Insane: America's Criminal Treatment of Mental Illness by Alan Roth

Reviewed by Patrick Howell, S.J.

Roth has assiduously written a masterful treatise about how we are “shunting some of the most vulnerable people in America into jails and prisons” – and why they are so mistreated once they get there. Although the overall number of people behind bars has slightly decreased in recent years, the proportion of prisoners with mental illness continues to go up. Those frequently arrested in New York, Los Angeles, Seattle, Chicago, and elsewhere are far more likely than others to have mental illness and to require antipsychotic medications while incarcerated.

Along with race and poverty, mental illness has become the salient feature of mass incarceration. It’s shocking enough that one of every three African-American men will be arrested in their lifetimes, but for Americans with serious mental illness, as many as one in two will be arrested at some point in their lives.

The great tragedy is that America has the resources to treat mental illness with care, compassion, and effectiveness. But as a society, we have chosen not to do so.

The turning point came in 1963 when President John Kennedy signed the Mental Retardation Facilities and Community Health Centers Construction Act (90). The goal was an enlightened one to reduce institutionalization of people with disabilities and people with mental illness by building community health centers for outpatient treatment and to allow for integration of the individual within the natural bonds of affection and acceptance of one’s own neighbors and families. But the result was a terrible vacuum because the community centers were never adequately funded or built. The states emptied out their “insane asylums,” but those with serious mental illness more often ended up on the streets and from there often enough in the local jail. Their illness was further compounded by incarceration. In a chapter entitled “Destined to Fail,” Roth explains the criminal justice system, “is not only receiving huge numbers of people with mental illness, it is also getting the sickest of the sick – those who most urgently need intensive treatment” (112). Patients do best when treatment is started early; an untreated illness almost always gets progressively worse. In addition, three-fourths of prisoners with mental illness also gave substance use problems, often the result of self-medicating with alcohol or street drugs. Roth further explains that jails are run by control and coercion, precisely the opposite of what effective treatment might mean from those suffering from mental illness. Consequently, the psychological issues often worsen within a jail or prison environment.

Roth’s research is prodigious. Her powerful narrative lays bare the true costs of incarcerating our nation’s mentally ill citizens. She has visited the jails and the prisons; she has documented the poignant cases of those with mental illness repeatedly jailed and often abused by the prison systems. She has talked with reformers and mental health professionals who offer superb insights into what is actually needed, but for which the political will of the civic community is sorely lacking. This book is must reading for anyone concerned about the care and treatment of those with chronic mental illness and about how our incarceration systems have become the largest psychiatric facilities in the country.

Patrick Howell, S.J., is chair of the National Seminar on Jesuit Higher Education.