‘Insane’: How The Prison System Uniquely Harms Those With Mental Illness

Alisa Roth, journalist and longtime reporter at Marketplace, turns her lens to the treatment of mental illness in the criminal justice system in her first book, “Insane: America’s Criminal Treatment Of Mental Illness.” Roth applies her years of experience dealing with tough subject matter — she’s investigated across a slew of beats from the Syrian refugee crisis to the treatment of PTSD in veterans — and gives insight into the media-shy world of American prisons — and the mental health crises within — in her first book, released this past April.

Roth’s book has come out at a crucial point, as interest in prison reform and justice surges nationwide.

And for good reason, as Roth explains in her debut book: We’re jailing more people than ever before, and up to half of our enormous prison population may have mental illness.

Those are staggering numbers — and people with mental health issues are more likely to be arrested, less likely to make bail, more likely to get a longer sentence, more likely to end up in solitary, and less likely to make parole.

“It’s hard to convince courts to find solitary confinement is unconstitutional,” says Roth, saying that “on a practical level,” jails and prisons don’t have many other “tools” of discipline. Solitary confinement, known to cause mental illness symptoms in otherwise healthy people, only exacerbates existing mental illness — and its rampant use is examined in “Insane.”

The criminal justice system, one could say, is thus set up to entrap those with mental illness in a vicious circle of punishment and deprivation: if discipline, and not rehabilitation and treatment, is the goal, then it seems unlikely those with mental illness can improve their lives in anyway once entering the system.

And enter the system, they probably will. The largest providers of psychiatric care in the United States are not hospitals, but jails.

“Insane” give us an inside look at a system that seems opaque and impossible to understand from the outside. Roth’s access becomes our access. Her extensive reporting covers the system — and goes deep, with intensive interviews — across the country, including New York’s Rikers Island, Cook County Jail in Chicago, the Alabama Department of Corrections, and community mental health care providers in Oklahoma.

The book started when Roth realized, through her reporting, that there was a large group of people “nobody was really talking about” — perhaps because of the stigma that garners them little public attention or support. But Roth thinks there can be no talk of reform without addressing mental health issues in the United States.

In this interview exclusive with Oxygen.com, Alisa Roth talks about how this national crisis came to be. Scroll to the end to read an excerpt.

OXYGEN: How did you get interested in the plight of the mental health in the criminal justice system?

ALISA ROTH: As you say, I was doing a lot of reporting on the criminal justice system, and I realized that although we talk a lot about race in the criminal justice system and we’re starting to talk more about the role of poverty, there was little sustained discussion about mental illness. As I started reporting on the issue all over the country, I found I was seeing the same problems involving people with mental illness repeatedly — whether with police or in jails or court — and I realized this is very much a national crisis, with similar causes, playing out at a very local level.

How long did this book take to research? For you to track down and gain the trust of the many people who shape its narrative around?

AR: I was fortunate to spend a year as a Soros Justice Fellow, doing some of the initial reporting on it, and then it was about another two years from getting the book contract to turning in the final manuscript. That’s pretty fast in the book publishing universe, but it felt long from a daily news perspective.

Gaining the trust of sources was one of the big challenges. In some cases, it was just about being present and proving myself — with one character (the man I call Kyle Muhammad), I showed up for every single court hearing and went with his mother every time she visited him in jail. By the time he got out of jail, he and his lawyer and his social worker and the rest were all used to having me around.

But it wasn’t just the people with mental illness — I had to convince wardens, for example, that I really wanted to tell the fullest, fairest story possible, and that to do that, I really needed access to their jails.

What was a challenge in writing this book the casual reader may not expect?

AR: I was dealing with two of the most closed, media-shy systems that exist: mental health care and criminal justice, so getting access to information and sources was extremely difficult.

And while we talk about the criminal justice system as a cohesive entity, it’s not at all, it’s really a patchwork of tens of thousands local jurisdictions and agencies so sometimes even figuring out where to ask for information was difficult.

Can you point out some news or statistics that may have prompted your interest — or informed how/why you wrote what you did?

AR: The numbers around the criminal justice system generally are staggering — more than two million people incarcerated in this country. And when you look at data on the number of incarcerated people with mental illness, it’s also shocking — by some counts, as many as half of the people in jail or prison today have a mental illness. When you talk about women, the numbers are even higher.

How do race and gender intersect with mental health and its criminalization in our system?

AR: African-Americans and Hispanics are terribly over-represented in the criminal justice system. At the same time, lower-income communities of color are less likely to have access to mental health care.

