Care Over Cages: An alternative to mass incarceration, homelessness for America's mentally ill
What should a society do with its mentally disabled citizens? In America, we have decided that mass incarceration and homelessness are the way to go. I beg to differ and offer a more humane, affordable alternative.
Darryl Finkton Jr
I try to give concrete and actionable answers to some of society’s “hardest problems.” I am currently taking on poverty in America, an issue we cannot discuss without addressing the ugly elephant in the room: our embarrassingly inhumane mental health crisis.
Solving the Mental Health Crisis
Some individuals temporarily cannot care for themselves. Others will never be able to care for themselves. Some people are currently unable to integrate safely into society. A small few will never be able to safely join a free society. We are failing all of these people.
Caring for the mentally ill
The history of the mentally ill in the United States is a tragic one. In the 17th and 18th centuries, the mentally-ill were seen as possessed by demons or animals. They were then treated as such. For centuries, things didn’t change much.
In the late 19th century, the first state-run mental health institutions emerged. These state-run facilities were widespread in 1946, when TIME magazine ran its “Bedlam 1946” exposé. Author Albert Q. Maisel titled his critique, “MOST U.S. MENTAL HOSPITALS ARE A SHAME AND A DISGRACE.” He calls the state-run mental health facilities in Pennsylvania and elsewhere, “little more than concentration camps.”
Maisel goes on to say, “Beatings and murders are hardly the most significant of the indignities we have heaped upon most of the 400,000 guiltless patient-prisoners of over 180 state mental institutions.” Astute readers will notice similarities to modern institutions in the US. “The fact is that beatings are merely the extreme end product which thrusts upon overworked, poorly trained and shamefully underpaid employees the burden of controlling hundreds of patients whom they fear and despise.”
Not all mental health institutions were criminal. Some provided actual care. “Intensive treatment of this sort is expensive. It cost $6 a day as opposed to $1.20 a day in Ohio's large and essentially custodial mental institutions.” Treatment has its costs, but its benefits were and are clear.
“The gain to the state is obvious. For something less than $300 — spent on six weeks of intensive treatment — the state receives a high proportion of useful, economically productive citizens, while the custodial institutions, harboring identical cases, send as much or more per patient at their deceptively cheap rate of and, in the end, fail to restore the majority of these citizens to society.”
Still, high-achieving mental health institutions remained “stymied for the lack of appropriations,” and staff turnover remained high due to “pitifully low payments.”
Fast forward to 1963 and mental health services were still in a deplorable state. President John F. Kennedy signed the Community Mental Health Act with the stated goal of moving care from institutions and into outpatient community centers, with federal funding. This would end up being Kennedy’s final piece of legislation, and the funding never fully appeared, but the deinstitutionalization began. Congress then established Medicaid and Medicare in 1965 and excluded mental health, further diminishing funding.
Today, psychiatric beds are down over 90% from their peak in the 1950’s.
“In 1955 there were 558,239 state and county psychiatric beds available, or about 340 beds per 100,000 population. Currently, there are about 35,000 state psychiatric beds available, or about 11 beds per 100,000 population.” - Treatment Advocacy Center
Over the years, the funding continued to dry up. This wasn’t a simple case. These institutions were often horrific. But as a society we did nothing to come up with an alternative. The result is that today, the largest providers of mental health services are jails. Cook County in Illinois, Los Angeles County, and Rikers Island in New York are the three largest. We are now fighting a parallel fight as a society to close these institutions due to their deplorable and inhumane conditions.
Outside of prisons, we can find the mentally ill on the streets. Of the approximately 570,000 homeless in the US, at least 25% have been confirmed to be seriously mentally ill, and 45% have any kind of confirmed mental illness. Studies show that between ~25-40% of discharged mental health patients from state hospitals end up homeless within 6 months.
It is a cycle. As more psychiatric beds are lost, more mentally ill people end up homeless and on the streets. As more mentally ill are homeless, more of them are arrested. With 2.3 million people incarcerated in the US, the size of the problem is staggering.
“An estimated 56 percent of state prisoners, 45 percent of federal prisoners, and 64 percent of jail inmates have a mental health problem.”
The cycle of trauma and violence through a mental health lens
Humans have a wide variety of personalities, temperaments, and cognitive functions. It can be difficult to say what is a gift or a disease. The line boundaries between focus and obsession, dedication and addiction, faith and delusion are determined by society. Culture is the collective set of norms that a society chooses to support, that guide us towards behaviors that we want to encourage and steer us from feelings and actions we want to suppress.
In the US, the Diagnostic and Statistical Manual of Mental Health Disorders is in its 5th iteration, commonly referred to as DSM-5. The goal of this document is to provide a common clinical language around psychopathology. The document has plenty of critics.
