1 Boring Old Man

There is so much divisiveness in discussions of matters that have to do with Mental Health and Mental Illness that it’s sometimes difficult to separate the wheat from the chaff. There’s a strong backlash to the medicalization of psychiatry, the heavy use of medications, the DSM-III etc. diagnostic system, and the claim/implication that all mental illness has some biological basis. On the other side there are claims that psychological counseling focusing on trauma and recovery will clear up most problems now called mental illness. It’s kind of hard to find much to read that doesn’t have some sort of rhetorical bias, visible in the first several paragraphs.

Back in my days on the wards as the de-Institutionalization of mental hospitals was winding down, it would’ve been pretty hard for anyone to maintain a belief that things were going very smoothly. Our admission units were full of people, many psychotic, and hospital beds were evaporating like a sno-cone dropped on hot pavement. At seminars and meetings, the topic was often punctuated by the Szasz meme of that day about the Myth of Mental Illness, and then back to work at the Grady Hospital Emergency room where things didn’t feel a bit mythical at all. Nobody I knew wanted to re-open any huge mental hospitals again. We just wanted short term beds to stabilize patients, and that didn’t mean just medicate, it meant trying to find a source of food and shelter that worked – a social placement, a life. The flow and the dwindling resources worked against that goal, resulting in the revolving door hospitalizations, very high rates of recidivism, and homeless people on the streets and sleeping under the bridges. The back-up promised by the Community Mental Health Movement seemed to be disappearing. The police that had to deal with these patients were fed up and vocal about it when they brought someone in for the second time in a week because the last hospitalization was so brief.

transinstitutionalization A process whereby individuals, supposedly deinstitutionalized as a result of community care policies, in practice end up in different institutions, rather than their own homes. For example, the mentally ill who are discharged from, or no longer admitted to, mental hospitals are frequently found in prisons, boarding-houses, nursing-homes, and homes for the elderly.
A Dictionary of Sociology , 1998

The popular account of why people with serious mental illnesses [SMI] are overrepresented in jails and prisons is usually structured as follows: deinstitutionalization, combined with inadequate funding of community-based treatment for individuals in need of mental health services, has led to the criminalization of mental illness and attendant increases in incarceration rates. This represents a return to the conditions that psychiatric institutions were originally designed to alleviate. Indeed, the mainstream assumption that the state psychiatric hospital and criminal justice systems are functionally interdependent — a phenomenon described as transinstitutionalization — is commonly accepted.

Does transinstitutionalization explain the overrepresentation of people with serious mental illnesses in the criminal justice system?

by Prins SJ

Community Mental Health Journal. 2011 47[6]:716-722.

Abstract: Although there is broad consensus that people with serious mental illnesses [SMI] are overrepresented in correctional settings, there is less agreement about the policy trends that may have created this situation. Some researchers and policymakers posit a direct link between deinstitutionalization and increased rates of SMI in jails and prisons, a phenomenon described as transinstitutionalization. Others offer evidence that challenges this hypothesis and suggest that it may be a reductionist explanation. This paper reviews claims from both sides of the debate, and concludes that merely increasing access to state psychiatric hospital beds would likely not reduce the number of people with SMI in jails and prisons. A more nuanced approach is recommended for explaining why people with SMI become involved in the criminal justice system and why developing effective strategies to divert them out of jails and prisons and into community-based treatment is needed to improve both their mental health and criminal justice outcomes.

Discussion In the debate summarized above, proponents of the transinstitutionalization hypothesis may be mistakenly drawing a causal connection between two merely correlated trends: the decline in availability of state psychiatric hospital beds and the rise in prevalence of SMI in jails and prisons. More specifically, they may [a] misinterpret deinstitutionalization as a flood of individuals who were released from state psychiatric hospitals only to be arrested and incarcerated, [b] conflate evidence that people released from psychiatric hospitals often require re-hospitalization with evidence that jails and prisons are serving that function [c] erroneously assume that people who require inpatient services are clinically and demographically similar to people with SMI who wind up in jails and prisons and [d] underestimate the effectiveness of high quality community-based treatment. The evidence against the transinstitutionalization hypothesis is compelling because [a] most people released from state psychiatric hospitals do not appear to end up incarcerated, [b] the characteristics of people with SMI in jails and prisons differ from both the characteristics of people who were deinstitutionalized and the past decades’ increasingly forensic state psychiatric hospital population, and [c] many agree that community-based treatment works for the majority of people with SMI.

