For lack of alternatives, thousands of mentally ill individuals are trapped in the justice system. In a conversation with TCR, Alisa Roth, author of “Insane: America’s Criminal Treatment of Mental Illness,” says change will only happen when we reexamine our attitudes towards mental illness.
In her career as a journalist, Alisa Roth has written about people in what she calls “forgotten communities,” such as immigrants and the poor. But when she began focusing on the mentally ill trapped in the U.S. justice system, after a friend’s brother was locked up, Roth discovered what she came to realize was the most forgotten community of all.
“I can’t think of a group that’s more reviled and more misunderstood,” she told TCR. In a discussion with staff writer Isidoro Rodriguez about her new book, “Insane: America’s Criminal Treatment of Mental Illness,” Roth, a former Soros Justice Fellow, describes how jails and prisons have become the nation’s principal institutions for treating mentally troubled individuals, and suggests that strategies for developing more humane, treatment-oriented alternatives have to begin at the state and local levels.
The Crime Report: What was the catalyst for writing this book?
Alisa Roth: I can’t think of a group that’s more reviled and more misunderstood than people with mental illness who are in the criminal justice system. We talk about the issue of race in the criminal justice system, we talk about the issue of poverty in the criminal justice system, but we don’t talk about mental illness. These three intersect and overlap, but we can’t think about global reform without addressing the mental health question.
As I mention in the book, I have a friend whose brother developed a severe mental illness and committed a horrible crime. As I was thinking about this whole system, it kept coming back to him. If we as a society can allow him to see an alternative outcome, and not spend the rest of his life in prison, we can allow that for other people who have done less morally or criminally complicated things.
TCR: Through the process of this book, what hurdles did you have to overcome?
AR: I chose two of the most closed systems to look into. The criminal justice system is extremely closed in terms of access, in terms of data, and in terms of information. Likewise, the mental health care system is bureaucratic and complicated. So just figuring out where treatment is being provided, and who should be providing that treatment is difficult.
Then there’s the whole health care aspect. People are not allowed to, or are unwilling to, share information about treatment. And there’s the stigma question in both systems. There is still shame attached to having a mental illness or having a family member with mental illness. We march for breast cancer or AIDS, but we don’t want to talk about mental illness and we don’t want to admit it. So, getting people to open up and say “yes, I do have this issue” or “yes, my child does have this issue and these are the struggles we are going through,” is very difficult. I am very grateful to all the people who were willing to share their stories with me.
TCR: How did dealing with this affect you, and how do you move forward after seeing what you have seen?
AR: I feel a great responsibility and duty to share these stories and spread them. I have the means to tell the world about these horrible situations, whether it’s the really awful abuses or just the day-to-day low-level abuses of being locked up with a mental illness. So, I feel privileged to share that.
Keeping that in mind was a way to mitigate the awfulness of it, but it’s traumatic reporting. I had a lot of nightmares about jail and prisons. I have a lot of friends who work in this universe, so it was great to be able to compare notes and talk about what we have seen. It is traumatizing and exhausting, but I kept thinking that I got to walk out of there at the end of the day, and I needed to take advantage of that to tell the world about how bad the problem is.
TCR: One of the subjects in your book is the practice of solitary, and you note that it is still in effect despite being considered a form of torture by the United Nations. Why do you think it is still being practiced in the U.S.?
AR: There are a lot of pieces that go into this answer. Unfortunately, we have abandoned the notion of reform and rehabilitation in our criminal justice system. We’ve moved back to the punitive notion. In some measure we think that people who are locked up in jail or prison deserve what they get. There is a dehumanizing aspect to the whole criminal justice system, and solitary confinement is part of that. If we don’t think of somebody as a full human being, then it becomes easier to do something really awful to them. If you think of this person as your brother, or our uncle, or your husband, it’s much harder to lock them in a box 23/7.
There’s also the fact that so many of us don’t know what goes on in the criminal justice system. The system as a whole is so abstract for such a large portion of our population, that we just don’t think or know about it. People have no idea that there are tens of thousands of people locked in solitary confinement on any given day. In a lot of places and for a very long time it’s just been how it’s done. It’s a very easy solution to put someone who is being unruly or difficult out of sight and out of mind. I think it speaks to a larger issue: We take people with mental illness, we lock them away, someplace we don’t need to see them. If we put them in jail or prison we don’t need to see them or step over them on our way to Starbucks in the morning. Solitary confinement is a reflection of that. But it makes everything so much worse.
