How the Mental Health Industry Fails the Mentally Ill

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Rikers Island

Rikers jail complex, New York City. Photo by Formulanone via Flickr

Most experts acknowledge that the seriously mentally ill are a formidable challenge to the resources of the justice system. DJ Jaffe, executive director of MentalIllness Policy Org, a nonpartisan think tank, argues that mental health authorities’ failure to address the issue has placed the burden unfairly on police and the courts.

In Insane Consequences: How the Mental Health Industry Fails the Mentally Ill, Jaffe says that it’s long past time for the nation to make this a priority. In a conversation with TCR’s Isidoro Rodriguez, Jaffe explains why he wrote the book, how the mental health “industry” has helped to distort public opinion about mental illness, and why he thinks Republicans are “better” on the issue than Democrats.

The Crime Report: What was your motivation for writing this book?

DJ Jaffe: About 20-30 years ago I became guardian to my wife’s sister-in-law, who had schizophrenia. We didn’t know she had schizophrenia. She was an adorable teenage girl living in Wisconsin with her old-world mom and they were getting into fights. We thought it was just a culture clash between an American teen and an old-world mom and that we would bring her to live with us and everything would be fine.

We would listen to her saying that people were planting transmitters in her head or the buildings in New York were going to fall on her. We’d hear her screaming in her room at the voice only she could hear. Eventually we called the police [who] took her to a hospital. Back then, the hospital would take people who were seriously mentally ill; so she got in and was stabilized after maybe a month. But she would come out and it would keep happening, and we didn’t know what was wrong with her because they wouldn’t tell us. Eventually, in passing, a nurse told us she was schizophrenic. So, we looked it up. We were shocked by our ignorance. I started volunteering for a local group dealing with the issue, and started raising money for them. [The experience] made me realize how messed up the system was.

TCR: In your book, you discuss ways in which the mental health industry has skewed public opinion about the seriously mentally ill in this country. What part do the media play in this?

 DJ: The media repeat all of the myths: The mentally ill are no more violent than others, everyone recovers, prevention works. The media, for instance, will continually emphasize the success of “peer support.” One person with a mental illness talking to another person with mental illness. There’s no data showing this has led to improvement by any meaningful metric, but this story is everywhere. It’s very tough for the media, I think, because they’re relying on so-called experts.

What the media should do is talk more often with police and criminal justice about these issues. Ten times as many people with mental illness are incarcerated as are hospitalized. The police have much more experience. The police and sheriffs can’t do what the mental health system does, which is when they get a call, say that the person is too ill, or has “high needs”—we can’t do anything for them. The police and sheriffs don’t have that option: they have to go in. They are much more realistic and want to help because it puts their lives in danger as well ….when the seriously mentally ill go untreated. All the progress that’s come out has been the result of the criminal justice system speaking up after tragedies: Kendra’s Law in New York, Laura’s Law in California, the reform of the Baker Act in Florida.

TCR: What can police do to get this sense of urgency and understanding out to the public?

DJ: This is where I’m trying to focus my efforts. The criminal justice system has not gotten involved at the political level in changing things. When there’s an incident where an officer shoots someone, the answer is always, “we’re going to train police better.” But the answer really is we have to get the mental health system to not turn these people over to police. That should be the answer.

And the danger goes the other way. A large amount of line-of-duty deaths are on mental illness- related calls. So, what they really need to do is get involved politically. Sheriffs around the country are outraged because they’re running the largest mental hospitals. The largest mental hospitals are [today] the Rikers Island [jail complex] in New York, the Los Angeles County Jail, and Cook County Jail. My effort is to get police and sheriffs involved in political change. Now, whenever there is a high-profile instance of violence, the reaction is to form a joint task force of police and mental health people. The police assume the mental health people know more, so when they start proposing solutions, the criminal justice system doesn’t know enough to say those will hurt.

