April 4 is the birthday of Dorothea Dix (1802-1887) the social reformer and later a Civil War nurse best known for visiting prisons and institutions warehousing the mentally ill in the 1840s. Dix advocated for the humane care and treatment of those suffering from mental illness and, as one scholar noted, she "played an instrumental role in the founding or expansion of more than 30 hospitals for the treatment of the mentally ill." In an excerpt of her 1843 report to the Massachusetts Legislature, she observes, "Prisons are not constructed in view of being converted into County Hospitals, and AlmsHouses are not founded as receptacles for the Insane." As a humane alternative she called for well-built, well-run mental asylums. How far have we come since Dix spoke up? Not far enough.
What would Dix have made of conditions in United States jails, prisons, and penitentiaries in the 21st century? They are today, some of the largest and the worst providers of mental health care in the U.S. Facilities built for incarcerating individuals found guilty of crimes are not intended or equipped to be places for treating their underlying mental health problems. Indeed, many people are incarcerated because their failure to receive appropriate high-quality care spiraled into behavior that led to incarceration.
The problem is enormous. A U.S. Department of Justice survey conducted in 2011-12 and released in 2017 found that "about one in seven state and federal prisoners (14 percent) and one in four jail inmates (26 percent) reported experiences that met the threshold for serious psychological distress."
In the 1950s, a deinstitutionalization movement began with the introduction of new psychoactive medications. Deinstitutionalization got a boost in the 1960s after the passage of Medicare and Medicaid legislation. In this era, supporters of deinstitutionalization worked to substitute humane, well-funded, community-based care for large, under-resourced facilities that warehoused the mentally ill. This well-conceived deinstitutionalization movement failed to achieve its goal because, in the words of Stanford Law School's Three Strikes Project, "some politicians seized upon it as a way to save money by shutting down institutions without providing any meaningful treatment alternatives. This callousness has created a one-way road to prison for massive numbers of impaired individuals and the inhumane warehousing of thousands of mentally ill people."
A 2015 Stanford report carried the provocative title "When did prisons become acceptable mental health facilities?" The answer is they never did and, moreover, they never should be seen as having that role.
But, tragically, prisons and jails do have the responsibility of caring for a large population in need of mental health services and it is a costly one for patients and for society. A study of mental illness in Pennsylvania conducted by the University of Southern California Leonard D. Schaeffer Center for Health Policy and Economics found that approximately 25 percent of prison inmates had been diagnosed with a serious mental illness. The report's authors conclude that while federal and state prisons are, by necessity, providing more mental health services to make up for gaps in the general health care system, local jail inmates "do not have the same access to education and counseling while incarcerated as federal and state prisoners." Using data from 2014, the researchers calculated that 12,892 inmates in Commonwealth of Pennsylvania prisons had serious mental illnesses and their overall costs in 2015 amounted to nearly half a billion dollars.
Hidden behind the big data and the big dollars are suffering individuals being ignored or even callously mistreated while incarcerated, sometimes with deadly consequences. Periodically we see headlines such as "Video shows police laughing as mentally ill inmate dies" and "Three Milwaukee jail staffers charged in dehydration death of mentally ill inmate." Stories about mistreatment of mentally ill inmates seem to come and go regularly, as if incarceration, mistreatment, and abuse are something to acknowledge and then to ignore. It does not have to be that way. Dorothea Dix found using prisons to warehouse and abuse the mentally ill objectionable in the 1840s and so it should be today.