Lack of appropriate access to mental health care for the seriously mentally ill in the U.S. is a critical issue. Such lack of access can lead to significant, adverse living outcomes for individuals living with mental illness, including homelessness and incarceration. It is a disturbing fact that the criminal justice system is increasingly “housing” people with serious mental illness in the U.S. (Torrey, E. F., Kennard, A. D., Eslinger, D., et al. 2010. More mentally ill persons are in jails and prisons than hospitals: a survey of the states. Arlington/Alexandria, VA: National Sheriffs Association and Treatment Advocacy Center). As an example, in 2015 it was estimated that as many as 4,000 mentally ill inmates were housed in the Los Angeles county jails on any given day (https://www.nytimes.com/2015/08/06/us/los-angeles-agrees-to-overhaul-its-jail-system.html). In the 1800s, the US criminal justice system did not distinguish between mental illness and criminal intent, and therefore the most severely mentally ill were housed in prisons. It is startling and discouraging that, in 2017, we are still criminalizing mental illness.
In the late 1800s, Dorothea Dix raised public awareness about the plight of the mentally ill in jails and prisons, and, as a result of this work, the US Congress created mental asylums. For a century, these hospitals were responsible for housing the population with serious mental illness; the understanding was that mentally ill individuals did not belong in prisons and jails, and instead should be appropriately treated and cared for. However, financial pressures, the presence of abuses of the mentally ill in these institutions, and therapeutic optimism led to deinstitutionalization and the increasing closure of residential mental hospitals. In 1963 John F. Kennedy signed the Mental Health Act, which shifted funding from state residential hospitals towards community-based treatment. This enabled more people with mental illness to return to live within the community. Around this time, there was also research released that critiqued the state hospital system and the validity of psychiatric diagnoses (Rosenhan, David L. “On Being Sane in Insane Places”, 1973. Science). Further, the introduction of Medicaid and Medicare shifted funding from institutions such as state hospitals. While overall these changes produced an improvement in the housing situation for many patients and their families by providing community-based alternatives to state hospitals, an inadvertent consequence of the belief that “desintitutionalization” itself would be curative was that those people with more severe mental illness have been left without an appropriate housing or treatment option. The proportion of people with the most severely impaired mental illness are increasingly lost from the community – many become housed in prisons (Frank, Richard G. and Glied, Sherry A. 2006, “Better But Not Well: Mental Health Policy in the United States since 1950”). Increasing homelessness and incarceration of the mentally ill has largely reversed the gains won by Dorothea Dix; the result is that we are incarcerating and treating as criminals those individuals in most need of mental health treatment. Mental illness recovery requires access to stable supported housing conditions, adequate mental and physical healthcare, and a decent quality of life.
Unfortunately, structural characteristics of the current system are making it progressively more likely that those with mental illness will stay in prison longer, and be placed within an environment which can worsen their mental health symptoms. For example, if an individual with serious mental illness fights with a prison guard, they are likely to be moved to solitary confinement, and punished with an extended sentence in prison (Treatment Advocacy Center, “The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey”, April 8, 2014). Living in the community, disturbing behavior may lead to eviction from stable housing environments, and the combination of poverty and limited access to housing means that those with mental illness are more vulnerable to criminal and abusive environments.
Simulation modeling work has provided a way of visualizing and modeling the housing situation for individuals with serious mental illness in the U.S. (Johnson K, Alevras D, Falconer E, Docherty JP. “An Agent-Based Explanation for 20th Century Living Situation Changes in America’s Severely and Persistently Mentally Ill Population,” AnyLogic 2014). We demonstrated, using an agent-based simulation model, why the population with the worst symptoms are more likely to pool within jails and prisons. The model accounts for the fact that in certain housing situations such as jails, prisons, and long-term hospitals, patients are kept longer when they have mental health relapses, while other living situations, such as shelters, assisted living, community hospitals, or private or subsidized residences, will tend to evict those who demonstrate disturbing behaviors associated with mental health relapses. This means that the healthier proportion of the population will be able to live in relative stability within the community, while those with more severe illness will end up pooling within jails and hospitals. With the closure of hospitals, this means more and more people will remain in the prison system. As such, the current U.S. system is set up in such a way as to increasingly “burden” the criminal justice system with those with severe mental health issues. Governments, however, can lower such prison rates and the resultant cost burden by taking actions to improve mental health treatment and housing alternatives within the community.
To address the overwhelming and urgent needs of the mentally ill, actions need to be taken to address the insufficiencies in both the mental health and criminal justice systems, as well as to improve access to stable housing alternatives for the mentally ill. There is some suggestion that we return to long-term hospital care (“Improving Long-term Psychiatric Care, Bring Back the Asylum,” Journal of the American Medical Association, January 21, 2015). We also need to proactively identify individuals who are at high risk for incarceration, and re-incarceration, and divert them earlier from the criminal justice system to appropriate mental health services within the community. Effective mental health case management by community-based providers is essential for these high-risk individuals. Finally, as our simulation model demonstrated, access to stable long-term housing is critical to help support mental health recovery and to reduce the population of the seriously mentally ill that end up incarcerated.