How the Mental Health Industry Fails the Mentally Ill

A new book argues that mental health authorities’ failure to address the public safety challenge posed by individuals with serious mental illness unfairly shifts the burden to police and the courts. DJ Jaffe, the author, explains why in a conversation with The Crime Report.

Most experts acknowledge that the seriously mentally ill are a formidable challenge to the resources of the justice system. DJ Jaffe, executive director of MentalIllness Policy Org, a nonpartisan think tank, argues that mental health authorities’ failure to address the issue has placed the burden unfairly on police and the courts.

In Insane Consequences: How the Mental Health Industry Fails the Mentally Ill, Jaffe says that it’s long past time for the nation to make this a priority. In a conversation with TCR’s Isidoro Rodriguez, Jaffe explains why he wrote the book, how the mental health “industry” has helped to distort public opinion about mental illness, and why he thinks Republicans are “better” on the issue than Democrats.

The Crime Report: What was your motivation for writing this book?

DJ Jaffe: About 20-30 years ago I became guardian to my wife’s sister-in-law, who had schizophrenia. We didn’t know she had schizophrenia. She was an adorable teenage girl living in Wisconsin with her old-world mom and they were getting into fights. We thought it was just a culture clash between an American teen and an old-world mom and that we would bring her to live with us and everything would be fine.

We would listen to her saying that people were planting transmitters in her head or the buildings in New York were going to fall on her. We’d hear her screaming in her room at the voice only she could hear. Eventually we called the police [who] took her to a hospital. Back then, the hospital would take people who were seriously mentally ill; so she got in and was stabilized after maybe a month. But she would come out and it would keep happening, and we didn’t know what was wrong with her because they wouldn’t tell us. Eventually, in passing, a nurse told us she was schizophrenic. So, we looked it up. We were shocked by our ignorance. I started volunteering for a local group dealing with the issue, and started raising money for them. [The experience] made me realize how messed up the system was.

TCR: In your book, you discuss ways in which the mental health industry has skewed public opinion about the seriously mentally ill in this country. What part do the media play in this?

 DJ: The media repeat all of the myths: The mentally ill are no more violent than others, everyone recovers, prevention works. The media, for instance, will continually emphasize the success of “peer support.” One person with a mental illness talking to another person with mental illness. There’s no data showing this has led to improvement by any meaningful metric, but this story is everywhere. It’s very tough for the media, I think, because they’re relying on so-called experts.

What the media should do is talk more often with police and criminal justice about these issues. Ten times as many people with mental illness are incarcerated as are hospitalized. The police have much more experience. The police and sheriffs can’t do what the mental health system does, which is when they get a call, say that the person is too ill, or has “high needs”—we can’t do anything for them. The police and sheriffs don’t have that option: they have to go in. They are much more realistic and want to help because it puts their lives in danger as well ….when the seriously mentally ill go untreated. All the progress that’s come out has been the result of the criminal justice system speaking up after tragedies: Kendra’s Law in New York, Laura’s Law in California, the reform of the Baker Act in Florida.

TCR: What can police do to get this sense of urgency and understanding out to the public?

DJ: This is where I’m trying to focus my efforts. The criminal justice system has not gotten involved at the political level in changing things. When there’s an incident where an officer shoots someone, the answer is always, “we’re going to train police better.” But the answer really is we have to get the mental health system to not turn these people over to police. That should be the answer.

And the danger goes the other way. A large amount of line-of-duty deaths are on mental illness- related calls. So, what they really need to do is get involved politically. Sheriffs around the country are outraged because they’re running the largest mental hospitals. The largest mental hospitals are [today] the Rikers Island [jail complex] in New York, the Los Angeles County Jail, and Cook County Jail. My effort is to get police and sheriffs involved in political change. Now, whenever there is a high-profile instance of violence, the reaction is to form a joint task force of police and mental health people. The police assume the mental health people know more, so when they start proposing solutions, the criminal justice system doesn’t know enough to say those will hurt.

