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Look behind the rapidly growing trend to send severely mentally ill people to jails while dangerous individuals for whom incarceration is more appropriate are committed to psychiatric hospitals and you'll find a complex interplay of economic, social, and political factors.
This trend, which psychiatrist and public health official John M. Oldham, M.D., calls transinstitutionalization, is yet one more example of fallout-not all of it bad-from the decades-long deinstitutionalization movement that swept through the state hospital systems in the U.S.
Oldham is vice chair of the psychiatry department at Columbia University, director of the New York State Psychiatric Institute, and chief medical officer of the New York State Office of Mental Health.
Prior to 1990-a date that Oldham admits is arbitrary-severely mentally ill people who in an earlier era would have been hospitalized were in ever-greater numbers being "criminalized." But the pattern generally went in one direction only-untreated, often chronically psychotic individuals were incarcerated to get them off the streets and into a secure institution that would still accept them.
As this decade began, however, another trend gained momentum when the trickle of convicts who were being committed to now-empty psychiatric hospitals became a torrent, he explained at a lecture at APA's Institute on Psychiatric Services in Washington, D.C., last fall.
At the same time states were escalating the emptying of their public psychiatric hospitals, the American public became enthusiastic about enacting much stricter laws to govern psychiatric commitment. Accompanying both of these patterns was a nationwide trend to slash mental health budgets in the face of shrinking funds and cries by voters for lower taxes. Then hysteria was stirred up by the media in reporting incidents of violence by mentally ill people, the growing intolerance of allowing potentially dangerous persons to remain uninsti-tutionalized, and "a criminal justice system that can't say no." These factors set the stage for transinstitutionalization, which does little to meet the needs of any of the people being shuffled between institutions, Oldham suggested.
Recent surveys in the state of New York, where there are only 6,000 patients in state hospitals (in 1955 there were 110,000), show that the only population whose numbers are increasing in these hospitals are forensic patients, most of them shifted there from the criminal justice system, he pointed out. At one of New York's state hospitals, Manhattan Psychiatric Center, 61 percent of current patients arrived via that route.
Psychiatrists and mental health professionals also shoulder some of the responsibility for criminalization of the mentally ill and the "forensification" of former inmates. Without solid supporting data, "we prematurely began to preach that the mentally ill population is no more dangerous than other people," Oldham said. While this has been argued for all the right reasons, he noted, data now indicate that the contention is neither entirely accurate nor especially informative.
There are some psychotic symptom states-not diagnoses, Oldham was careful to point out-that when untreated are, in fact, related to an increased risk of violence by mentally ill individuals. He cited recent research showing that a psychotic person who "feels personally threatened or experiences intrusive thoughts that override self-control" is more likely to commit a violent act. In addition, when a major mental disorder is comorbid with substance abuse, the violence risk rises dramatically.
This type of information provides clinicians, health policymakers, and elected officials with useful data that can steer decision making regarding treatment for the seriously mentally ill in a rational and constructive direction.
Of course other problems fostered by both deinstitutionalization and the current economic and social climate also will have to be addressed if the process of crimin-alizing the mentally ill is to be effectively reversed. Among the obvious ones are devoting resources to ensuring that once severely or chronically mentally ill people are sent back to the community, jobs and adequate housing are in place for them. Another task is clearing up the "fuzzy boundaries" between criminal behavior and psychopathology so that the differences are clear to the public and the officials they elect to ensure their safety.
Concerned advocates and public officials also will have to work to undo the fragmentation of state and local health and social services systems into separate agencies assigned to deal with substance abuse, mental retardation, or mental health, Oldham emphasized. These unworkable arrangements and "the penny-pinching legislators" who devised them ignore the fact that patients do not easily align themselves into such neat categories and that comorbidity aggravates many of their disorders and, when inadequately treated, contributes to just the types of behaviors that scare the public about the mentally ill, he noted.
Oldham's prescription for a better future for these troubled and troubling patients includes research that leads to treatment innovations and improvements; interagency collaboration, which, he acknowledged, is extremely hard to accomplish but has never been as important as it is in the current climate; and "clinically informed decision making in the context of a patient's right to good treatment, the public's right to safety, and the political system's need for appropriate distribution of limited fiscal resources."