DJ Jaffe

For instance, if you ask any officer, any sheriff, what we have to do to solve the mental health problem, they are going to instantly say, we need more hospitals because we can’t get people in, we need them to hold people longer so they’re really stabilized, we need easier civil commitment processes, and we need to be able to keep people on medication when they’re outside the hospital. Brilliant solutions. [But] if you ask a person in the mental health industry the same thing they will say we have to reduce stigma, we have to do more public education, and we have to train police better. All these things are totally irrelevant to solving the problem.

TCR: In your book you do write that stigma is one of the hurdles to solving this problem.

DJ: I don’t believe there is stigma to being mentally ill. It’s a no-fault biologically based illness, so there’s no stigma to having it and we should stop teaching that. But the system has diverted attention away from the sickest individuals, the small minority who commit violence. In public service announcements you won’t see homeless and psychotic people eating out of dumpsters. They won’t admit that some people need hospitals or some people don’t recover. The whole stigma movement is premised on diverting attention from those [individuals] the police and sheriffs are called to intervene with.

That takes attention away from the solutions. The mental health industry’s response to high-profile acts of violence is to tell the media: “That’s stigmatizing, don’t report on that, the mentally ill are no more violent than others.” What I say, is that our response should be to propose solutions to that very real violence that did occur and hope the media reports on it.

TCR: Why is there, seemingly, so much resistance to serious and practical reform?

DJ: You’d have to ask the people who are doing it. I’m not being coy. We all want to feel that we’re helping, so we often default to easier things. There are also financial incentives to do the easier job. Taking care of people with serious mental illness is exceedingly difficult and time-consuming, and people aren’t paid enough to do it. But, why, for instance, are they saying that we should put more money into prevention when there is no way to prevent it? My mind boggles. We don’t even deal with seriously mentally ill adults.

There are worthy social services today that focus on the issues of “trauma” or “at-risk” individuals. Trauma is not a mental illness, everyone loses a loved one, or experiences [personal stress] like losing a job. That’s not mental illness. We’re wrapping all these social services in the mental health narrative and diverting funds that should go to help the seriously mentally ill.

TCR: In your book, you note the success of mental health courts. Is that a sign of progress?

 DJ: Mental health courts are, again, an example of turning this problem over to the criminal justice system. As long as the mental health system isn’t doing its job, mental health courts are needed. The fascinating thing about them is what they do. If a prosecutor or district attorney believes a person who has been charged with a low-level crime has a mental illness, they may divert him or her to a mental health court. The mental health court will say, if you accept treatment for X amount of time, we will drop your charges and the person comes back every week to see if he’s still complying. Basically, you have somebody who has committed a crime—often because the mental health system didn’t treat them—deferred to a court, which then tells the mental health system to treat them. It’s a long, unnecessary round trip. The mental health system should just treat them.

Now, there is no single solution. But something I strongly support is assisted outpatient treatment. Basically, it’s the same thing as a mental health court, except it happens before the crime is committed, after the person already has a history of multiple instances of homelessness, arrest, incarceration, or hospitalization due to being off medication. If the person has that history, then the court, with all due-process protections, can order the person to six months of mandated and monitored treatment while he or she continues to live in the community. It doesn’t involve criminal justice, it doesn’t involve locking someone up or in-patient commitment, it’s less expensive, less restrictive, more humane. We should make more use of that.

TCR: However, according to your book, one of the main groups resisting solutions like assisted outpatient treatment and mental health courts are civil rights activists, who claim that such methods encroach on people’s rights. 

DJ: I just don’t understand the opposition. It’s an anti-science, anti-common sense, anti-public and anti-patient position. Being psychotic is not a civil right to be protected; it’s an illness to be treated. They fail to understand that. People with mental illness lack the maturity of their faculties. They have an inability to exercise free will. We shouldn’t protect the civil rights of a person who thinks the devil planted a transmitter in his head and he has to shoot first or the devil will get him. We should be helping such people regain their ability to exercise free will.

TCR: In addition to being anti-patient, you point out that many today are also anti-medication. 

DJ: In general, both the civil libertarians and the anti-psychiatry movement fail to differentiate between serious mental illness and people who need their mental wellness improved or have minor issues. So, a lot of what they say is true about those with minor mental health issues, but it’s not true about the seriously mentally ill. There are people with minor mental health issues who can get by without medications, but most of the seriously mentally ill, mainly those who are bipolar or suffering from schizophrenia, need medications in order to access other support.