DJ Jaffe

For instance, if you ask any officer, any sheriff, what we have to do to solve the mental health problem, they are going to instantly say, we need more hospitals because we can’t get people in, we need them to hold people longer so they’re really stabilized, we need easier civil commitment processes, and we need to be able to keep people on medication when they’re outside the hospital. Brilliant solutions. [But] if you ask a person in the mental health industry the same thing they will say we have to reduce stigma, we have to do more public education, and we have to train police better. All these things are totally irrelevant to solving the problem.

TCR: In your book you do write that stigma is one of the hurdles to solving this problem.

DJ: I don’t believe there is stigma to being mentally ill. It’s a no-fault biologically based illness, so there’s no stigma to having it and we should stop teaching that. But the system has diverted attention away from the sickest individuals, the small minority who commit violence. In public service announcements you won’t see homeless and psychotic people eating out of dumpsters. They won’t admit that some people need hospitals or some people don’t recover. The whole stigma movement is premised on diverting attention from those [individuals] the police and sheriffs are called to intervene with.

That takes attention away from the solutions. The mental health industry’s response to high-profile acts of violence is to tell the media: “That’s stigmatizing, don’t report on that, the mentally ill are no more violent than others.” What I say, is that our response should be to propose solutions to that very real violence that did occur and hope the media reports on it.

TCR: Why is there, seemingly, so much resistance to serious and practical reform?

DJ: You’d have to ask the people who are doing it. I’m not being coy. We all want to feel that we’re helping, so we often default to easier things. There are also financial incentives to do the easier job. Taking care of people with serious mental illness is exceedingly difficult and time-consuming, and people aren’t paid enough to do it. But, why, for instance, are they saying that we should put more money into prevention when there is no way to prevent it? My mind boggles. We don’t even deal with seriously mentally ill adults.

There are worthy social services today that focus on the issues of “trauma” or “at-risk” individuals. Trauma is not a mental illness, everyone loses a loved one, or experiences [personal stress] like losing a job. That’s not mental illness. We’re wrapping all these social services in the mental health narrative and diverting funds that should go to help the seriously mentally ill.

TCR: In your book, you note the success of mental health courts. Is that a sign of progress?

 DJ: Mental health courts are, again, an example of turning this problem over to the criminal justice system. As long as the mental health system isn’t doing its job, mental health courts are needed. The fascinating thing about them is what they do. If a prosecutor or district attorney believes a person who has been charged with a low-level crime has a mental illness, they may divert him or her to a mental health court. The mental health court will say, if you accept treatment for X amount of time, we will drop your charges and the person comes back every week to see if he’s still complying. Basically, you have somebody who has committed a crime—often because the mental health system didn’t treat them—deferred to a court, which then tells the mental health system to treat them. It’s a long, unnecessary round trip. The mental health system should just treat them.

Now, there is no single solution. But something I strongly support is assisted outpatient treatment. Basically, it’s the same thing as a mental health court, except it happens before the crime is committed, after the person already has a history of multiple instances of homelessness, arrest, incarceration, or hospitalization due to being off medication. If the person has that history, then the court, with all due-process protections, can order the person to six months of mandated and monitored treatment while he or she continues to live in the community. It doesn’t involve criminal justice, it doesn’t involve locking someone up or in-patient commitment, it’s less expensive, less restrictive, more humane. We should make more use of that.

TCR: However, according to your book, one of the main groups resisting solutions like assisted outpatient treatment and mental health courts are civil rights activists, who claim that such methods encroach on people’s rights. 

DJ: I just don’t understand the opposition. It’s an anti-science, anti-common sense, anti-public and anti-patient position. Being psychotic is not a civil right to be protected; it’s an illness to be treated. They fail to understand that. People with mental illness lack the maturity of their faculties. They have an inability to exercise free will. We shouldn’t protect the civil rights of a person who thinks the devil planted a transmitter in his head and he has to shoot first or the devil will get him. We should be helping such people regain their ability to exercise free will.

TCR: In addition to being anti-patient, you point out that many today are also anti-medication. 

