Behind Bars, Mentally Ill Inmates Are Often Punished For Their Symptoms

Jul 10, 2018
Originally published on July 13, 2018 1:32 pm

By some accounts, nearly half of America's incarcerated population is mentally ill — and journalist Alisa Roth argues that most aren't getting the treatment they need.

Roth has visited jails in New York, Chicago, Los Angeles and Atlanta and a rural women's prison in Oklahoma to assess the condition of mentally ill prisoners. She says correctional officers are on the "front lines" of mental health treatment — despite the fact that they lack clinical training.

"Most of [the correctional officers] will talk about how this is not what they signed up," Roth says. "Most of them have not had much training in dealing with mental illness — or they've had none at all."

Roth witnessed high-risk prisoners in solitary confinement or chained up or wearing restrictive jumpsuits — which tended to exacerbate the prisoners' distress.

Therapy, when available, was often conducted under stressful conditions. Roth describes one session in the Los Angeles County jail that took place through the slots of a cell door — forcing the prisoner and therapist to yell to be heard.

"The entire [jail] tier can hear everything that you're saying," Roth says. "Especially in a place where showing any weakness can be really dangerous ... people are particularly unlikely to disclose anything personal or her that would make them vulnerable."

Roth chronicles her findings in the book, Insane: America's Criminal Treatment of Mental Illness.


Interview Highlights

On estimating the number of people with mental illness in jail and prison

It's complicated, because statistics in the criminal justice system are notoriously poor and how we define mental illness is complicated. ... Some jails might count PTSD as a mental illness and others use people who are really underqualified to be to be diagnosing the disease and so end up with severe undercounts. But 50 percent is a good estimate.

On punishing mentally ill prisoners for self-harm, which is frequently a symptom of their illness

One of the other things that we see often is that somebody will try to hurt themselves — either an actual suicide attempt or a cutting "self-harm incident" as they're called — and [that person] will be punished for trying to commit suicide or for trying to cut themselves.

And in this sort of irony of ironies, some states or counties have passed rules which say, OK this person has mental illness — the cutting is a symptom of the mental illness — so we're not going to punish that behavior. But then they'll be punished for something like possession of a weapon if they used a razorblade or a pencil to cut themselves, or they'll be punished for destruction of state property for tearing a sheet to tie it into a noose.

On how solitary confinement affects mentally ill prisoners

Jails and prisons have all kinds of rules and regulations. ... Some of them are for security and some of them are just basically for the sake of rules, like where you have to stand when they do the count or where you have to stand to receive your food tray, things like that. And when people can't follow the rules, either because they don't understand them or because their paranoia makes them think that following the rules is going to get them hurt, the punishment is solitary confinement, which basically means being shut in a windowless room by yourself 23 hours a day. And it can make people who are sane completely mentally ill, but for somebody with mental illness it's absolutely devastating. ... If you're paranoid and you're afraid that your food is being poisoned or that people are out to get you, being locked in this room by yourself really makes it worse.

On how common tactics by law enforcement don't work the same way with mentally ill prisoners

The training [for a correctional officer] really suggests that you should take control, you should maintain control and when you feel like a situation or a person is getting out of control the response is to escalate. So: "Stand up. I told you to stand up. Stand up right now!" And it continues in that vein until the person complies or you have to use force to make them comply.

For a person with a mental illness, particularly one who is paranoid, this is absolutely terrifying. It's terrifying for anybody. It's intended to be frightening, but for a person with mental illness it's incomprehensibly terrifying, and so the result is often that the person with mental illness responds in exactly the opposite fashion ... by lashing out or fighting back. And this leads to this cycle of escalation where really what you want to be having is de-escalation.

