De-Criminalizing Mental Illness

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Ethan Miller / Getty

A prisoner in handcuffs

Correction appended: Aug. 16, 2007

"Psycho." "Freak." "Jason from the horror movie." These are the answers that counselor Habsi Kaba gets from Miami police officers when asked to describe people with mental illness. Such stereotypes are surprisingly common, says Kaba, and not just within law enforcement. But these misconceptions are especially dangerous when they're held by police, who are often forced to make split-second, life-or-death decisions about mentally ill suspects. "The worst thing you can have is power and lack of knowledge," Kaba says.

Just ask Mike, 31, who knows firsthand. Mike suffers from schizophrenia, bipolar disorder and depression. Since the age of 17, the Los Angeles native has been repeatedly arrested during psychosis for nuisance crimes like disturbing the peace, only to serve his time, fall off his medication and get arrested again. On three separate occasions, his hallucinations were so severe he tried to commit suicide by provoking the police to shoot him. Though he is receiving treatment, rising health care costs and declining federal help mean Mike will likely end up in jail again.

L.A. Police Lieutenant Richard Wall told Mike's story to members of the House Judiciary Committee in March, in support of the 2007 Second Chance Act, which aims to reduce recidivism, in part with better mental health treatment for prisoners returning to society. Prisons, Wall testified, have become the nation's "de facto" mental health care provider. According to the Federal Bureau of Justice Statistics, there are currently 1.25 million inmates like Mike, with debilitating disorders ranging from schizophrenia to post-traumatic stress disorder, abandoned in the U.S. prison system instead of receiving treatment in hospitals.

"If you think health care in America is bad, you should look at mental health care," says Steve Leifman, who works as a special advisor on criminal justice and mental health for the Florida Supreme Court. More Americans receive mental health treatment in prisons and jails than hospitals or treatment centers. In fact, the country's largest psychiatric facility isn't even a hospital, it's a prison — New York City's Rikers Island, which holds an estimated 3,000 mentally ill inmates at any given time. Fifty years ago, the U.S. had nearly 600,000 state hospital beds for people suffering from mental illness. Today, because of federal and state funding cuts, that number has dwindled to 40,000. When the government began closing state-run hospitals in the 1980s, people suffering from mental illness had nowhere to go. Without proper treatment and care, many ended up in the last place anyone wants to be.

"The one institution that can never say no to anybody is jail," Leifman says. "And what's worse, now we've given [the mentally ill] a criminal record."

Most police officers aren't trained to deal with people suffering from severe mental illness. But because they are the first to respond to calls involving psychiatric crises, police are in a unique position to fix the crippled system. That effort is now under way, thanks to Crisis Intervention Teams (CIT), which are being adopted by a growing number of police departments across the country. The concept was pioneered by the Memphis Police Department in 1988 after an officer shot and killed a person suffering from schizophrenic hallucinations. Working with the National Alliance for the Mentally Ill and two local universities, Memphis police trained and organized a unit of officers specifically to deal with people in psychosis — a mental state commonly suffered by patients with severe mental illness in which their thoughts don't match up with reality.

In these cases, normal police procedures often increase the chances of violence, confusion and even death. So, police officers are taught to approach psychotic suspects in a different way: by speaking softly, rather than shouting commands, repeating phrases, holding hands palms-up instead of holding a gun or badge, and wearing plainclothes instead of uniforms. These actions may seem minor, says Kaba, who is the CIT training coordinator for the Miami Police Department, but they go a long way in breaking down the barriers — psychological and otherwise — that often exist between the mentally ill and police.

The ultimate purpose of the CIT program is perhaps empathy. Using a device called Virtual Hallucinations, officers can begin to understand what it's like to be in the grip of a severe and untreated mental illness. Made by the pharmaceutical company Janssen, the rig and headphones simulate the disturbing and disorienting environment of a psychotic episode. After using the rig, Lt. Wall of the LAPD says he was struck by the idea of being exposed to such chaos all the time. "It's just a scary thing," Wall says, "I can do it and walk away from it." Those with serious mental illness, however, cannot.

Community members like John Kowal, 54, work with CITs to provide officers with a more intimate knowledge and understanding of psychosis. Kowal, who suffers from bipolar disorder and alcoholism, has been working with Miami's Police Department and inmates as a "peer specialist." His duties range from consultant to mediator to companion. "I can bond with [mentally ill inmates]. I can say, 'Hey, I was in jail. I take medicine. It's worth it,'" Kowal says. "I don't go by a book. I'm like a friend."

Likewise, the program challenges stereotypes of law enforcement officers as trigger-happy bullies. "Just like police don't understand people with mental illness, we don't understand them," Kaba says. "They're social workers, they're brothers and sisters, they're priests. They play every role out there."

Some officers initially dismissed the CIT program as run-of-the-mill sensitivity training or extreme political correctness, but Cindy Schwartz, director of Florida's Eleventh Judicial Circuit Criminal Mental Health Project, says those same officers now marvel at the program's success. The CIT model has received numerous awards from nationally recognized mental health organizations, law enforcement agencies, and humanitarian groups for treating mental illness as a disease, not a crime. Such change cannot come too soon.

Last December, the Advocacy Center for Persons with Disabilities filed a federal lawsuit against the state of Florida, alleging that it was violating the civil rights of hundreds of mentally ill convicts and inmates awaiting trial by leaving them jailed and without treatment. "We reached a crisis point," says Leifman, the Florida judge, of the state's inability to address mental illness. "We have hundreds of defendants languishing in jail." It got so bad that two mentally ill inmates in a Pensacola, Fla., jail died after being brutally subdued by guards. And in Clearwater, Fla., a schizophrenic inmate gouged out his eye after waiting weeks for a hospital bed.

In June, New York legislators passed a bill outlawing solitary confinement for mentally ill inmates after a study found that such isolation — to which mentally ill prisoners are often subjected — worsened psychiatric symptoms and often led to self-mutilation or suicide attempts.

When it comes to mental health care in the U.S., Leifman says, history is repeating itself. During the 1800s, long before state-run agencies existed to treat mental illness, families would simply drop their loved ones off at jails or prisons, where their conditions remained untreated. Then came state-run hospitals that Leifman refers to as "horror houses" given that patients were usually either neglected or abused — experiments involving drugs and electroshock therapy inspired movies like One Flew Over the Cuckoo's Nest and finally drew the public's attention to the civil rights abuses of people with mental illness. There appeared a glimmer of hope in 1963, when President Kennedy, in what would be his last public bill-signing, authorized $3 billion to create the first national network of mental health facilities. But after Kennedy's assassination, the country turned its focus to Vietnam and not one penny went into the project.

"It's the one area in civil rights that we've gone backwards on," says Leifman, noting that nearly half of the nine floors in Miami-Dade's County Jail are mental health wards, even though the building is "more like a warehouse than a facility." He decries the conditions that these inmates face, including vermin-infested, decrepit buildings that lack adequate ventilation, lighting and water supplies. Leifman also laments the amount of taxpayer dollars used to fund such an inadequate system. Taxpayers in Miami-Dade County spend $100,000 each day to house the mentally ill in prison; moreover, studies show that people with mental illness stay in jail eight times longer than other inmates, at seven times the cost.

"We can't really build our way out of the problem. It's not just about state hospital beds or jails," Leifman says. "We need to really take a hard look at how we're dealing with the problem overall."

The original version of the story incorrectly stated that CIT was created by the Memphis Police Department after one of its police officers was shot and killed by a person suffering from schizophrenic hallucinations. In fact, the schizophrenic man was shot and killed by police.