“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.” - Former National Institute of Mental Health Director, Thomas Insel
The American Psychiatric Association itself notes the limitations of the DSM, stating, “DSM-5 was developed to meet the needs of clinicians, public health professionals, and research investigators rather than all of the technical needs of the courts and legal professionals.”
This is truly problematic. Why do we need separate clinical and legal definitions and clusters for mental health disorders?
Imagine an example where a young person comes into a clinic. That your person has been subjected to years of abuse and trauma. They have been the victim of abuse, they have seen friends murdered, and have become violent themselves. Initially, the young person expressed that violence through fights. More recently, this young person has been using weapons to assault others and has even attempted to kill another young person. What would we say is happening here clinically?
This young person is dealing with a severe traumatic disorder, and their violent behaviors result from this trauma. What then should we do to stop this cycle of trauma? If this were any other medical specialty, we would treat the disease, in this case, violence and trauma being the disease. Then why is the American Psychiatric Association saying that its best efforts at categorizing and finding a common language around mental health disorders do not apply to the legal system?
If violent crime is caused by a disease, then defendants should seek care instead of incarceration. The world is finally waking up to the absurdity of this concern. We want people to see that their criminal behaviors are a disease, and we want them to receive treatment for this behavior. We do not want to send people to places that increase the likelihood of violence and future criminal behavior.
We are treating trauma and abuse by putting people in some of the most horrendous conditions on the planet. Prisons make people worse and destroy communities (1, 2, 3, 4, 5). Laura Berry, an incarcerated woman in the US writes of her male supervisor in prison, “He raped me...and then I realized I was pregnant.” The officer did not take the news well.
“He attempted to induce an abortion by making me take quinine and turpentine. He threatened my life and told me that I had to point the finger at another guard who had also been sexually harassing me. I did, but eventually the true identity of my rapist was revealed; he took an extended leave for back problems but continued to call me by phone and tell me what to say and do.”
Our jails and prisons are hells. They are not places of treatment for mental health disorders. An anonymous prison guard who leaked 2,000 photographs from Alabama’s St. Clair Correctional Facility wrote, “The day to day treatment of these men does nothing but foster anger and despair...Until major changes take place in our sentencing and housing of these men it will only continue to get worse.”
The leaked photos were so gruesome that the New York Times refused to publish the vast majority. Those that were published have since been scrubbed from the internet. A dedicated reader can find them. NYT journalist Shaila Dewan wrote, “The photos showed a litany of blood, gore, nudity and indignity, treatment rooms and murder scenes, and a plea for help scrawled on a wall in blood. Some seemed to have been taken by people oblivious to the slave markets and lynchings the images invoked.”
In the past few centuries, we have not made much progress in how we treat the vast majority of our mentally ill in this country.
The solution to our mental health crisis: Treatment, care, and common sense
Mental health treatment is hard. Thanks to antidepressants, anti-anxiety medications, mood stabilizers, and antipsychotics, we have been able to provide some symptom relief for patients and have been able to treat mental patients outside of medical facilities. Mental health clinicians also have psychotherapy, brain stimulation, and residential treatment programs at their disposal.
However, none of our current mental health drug treatments are curative. Side effects can be severe, including nausea, vomiting, sexual problems, suicidal problems, new or worsening depression/anxiety/psychosis, sudden changes in mood/behavior, mania, nightmares, difficulty thinking or remembering, difficulty sleeping, tics/tremors, and more. The drugs do not work the same for everyone. It can take years working with a clinical team to find a stable medical treatment for and with a patient.
Our medicines have improved much due to formerly illicit drugs. Early clinical studies testing the effects of medical marijuana have been widely successful. Cannabidiol, or CBD, was shown to have anxiolytic, antipsychotic, and neuroprotective properties. Recent research led to CBD recommendations for treating schizophrenia, social anxiety disorder and autism spectrum disorder, attention deficit hyperactivity disorder, insomnia, anxiety, bipolar disorder, posttraumatic stress disorder, and Tourette syndrome. While more research is of course needed, these early results are exceptional. CBD side effects include “dry mouth, low blood pressure, lightheadedness, and drowsiness. Signs of liver injury have also been reported in some patients, but this is less common.”
There has been much debate about marijuana use and mental health disorders. The above would suggest that, perhaps, mentally ill people noticed the benefits of CBD well before the rest of us. Let’s run the clinical trials to find out.
