In 1843, social justice crusader Dorothea Dix went before the Massachusetts Legislature with the intention of addressing an acute problem of the day: the incarceration of people with mental illness. Her declaration to the assembly highlighted the "state of Insane Persons," protesting that they were confined "in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience." Her efforts led to the creation of the state's first mental health hospitals. For the next several years, Dix travelled from state to state, repeating her cycle of advocating for special facilities for people living with mentally illness apart from jails and prisons. Though she was successful in many states, her work now stands as ancient history. When it comes to mental health, we have retreated back to the days of the "cages, stalls and pens."
Racism pervades the prison industrial complex. No serious attempt at reform can ignore this.
In many communities, jails have become the only option for police confronted with a person in mental health crisis in public. The reason behind this is obvious: the virtual shutdown of the nation's public mental health care system for which Dix fought. From 1970 to 2002, the per capita number of public mental health hospital beds plummeted from 207 per 100,000 to 20 per 100,000. The intent of these closures was to dismantle large, often punitive mental institutions and replace them with community-based facilities that would have a more patient-centered ethos. Unfortunately, these closures took place at a moment when neoliberalism was on the rise. In the name of fiscal responsibility, most states simply did not replace mental health institutions. In many instances, jails became the quick fix to handle poor people who had mental health crises and no access to treatment.
By 2004, a Department of Justice survey found that 64 percent of local jail populations and 56 percent of those in prisons had symptoms of mental illness. More recent studies cited in a 2014 report by the National Research Council show no abatement of this situation. The presence of mental illness among incarcerated women is particularly acute. A 2009 survey of Maryland and New York jails showed that 31 percent of women had serious mental illnesses, more than double the rate for men.
Though no Dorothea Dix figure has emerged in 2015, at long last policy makers and researchers are waking up to the issue. More than 50 counties, including Champaign, Illinois, where I live, have passed a resolution circulated by the Council on State Governments, backing treatment in the community rather than incarceration. This resolution, part of an initiative called "Stepping Up," comes on the heels of major research reports by Human Rights Watch and the Urban Institute on the challenges of mental illness in jails and prisons.
While attention to this problem is long overdue, the framing of Stepping Up as well as the work by Human Rights Watch and the Urban Institute suffers from a common but crucial blind spot: no mention of race. As Michelle Alexander and others have tirelessly pointed out, racism pervades the prison industrial complex. No serious attempt at reform, let alone transformation, can ignore this.
Overlooked Issues of Race
In the intersection between mental health and incarceration, at least four racial issues surface. First, the petition and recent reports present a static model of the relationship between mental health and incarceration. The assumed dynamic holds that people have pre-existing mental health issues, which get misinterpreted as criminality, resulting in arrest and lockup. The cure then becomes putting people into treatment rather than behind bars.
Mass incarceration has exacerbated and further racialized the problems of mental illness. It is both cause and effect.
While choosing treatment over incarceration may represent a step forward, policy makers and practitioners need to dig deeper into the complex root causes of mental illness. Often, treatment is far from enough. Mental illness can be the product of individual circumstances - a traumatic event, a person's brain chemistry or even their genetic makeup. However, a considerable body of research links many instances of mental illness to experiences of poverty and violence, which are disproportionate realities in poor communities of color.
Researcher Jack Carney outlines the relationship between poverty and mental illness in his provocatively titled article, "Poverty and Mental Illness: You Can't Have One Without The Other." Indeed, the violence of poverty can often trigger poor mental health. People may have mental illness because they have grown up without sufficient nutrition or without access to adequate education, housing or career opportunities. Mental illness may also be precipitated by an environment where fear of racialized police violence, deportation or domestic abuse is a constant reality.
These are structural problems which medication, therapy groups or wraparound services cannot reverse. As "Elizabeth," a homeless Massachusetts woman with a history of mental health problems, told Susan Sered, a Suffolk University professor, "I don't need to talk about my problems. I need a place to live so that I won't be scared all of the time."
The Trauma of Incarceration
Secondly, mass incarceration, which disproportionately impacts poor people of color, has exacerbated and further racialized the problems of mental illness. It is both cause and effect. Cycling in and out of prisons and jails is traumatic, often undermining prospects for economic and social stability. Long-term incarceration, especially in high security or supermax facilities, accentuates the problem. All of this has worsened due to the cutbacks in education and job training programs in prison in the last three decades, heightening the possibility of depression while incarcerated and lack of opportunity after release.
