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Caged and Crazed: An Examination into the Causes of Criminalization of Mental Health Patients

in the United States

12/9/13

AMST 203-01

Professor Scholnick

The College of William and Mary


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Introduction

Since the decades following World War II, Americas population of people with a mental

illness has had few options for treatment and housing. Once tended to by relatives or friends in

local communities, during the late nineteenth and early twentieth centuries the mentally ill began

finding themselves inside institutions. Then with changing social attitudes after World War II,

the mentally ill were released from confinement into another system, the United States

Department of Corrections. However, this transition from hospitalization to incarceration in the

criminal justice system has had major consequences on the quality of care for those with mental

illnesses. Deinstitutionalization has lead to the criminalization of the mentally ill and the

overcrowding of correctional institutions.

The purpose of this paper is to inform the reader of the causes behind the current

overcrowding of the mentally ill within correctional institutions and to suggest solutions. This

study helps the reader understand the need to change the current treatment of the mentally ill in

correctional facilities. This is an important issue in the modern era because the current system of

housing mental patients in prisons is unsustainable. To reduce the rate of recidivism, society

needs to prioritize prison reform and provide more facilities to treat the mentally ill.

In this paper, we will first examine the literature that has been written on the topic of the

history of deinstitutionalization and the effects on the criminal justice system in the United

States. Then we will identify how this paper is both similar and different from the literature

written previously. Next, the hypothesis will be tested through use of the previously written

literature. Finally, we will examine how the criminalization of the mentally ill has impacted the

current correction system and suggest future improvements on the housing and care of the

mentally ill.
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Literature Review

There are many available studies about the effects of deinstitutionalization in the United

States. Many use statistics to validate their claims. The articles and books I use in this report

come from journals on psychiatry, news media, and academic journals. The sources were

relatively easy to find through academic database searches. Because of the moderately large

amount of literature written on the subject, the sources are relevant to the topic and often argue

similar points. However, there are several sources that explain more of the history of the topic

without examining the modern day implications and solutions to the problems. Such sources are

generally found in the background information sections and not in the conclusion.

Firstly, Grobs article focuses on the historical social aspects and treatment of the

mentally ill up to the late 1980s and deinstitutionalization. He stresses the importance of social

factors as a cause for the shifting paradigms in dealing with the mentally ill. He also gives brief

descriptions of the legislation and lawsuits dealing with the treatment, care, and housing of the

mentally ill at local, state, and federal levels.

Lamb and Weinbergers article is from a journal on psychiatry and studies the number of

persons with severe mental illness who are placed into the criminal justice system and whether

this number has increased since deinstitutionalization. Lamb also mentioned Penroses

contributions to the understanding of waning mental health facilities and the increase of the

incarcerated mentally ill.

Torreys article, found in a news source, cites two chapters from a book on mental health

in America. The chapters study the history of deinstitutionalization and argues that moving

mentally ill patients from mental hospitals to prisons has not helped society economically,

socially, or physically to remedy the problem of the lack of long-term mental health centers.
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Clemmitts article discusses the modern day problems that prisons and prisoners face

including basic health care, lack of educational, vocational, or substance-abuse programs, and

lack of funding. She also mentions the unusually high rate of mental illness inside prisons and

provides an outlook for the future of prison health care.

In addition, several sources from the Bureau of Justice Statistics give statistics on the

prevalence of certain health, mental health, and treatments inside prisons. The study from 2006

is particularly important because it shocked the federal government by stating that over half of

the inmates in federal, state, or local prisons or jails in the United States have a mental health

problem. This report found 56% of state inmates, 45% of federal inmates, and 64% of local jail

inmates have a mental health problem including a recent history or symptoms of a mental health

problem (James and Glaze, 1).

This report is similar to the articles mentioned above because it relates the causes of

deinstitutionalization to the current problems facing the criminal justice system in the United

States. It calls upon knowledge of problems within prisons and the reasons for those problems

including the most significant cause of overcrowding of the mentally ill inside prisons,

deinstitutionalization. However, this paper differs from the other reports by claiming that

deinstitutionalization caused the criminalization of the mentally ill and it gives ideas of how to

remedy the problems now facing prison systems.