Women are the fastest growing population of prisoners, and a far larger percentage of women in jails and prisons have a mental illness. In some cases, the mental illness and the incarceration are part of a broader cycle: I met women in Oklahoma, for example, who had been incarcerated on drug charges, stemming from substance use that was part of an effort to self-medicate a mental illness. And once they were incarcerated, they were separated from their children, which further added to the trauma.

When did prisons start to become the new asylums? Is the underlying problem that the modern world hasn’t reconciled how it will treat and care for people with mental illness?

AR: We have this notion that closing down the state hospitals in the 1960s and 1970s sent all the people in them into the criminal justice system.

In fact, even at the peak of the state asylum system, there were still many people with mental illness living in the community and getting outpatient treatment, rather than being put in institutions. And when we look at the demographics of the old institutions and of jails and prisons today, we find that they are very different.

The woeful inadequacy of mental health care in the community is certainly part of the problem. But this crisis is also part of the story of mass incarceration: we are locking up enormous numbers of people, often for relatively low-level crimes—and in doing so, we are also arresting large numbers of people with mental illness.

Many people with mental illness also have a substance use disorder, so the War on Drugs — which resulted in the arrest of many many people for things like drug use, drug possession, selling drugs, etc. — also caught a lot of people with mental illness.

Who do you envision your audience to be?

AR: Criminal justice reform has been called an urgent policy priority by members of both parties. I hope to draw the attention of those involved in the national conversation about criminal justice reform to this all too ignored epidemic of mental illness in our jails and prisons.

But I also hope to reach anybody who cares about the criminal justice system or about mental illness, or really about justice in this country.

The following is an excerpt adapted from Insane: America’s Criminal Treatment of Mental Illness by Alisa Roth. Copyright © 2018 by Alisa Roth. Available from Basic Books, an imprint of Perseus Books, a division of PBG Publishing, LLC, a subsidiary of Hachette Book Group, Inc:

Kyle Muhammad’s life has been marked almost equally by the criminal justice system and the mental health care system. Diagnosed years ago with schizophrenia, he has struggled for decades to build a stable life for himself. By my best count, the police have picked up Muhammad at least eighteen times in the thirty- five years or so since he was first diagnosed. Mathematically, that’s an average of about once every other year. In reality, the arrests ebb and flow with the state of his disease, so there are good years, when he isn’t arrested at all, and there are not‑so‑good years, when he is picked up three times or more.

On at least two of these occasions, Muhammad was so obviously sick that when the police found him, they took him straight to the hospital. More often, however, he was arrested and booked for low- level misdemeanors: there were a couple of petit larceny charges and a couple of quality-of-life crimes, like jumping the turnstile and criminal trespass, a charge that can be leveled simply for lingering in the hallway of an apartment building or in front of a store when a cop thinks you shouldn’t be.

There were also more serious crimes. He mugged somebody in New Jersey in the mid- 1990s, for which he was given six months of probation and ordered to get a mental health evaluation and counseling.

Then there was the bank robbery. He was thirty-seven. It happened when he was working as a school- bus driver and living with a roommate. At the time, he had been managing his illness relatively well; he was on medication, and it had been five years since the last time he’d ended up in the hospital or been arrested. Then sometime around July 2000, he quit taking his medication. Six months later, he started decompensating. Then late one morning in early March 2001, he walked into a branch of the Fleet Bank in Queens. He handed the teller a note demanding money. He was unarmed but indicated that he had a gun. She gave him the money he had asked for, and as soon as he turned to leave, she called the police.

He was too out of it to notice, but he and the teller knew each other. Until two weeks earlier, Muhammad had driven the school bus that her child rode to school every day. Muhammad didn’t get very far after the robbery. He was standing on the sidewalk out in front of the bank when the police showed up.

After he was arrested, the judge ordered him to undergo a 730 exam—what competency exams are called in New York, after article 730 of New York’s Criminal Procedure Law. Muhammad was given medication and found fit to stand trial. He took a plea bargain for two and a half to five years in prison and was sent upstate to Sing Sing. There he was housed in the Residential Crisis Treatment Program, a twenty- two- bed unit for prisoners who are believed to be a danger to themselves or others or who otherwise appear to need serious psychiatric help. For several months before he was released, he lived on another special unit for prisoners with mental illness, one designed to help with reentry into society. In all, he was locked up for about two years. Through all of it, he was ostensibly being treated for his disease.

Nonetheless, when he got out, doctors felt that he was sick enough to be discharged directly into a state-run psychiatric facility on Staten Island where he had been frequently before his arrest; it was the seventh time he had been admitted there in eight years.

[Photo: Book cover c/o Basic Books. Headshot of Alisa Roth, by Matthew Septimus]