While [they are] psychotic, no programs will accept them. However, it is true that medications have side effects, and those side effects can be devastating. No one’s denying that, and we need more research on it, but as a kind and compassionate society we have to help those who need help the most. What these groups are focused on are those who need help the least, and they are using them as the poster children for what we should be doing. There is clear evidence, mainly from deinstitutionalization, that medications help people. They got them out of the hospitals.

TCR: Most mental health facilities exist in prisons, and most incarcerated individuals who are mentally ill wind up worse when they come back out—and end up incarcerated again. How can we stop this revolving door?

 DJ: One positive solution is community monitoring of people coming out of jails. One of the proposals that I make in the book is that there should be mandatory evaluation. We’re spending millions on outreach. We’re going to grammar schools and giving speeches and training people to identify the asymptomatic, but we know who the most seriously mentally ill are and who we should help: the ones who are most prone to homelessness, arrest, incarceration, or violence. There should be mandatory evaluation of everyone coming out of prisons or jails who used mental health services or needed [those] services while they were there, to see what they need to stay safe in the community. But we’re just releasing them and saying “time served.”

TCR: In one chapter, you advocate changing the Health Insurance Portability and Accountability Act (HIPAA).  Why?

 DJ: HIPAA is a patient confidentiality law and, depending on the state, once your child turns a certain age he or she is entitled to confidentiality. This means the parents can’t know what’s happening. How this plays out, frequently, is parents provide housing for a mentally ill kid or have placed him in a program that’s providing housing—and the kid goes missing. If the parent calls the program, the program can’t tell them the kid is missing. If they’re missing from their own house, and the parents call the hospitals, the hospital won’t tell them if they’re there.

This just happened recently to the former president of the New York State [organization of] chiefs of police who has a mentally ill kid who went missing from the program. Even though he’s a police chief, he still could not find out if his daughter was in a hospital when he called around. When your relative gets out, you’re not allowed know the diagnoses, what medications they’re on, what outpatient program they’re supposed to go to. [That means] parents can’t arrange transportation, can’t see that prescriptions are filled, or that appointments are kept.

The typical media story is “why didn’t the parents do anything?” People don’t realize that we have all the responsibility but none of the authority. If you’re providing housing, case management, and transportation services out of love, you should be able to get the same info that those that provide those services for money get. If I were an insurance company providing medications, I would be able to get that info.

TCR: One of the most surprising details of your book is that you strongly believe that this new administration will make positive steps towards change. Why?

 DJ: On this issue, Republicans are a lot better. Democrats are willing to throw money at mental health, but aren’t willing to admit the politically incorrect things that are necessary to admit to help the seriously ill. Democrats won’t admit that some mentally ill are more violent than others, that not everyone recovers, that they are more violent than others, that some need hospitals, that involuntary commitment can be a good thing.

Republicans see this as a quality- of-life thing. They see homeless people eating out of dumpsters, they see jails fill up, and want to know why we’re not helping those people. The legislation aimed at helping the seriously mentally ill is mainly coming from republicans. I hate to admit it, I’m a Democrat, but we’ve been basically useless. We throw $100 million at children’s issues, and serious mental illness, schizophrenia and bipolar disorder, are mainly adult illnesses.

Suicide is a huge one. It’s exceedingly rare. We’re throwing a lot of resources at it that haven’t reduced suicide in any way, shape, or form, and we’re throwing them at kids who are the least likely to commit suicide. It’s primarily an adult illness. But kids are a sympathetic population and so they get greater resources. And that sympathetic population plays an important part in who gets served by government.

Isidoro Rodriguez is a contributing writer to The Crime Report. Readers’ comments are welcome.

9 thoughts on “How the Mental Health Industry Fails the Mentally Ill

  1. —-How the Mental Health Industry Fails the Mentally Ill
    More to the point:
    —-How the Health Industry Fails the Mentally Ill
    It is the separation of the health industry into two segregated and highly unequal segments that is at the root of the failures.

    re: stigma

    “Stigma”, in its proper guise, is prejudice. “Acting upon a stigma”, in its proper guise, is discrimination. Without proper address, no problem can be solved. When people stop promulgating “stigma” and start addressing prejudice and discrimination we will know change has taken place.