Hypothesis Testing

Institutionalization of the Mentally Ill

Before the nineteenth century, people with a mental disability or illness were generally

not of great public concern. They were housed and cared for by family. If no family existed or

if the family felt they could not care for the affected individual, the individual was placed under
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the care of a county official and tended to in an almshouse. Placement in an almshouse was

usually only considered in the person was a danger to oneself or others. However, if necessary,

the individual could be continuously incarcerated in the almshouse. There was little to no social

responsibility to care for the individuals with mental illness in this time period (Grob, 334-348).

However, this paradigm of social responsibility began to change in the mid nineteenth century

and lasted through the 1950s (Torrey).

By the 1840s the movement towards institutionalization in psychiatric hospitals was

underway. Because of shifting attitudes towards those with a mental illness, the prevalent

thought was to institutionalize the mentally ill rather then let them be a burden on localities.

Coupled with the rise of public mental hospitals for the care and treatment of the mentally ill was

the rise of physicians and the organized medical profession. Although physicians were unable to

treat or cure mental illness, they believed the illness stemmed from factors influenced by the

environment. Therefore, if an individuals environment was thought to be causing harm or

perpetuating illness, the physicians prescribed a change in environment. This meant removing

the affected individual from their environment, which was often in and out of almshouses or

homeless, to an institution that provided a roof and care. Therefore the responsibility for people

with mental illness became the burden of the locality or state that governed the hospital (Grob,

334-348).

The transition from local care to state hospitals occurred in part out of financial

incentives. With the rise of state facilities to house the mentally ill, financial responsibility of

people with a mental illness was thus shifted from the localities to the state or federal levels.

Because the newly established welfare program would assume financial responsibility of those

housed in state or federal institutions, local governments began sending their aged or infirm
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patients from local almshouses, which were supported by taxes, to state institutions. This system

creates a divided responsibility between localities and states (Grob, 334-348). However, because

many state institutions forced localities to pay for their patients, local officials chose to retain

their insane in local almshouses. Therefore, the population of state institutions for the mentally

ill remained relatively low throughout the nineteenth century (Grob, 334-348). However, by the

1950s these hospitals housed approximately 550,000 patients (Grob, 334).

The system of divided responsibility for the care of the mentally ill created tensions

between local and state legislators in the early twentieth century. Because the divided authority

caused competition for the lowest price to retain the mentally ill, the quality of care in local

almshouses was particularly poor. Therefore, state legislators adopted laws that relieved local

communities from caring for the mentally ill. The idea behind this decision was that while the

cost of maintaining individuals with mental illness was greater at a state institution, the quality of

care was higher and some patients had the possibility of a cure and would therefore be less

expensive to care for in the long-term. These changes along with changing social attitudes

towards those with a mental illness lead to the institutionalization of the mentally ill.

Deinstitutionalization

After World War II, attitudes towards those with mental disabilities changed again in part

due to the number of returning veterans with mental illnesses like post-traumatic stress disorder.

These attitudes penetrated the thought of the physicians and psychiatrists of the time who

believed that experiences, social, and environmental factors contribute to the mental well being

of an individual. This resulted in less immediate referral to a mental hospital and an increased

emphasis on community treatment (Grob, 334-348).


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The rise of therapies and the first pharmaceutical anti-psychotic drug, chlorpromazine,

commonly known as Thorazine, which was released in 1955, greatly reduced the need for

institutionalization (Torrey). Practices such as early intervention and preventative treatment

were employed to shift the responsibility of the mentally ill back to the community. Increased

welfare of the federal government lessened the control of state institutions. The desire for

decreased control of federal and state governments in mental healthcare began a push for

community-based treatment facilities. This occurred because of arguments from psychiatric

critics, mental health rights advocates, and media reports leaking the inhumane conditions in

state mental hospitals. Also, Medicare and Medicaid removed people from institutions and

placed them in homes for the elderly or gave access to affordable treatment for the poor. No

longer was socioeconomic status a factor in institutionalization (Grob, 334-348). According to

Grob, Many of the changes in the mental health system, in other words, occurred because of the

expansion of services and recruitment of a new clientele rather than the substitution of one

service for another (344). Because of these factors, mental hospital populations declined

rapidly after 1965 (Grob, 334-348).

Deinstitutionalization is defined as: the policy of moving severely mentally ill people

out of large state institutions and then closing part or all of those institutions (Torrey).