This is not to say, however, that conclusive evidence currently exists on either side of the debate. More rigorous analysis to clearly define the causal relationship between deinstitutionalization and the overrepresentation of people with SMI in jails and prisons is certainly warranted [for example, retrospectively matching archival inpatient, arrest, and incarceration records]. The arguments presented above should also not imply that the cases for and against increased access to inpatient services are irreconcilable. Indeed, the most important takeaway from this debate may be a fact that is often overlooked by policymakers working to address this issue: people with mental illnesses are not a homogenous population. Increased access to acute and intermediate psychiatric beds may, in fact, be necessary for a small but high-risk, high-cost group of people with severe mental illnesses who cycle through emergency rooms and the criminal justice system without obtaining the treatment they need [Pasic et al. 2005 ]. For these individuals, shortages of 24-hour hospital care [and for this group and others with SMI, affordable housing more broadly] are indeed a problem.

Nevertheless, increased access to inpatient services may not be an optimal focus for a multi-systemic criminal justice/mental health policy strategy. The ramifications of casting too wide an inpatient net would not only be expensive, but would move away from the goal of full community integration of people with mental illnesses that is the hallmark of the rights and recovery movement [New Freedom Commission on Mental Health 2003 ]. Pragmatically, it might be argued, that reinstitutionalizing people with SMI who become involved in the criminal justice system is the lesser of evils, since treatment conditions in psychiatric hospitals are bound to be better than those in jails and prisons. This reasoning, however, addresses one problem by creating a new [but familiar] one, and avoids tackling the issues at the heart of the matter.

Broadly speaking, the popular account of current mental health policy is correct: people with SMI are being ‘‘locked up’’ in jails and prisons as was the case 200 years ago. Understanding why this is happening, however, is important for developing strategies to appropriately divert people with SMI out of jails and prisons and into the treatment they need to become productive members of their communities. The history of deinstitutionalization provides an intuitive but reductionist narrative about the reasons why people with SMI are overrepresented in correctional settings. At the very least, policymakers and researchers should treat the transinstitutionalization hypothesis with caution and not as a presupposition. Failure to approach this issue with the nuance it requires may unwittingly imply expen- sive interventions that will benefit only a fraction of the population at issue. For the large remainder of people with SMI in jails and prisons, other causes of their involvement with the criminal justice system should not be ignored. In this regard, shifts in philosophy and ideology behind the concept of deinstitutionalization are still relevant. For the majority of this group, the key to staying out of hospitals, jails, and prisons may be a place to live, a job or some income support, a meaningful relationship or social network, quality healthcare, or linkage to treatment instead of frequent arrest for substance use disorders — fundamental needs that can best be redressed in the community, not psychiatric or correctional institutions.

Prevalence of Mental Illnesses in U.S. State Prisons: A Systematic Review

by Seth J. Prins, M.P.H.

Psychiatric Services. 2014 65:862-872.

Objective: People with mental illnesses are understood to be over-represented in the U.S. criminal justice system, and accurate prevalence estimates in corrections settings are crucial for planning and implementing preventive and diversionary policies and programs. Despite consistent scholarly attention to mental illness in corrections facilities, only two federal self-report surveys are typically cited, and they may not represent the extent of relevant data. This systematic review was conducted to develop a broader picture of mental illness prevalence in U.S. state prisons and to identify methodological challenges to obtaining accurate and consistent estimates.

Methods: MEDLINE, PsycINFO, the National Criminal Justice Reference Service, Social Services Abstracts, Social Work Abstracts, and Sociological Abstracts were searched. Studies were included if they were published between 1989 and 2013, focused on U.S. state prisons, reported prevalence of diagnoses and symptoms of DSM axis I disorders, and identified screening and assessment strategies.

Conclusions: Definitions of mental illnesses, sampling strategies, and case ascertainment strategies likely contributed to inconsistency in findings. Other reasons for study heterogeneity are discussed, and implications for public health are explored.

• Ditton P: Mental Health and Treatment of Inmates and Probationers. Washington, DC, US Bureau of Justice Statistics, 1999.
• James DJ, Glaze LE: Mental Health Problems of Prison and Jail Inmates. Washington, DC, US Bureau of Justice Statistics, 2006.

"Among this handful, two reports by the U.S. Bureau of Justice Statistics have been cited at least 1,100 times, according to a recent query of Google Scholar. These reports used self-report surveys and defined mental illnesses as a current mental or emotional condition, a prior overnight stay in a “mental hospital,” or endorsement of symptoms of mental disorders in the Diagnostic and Statistical Manual of Mental Disorders [DSM]. Prevalence estimates were three to 12 times higher than in community samples, reaching as high as 64%."