On the responsibility the correctional officers have

In many, many places the corrections officers are really seen and used as the eyes and ears of the clinicians. And so the psychiatrists and the psychologists will come to the officers and say, "Who are your sickest people? Who needs to be sent out to the state hospital for treatment or who needs to go to our inpatient clinic inside the jail or prison?" And it puts the corrections officers in an odd position, both because they're forced to play this dual role of caretaker and enforcer, but, more complicated than that, is the fact that they really don't have the training. ... They haven't been given, in most cases, training to, say, identify schizophrenia versus depression. And because of, privacy rules, of HIPAA rules, they don't have access in most cases to the prisoners medical records. So they're responsible for caring for somebody, but they don't necessarily know what they're supposed to be looking for or what to do if they see a particular behavior.

Sam Briger and Mooj Zadie produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Scott Hensley adapted it for the Web.

Copyright 2018 Fresh Air. To see more, visit Fresh Air.

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. According to our guest, Alisa Roth, the three largest providers of mental health care in America are not hospitals but jails. Roth says the mentally ill are more likely to get arrested than the rest of us. Once behind bars, they may go long periods without needed medication and likely be subjected to noise, the loss of sleep, isolation, and rules and punishments they don't understand, all of which can lead to deterioration in their mental condition. Roth visited jails in New York, Chicago, Los Angeles, Atlanta and rural Oklahoma, talking with correctional officers, mental health professionals, inmates and their families. Alisa Roth is a former reporter for Marketplace and a frequent contributor to NPR programs. She's also written for The New York Review of Books and The New York Times. She spoke to FRESH AIR'S Dave Davies about her new book "Insane: America's Criminal Treatment Of Mental Illness."

DAVE DAVIES, BYLINE: Well, Alisa Roth, welcome to FRESH AIR. You begin this book with the story of a man named Bryan Sanderson. Tell us a little about him.

ALISA ROTH: Bryan Sanderson was a firefighter in Williamsburg, Va., who was living a pretty ordinary life when he developed bipolar disorder. He had a couple of suicide attempts, was in and out of the hospital and got pretty stable, went off his medication and started hearing voices. And at some point, a voice told him that he needed to go to Texas and open a homeless shelter.

So he started driving from his home in Williamsburg, had gotten as far as South Carolina when the voice told him he needed to pull over and stay in a hotel. He stopped. He stayed there for three days. And then the voice told him it was time to move on, so he packed up all his stuff, dragged it out in the hallway. The door had shut behind him - the door of his room had shut behind him - when he suddenly remembered that he'd forgotten something inside, and tried to go back inside, but his keycard wouldn't work.

A lot of us will have had this experience and know how frustrating it can be. But he, in his psychotic state, got furious, took all his stuff, threw it in the elevator, took off all of his clothes and was standing in the elevator, riding up and down completely naked when another hotel guest got on the elevator, notified the front desk, who called the sheriff's deputies. And soon after, they came and arrested him. He was charged with indecent exposure, which in South Carolina, you can spend three years in jail for.

DAVIES: And this was his first arrest, right? I mean, he had never tried to hurt anybody, despite, obviously, a serious mental illness. When he's in jail, he ends up in what they call the hole solitary - confinement. Why?

ROTH: He had become convinced that these corrections officers were trying to hurt him, and the voice told him that he needed to attack one. And so he did. And he ended up in solitary. And this is really, really common among people with mental illness. Jails and prisons have all kinds of rules and regulations that - you know, some of them are for security, and some of them are just basically for the sake of rules, like where you have to stand when they do the count or where you have to stand to receive your food tray, things like that.

And when people can't follow the rules, either because they don't understand them or because their paranoia makes them think that following the rules is going to get them hurt, the punishment is solitary confinement, which basically means being shut in a windowless room by yourself 23 hours a day. And it can make people who are sane completely mentally ill. But for somebody with mental illness, it's absolutely devastating.

DAVIES: Right. And so this is one of the ways in which we see this conflict between the correctional system, which is about confining people for all the various reasons society has decided to confine criminals. But confining them means a regimented life, a rule - correctional officers who are trained to impose those restrictions. And people who can't understand them - and the one thing they need is treatment, not being locked up.

ROTH: And it makes it so much worse. I mean, it's - if you're paranoid and you're afraid that your food is being poisoned or that people are out to get you, being locked in this room by yourself really makes it worse. And we see this in all kinds of ways where we really punish the symptoms of the mental illness itself.

