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Dealing with the mentally ill: We need to do better

More Americans receive mental-health treatment in prisons and jails than in hospitals or treatment centers. In fact, the three largest inpatient psychiatric facilities in the country are jails: Los Angeles County Jail, Rikers Island Jail in New York City, and Cook County Jail in Illinois. The Bureau of Justice Statistics reports that 56 percent of state prisoners, 45 percent of federal prisoners and 64 percent of jail inmates suffer from a significant mental illness.

Kevin S. Burke
Kevin S. Burke

Although many of these inmates committed violent acts, not all of them are felons; most of them are not violent. Individuals are often incarcerated with misdemeanor charges that are the result of behaviors caused by their psychotic thinking. Female inmates, by the way, have a higher rate of mental-health problems than male inmates.

Fixing this problem in an environment of budget cutting will not be easy, but it needs to happen.

The problem of what happens to people with mental-health problems in jails or prisons is not simply waiting for their inevitable release and their return to a community ill prepared to take care of themselves; rule violations and injuries from a fight are much more common among inmates who have a mental-health problem. Last week’s Star Tribune story on the selection of the new head of the St. Peter Security Hospital focused on the background of the new director, but the important point of that story may well be this: How do you provide a safe environment for staff and patients? Mentally ill prison and jail inmates are an enormous challenge.

From hospital beds to prison beds
In the early 1960s the State of New York had 85,000 inpatient psychiatric beds and 15,000 prison beds. By the early 1990s, the numbers were almost exactly reversed. New York is not unique in that role. Minnesota has a similarly sad history. Minnesota once had the St. Peter Asylum for the Insane, the Rochester Asylum for the Insane, the Faribault School for Imbeciles, the Fergus Falls Asylum for the Insane, the Anoka County Asylum for the Insane, and the Hastings Asylum for the Insane. In 1937 the patient census in the Fergus Falls hospital alone was 2,078. At its height, St. Peter had nearly 2,300 beds.

Today St. Peter has 16 inpatient psychiatric beds, Rochester has 16 inpatient beds, the Hastings hospital is closed, the Faribault facility is a prison, and if you are interested, you might be able to purchase the building in Fergus Falls. Minnesota is now more politically correct since we no longer refer to people with mental illness as being insane or being imbeciles. But breaking the promise of providing community-based mental-health services to replace antiquated institutions is more destructive than insensitive descriptions of people who are sick.

State prisoners and local jail inmates who have a mental-health problem are twice as likely as inmates without mental-health problems to have been homeless in the year before their incarceration. Past physical and sexual abuse is more prevalent among inmates who have mental-health problems. One study found that about 18 percent of the prisoners who had a mental-health problem said that they had lived in foster homes, agencies or institutions while growing up.

Little re-entry success, little actual treatment in prison
Recidivism of all inmates is a serious problem in Minnesota. A Legislative Auditor’s report found that nearly 60 percent of released inmates do not make the transition to being in the community successfully. It is particularly troublesome for released mentally ill inmates. Predictably there are low rates of employment and high rates of illegal income among inmates who have mental-health problems. Inmates who have high mental-health problems also have high rates of substance dependency or abuse. Yet nationally only a third of state prisoners who have a mental-health problem have received treatment since admission. Minnesota has in recent years fairly drastically cut back on both mental-health and chemical-dependency treatment in our prisons.

Untreated mental illness can destroy lives — not just the lives of the afflicted, but the lives of their families as well. The quality of life for individuals who have untreated mental-health problems and are homeless is abysmal. Many are victimized regularly. A recent study found that 28 percent of homeless people with previous psychiatric hospitalization obtained some food from garbage cans, and 8 percent used garbage cans as a primary source of food. People with untreated psychiatric evidence spend twice as much time in jail as non-mentally ill individuals and are much more likely to commit suicide. Twenty-five percent of all parents killed by their children had children with untreated mental illnesses. All of this is well known among the psychiatric community.

Appropriate community-based treatment needed
The data is easily available to policymakers, yet by and large we continue to ignore the problem of how to best treat people with mental illness. The institutions are gone, but there is inadequate community-based support.  Instead we put too many mentally ill people in jails and prisons. Mental illness is not an excuse for criminal behavior. It is also not a sign of moral failing or a contagious disease. Jails and prisons are expensive, and they are not any more capable of curing mental illness without treatment than they are of curing cancer without chemotherapy. Diverting people with mental illness away from jails and prisons toward more appropriate community-based mental-health treatment will not just enhance public safety; it is likely to be cheaper.

Given the prevalence of mental illness, why are we so persistently unsuccessful in treating it?  

First, we do not have enough psychiatrists. Medical schools need to become far more aggressive in filling the community with competent, caring psychiatrists. Second, although modern medicine has made great advances in the types of medication, the medication most frequently prescribed for the poor tends to be medication with the most severe side effects. Doctors prescribe 1960s-era medication because these drugs are the cheapest. It is no wonder people stop taking the medication. Advances in medication can make a huge difference in making life livable for the mentally ill. Third, until recently courts have been transferring people who, a generation ago, were in asylums for the insane to prison, jails and sleeping under the viaducts of freeway bridges.

Mental-health court initiatives need to spread
True, more recently courts have changed. There are mental-health courts in Hennepin and Ramsey counties modeled after drug courts. These initiatives need to broaden throughout the state. Mental illness is not, after all, an urban phenomenon. People in greater Minnesota are mentally ill, too.

Minnesota has had two national leaders on mental-health reform: the late Sen. Paul Wellstone and former Rep. Jim Ramstad. There have been a few state legislators who have focused on the issue, but what is fundamentally needed now — desperately needed now — is a clarion call from Minnesota’s top political, judicial and medical leaders to fix the system of mental health. If that occurs thousands of people with mental illness can have better, productive lives and the misery of their families can come to an end. Minnesota will be a better, safer place.

Judge Kevin S. Burke has served on the District Court for 27 years. He served as the chief judge for four terms. On Thursday he will become president of the American Judges Association.

Comments (1)

  1. Submitted by Richard Beens on 09/13/2011 - 11:59 am.

    Excellent article! As a long time Board Member and phone room volunteer at Crisis Connection, a suicide and crisis hotline, I can attest that the societal “safety net” has long ago vanished for the vast majority of the mentally ill. We handle 50,000 to 60,000 calls per year, mostly from the seven county metropolitan area. Shame, insurance limitations, and lack of public funding leaves many of our callers with nowhere else to turn.

    Judge Burke hits the nail on the head. As a former prosecuter and public defender, I have watched every year as our legislators, afraid of “mollycoddling criminals,” pass increasingly harsh and mandatory sentences that fail to address the underlying mental illnesses that lead many into criminal acts. Its like treating a problem with chemotherapy when an aspirin would work just as well.

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