Pumpjack Book Reviews

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Book Review: Insane: America's Criminal Treatment of Mental Illness by Alisa Roth


A difficult look at a challenging topic; a hard book but not hopeless

Insane: America’s Criminal Treatment of Mental Illness by Alisa Roth is a deep, disturbing examination of how people with mental health issues fare in our criminal justice system. Spoiler alert: not well.

Roth is a journalist, with strong writing, interviewing and investigative skills, and she uses these skills to their fullest bringing the complex issue to tragic life.

“There is still little consensus about the rationale for incarceration: is it deterrence, rehabilitation or retribution? Given the dramatic overrepresentation in our jails and prisons of people of color and low-income people, it could be argued that the reality has as much to do with oppression and social control as it does with any coherent theory of punishment. Regardless, we have created a system that has left the United States with by far the highest per capita incarceration rate of any large nation in the world.”

The book, then, is a balanced, nuanced and sympathetic look at what happens when we train, staff and fund police and prison systems to punish, incarcerate and hopefully rehabilitate criminals, when the actual “consumers” of these services are increasingly likely to be people with severe mental health issues. In other words, we have the right solution for the wrong problem.

It starts at the first point of contact. Today’s police are trained to enforce laws and neutralize threats quickly and at the lowest risk of personal injury to themselves and others, and then move on to the next issue. That approach usually involves aggressively taking control of the situation and requiring immediate compliance. That simply doesn’t work for people who are in the midst of a mental health crisis. Being yelled at and required to comply with shouted orders can confuse and befuddle, and suddenly a moment in which someone needed patience, support and their meds becomes a gateway interaction a lifetime in prison. Or worse.

And the police know this, at least according to Roth. They know their training and engagement protocols don’t work with people who have mental health issues. But they don’t have the funding, training or support to actually help. So in the worst case, a family (already burdened by lack of resources for people with mental health concerns) calls for the only help available to them, the police, when a loved one is in crisis, knowing they may well be signing a death warrant because such calls too often end in gunfire. In the best case scenario, the police are forced to incarcerate the person, knowing full well they won’t get the help they need in prison or ever get better.

In fact, once in the prison system, people with mental health issues tend to get much worse very quickly. Prisons are stuffed with the worst of the worst, the most violent criminals and the most severe mental health cases. Chronically underfunded, there’s simply not enough people or resources for, well, anything. Psychiatric treatment is mostly non-existent, medication protocols are erratic and often unenforceable, and the rules and regulations, and infractions for breaking them, are designed to keep rational people in line and protect staff from violence, but that tends to catch up the mentally unwell in too large of nets. Unable to meet the demands of a highly regulated environment, most people with mental illness are forced into isolation for breaking the rules, and that makes all mental health conditions worse.

And so they sit in tiny cells getting worse and worse, sometimes in their own waste, sometimes committing truly revolting acts of self harm, sometimes committing violence against guards and sometimes attempting suicide. And sometimes succeeding.

And the guards know it’s unsustainable. They know they can’t help in meaningful ways. They’re not doctors or psychiatrists — which, though often on staff, are in laughably short supply with case loads of dozens if not hundreds. It’s a recipe for disaster and getting worse. Our prisons are way above capacity and filled with folks who need so much help.

“Although the overall number of people behind bars in the United States has decreased in recent years, the proportion of prisoners with mental illness has continued to go up. In 2010, about 30 percent of people at New York’s Riker’s Island jail had a mental illness; in 2014, the figure rose to 40 percent, and by 2017, it had gone up to 43 percent. Studies of the most frequently arrested people in New York, Los Angeles, and elsewhere have found that they are far more likely than other to have mental illness, to require antipsychotic medications while incarcerated, and to have a substance abuse problem.”

And as with most social issues, the help these folks need requires funding, and funding is not forthcoming. With no reliable advocates, and no profit to be made in the kind of institutional settings and treatment options needed, we’re stuck in terrible rut. And that rut stretches back to the 80s. The common belief is that Reagan defunded mental health treatment, but the truth is more complicated. There was a simultaneous push to localize care in community based settings to help de-stigmatize people with mental health issues, and so institutions began to transition, but the loss of funding meant people were released into communities with no viable options to take the place of psychiatric facilities. As funding pressures intensified, solutions became increasing ragged with the traditional prison system left to pick up the slack.

“Finding ways to stop the incredible growth in the number of people with mental illness we shunt into the criminal justice system is obviously complicated. The approaches [she details] are certainly moves in the right direction: training police to respond in a more sympathetic, health-care-oriented way; building diversion programs to help people get out of the system when they get caught up in it; or making it easier for people to get mental health care.”

In other words, we know what works, and we know what’s required to make it work. The only thing lacking is the political will to fund it.