So one of the other things that we see often is that somebody will try to hurt themselves, either an actual suicide attempt or cutting - you know, a self-harm incident, as they're called. And then people will be punished for trying to commit suicide or for trying to cut themselves. And in this sort of irony of ironies, you know, some states or counties have passed rules who say, OK, this person has mental illness; the cutting is a symptom of the mental illness, so we're not going to punish that behavior. But then they'll be punished for something like possession of a weapon if they used a razor blade or a pencil to cut themselves, or they'll be punished for destruction of state property for tearing a sheet to tie it into a noose.

DAVIES: Right, which can add to their sentence, increase harsh conditions of confinement. Bryan Sanderson eventually gets sent to the mental hospital that's part of the penal system there - right? - and eventually gets, like, medication, is eventually released, kind of restores his life a bit. And then he goes off the medication and becomes convinced his neighbor is making bombs, breaks into the neighbor's house, finds - what is it? - sugar and garden soil.

ROTH: I think it was butter and garden soil.

DAVIES: OK.

ROTH: Another baking ingredient.

DAVIES: Right - calls the police, and the police come and immediately recognize what's happened, right? The police officer knew him and actually took him to a mental facility. He ends up attacking a woman who's interviewing him because he thinks she's the devil. And then a police officer makes a judgment about what happens to him next. You write in the book that the decision to send him to jail then rather than hospitalization was a fateful decision for him. Why?

ROTH: So Bryan is wandering around the campus of this mental hospital - the psychiatric facility - after he punched the technician, and the police officer comes up to him. He's completely disoriented. He thinks he's - in the years between developing bipolar and this point, he's done a lot of trainings with police officers in how to deal with people with mental illness. So he actually thought this was all part of a training. He didn't know what was going on.

The police took him to jail. And he was - he describes it as being in this sort of fog, like blacking out and coming to. But he really didn't know where he was, and he would wake up on the floor of his cell, and it was all wet, and he didn't know why he was there or where he was. And after a couple of days, the voice told him that he needed to blind himself. Bryan is a very religious man. There are a lot of references in the Bible to blinding oneself in some kind of - you know, in response to one's sins. And the voice told him he needed to do that. And so he did.

They took him then to a regular hospital, where he underwent surgery, woke up a couple of days later, again, had no idea where he was or why he was there. His mother told me she came to visit him. And here he is, strapped to the bed, guarded by two police officers, and he's talking about opening another homeless shelter. And he really had no idea where he was.

The thing I think that was most astonishing about this very astonishing story to me was reading the psychiatrist's report. So while he's in this hospital after the surgery, a psychiatrist comes and evaluates him. And in the notes, the psychiatrist said that Bryan had no idea where he was; he didn't know why he was there, but that he, the psychiatrist, didn't see any reason why Bryan couldn't be taken back to jail. And I look at this, and I wonder, what exactly was the psychiatrist thinking would be accomplished by sending Bryan back to jail? And why did he need to be there? He wasn't a danger to anybody except himself. And at this point, he wasn't even really a danger to himself because he couldn't see anything anymore. But they did send him back to jail, and they actually put him back on the same unit where he had blinded himself.

DAVIES: You know a lot of this because he survived all this, and you were able to interview him. Where is he now? What became of him?

ROTH: Bryan lives in Williamsburg. He lives a very narrow life because he obviously can't drive, and he lives a little bit outside the city on this road that would be really treacherous for somebody to walk on if you can't see where you're going. And he's too far out of the city for the paratransit to come and pick him up. Fortunately, for Bryan, he has a very, very devoted mother who also lives in Williamsburg. And so she comes by regularly and makes sure he has food, takes him to the doctor, and to get his haircut and takes care of his bills and things like that.

He has friends who bring him food. He runs a regular support group at a church - I mean, it's in a church, but it's not associated with the church - for people with mental illness. So he does that once a week. And he does occasional trainings with police and other law enforcement around the state to teach them how to deal with people with mental illness. But it's a very different life than he had before and a very different life than he had imagined for himself.

