.
Our criminal justice and mental health care systems are dark stains on the honor of this nation.
We can’t stop there, though. We’ll never see true criminal justice reform until we fix and appropriately fund our shattered mental health care system. Individuals with serious mental illness and intellectual disabilities must have a place to get care instead of being forced to live on the streets. Over time, increased funding for mental health care will pay off financially and keep us safer; providing appropriate care to someone with serious mental illness ultimately costs less than incarcerating them. It also reduces crime.
Our criminal justice and mental health care systems are dark stains on the honor of this nation ― but they can still be washed out. People with mental illness and intellectual disability deserve a health care system that relies on nurses and physicians, not correctional officers. Jails and prisons are designed to be places of punishment, so let’s stop filling them up with people who need healing.
In these politically divided times, this is one of the few issues that sees clear bipartisan agreement. If we really want to grasp the unity that has been evading us and prove we are still one America, here is our chance.
Brian Barnett is a post-doctoral fellow in the Partners Healthcare Addiction Psychiatry Fellowship and a clinical fellow in psychiatry at Harvard Medical School. You can follow him on Twitter @BrianBarnettMD.