TCR: Your book also criticizes the dangerous mistakes made by judges, and attorneys, who have no experience with the mentally ill. One example is your story of Jamie Wallace, a young boy suffering from mental illness and multiple physical disabilities, who eventually killed himself in prison due, in part, to a judge’s inability to understand his circumstances. How do we increase awareness and understanding of mental illness so that we may better avoid tragedies such as this?
AR: As awareness of the problem of large numbers of the mentally ill in the criminal justice system grows, judges and attorneys are more attuned to it. It’s not that people don’t know it’s there, but it’s as much as about changing attitudes as anything else. I talk to a lot of judges and I’ve said “Hey, in a lot of cases you’re being asked to make what’s effectively a medical decision and you’re not a doctor; you’re a judge. ‘
The best answer I heard, and it makes sense to me to a degree, is the judge who that’s what he does all the time. He takes the best information he can get and makes a decision based on that. So, he’s not making a medical judgement, per se; he’s taking the information that the psychiatrist, the therapist, and the attorneys give him and using that to make a decision. Jamie Wallace’s case was particularly egregious. He was so young, so sick, and had a developmental disability on top of it. I found it heartbreaking to think that the judge couldn’t see a way to understand. And the judge was playing very much by the rules.
Jamie Wallace was failed by the system at every level, over and over again. A forensic psychiatrist who read about him said he should never have been declared competent or even been standing in that courtroom. The judge made an awful decision, but he also made a mistake in letting him even be in that courtroom that day. You have to wonder how it would have been different if he had been wealthier, or his parents had been more educated, or if he had been in a different state.
TCR: Jamie Wallace’s story is an example of the mistakes that can be made as a result of the disorganized bureaucracy of the criminal justice system. At a time when so many are pushing for better training within that system to fix the problem, and others are fighting to keep the mentally ill out of that system entirely, which do you feel is the better option?
AR: In an ideal world, we would be able to keep everybody with a serious mental illness out of the criminal justice system. In an ideal world, we’d be able to keep a lot of people without a mental illness out of the criminal justice system. We lock up a lot of people very easily. I think that diversion is absolutely critical, but in order to make wide scale diversion possible, we can’t just look at this little tiny piece of the problem. We have to remember that we are operating in a very large ecosystem, not just of criminal justice but also of mental healthcare. We need to see wide-scale reform of both these systems so that people aren’t getting to the point where they’re so sick.
You see people in jail and prison who are sicker than a lot of people you see in psychiatric hospitals. We need to be catching the diseases earlier and treating them earlier. It’s great to train the cops to not arrest people, but if you don’t have some place for the cops to take them that’s not jail, they’re still going to wind up in jail. That’s what happened in San Antonio when they created their crisis center system. [They realized] you can train cops as much as you want, but they’re still going to take people to jail if there’s no other option. The other part of it is, as long as we are going to have people that end up in the criminal justice system, we have to make sure that when they’re there, they’re getting the treatment that they need and not just being warehoused in prisons.
TCR:A popular talking point now is de-institutionalization, starting when the majority of state-run mental health hospitals were closed during the 1960s. However, your book insists that there were other, more important, causes for the problem. Can you expand on that?
AR: De-institutionalization is a fabulous talking point. It has this very neat narrative: Dorothy Dix found people locked up in jail; realized this was not the place for them; they weren’t getting the treatment they needed; wardens were saying they couldn’t handle this; she pushed for the creation of the asylum system; everything was great until it all went to hell and we had to open up the doors and let everyone out. Then, without treatment, people were ending up in the criminal justice system. And it has a very neat solution: if this is how we got there, then all we have to do is treat the mental illness and we’ll get people out of the criminal justice system.
Unfortunately, it’s way more complicated than that. Even when you look at the heyday of institutionalization, during the middle of the last century, there were a lot of people in institutions, but it was not the majority. There were still a lot of people living at home or elsewhere, or getting treatment in the community. The population in institutions tended to be older, white, female, and very heavy on people with a diagnosis of schizophrenia. The people now locked in the criminal justice system are overwhelmingly young, male, and not white.
I think we also have to look at the story of mass incarceration. We’ve started locking up way more people than we ever did…and when you cast such a big net, of course you’re going to pull in a lot of people with mental illness. When you break it down even further and look at co-occurring substance use disorders, a very large majority of people with mental illness in the criminal justice system have a co-occurring substance use disorder. So, if we’re arresting tons of people for drug possession, drug use, drug selling, drug dealing, it makes perfect sense that we’ll pick up people with mental illness.