DAVIES: And hopes someday he'll get his sight back.

ROTH: He does.

DAVIES: Alisa Roth's book is "Insane: America's Criminal Treatment Of Mental Illness." We'll talk some more after a short break. This is FRESH AIR.

(SOUNDBITE OF CUONG VU AND PAT METHENY'S "SEEDS OF DOUBT")

DAVIES: This is FRESH AIR. And we're speaking with journalist Alisa Roth. She has a new book about the concentration of mentally ill people in America's prisons and jails. It's called "Insane: America's Criminal Treatment Of Mental Illness."

Do we know how many people held in American jails and prisons have serious mental health issues?

ROTH: By some counts, as many as half of the people in our jails and prisons have a mental illness. It's complicated because statistics in the criminal justice system are notoriously poor, and how we define mental illness is complicated. So there are certain clear factors that we can say, oh, yes, this is a clear indication of, say, schizophrenia or bipolar disorder. But some jails might count PTSD as a mental illness and others use people who are really underqualified to be diagnosing the disease and so - end up with severe undercounts. But 50 percent is a good estimate.

DAVIES: You spent a lot of time in the Los Angeles County Jail and have some really vivid descriptions of what you saw. Prisons aren't easy places for reporters to get into. Talk a little bit about getting access and kind of how it happened there.

ROTH: The Los Angeles County Jail was very welcoming and really let - they let me come in multiple times and spend hours and days observing, following deputies around, talking to deputies. And it was amazing to be able to have that kind of access. But in many cases, I spent months, even years, trying to get in and still, in some places, wasn't allowed in at all. And I think this is part of the problem that so many of us have no understanding. Even though it's our tax dollars that are funding all of this, we have no idea what's going on in these places, even in the general population, let alone what we're doing with people who have mental illness, who are in these sort of jails within the jails.

DAVIES: You spent some time in the high observation unit of these towers, the Los Angeles County Jail, for prisoners who can't safely share a cell with other inmates. What did it look, feel, smell like?

ROTH: So the high observation, or high obs, units are divided in sort of three sections. So they'll have a pod with three sections. And the deputies sit or stand in this big open area that separated from the pods by big walls of glass. I mean, from the outside, it feels almost zoo-like. And I don't mean that, of course, to be insulting to the people who are inside it. But there's this very peculiar sense of watching and being watched. And you go inside. And most of the prisoners are in their cells. And you'll see that some of them are either under the bed or curled up in front of the door often with a T-shirt or a sheet or a towel tied around their heads, which the guards, the corrections officers, attribute to trying to drown out the voices. I suspect that they might also just be trying to drown out the noise because jails are very, very loud places. Their...

DAVIES: When you say the voices, you mean the voices in their heads, so, yeah.

ROTH: Yes, I'm sorry, the voices in their heads. But they're loud. The jails are loud. They're disorienting. There's the slamming of the doors. There are - some of the prisoners are banging on the doors constantly. And so imagine a metal and plexiglass door in a metal frame that's just being pounded on incessantly. There's - people are yelling. Sometimes you walk past the doors of the cells and the person inside is just screaming at you, screaming at - sometimes at people that we can't see. So only they can see. Some of the prisoners are just staring out the window.

DAVIES: And so what you have is a circumstance where all of these prisoners are here and is relatively close to one another, confined to their cells almost all the time. And guards have to be conscious of their safety as well as their own safety. What are some of the indignities that are dictated by the guards or at least a result of the guards' efforts to keep everybody safe?

ROTH: Well, for starters, when you come out of your cell for out-of-cell time on the high obs unit, people are handcuffed. And then when you're taken to this center area for out-of-cell time, you're seated at this table. And your non-dominant hand is then handcuffed to your chair. So you can't really walk around or you can walk around but as much as, like, a dog on a chain in a yard. Often, they're not allowed to wear their own clothes. The prisoners who are on suicide watch are made to wear what are sometimes called turtle suits. They're like smocks made out of this very heavy material that can't be torn into a noose or a weapon. And so they're basically wearing it and it's like wearing a heavy hospital gown all the time.