    Harold A. Maio, retired mental health editor

  2. I agree with most of what DJ Jaffe has to say. However, there are some issues that I want to address where criminal justice is concerned. Advocates need to be very cautious in navigating the complexities of assessing who is to blame for all of these problems and where the solutions lie. Criminalization of severe mental illness (SMI) means unjust conviction and punishment of someone who was not able to conform their behaviors to the law. SMI, i.e. Schizophrenia and other disorders that cause psychosis are not psychological disorders, the most grave and dangerous symptoms are neurological. Most people do not understand this.

    I agree that there are elements within criminal justice, such as wardens and sheriffs who have been the most reasoned and lucid advocates for jail diversion. They get to see SMI up close, and there is nothing like direct exposure to help someone to gain insight into SMI. Exposure, however, is not enough. Most of these advocates and orgs such as Stepping Up Initiative are geared up to combat mass incarceration of the mentally ill via coordinated plans of action to get and keep people in treatment, before they cross over the line and commit crimes. They also call for jail diversion as much as possible. Their activism is geared toward the non-violent offender, which leaves the most seriously ill behind to be punished.

    It is the criminal justice system (principally prosecutors and judges) and legislators who have conducted a war on the insanity defense. The consequences of this war do not land solely on the unjustly punished, it also trains the general public to not be able to understand and identify ‘insanity’ (which is a legal term, which in the case of M’Naghten’s Rule, has been purposefully defined to be dissonant with the medical science of psychosis). This conditioning of the general public by the criminal justice system is to be blamed (in part) for the constant stream of horrific incidents of violence in the community. Psychosis (which should be definitional of insanity) is not being identified and dealt with before tragedy strikes. The mental health industry is riddled with people who do not understand psychosis, so they along with misguided civil libertarians are a huge part of the problem.

    Where Jaffe refers to community monitoring of people released from jail, there is a lack of specificity. What is needed is supported (vs supportive) housing where people have on-site monitoring and support with medication adherence. The same supported housing that they need when exiting jail is what was needed before they were put in jail in the first place. There are people who are too ill to be living at home with families who also belong in this type of residency. This is where we have an ‘Olmstead’ problem. Olmstead has been intentionally misinterpreted. So the problem analysis is much more complex than presented here.

  3. Again, call it stigma or discrimination…this is not why treatment is lacking. Not my problem, not on my dime and pure misunderstanding, for which you can reread D.J. on the poor quality of reporting both by thee “industry” and the press that takes them as neutral experts. I often remind our common groups that the practitioners prefer clean well groomed clients they could imagine greeting at the country club, opera, or golf links. That loud, agitated and smelly guy? “we don’t have time for this one.” If there is discrimination, perhaps the “industry” should examine its own eyes first!

    My hat off to Isodoro for a better journalism. Is there any chance this will be put to a larger public audience? Do you ever seek publishing in national magazines or specials in the newspress? D.J., Sally Satel, AnarchistSoccerMom and others have helped us so much by appearing in several such public venues, after publishing first as internal pages of narrower distribution.

  4. Another failing of the psychiatric system is the frank cover up of damages incurred from the procedure electroshock ( ECT). Physicians for decades have been knowingly inflicting NFL type head injuries with every procedure. No FDA testing of device or procedure for safety or effectiveness. Devices have never had to have pre-market approval. APA in 1990 all voted to withhold brain damage from consent for this procedure. Physicians have A duty to warn and protect. They are literally “practicing medicine” at the expense of a vulnerable population. It is negligent at best, but I feel it is criminal. Recently the DK law firm in CA has filed a class action product liability suit around devices used in electroshock that will extend back to 1982. Please see to join and see blog article with link to filed suit. Yesterday a law firm was secured in Canada for a national class action around same issue. We need media attention brought to this. Standard of care has not been met on several fronts that we will pursue for medical malpractice claims in the future as well. These suits ate based in mechanism of trauma recognized in emergency medicine, neurology, and even psychiatry.