Between 1955 and 1994, approximately 92% of patients were moved from mental hospitals to

other locations. During that time, Rhode Island had the highest rate of deinstitutionalization with

a rate of 98.2% (Torrey). Of these patients who were moved to another setting whether it be

back to their community, families, other care facilities, the streets, or a correctional institution,

50-60% were diagnosed as schizophrenic, 10-15% manic-depressive, and 10-15% had another

brain disease such as: epilepsy, strokes, Alzheimers, or trauma (Torrey).


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California was the first state to deinstitutionalize with the implementation of the

Lanterman-Petris-Short (LPS) Act of 1969. This law made it more difficult to involuntarily

hospitalize or retain the mentally ill which contributed to deinstitutionalization. In studies

showing the effects of the LPS Act, Marc Abramson found that the number of mentally ill in the

criminal justice system in the first year doubled. Abramson also coined the phrase

criminalization of mentally disordered behavior (Torrey). Abramson summarized his

findings stating: If the mental health system is forced to release mentally disordered persons

into the community prematurely, there will be an increase in pressure for use of the criminal

justice system to reinstitutionalize them (Torrey). Here Abramson shows the redirected

pressure to institutionalize the mentally ill after releasing them from a mental hospital. This

pressure to force those with mental illness back into an institutionalized setting after

deinstitutionalization often lead to the mentally ill being housed in the criminal justice system.

There are many ways a person with a mental illness can enter into the criminal justice

system. Firstly, certain mental illnesses such as schizophrenia and manic-depressive disorder

may cause inappropriate behavior which can be punishable under the heading disorderly

conduct. Often with people who hallucinate, they will feel a desire to strike those who attempt to

come too close and will be arrested for assault. Also mental illness can lead one to steal because

of a delusion that they have no need to pay, such as eating a meal and leaving before paying.

Often alcohol and substance abuse problems accompany mental illness. These behaviors, in

addition to trespassing, also cause the mentally ill to be arrested. Generally those with mental

illness will commit misdemeanors, however, violent felons, mentally ill or not, are generally

immediately taken to prison before the determination of an illness. Until 1991, it was standard

practice in Idaho to incarcerate those with a mental illness who had no charges just as a holding
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tank until a bed in a psychiatric hospital could be found (Torrey). Both police and people with

mental illnesses used mercy bookings in order to gain access to a bed with shelter and food.

Lastly, public mental hospitals have a priority to admit those with a criminal charge. This led

some family members to charge a mentally ill relative as an avenue to pursue treatment inside a

correctional facility (Torrey).

Another way to measure the prevalence of deinstitutionalization is to examine the arrest

rate of the mentally ill. Studies done prior to the beginning of deinstitutionalization did not find

a higher arrest rate than for the general population. Virtually every study done since

deinstitutionalization began has found the opposite (Torrey). One year after the LPS Act was

implemented, a study found that discharged patients with no arrests prior to hospitalization were

arrested 2.9 times more frequently than the general population. Additionally, those with a prior

arrest were arrested eight times more frequently than the general population (Torrey). Because

of the increased rates of arrest for the mentally ill, the population of mentally ill persons in New

York prisons surpassed the number of patients in the state psychiatric hospitals. Similarly, Los

Angeles County Jail became the largest asylum of mentally ill people in country (Torrey).

The move to incarcerate the mentally ill is also demonstrated in the increased rate of

violent crime after release from a mental institution. psychiatricization of criminals. This

theory hypothesized that the increased rate of violent crime after hospital discharge was due to

jail and prison overcrowding and that mental hospitals were increasing admitting individuals

formerly dealt with by the criminal justice system (Lamb & Weinberger). This increase in

violent crime speaks to the poor treatment options existing inside the criminal justice system of

the time for people with mental impairments.


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Because many previously institutionalized people are without appropriate shelter upon

release, a study was conducted of the mentally ill living on the streets after deinstitutionalization

policies had begun. A study found that 76% of the homeless mentally ill in Los Angeles had

been arrested as adults. Similarly, 74% of the mentally ill prisoners in the Los Angeles County

Jail had been previously arrested. These numbers speak to the prevalence of the criminal justice

system in relieving the problems of the mentally ill as well as the homeless. The mentally ill

often rotate back and forth between being homeless and being in jails or prisons (Torrey).

This cycle of homelessness and criminalization has been caused by the lack of appropriate

institutional setting for those with a mental illness.