DJ: In general, both the civil libertarians and the anti-psychiatry movement fail to differentiate between serious mental illness and people who need their mental wellness improved or have minor issues. So, a lot of what they say is true about those with minor mental health issues, but it’s not true about the seriously mentally ill. There are people with minor mental health issues who can get by without medications, but most of the seriously mentally ill, mainly those who are bipolar or suffering from schizophrenia, need medications in order to access other support.

While [they are] psychotic, no programs will accept them. However, it is true that medications have side effects, and those side effects can be devastating. No one’s denying that, and we need more research on it, but as a kind and compassionate society we have to help those who need help the most. What these groups are focused on are those who need help the least, and they are using them as the poster children for what we should be doing. There is clear evidence, mainly from deinstitutionalization, that medications help people. They got them out of the hospitals.

TCR: Most mental health facilities exist in prisons, and most incarcerated individuals who are mentally ill wind up worse when they come back out—and end up incarcerated again. How can we stop this revolving door?

 DJ: One positive solution is community monitoring of people coming out of jails. One of the proposals that I make in the book is that there should be mandatory evaluation. We’re spending millions on outreach. We’re going to grammar schools and giving speeches and training people to identify the asymptomatic, but we know who the most seriously mentally ill are and who we should help: the ones who are most prone to homelessness, arrest, incarceration, or violence. There should be mandatory evaluation of everyone coming out of prisons or jails who used mental health services or needed [those] services while they were there, to see what they need to stay safe in the community. But we’re just releasing them and saying “time served.”

TCR: In one chapter, you advocate changing the Health Insurance Portability and Accountability Act (HIPAA).  Why?

 DJ: HIPAA is a patient confidentiality law and, depending on the state, once your child turns a certain age he or she is entitled to confidentiality. This means the parents can’t know what’s happening. How this plays out, frequently, is parents provide housing for a mentally ill kid or have placed him in a program that’s providing housing—and the kid goes missing. If the parent calls the program, the program can’t tell them the kid is missing. If they’re missing from their own house, and the parents call the hospitals, the hospital won’t tell them if they’re there.

This just happened recently to the former president of the New York State [organization of] chiefs of police who has a mentally ill kid who went missing from the program. Even though he’s a police chief, he still could not find out if his daughter was in a hospital when he called around. When your relative gets out, you’re not allowed know the diagnoses, what medications they’re on, what outpatient program they’re supposed to go to. [That means] parents can’t arrange transportation, can’t see that prescriptions are filled, or that appointments are kept.

The typical media story is “why didn’t the parents do anything?” People don’t realize that we have all the responsibility but none of the authority. If you’re providing housing, case management, and transportation services out of love, you should be able to get the same info that those that provide those services for money get. If I were an insurance company providing medications, I would be able to get that info.

TCR: One of the most surprising details of your book is that you strongly believe that this new administration will make positive steps towards change. Why?

 DJ: On this issue, Republicans are a lot better. Democrats are willing to throw money at mental health, but aren’t willing to admit the politically incorrect things that are necessary to admit to help the seriously ill. Democrats won’t admit that some mentally ill are more violent than others, that not everyone recovers, that they are more violent than others, that some need hospitals, that involuntary commitment can be a good thing.

Republicans see this as a quality- of-life thing. They see homeless people eating out of dumpsters, they see jails fill up, and want to know why we’re not helping those people. The legislation aimed at helping the seriously mentally ill is mainly coming from republicans. I hate to admit it, I’m a Democrat, but we’ve been basically useless. We throw $100 million at children’s issues, and serious mental illness, schizophrenia and bipolar disorder, are mainly adult illnesses.

Suicide is a huge one. It’s exceedingly rare. We’re throwing a lot of resources at it that haven’t reduced suicide in any way, shape, or form, and we’re throwing them at kids who are the least likely to commit suicide. It’s primarily an adult illness. But kids are a sympathetic population and so they get greater resources. And that sympathetic population plays an important part in who gets served by government.

Isidoro Rodriguez is a contributing writer to The Crime Report. Readers’ comments are welcome.