And the people who aren't on suicide watch are made to wear jail scrubs, and their jail scrub's in a particular color that identifies them as a prisoner with mental illness. And then you're living your life in full view of all the officers, of all the visitors, of all the doctors, the clinicians, anybody who comes through. So all the doors have plexiglass on them. Your bed is right there. The toilet is right there. The shower has glass walls. It has a frosted glass to block, you know, to give you this modicum of privacy. But basically, you're living in full view. And everything is observed. And this is true generally. This is true in jails and prisons, generally, that you're sort of living this very public life. There's really very little privacy. But there's the added indignity when you have a mental illness and you get to see the psychiatrist or the social worker, you're brought out into this main area. It's the area where the deputies, you know, work on the computer. They talk on the phone. They drink their coffee. They hang out when they're not dealing directly with the prisoners. And so all of this is done in this big room where your fellow prisoners are lined up on a bench waiting for their turn to be seen by the doctor.

DAVIES: And how long do those doctor's visits typically take, which we will note don't have the privacy one would normally associate with a mental health consultation?

ROTH: They're quick. The ones I observed were - I don't know - five or 10 minutes at the most. And there's really no therapy involved, at least in Los Angeles County. It's what's called medication management for the most part, so you sit down, you talk to the doctor, he or she establishes what is that you need, looks at your records, prescribes medication. If it's a follow-up visit, you know, how are you doing with the side effects? That kind of thing. But there's not a lot of time or space to have, you know, long, deep discussions about how you might have gotten to this point or how to get you out of the situation you're in.

DAVIES: So no one-on-one therapy?

ROTH: Not in Los Angeles County, no.

DAVIES: You say that there's a particular problem, a not uncommon one, of prisoners who've smeared feces around their cells. Did you observe this?

ROTH: I did. There was one day I was in Los Angeles County Jail and the officers were going around to get people out of their cells for out-of-cell time. And, you know, the prisoners are supposed to have a certain number of hours each day and each week out of their cells. But the problem is a lot of them don't want to come out. And so the officers go around and knock on the doors and try and convince people to come out, so we went up to this one cell. And the officers are knocking on the door. And the man was just not responsive. And you could smell it before you even got to the door.

When the man didn't respond, I peeked in. And he was wrapped in one of these suicide-proof blankets on the lower bunk. You really couldn't even see his face. It was like he was in a cocoon. And they open - there's a slot in the cell door, like an oversized mail slot that they put trays through, where they put medications through. And so the officers opened the slot. And it was just this overpowering stench. And when I looked in, you could see that the feces had been smeared all over the walls. And it was this very - it was disturbing because it was so deliberate. But this is really common in jails and prisons. So when you talk to psychiatrists or psychologists in the outside world, it's not something they see very often. But in jails and prisons, it's really, really common.

DAVIES: Right. And clinically, is there an explanation for this?

ROTH: Desperation, severe sickness. It's something that people have control over in a life where they otherwise have very little control.

GROSS: We're listening to the interview FRESH AIR's Dave Davies recorded with Alisa Roth, author of the new book "Insane: America's Criminal Treatment Of Mental Illness." We'll hear more of their interview after a break. And Maureen Corrigan will review the new novel "My Year Of Rest And Relaxation." I'm Terry Gross. And this is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to the interview FRESH AIR's Dave Davies recorded with journalist Alisa Roth. Her new book, "Insane: America's Criminal Treatment Of Mental Illness," is about how jails and prisons have become warehouses for the mentally ill, where they often receive inadequate care and their mental health further deteriorates. Roth visited jails in New York, Chicago, Los Angeles, Atlanta and rural Oklahoma talking with correctional officers, mental health professionals, inmates and their families. When we left off, Roth was talking about how some mentally ill prisoners smear feces all over their cells.

DAVIES: So we have this circumstance in this prison and others where correctional officers are confronted with, at times, threats to their own safety, the indignity of having, you know, bodily fluids thrown at them. And they see what these inmates are going through. They see that when they have to talk to a doctor, it's chained to a metal bench with no privacy. You talked to a lot of correctional officers about this in Los Angeles and elsewhere. How do they regard the system? How do they regard their jobs?

