Locking Up The Mentally Ill

To the Editors:

David Cole’s “The Truth About Our Prison Crisis” [NYR, June 22], not surprisingly, does not mention the perhaps 200,000 severely mentally ill in jails and prisons. Despite recognition for decades of the prisons as the “de facto mental hospitals” there is relatively little concern among the populace, or officials, about that development. Indeed, implementation of “transinstitutionalization” proceeds. In 2015 the National Association of State Mental Health Program Directors asserted that the state hospital is no place for long-term care.

C.E. Smith, M.D.
Mobile, Alabama

David Cole replies:

Dr. Smith is right. People with mental disabilities, both psychiatric and cognitive, are represented in our prisons and jails at two to six times their rate in the general population. The number of just the “severely mentally ill” behind bars is likely far greater than 200,000. The neglect of this population by state legislatures—including through the closure of mental hospitals, the failure to provide adequate community care, and the expansion of prisons to fill the gap—has much to do with it. But public indifference also plays a part. In California, legislation and court orders have reduced the overall prison population by nearly 25 percent. But both the percentage and the absolute numbers of prisoners with mental disabilities have increased over that period. California prisoners with a “serious mental disorder” now make up over 30 percent of the prison population—an increase of 150 percent since 2000. Unless we intentionally confront the practice of warehousing the mentally ill in prisons and jails, it will continue.

Using the criminal justice system to respond to mental illness is counterproductive, because incarceration exacerbates psychiatric disabilities. The best responses are diversion programs, in which individuals are shifted from the criminal justice system and toward meaningful treatment, both before they are booked for a crime and afterward. These programs have been shown not only to reduce jail and prison populations but also to save money. Miami-Dade County has had particular success diverting people with mental health issues away from the criminal justice system.^* Counties and states would be well advised to recognize the long-term benefits of investing in those features that make diversion programs successful: housing, services, and support in the community. Such reforms make good fiscal sense, help to reduce mass incarceration, and, most importantly, are fair. Locking up human beings because they have mental disabilities we are unwilling to treat effectively, by contrast, is fiscally irresponsible and morally suspect.