In 1939, British psychiatrist Lionel Penrose studied crime rates in European cities and

found that prison and psychiatric hospital populations were inversely correlated ("The Lionel

Penrose Papers). As the population of psychiatric hospitals fell during the 1950s-1980s, the

population of the mentally ill in prisons increased. This is coined the balloon theory because if a

balloon is pushed in one spot, the opposite spot bulges. In a study of the balloon theory from

1904 to 1987, George Palermo found that:

The number of the mentally ill in American jails and prisons supports the thesis of

progressive transinstitutionalism. The authors believe that the statistical evidence

derived from the national census data corroborates their clinical observation that

jails have become a repository of pseudooffenders- the mentally ill. Our opinion

is that our results probably reflect the state of most United States jails. (Torrey)

The statistics show the between 1980 and 1995, the population of prisons and jails

increased by 216% while the general population increase by only 16% (Torrey). This shows the

likely increased rate of arrests for people with mental illness after deinstitutionalization.
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In addition to an increase of arrest rates for the mentally ill, social attitudes surrounding

deinstitutionalization lead to criminalization of mentally ill criminal offenders. Societys fear of

the mentally ill, stemming from a lack of understanding, naturally leads them to favor

incarceration to contain the problem. Mental patients who are violent may have a difficult time

in a typical institutional setting because of a lack of security. Community health professionals

are not only reluctant but may also be afraid to treat [mentally ill offenders], especially when

measures are not adopted to ensure staff safety. Then these mentally ill persons are left for the

criminal justice system to manage (Lamb & Weinberger). The lack of proper treatment and

care for mentally ill offenders leads them into the criminal justice system.

Americas views on offenders also contribute to the desire to incarcerate those who have

committed criminal offenses, regardless of mental status. The public has traditionally believed

that any sentence other than prison is to lenient for serious offenders, even if they are mentally

ill (Lamb & Weinberger). This demonstrates the pressures of society to conform. If an

individual is unable to conform to the natural laws of society, they are labeled and often

incarcerated. If a mental hospital is unavailable for those who need it, they will often be

incarcerated in the correctional systems.

Counter-Arguments

Some believe that deinstitutionalization did not significantly impact the criminalization of

the mentally ill. There are a number of other reasons the rate of incarceration of the mentally ill

could have increased. Firstly, there is a lack of long-term mental hospitals which limits the

options one has for extended or lifetime treatment. Secondly, because of the lack of access to

appropriate mental hospitals, the existing institutions have stricter entrance criteria for those with

a mental illness to ensure the most severely ill have preference. Thirdly, there is a definite lack
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of community mental health care which would prevent those with a mental illness from needing

to be hospitalized. Similarly, those who are transferred from a correctional institution have a

more difficult time transitioning to the community if they have a mental illness. Individuals

who have been incarcerated have been shown to earn 40 percent less annually than they had

earned prior to incarceration (Council of State Governments Justice Center). Because of

past incarceration status, individuals have a hard time finding equal employment as prior to

incarceration and therefore have a more difficult time transferring back to the community.

Another reason those with a mental illness are more likely to enter the criminal justice

system over a mental hospital is A belief by law enforcement personnel that they can deal with

deviant behavior more quickly and efficiently within the criminal justice system then in the

mental health system (Lamb & Weinberger). Law enforcement officers may perpetuate the

criminalization of the mentally ill by targeting and arresting the mentally ill at a higher rate than

that of the general population. Lastly, societys attitudes towards those with mental disorders

who commit crimes leads them into the criminal justice system because criminal offense

outweighs a mental illness in need for containment.

Conclusion

What implication does the trend of criminalization of the mentally ill have on the current

correctional system? According to Clemmitt, Americas prisons have become a dumping

ground for the mentally ill (Clemmitt, 3). This overcrowding of a population with special

needs puts a huge burden on the corrections system that it is simply not equipped to handle. The

dumping of the mentally ill inside prisons leads to a variety of problems which exacerbate the

already poor conditions inside prisons and jails.