Several Phase 3 clinical trials are now testing MDMA-assisted therapy as a treatment for refractory Post-Traumatic Stress Disorder, i.e. when all other treatments have failed. The data from earlier trials show a strong clinical response with limited side effects. The Multidisciplinary Association for Psychedelic Studies recently completed a Phase 2 study on the safety and efficacy of LSD-assisted psychotherapy in patients with life-threatening illnesses experiencing associated anxiety. The study showed a statistically significant reduction in anxiety with no serious adverse events. These are promising results. Intranasal ketamine has been approved to treat depression. Whereas SSRIs can take weeks to show an effect, ketamine reduces depression in a few hours. The drug was approved after only one pivotal trial, given the effect and strong safety profile.
These medicines all have something in common, they are all scheduled narcotics. Except for ketamine (schedule 3), all others were previously listed as schedule 1 narcotics. A schedule 1 narcotic is defined as “chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse.”
How could it be that chemicals that apparently have no medical use, are all being used in clinical trials to treat hard to treat diseases, and they are showing great results, with great safety profiles?
We declared a War on Drugs and just so happened to choose some incredibly beneficial drugs to ban.
The War on Drugs began with President Nixon, and the passing of the Controlled Substance Act (CSA) in 1970. The CSA created the narcotic schedules and provided the federal government with the necessary tools to enforce draconian drug laws. The Drug Enforcement Agency, or DEA, was established in 1973.
Former Nixon domestic policy chief John Ehrlichman explains this best in a quotation attributed to him by journalist Dan Baum in his controversial article, “Legalize it all: How to win the war on drugs”
“The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people...You understand what I’m saying? We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin. And then criminalizing both heavily, we could disrupt those communities, we could arrest their leaders. Raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”
Whether we agree or not with this being Nixon’s master plan, this is what happened. There are several excellent sources on the disastrous effects of the War on Drugs (1, 2, 3) and the hypocrisy behind our national views on drug use (1, 2). The unbelievably devastating results of the War on Drugs can be felt all around the world, with hundreds of thousands of people dying over this misguided policy (1, 2). And for what? In 2018, 68,000 people died from accidental drug overdoses. That same year, 40,000 people died from car accidents, 30,000 people died from falls, 95,000 people died from alcohol, and 48,000 people died from suicide. These are all tragedies. But to use scare tactics about drug use as a reason to arrest and/or incarcerate millions of Americans is downright shameful. We need to do a better job of preventing drug overdose, just like educating people on safe driving, safe alcohol consumption, suicide prevention, etc.
We have to stop this.
Excessive drug use can be expensive and dangerous. There are intelligent ways to combat this. Portugal has notably decriminalized all drugs with great success. Oregon recently decriminalized as well. This is a health issue, not a legal one.
If attempting to make a popular argument, this is where we talk about harm reduction and making drug dealers the bad guys. Drugs are popular for a reason, people like them. And whether we legalize them or not, people will use drugs. We are only making it much more dangerous and much more expensive. These are cheap products to produce, the vast majority of users will have limited health risks if appropriate regulation is put in place and the potential social benefits from ending this nonsensical war are astronomical. We could generate an estimated $107Bn each year by eliminating our spending on drug enforcement and taxing drugs. We can spend ALL of that on mental health care to help not only those who would like to reduce their drug use but to help the 10 million Americans with severe mental illnesses and the 44 million with any mental health illness.
The solution here is simple, legalize, safely manufacture, regulate, and tax street drugs. In 2016, 1.9 million people used cocaine, 4.4 million used opioids and recreational pain medication, and 500,000 used methamphetamine. The vast majority of these people did not become addicted and did not die. Similarly, the vast majority of the 175 million Americans that drank alcohol in 2016 did not become alcoholics and did not die. That does not mean that alcohol should not be regulated, that people cannot die from alcohol, or that we shouldn’t treat those that do develop alcoholism. Life has risks, and adults have to understand how to manage those risks. People are using drugs and are going to continue using them. Let’s ensure that they have well-manufactured, labeled drugs, understand what combinations are deadly, know where they can seek help reducing their use, and have the treatments for overdose readily available.
When it comes to drug abuse, we have made the cure far worse than the disease.
Moving beyond drugs
There is more to mental health than just medicines. As mentioned above, mental health treatment is hard, and all available therapeutics have some unwanted side effects, some quite extreme. The way forward must include improving and testing our treatment toolkit. Norway recently became the first country to include medication-free treatment wards as a standard option for patients in their state-run system. Dr. Magnus Hald, a psychiatrist in Norway that has been helping to develop these drug-free treatment units says, “ "For most of the patients that we have, it works...Some patients will never go back to using any kind of drugs. And some patients might go back to drugs after some time and some patients may just reduce their doses."