    • Please don’t bash ECT in general. It has saved my life, and I won’t hesitate to seek it again if I feel myself slipping back into the horrible black pit of depression. My mother even had it in 1960, when it was not so gentle, and she preferred it to medication.

      I do agree that it must be regulated. I was lucky that I was able to go to a large university psychiatric hospital where it is administered every day, as compared to a local hospital that administers it only twice a week. I wouldn’t go there. I don’t trust them.

      The unfortunate thing is that so many people who could benefit from ECT don’t have access to well-trained, experienced physicians to administer it. Thanks for watching out for those people.

      But, again, please don’t bash it in general. I would probably be dead if not for ECT.

      • I agree Pam. My father wouldn’t be here today were it not for ECT. Has saved him twice. In fact, he is still having treatments 2x a week right now. 🙂

  5. There is a stigma to mental illness….I am thankful we are finally addressing it. There is a shame and stigma to mental diseases, we all know this, especially when a crime is involved. The stigma is clearly on display when we execute the mentally diseased…although we know they had a compromised freewill many just do not care….that is a real stigma. Let us distinguish between the criminally mentally diseased…and non criminal ones for these are two different groups. I believe the criminally mentally diseased are mainly males and crime is by far a male problem. We are failing males who are mentally diseased, strange because it is mainly males who fail them. The lack of a freewill and testosterone is a bad combination for the mentally diseased population ….. following the rules is almost impossible. however, the prison system will always have to deal with this portion of the mentally diseased, and this is not a money problem as much of a mismanagement problem. Through neglect of the mentally diseased, prisons are inventing crisis’s out of thin air, and these are costly, in law suits and repeated hospitalizations and then they need more staff to put out the fires that they create. First of all the prisons should not be managing mental health staff, they leave them powerless, when the prison gets caught mismanaging they simply ask for more funding and then they mismanage that funding, a mad revolving cycle, where the prisons are actually rewarded for failure. I agree the mental health field is failing for where are they, we don’t really hear from them often, where is there voice? That is because many of them also suffer with mental diseases, if you want to start testing individuals for mental health, start with the mental health industry, and then test the President and congress, I bet we would all be totally shocked at the findings. Because the functioning mentally diseased are everywhere and they do much more damage to a society then the the insane criminals we have behind bars, the mentally diseased that do not hide their disease are safer then the functioning mentally diseased that blend into a society. But these too “the functionally mentally diseased” are still diseased and we should view then sympathetically, for they too did not ask for the disease of psychopathy. Our President needs help, but he is not getting it….makes you wonder!! Other countries are much better advanced in their understanding of mental diseases, we have fallen so far behind.

  6. Mad people don’t “lack the maturity of their faculties”. YOU lack the maturity of your faculties. Few people are hurt by “men who believe they have a transmitter in their heads”. Few of those men carry firearms, few of those who do will ever discharge them, and, when they do, it’s AFTER they’ve been repeatedly victimized. By contrast, you want to treat Mad people WORSE than criminals. LAW-ABIDING PEOPLE are the ones you want subjected to pro-force psychiatry, a pseudoscience, pseudojustice wreck of our Constitution. They’re the people you want to see hunted, chased, chained, kidnapped, caged, and narcoticized, simply because they’ve disobeyed their doctors. NONE of them support pro-force psychiatry, and many of them *become* “easy to care for” *AFTER* they’ve fled it. As a “professional” anti-Mad propagandist, you aren’t “caring” for any Mad people today, and you aren’t trained at any form of health care. From your cushy role, you’ll also never be held accountable for psychiatry, as a politician might. Yet, despite your background, you insist on bashing everyone who is willingly or unwillingly involved with psychiatry. You should have told TCR about pro-force psychiatry’s recent wipeouts in the real-world:

    The “Helping Families in Mental Health Crisis Act”, 1.0 and 2.0, failed.

    Kendra’s Law was not made permanent.

    NAMI’s pro-force ticket bombed its campaign to lead that org.

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