ROTH: Most of them will talk about how this is not what they signed up for, how they thought that they were going in to be a law enforcement officer of some kind. And in fact, they've ended up on the front lines of mental health care. And while this is starting to change, most of them have not had much training in dealing with mental illness or they've had none at all. So they're walking into a situation where people are acting often erratically, sometimes in a threatening fashion. And they the - they, the officers, don't necessarily know why that's happening. They don't necessarily know how to respond to it. And in many cases, the training that they have received goes completely counter to what they should be doing.

So a corrections officer, like other law enforcement, the training really suggests that you should take control, you should maintain control. And when you feel like a situation or a person is getting out of control, the response is to escalate. So stand up. I told you to stand up. Stand up right now. And it continues in that vein until the person complies or you have to use a use of - you know, use force to make them comply. For a person with mental illness, particularly one who is paranoid, this is absolutely terrifying. I mean, it's terrifying for anybody. It's intended to be frightening. But for a person with mental illness, it's incomprehensibly terrifying. And so the result is often that the person with mental illness responds in exactly the opposite fashion, so by lashing out or fighting back. And this leads to this cycle of escalation where really what you want to be having is de-escalation.

DAVIES: You know, when you have mentally ill people who are kept in jail, it's obviously difficult. Most prisons have a hospital, a place that's considered to be specifically designated for treatment of the incarcerated, right? And I guess guards sometimes have to help in making decisions about who goes to those places. Tell us about that.

ROTH: In many, many places, the corrections officers are really seen and used as the eyes and ears of the clinicians. And so the psychiatrists or the psychologists will come to the officers and say, who are your sickest people? Who needs to be sent out to the state hospital for treatment? Or who needs to go to our inpatient clinic inside the jail or prison? And it puts the corrections officers in an odd position, both because they're forced to kind of play this dual role of caretaker and enforcer but more complicated than that is the fact that they really don't have the training, so they haven't been given in most cases training to, say, identify schizophrenia versus depression. And they - because of privacy rules, of HIPAA rules, they don't have access in most cases to the prisoners' medical records. So they're responsible for caring for somebody, but they don't necessarily know what they're supposed to be looking for or what to do if they see a particular behavior.

DAVIES: So there's never enough treatment beds - right? - in prison, out of prison, and for the limited beds that are available in a correctional institution, guards have a role in deciding who gets to go there. What are conditions like in these prison hospitals, if you will? Are they better?

ROTH: In some cases, they are. In Los Angeles County, they are. It's a separate unit that's a licensed behavioral health care facility. The cells - it's just - it's a little bit quieter. It feels a little bit more like a hospital, even though the people are locked in cells. In Los Angeles, in particular, it's odd because - because of the licensing and so on, they're more likely to treat people over objection. In other words, if the prisoner doesn't want to get medication, the hospital part of the jail is more likely to force them to take it with a judge's order and so on. And so the people often seem healthier and saner than the people you see on high obs. But yeah, it feels a little bit more like a clinic. The food is often said to be better. The restrictions are a little bit looser, but it's still in a jail, and it still feels like a jail. And there are a lot of people who say that you cannot do good psychiatric care in a jail or prison.

DAVIES: Do prisoners fake a mental illness in order to get to the hospital? Or do correctional officers believe that they're faking and psychiatrists, mental health professionals?

ROTH: The - certainly, some people do fake mental illness and are apparently more likely to do so in a jail or prison setting. There's just more to be gained by, say, getting out of the general population. They'll say - you know, you hear stories about either a prisoner who's scared to live on the general - in general population for some reason and so he'll fake mental illness because he sees the mental health unit as a safer, more contained place. You hear terrible stories of people who allegedly fake mental illness to go and take advantage of the people with mental illness.