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Prisons are chronically underfunded and understaffed. The combination of

overcrowding and the rapid expansion of prison systems across the country adversely affected

living conditions in many prisons, jeopardized prisoner safety, compromised prison

management, and greatly limited prisoner access to meaningful programming (Haney). This

means prisons do not have proper training for staff to learn how to specifically deal with mental

health patients. This also means they lack the resources to initiate programs to help with therapy,

reentry, education, vocational therapy, or substance-abuse programs. Additionally, because of

scarce funds, prisons must prioritize the allocation of financial capital. Generally, prisons chose

to spend resources curing infectious disease before mental disease. Similarly, they will also

choose to fix a structural problem with the building itself before allocating money to mental

health treatment (Clemmitt, 3). Also, because of negative attitudes the correctional system,

health professionals generally choose to avoid prisons and jails. In fact, there are no longer any

academic programs to train health workers to deal with prison populations (Clemmitt, 7). The

lack of proper training for prison staff serves to continue the cycle of poor treatment inside

correctional facilities for the mentally ill. These findings show that American society is more

willing to spend money building more prisons to house the mentally ill rather than establish

community based treatment centers. As a society, we focus more on post-accidental care than

preventative care.

There are several solutions to the problem of prisoners in need of mental health services.

Prior to arrest, police officers should receive training on how to deal with problems exhibited by

the mentally ill. Secondly, employ psychiatric emergency teams combining the forces of a law

enforcement officer and a mental health professional to handle the situation. Once a prisoner is

within the justice system routinely screen incoming inmates for mental health problems to
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identify when treatment is necessary then employ psychiatrists to handle the treatment. Through

the screening process, the mentally ill convicted of minor crimes or crimes stemming from the

illness should be transferred to mental health centers, thus reducing the burden on prisons and

jails. In cases where prisoners are convicted of relatively minor crimes, outpatient commitment,

court-monitored treatment, or treatment as a condition of probation or parole should be

considered. If a prisoner is either a violent offender or consistently being reincarcerated,

mandatory treatment for the mental illness should be procured. Upon reentry into society,

prisons and jails should employ case managers to provide outreach services and mentoring

services to the mentally ill. Lastly, the use of pharmacology in prisons should be continued post-

release to reduce the rate of recidivism for those with mental illnesses (Lamb & Weinberger).

In this paper I argue that the deinstitutionalization of the mentally ill from psychiatric

hospitals beginning in 1955 has lead to the criminalization of the mentally ill in prisons and jails.

The evidence presented here from academic journal articles, books, and other sources supports

this hypothesis. I present the impacts that criminalization has caused as well as several possible

solutions to remedy the problem. Currently, Americas correctional system is facing a crisis

caused by the deinstitutionalization of mental patients; however, this trend can be reversed

through education and training programs, community mental health centers, and more treatment

options for those with a mental illness.


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References

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CQ Researcher. 17.1 (2007): 1-24. Web. 9 Dec. 2013. <www.cqresearcher.com>.

Council of State Governments Justice Center. Council of State Governments Justice Center.

Reentry Matters: Strategies and Successes of Second Chance Act Grantees Across the

United States. New York: Council of State Governments Justice Center, 2013. Web.

Grob, Gerald. "The Severely and Chronically Mentally Ill in America: Retrospect and

Prospect." Trans. Array Sickness & Health in America: Readings in the History of

Medicine and Pubic Health. . Third Edition, Revised. Madison, Wisconsin: The

University of Wisconsin Press, 1978. 334-348. Print.

Haney, Craig. "The Psychological Impact of Incarceration: Implications for Post-Prison

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Children, Families, and Communities. (2001): n. page. Web. 9 Dec. 2013.

<http://aspe.hhs.gov/hsp/prison2home02/haney.htm>.

James, Doris J., and Lauren E. Glaze. United States. Department of Justice. Mental Health

Problems of Prison and Jail Inmates. Bureau of Justice Statistics, 2006. Print.

Lamb, H. Richard, and Linda E. Weinberger. "Persons With Severe Mental Illness in Jails and

Prisons: A Review." Psychiatric Services. 49.4 (1998): n. page. Web. 9 Dec. 2013.

<http://ps.psychiatryonline.org/article.aspx?articleid=81232>.

"The Lionel Penrose Papers." Wellcome Library. Wellcome Trust, 29 Nov 2013. Web. 9 Dec

2013. <http://wellcomelibrary.org/using-the-library/subject-guides/genetics/makers-of-

modern-genetics/digitised-archives/lionel-penrose/>.
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Torrey, E. Fuller. "Deinstitutionalization: A Psychiatric "Titanic"." Trans. Array Out of the

Shadows: Confronting America's Mental Illness Crisis. John Wiley & Sons, 1997. Web.

9 Dec. 2013.

<https://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html>.