"Insane"

I was a student intern at the St. Louis State Hospital on Arsenal Street about 50 years ago. Initially called The St. Louis County Lunatic Asylum when it opened in 1869, the original buildings were still the heart of the campus in the early 1970s. None of these buildings was air-conditioned, so the hot, steamy St. Louis weather heated these massive brick buildings to unbearable temperatures; the air was rank. The hospitalized were in sparsely furnished cells and those who acted out were in locked down units. The place looked more like a prison than a hospital.

At the time, this was home for some people. Some had been committed after being arrested for minor violations like shoplifting or loitering; others had committed a more serious crime, such as assault. The non-criminals exhibited schizophrenia and other classic mental health diagnoses; they were living at the asylum because they could not afford private care.

I was assigned to a ward of young men. My psychiatrist-supervisor said this was one of the least hopeful wards. “These boys will probably spend the rest of their lives institutionalized because they have so few good years to draw on for recovery.”

As I read “Insane” I was struck by how little has changed since then. More than half the 2.2 million-plus prisoners in the United States suffer from some kind of mental illness. The author cites a study by the U.S. Bureau of Justice Statistics that reports 75% of women who are locked up are mentally ill. Half of the people executed since 2000 were diagnosed with mental illness or substance use disorder. American prisons have become warehouses for the mentally ill and they are staffed by correction officials who are not trained to be mental health providers.

Prisons in New York, Los Angeles and Chicago are the three largest providers of mental health care in the U.S. Alejandro Fernandez, a Los Angeles correction official told Roth: “We, as deputies, know how to arrest people. We know how to put people in jail. We don’t know how to take care of people with mental illness.” Roth’s investigation of the widespread incarceration of the mentally ill reveals the impossible burdens placed on correctional officers to act as mental health providers when they have no relevant training.

She points out the racial disparity in U.S. incarceration that has locked away several generations of African-American men at a rate noticeably outpacing that of whites. This practice is described as “The new Jim Crow.” Roth predicts the treatment of the mentally ill will be the next civil rights issue.

The U.S. has never known what to do with the mentally ill. The writer traces the long history of how the United States has addressed mental health beginning with Benjamin Franklin and other founders of our nation. She contends that locking them up is the worst option of all. “We continue to treat people with mental illness almost exactly as we did before electricity was invented, before women had the right to vote and before the abolition of slavery. Locking up vulnerable people in inhuman conditions is fundamentally immoral.”

The thumbnail profiles Roth presents to support her argument are shocking, stomach-turning and heartbreaking. Her stirring writing about the toll of incarceration delineates the central tension between society’s desire to punish lawbreakers and society’s responsibility to care for the sick. She is convinced most mentally ill prisoners would be better served outside of prison. Such treatment would be less expensive and easier to manage. The book concludes with promising examples of programs from around the United States where the juncture of care for mental illness within the criminal justice system has shown signs of improvement.

By the end of the book, it is obvious the title is a double entendre. “Insane” refers to the seriously mentally ill, but it is also a searing accurate description of the lack of mental health services provided by the U.S. The same failed policies are tried over and over again. Expecting different outcomes is insane, she maintains.

Alisa Roth traveled across the United States to gather stories from detainees, clinicians, lawyers and police. Her first hand observations and summaries of research are deep, broad and well documented. Roth has provided an eye-opening book about mental health care in the U.S. She asks, “Will our policymakers have the will to make changes?”