In addition, offering quality mental health treatment in prisons and jails can be difficult. On the one hand, as psychology professor Craig Haney has noted, "prisoners are reluctant to open up in environments where they do not feel physically or psychologically safe." On the other, institutional realities - violence, poor food, lockdowns, isolation and racial discrimination - further inhibit progress for mental health patients. As James Pleasant, currently finishing his 13th year of incarceration in Minnesota, said, "Sleeping on a concrete slab will not solve mental health issues."
Even if treatment is effective, Haney argues that the transition to care outside of prisons is frequently "spotty" because there's not an effective pass-off to the service providers in the community. Some war veterans and survivors of violent attacks may qualify for PTSD therapy, but such services are rarely available to those suffering from post-incarceration stress. They are left to cope for themselves, generally with very few resources.
Racial Stereotyping and a Lack of Cultural Competency
A third key issue is racial stereotyping. This takes several forms. At the level of day-to-day police responses, Dr. Tiffany Townsend, a senior director in the American Psychological Association's Public Interest Directorate, has stressed that Black people are "more likely to be ushered into the criminal justice system" as opposed to being placed in treatment. In other cases, stereotyping can have even more serious consequences. The cases of Ezell Ford in Los Angeles, Lavall Hall in Miami Gardens and Michelle Cusseaux in Phoenix, all killed by police, constitute evidence that Black individuals in mental health crises run serious risks of being criminalized and "treated" with fatal gunfire rather than de-escalation or crisis intervention techniques.
Lastly, mental health treatment, both within carceral institutions and beyond, reflects the greater racial politics of society at large. From the days of diagnosing runaway enslaved people with an affliction called drapetomania in the 1800s to the labeling of Black protesters in the 1960s as schizophrenic, the mental health establishment has a considerable legacy of racist practice.
This history still impacts the attitudes of both mental health practitioners and patients. In 1999, a surgeon general's report noted the inferiority of mental health services provided to people of color. A 2014 research team from Morehouse College of Medicine showed that the problems persist. Such disparities are reinforced by the lack of people of color, especially African Americans, among mental health care professionals. According to a recent article posted by the National Alliance on Mental Illness, Black people make up just 3.7 percent of members in the American Psychiatric Association and 1.5 percent of those in the American Psychological Association.
Black psychologist Dr. Josephine Johnson argues that "cultural competency," which the National Institutes of Health define as "the ability to deliver services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients," is an "ethical mandate." Cultural competency of care providers for those who have had involvement with the criminal legal system may be especially critical for those who have had negative experiences with white authority figures along the street-to-prison pipeline.
The lack of cultural competency appears in the carceral setting as well. In an interview with Truthout, Melissa Thompson, a professor at Portland State University, said that in researching her book Mad or Bad? Race, Class, Gender, and Mental Disorder in the Criminal Justice System, she found racial disparities between Black people and white people "quite pervasive." She carried out both in an intensive study of Hennepin County Jail in Minnesota and a review of national data. She cited racial differences in regard to mental health relating to how people were charged, their access to and quality of treatment received in prisons and jails as well as conditions of probation and parole. These differences even remained when she "confined her analysis to those who self-identified as mentally ill."
Mental Health Support or Medical Control?
Finally, even if present efforts in carceral mental health do develop a racial consciousness, it may not be enough. Some researchers fear we may be shifting from one punishment paradigm to another, as some people describe it, from a prison industrial complex to a "treatment-industrial complex."
Sociologist Susan Sered expressed the concern to Truthout that the transition from "criminal" to "mentally ill" points to a change in status from "someone who did something bad and can serve his or her debt to society" to "someone who is fundamentally and permanently sick."
In her view, an uncaring or poorly conceptualized mental health "alternative" could end up looking much more like medical control and even experimentation rather than a genuine transformation of public policy and invigoration of the communities that have been devastated by mass incarceration and criminalization of their populations.
Hence, while the call for reducing the population of people living with mentally illness in jails is timely and necessary, advocates of mental health decarceration need to embrace a more nuanced analysis of the intersection between race, mental illness and incarceration. Without this, little substantive change is likely to result.