Using policing tactics such as “broken windows” and “stop and frisk,” allowed us to lock up huge amounts of people [and] made it easier to arrest people with mental illness. I think that the story of mental illness in the criminal justice system is as much a story of mass incarceration as it is of de-institutionalization. The one piece of the story that is important, even if we don’t quite tell it right, is that we do have a severe lack of mental health care in the community and we have made it extremely difficult to get treatment for mental illness. But it’s not that everybody was getting treatment in a hospital and now they can’t get it, we just don’t have that and we’ve never had it.
TCR: How can we get people to start viewing mental illness seriously?
AR: I think we’re starting to move in that direction, very slowly. We’re seeing more people acknowledging an issue with depression or anxiety. We’re still not seeing a lot of actors come up at the Oscars and mention that they have schizophrenia, but I think it’s becoming more socially acceptable to talk about these things. We know that people can change, and society can change. There was a time that people didn’t talk about HIV or cancer, and now we wave flags for it. We need to get over the fear and stigma [attached to] mental illness in our society. The narrative in the media and in politics that links mental illness and violence is very damaging. And it’s hard to get over that stigma when every time something bad happens somebody is out there pointing a finger at mental illness.
TCR: Are tools such as Crisis Intervention Teams (CIT), deescalation and community policing having a positive effect on the problem?
AR: Like so many things in criminal justice, there is not a ton of data or evidence-based research to show one way or another. The data in places such as Miami or San Antonio show that these things work. Miami says that it’s cut the number of officer-involved shootings. In San Antonio, the system has prevented them from expanding the jail. People who study policing say that CIT is just good policing—-going back to the kind of policing we had before “professionalized” law enforcement. It was the cop walking the beat who knew the people in the community. There’s no reason to run into every situation like it’s a battleground. Police officers always talk about how they see people on the worst day of their lives. That narrative is used sometimes as a reason why you need to be on your guard. But I’ve also heard it used as a reason to be gentle, kind, and thoughtful because they’re there to help.
Getting police to respond in a more thoughtful, more community/medically oriented way, instead of the tough, warrior way, is terrific. The big caveat is that if you don’t have the whole system set up to accommodate this it can only get you so far. You might deescalate a particular situation, but if you don’t have any longer-term solutions, you’re going to be back picking up the same person with no place to go. Often communities think CIT will be a step to solving the problem, but you have to think about how you’re going to divert, what’s the mental health treatment going to be, and how do we make sure we’re not picking people up again next week or next month.
TCR: Does change need to start at a federal level? And do you see potential for change under the current administration?
AR: The thing about criminal justice is that so much of it happens on such a local level that, on the flip side, a lot of reform can also happen on a local level. If I’m in Manhattan, and get arrested, it could potentially be a different outcome then if I’m in the Bronx or New Jersey. Because it’s so local, I think the federal question is almost irrelevant. Even the laws of involuntary commitment are handled at a local level. I think with a lot of laws, particularly with HIPAA (the Health Insurance Portability and Accountability Act) and involuntary commitment, it really comes down to a very narrow line of navigating between civil liberties and safety for the person and the public.
We obviously don’t want to go back to the time when somebody could have a child committed to a hospital for not being religious enough or dating the wrong person. On the other hand, I think we’ve made it so difficult to get somebody hospitalized that we’re in this perpetual crisis management mode. The way it’s set up now is that you really have to be at a crisis point in order to make involuntary commitment possible. Likewise, with HIPAA, I don’t want my business broadcast all over the place. On the other hand, the very nature of mental illness means that the person is not, necessarily, capable of making decisions for himself, or even providing the information that the doctors need. I’ve heard families talk about managing to get their adult child hospitalized, but then not being able to convince the doctor to talk to them about what has or hasn’t worked in the past. As with any other illness, the more information the clinician has, the better they can treat the problem.
HIPAA is also widely misunderstood. It’s used as an excuse for stonewalling families and other people trying to get information. I think the more important question, is how do we figure out how to loosen these laws a little bit to make things easier and more effective without throwing all the civil liberties out with it. As for the current administration, I think this is a big wildcard. It doesn’t seem to be a big priority except on those occasions when something awful happens and suddenly there’s talk of bringing back asylums and more mental health care. Between seeing real change at a local level or at a federal level, I have a little bit of hope that at the local level there is potential for reform.
Isidoro Rodriguez, a staff writer for The Crime Report, covers policing and mental health issues. He welcomes comments from readers.