Don't Blame Deinstitutionalization

We know for certain that too many people with mental illness are locked up in U.S. jails and prisons. But deinstitutionalization is not to blame.

We have some of the facts from Arthur Lurigio of Loyola University Chicago, writing in the June 2011 issue of Federal Probation Journal. He points out that the number of people with psychiatric histories in jails and prisons did not increase during the first twenty years of deinstitutionalization. Lurigio notes:

The 2 percent increase in the proportion of men with previous psychiatric hospitalizations sentenced to prison between 1968 and 1978 is much too small to account for all of the men who were released from psychiatric hospitals.

Some people think that a certain proportion of our population is unfit for society and will always end up locked up somewhere. They believe that if hospital populations go down, prison populations must go up, and vice versa. Lurigio calls this “the hydraulic fallacy.” Every modern society has a different rate of imprisonment, and these rates change over time. The current U.S. imprisonment rate is the world’s highest, with 724 people incarcerated per 100,000 population. The imprisonment rate of England and Wales is at about the midpoint worldwide, at 145 per 100,000. Hospitalization does not account for the difference. The U.S. now has about 30 psychiatric beds per 100,000 population. The U.K. has about 60.

The real difference is criminal justice policy. In the 1980s, U.S. law enforcement ramped up the war on drugs, while legislatures imposed zero tolerance sentencing policies, and passed three-strikes legislation. These changes disproportionately affected the urban poor, and swept tens of thousands of Americans into jails and prisons, including many people with mental illness. There are many more people with mental illness in our prisons and jails today simply because people with mental illness entered prison with their friends and neighbors, brothers and sisters and cousins. Throughout this period the census in state psychiatric facilities remained relatively flat while the prison population shot up.

According to Lurigio, the real risk factor for increased criminalization is poverty.

The risk factors that predict crime among people with severe mental illness are the same factors that predict crime among people with no serious mental illness…A large-scale, seven-year study of the relationship between socioeconomic status and mental illness suggested that poverty, acting through economic stressors, such as unemployment and lack of affordable housing, is more likely to be a precursor to, than a sequela of, serious mental illness.

The emphasis on incarcerating people for drug crimes also selected high numbers of people with co-occurring mental health and substance abuse disorders for criminal justice involvement.

Like dolphins among tuna, many mentally ill, drug-using persons are caught in the net of rigorous drug enforcement policies.

Another myth is the notion that treatment is the first step to reduce criminalization of people with mental illness. According to Lurigio, no studies have shown that the alleviation of psychiatric symptoms alone affects recidivism among criminally involved people with serious mental illness. What really helps is addressing other root causes of criminal behavior – substance abuse and other so-called criminogenic factors. This should not surprise us. As Lurigio writes,

Serious mental illness alone rarely leads people to commit crimes and, therefore, the treatment of mental illness alone is unlikely to prevent or reduce crime or recidivism. People with severe mental illness can benefit from the same evidence-based cognitive behavioral therapies that affect criminal thinking among people with no mental illness. Most important, integrated treatment for co-occurring psychiatric and substance use disorders is critical in helping people with severe mental illness manage their symptoms and change their potential criminal trajectories.

I am also struck by the role that stigma may have in all this. Many people among our new criminal justice populations are being diagnosed during jail house intake. If they were never diagnosed in today’s relatively accessible outpatient treatment environment, they would certainly not have had a place among the deinstitutionalized.

Mike Hogan's talk at the 2012 National Council conference also supports deinstitutionalization as a good thing. He mentions the incarceration patterns Lurigio identifies, and says one of the big problems with deinstitutionalization was that mental health experts did not get to control how it played out. He also notes that people who live in the community do prefer to stay there. People with experience of long-term psychiatric hospitalization do not ask to move back in..

Sources:

Lurigio, A. (2011). Examining Prevailing Beliefs About People with Serious Mental Illness in the Criminal Justice System. Federal Probation Journal, June 2011. http://www.uscourts.gov/uscourts/FederalCourts/PPS/Fedprob/2011-06/03_examining.html

European Sourcebook of Crime and Criminal Justice Statistics. Downloaded 9/10/12 from http://www.europeansourcebook.org/

Harcourt, B. (2007]. The mentally ill, behind bars. New York Times. Downloaded 9/9/12 from http://www.nytimes.com/2007/01/15/opinion/15harcourt.html

Mike Hogan's 2012 National Council IdeaTalk http://youtu.be/g1KDZxWNHss