We all have this idea that people with mental illness are dangerous. In fact, they're much more likely to be victims of violence or extortion, things like that. Certainly, the corrections officers often suspect that people are faking, and the clinicians do as well. And it's a real problem because often somebody is said to be malingering when in fact they're - they have a severe mental illness. And I think it creates this bizarre sense of distrust between the clinicians and the prisoners because there's this sense that you have to be kind of watching out not to have a fast one pulled on you.

DAVIES: Right. I mean, the whole basis of therapy is - right? - candor and honesty. And if the clinician is suspicious of a motive, it kind of undermines the whole process.

ROTH: Absolutely. Although I think even more detrimental to the therapy in jails and prisons is the lack of intimacy, the lack of, you know, intimacy in the sense of a private space to talk, the lack of consistency. So people often talk about, you know, yes, I see the psychiatrist, but I never see the same psychiatrist twice. Sometimes the, quote, unquote, "therapy" is done through a cell door, so these are thick, metal doors that you yell through or you talk through the food slot or these little tiny holes in the door.

DAVIES: The therapy is done with a therapist standing outside this heavy metal door yelling through a slot.

ROTH: Correct - with cells on either side, so it's not just that you're yelling through a metal door, but you're yelling through a metal door so that the entire tier can hear everything that you're saying.

DAVIES: Yeah, it's not exactly right.

ROTH: No, especially in a place where showing any weakness can be really dangerous or perceived as dangerous, so people are particularly unlikely to disclose anything personal or that would make them vulnerable.

DAVIES: We're speaking with Alisa Roth. Her book is called "Insane: America's Criminal Treatment Of Mental Illness." We'll talk some more after a short break. This is FRESH AIR.

(SOUNDBITE OF JERRY GRANELLI'S "NEVER GONNA BREAK MY FAITH")

DAVIES: This is FRESH AIR, and we're speaking with journalist Alisa Roth. She has a new book about the concentration of the mentally ill in our prisons and jails. It's called "Insane: America's Criminal Treatment Of Mental Illness."

You know, we used to have these huge state hospitals, which often had terrible conditions. There were exposes, and then there was a movement, I guess - what? - starting in the '50s, '60s, '70s to close those facilities and move people into treatment in community settings. Often, there wasn't enough treatment, still isn't. To what extent did that trend account for the high number of people incarcerated who are mentally ill?

ROTH: Not nearly as much as we would like to think. The story of the failed institutions and the closing down of these institutions is - I think of it as sort of a neat story. We can say that the asylums didn't work, so we shut them down; we released the people; they had no place to go, nowhere to get treatment, and their mental illness led them to commit all these crimes that then got them arrested, and here we are with our new asylums in the jails and prisons. And I think it's a neat story because we have the cause and we have the effect, and it has a very tidy policy solution because it implies that if we just gave people the mental health treatment that they needed, that they wouldn't end up in jail and prison. And I absolutely advocate for more mental health care, but I think it's more complicated than that.

So if we look at the population of the institutions at the height of institutionalization, which was back in, like, 1950, 1955, the people were largely white. They were largely female, largely elderly and had - were overwhelmingly diagnosed with schizophrenia. When we look at the population of our jails and prisons today, as we all know, it's largely male, largely young, largely not white. And when we look at the diagnoses, you see a much broader range - so in higher concentrations than you would see in the outside world, but you see bipolar disorder and schizophrenia and depression and all these other things. And the other thing is, I think there's this notion that at the height of institutionalization, everybody with mental illness lived in an asylum, and that wasn't the case. Even at that time, most people lived in the community. Most people were treated in the community, and then there was this percentage of people who lived in institutions.

So I think the estimates are in the single digits. Like, maybe a rise of, like, 4-7 percent in the incarceration rate can be attributed to the deinstitutionalization. You know, we have numbers that make this story look very plausible. So you can watch - if you graph, the population of the asylums starts dropping in the '50s and goes down to almost - effectively almost zero today. And the rise in the jail and prison population starts going up in the '70s with the beginning of the war on drugs, and it keeps rising. And so it looks on paper like there was just this exchange of populations. But really, I argue that this is part of the story of mass incarceration. So the war on drugs, things like broken-windows policing, the long sentences have really increased the number of people with mental illness in the criminal justice system along with everybody else.

