Alisa Roth

We often hear about mental illness in connection with criminal justice when there's a high profile crime and people rush to offer explanations (usually when the defendant is white). But the intersection of the two is much greater, and more tragic.

While people often link the issue of mental illness in correctional institutions to deinstitutionalization, the problem is much more complex and fragmented, as Alisa Roth outlines in her heartbreaking, enraging book. She goes through a variety of settings to show how decisions and policies, often made in isolation, combine to create a horror. Jails are our largest provider of mental health care. In 2017, 43% of inmates at Rikers Island had a mental illness. 1/4 of fatal police shootings involve a person with mental illness. Suicide is the leading cause of death in jails.

Jails are expected to fulfill contradictory functions: to control inmates, and also to treat their illness. They lack the capacity to do the latter, even in better run institutions or where improvements are being made. In some states, like Alabama, it's arguable as to whether they are trying. The desire to control inevitably results in restrictions on inmates that are counterproductive to treatment, even when the officers are actually trained in dealing with mental illness. The desire to punish also means that inmates lose "privileges" such as visits and exercise which are shown to improve treatment outcomes.

The ways in which bureaucracy frustrates itself are also evident. HIPAA means that corrections staff cannot be given medical information, even though they are effectively present for therapy and could use the information to treat inmates better. The 1965 Medicaid law prohibits federal funds from being used for large institutions. This means that when inmates are hospitalized, the state must pay for it themselves--increasing the incentive to keep costs down. States spend, on average, only $105 per capita on mental health, and there is a significant shortage of mental health care. 40% of psychiatrists do not accept insurance (though Roth cautions that since psychiatrists may operate dual practices, this may only reflect their private practice). Since prisons are often in remote locations they struggle to recruit staff, and even better located institutions don't pay competitively.

Politically, mental health is not a high priority, much less for those who have committed crimes. Many of those crimes are not significant, but mentally ill inmates are less likely to get bail. The long process of pretrial detention, waiting for competency hearings, and the slow wheels of the system worsen their illness. One of the more blackly comic episodes involves inmates watching Law & Order so they can pass their competency hearings. When they get out of jail, they don't have good access to mental health care, and so a cycle repeats. Some of the bright spots in the story involve departments that are making an effort to retrain officers and cities that are improving mental health care.

There is so much to this book--even though it's not exceptionally long. Roth visited institutions in various parts of the country and uses inmate stories--some graphic--to show the workings of the system. There are so many problems, and so many intersecting parts, that I didn't even know where to begin to start solving it.… (mehr)

I've read quite a bit on this topic over the years, but still this book shook me.

The most powerful aspect, for me, is that it's so much more than a thoughtful narrative citing facts and data. Alisa Roth takes us with her into the reality of what it's like for someone with a mental illness who gets caught in the criminal justice system. We meet patients and family, as well as cops and corrections officers and psychologists. We see the good, the bad, and perhaps worst of all, the indifference in how the sick are treated.

As the author points out, mental illnesses are diseases of the mind, just as cancer is a disease of the body. We would not ridicule a cancer patient. We would not lock a cancer patient in an isolation cell because he/she is too sick to live within the general population. It's about time we extended the same human courtesy to people with mental illness.

Insane is an exceptionally well researched, well written, profound, and disturbing look at the way we're treating an already marginalized segment of society. I would love for everyone to read this book. Until we start flinging open those closed doors and shining light into the darkness, the abuse will continue. And one day it might be your child or your spouse or your brother - or you - behind those closed doors.… (mehr)