As with any medical specialty, we don’t have the answers to how to treat all mental health diseases. More research is needed to evaluate the efficacy of drug-free treatments like Norway’s. But what we do know is that straight jackets, beatings, throwing people in the streets, putting them in cages, subjecting them to rape, etc. do not work. We need evidence-based therapies and continued research into how to change behaviors and treat the mentally ill. Once we have offered them reasonable treatment plans, we then have to treat patients like adults and allow them to say what feels right and what does not. For some, medicines will be a part of this treatment. For others, it may not.
Unfortunately, we do not currently have a pill that cures trauma and violence, but we have promising treatments. Common Justice, an offshoot of the Vera Institute, is implementing and developing alternatives to incarceration and victim-service programs for those involved in violent felonies. The program emphasizes a survivor-centric approach, thinking first about how to provide the victim with a sense of closure around the traumatic harm that has been done to them. For the perpetrator, the program is accountability-based. Unlike incarceration, the convicted individual must face the person they harmed and discuss what they have done. They must take ownership of their actions. A staggering 90% of victims, when asked if they would prefer to try this alternative to incarceration, say choose Common Justice over jail. This is not altruism. For anyone who has had to live in communities decimated by mass incarceration, it is clear that people do not come back from prison healed and ready to safely integrate back into the community. Victims know prison doesn’t work, and they don’t want to see anyone else hurt. The program works. Only 7% of responsible parties in Common Justice have been removed from the program because of committing a new crime.
“He sat in a restorative justice process with the young man he had beat and robbed, and with the man’s mother. They were together for hours and reached agreements about how he could make things as right as possible. When the circle ended and everyone else had left, he turned to me and asked, Can I stay in your office for a few minutes before I leave?...I asked him why. He said, You know, for all I’ve done and all that’s been done to me, I don’t know if I’ve ever heard a real apology before. Do you think I did alright?...Pardon my language, that is the scariest shit I ever did.” -Common Justice Executive Director, Danielle Sered
We do not have enough of these programs, and we have too many jails and prisons. Pablo, a victim that participated in the Common Justice program asked, “How many cops are there in New York?” The answer then was around 35,000. “And how many people work at Common Justice?” The answer at the time was 6. “That’s hilarious...it was y’all who could keep me safe.”
Restorative justice programs work. An analysis done by the Ministry of Justice in the United Kingdom on 3 restorative justice programs found that participation led to a 27% reduction in recidivism, generating 800% return in savings to the criminal justice system for every dollar spent on the programs. In the US, nearly 70% of those released from prison will be arrested 5 years. Norway, for example, has about 20% of its inmates being arrested after 5 years, and that is for a country locking up 10 times less people than we do in the US. The difference is a focus on rehabilitation in a humane environment. “It’s like Disney World compared to our prisons,” said a visiting U.S. parole agent. Crime will not go away. There will always be some people that cannot be safely integrated into society. That number of people is an order of magnitude lower than the number we are incarcerating in the US. And the way we should house those individuals is through a respectable inpatient mental health facility, not a cage.
So how do we solve our mental health crisis? Do what we already know works. Treat mental illness. By solving our mental health crisis (root problem) we get the bonus effects of ending mass incarceration and the war on drugs! Stop spending money torturing the poor and waging a fruitless war on medicines. Spend the money on treating the mentally ill. It will be expensive. Luckily, we already have a budget for it. Thanks to our obsessive use of policing and incarceration, we have a massive budget item that we can use to fund mental health.
Funding mental health treatment
It is unclear how much mental health care any society needs. The US spent about $225Bn on mental health in 2019. That is up 52% from 2009. In that same period, the prison population declined by 17%. We are doing better. We still have a long way to go.
We currently spend about $115Bn a year on police in the US, with another $80Bn spent on jails and prisons. I will not advocate here for a complete defunding of police. Instead, let’s talk about a meaningful reallocation. Drug enforcement requires ~$47Bn a year. That alone would lead to a 20% increase in the mental health budget. If we take drug legalization a step further, we can generate an estimated $58Bn a year in tax revenue. Combined, we are now looking at a 47% increase in our mental health budget without raising a single extra dollar.
While there are arguments to be made about how much funding we can remove from police, we have no space for U.S. style prisons. We should never have institutions so gruesome, that most of our journalists refuse to post pictures. If we are going to house people by force, it has to be done with treatment and rehabilitation at its core. That is therefore another $80Bn, or an 35% increase in our mental health budgets alone.
There are plenty of other funding sources for mental health services. These are very generous starts. It gives us a concrete answer to what we should do if we defund significant portions of our law enforcement. We should spend it on mental health, including restorative justice and inpatient mental health facilities. This funding should go to treating both perpetrators of violence and victims of violence. When we finally accept that violent perpetrators are almost always victims of violence themselves, perhaps we will finally start the collective healing process.
Darryl Finkton Jr.
Darryl Finkton Jr
Founder of End Poverty Make Trillions
Designing a better society