DAVIES: There's always a shortage of treatment. And it's - well, it's fascinating to read that in the hospitals that are in correctional settings, that a lot of the spaces and beds are taken up with people who the courts have ordered there so that they can determine whether they will be competent to stand trial. It's not treatment. It's for the adjudicative purpose of determining whether they're competent. This is a weird sort of perverse effect of the system. Tell us about it.

ROTH: It's a very bizarre kind of circle of events. So we have, for hundreds of years - long before we were a country, long before we had a legal system, there was this sense even back in English law that you shouldn't be put before a judge, you shouldn't have to stand trial if you didn't know what was going on, if you were too insane to understand why you were there - what we sort of generally refer to as competent to stand trial.

And so if a person comes into court and the judge or the person's attorney or whoever it is thinks this person is not sane enough to stand trial, he will ask for an exam, and the person will be sent out, usually, to be examined to determine whether he or she is in fact competent to stand trial, if he's able to understand all these things and if he's able to help his attorney to provide proper defense. But because there are such limited beds in the state hospitals, that defendant often sits in jail for a very, very long time - so weeks or months waiting, not for the trial to proceed, but just for a spot so they can see whether they're able to stand trial.

One of the many sort of ironies of this is, first of all, as you said, people are being treated to get them to a point of sanity to go on trial or to take a plea. They're not being made sane for the sake of getting well. But the other piece of it is that often, somebody will go through the whole thing; they're restored to competency, and then they're sent back to jail to sit and wait for the trial to proceed or for the case to proceed because so few cases go to trial. But the justice system moves so slowly in many places that this person will sit in jail for weeks or months and - not getting enough treatment - will then deteriorate again. And the process has to start all over again. But I talked to an attorney in Oklahoma. Somebody had said, well, he had this client who waited so long for treatment - for restoration...

DAVIES: Restoration of competency.

ROTH: ...Restoration of competency that he actually finished out what would've been the maximum sentence on the crime. And so he was released, and I called this lawyer. And I said, I heard you had this case, da-da-da (ph). And the lawyer said, I don't know which one you're talking about. I have so many cases that fit into that - those circumstances that I don't actually know which one you're talking about.

DAVIES: Wow. You know, it's clear from reading the book that you've spent a lot of time in a lot of correctional institutions and talked to a lot of inmates and guards and former inmates and families of people who have taken their own lives. And there are quite a few of those. And I know one thing that makes somebody a good reporter is their ability to empathize - to kind of put themself in the position of people they are writing about. And I know you must have done this with these correctional officers and inmates and mentally ill folks. And I'm wondering what kind of toll it takes on you. Do you dream about it?

ROTH: I did for a long time. I had nightmares about being in jail and prison. I stopped watching TV shows about jail and prison. Everybody's like you have to watch "Orange Is The New Black," and I watched it for a while. And I was like, I can't do this anymore. I still have a hard time reading about it. I just read "The Mars Room" by Rachel Kushner, which is a phenomenal book about a women's prison. And it took me a very long time to read it 'cause I could only read it in small doses.

DAVIES: Are you still reporting on this?

ROTH: I can't stop. There are so many stories that haven't been told. And every time I think I've heard all of them, somebody writes me or calls me and says, you know, here's the story of my son who died in this jail or who spent - you know, who got arrested - who called the police on himself after he broke into a pizza place and is now in jail. And there's just so much - I feel like there's so much going on inside these correctional systems - plural - that most of us don't know about and don't see that I think really needs to be brought to light in order to change it.

DAVIES: Alisa Roth, thanks so much for speaking with us.

ROTH: Thank you so much for having me.

GROSS: Alisa Roth is the author of "Insane: America's Criminal Treatment Of Mental Illness." She spoke with FRESH AIR's Dave Davies, who is also WHYY's senior reporter. After we take a short break, Maureen Corrigan will review a new novel about trying to sleep away existential angst. This is FRESH AIR.

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