(2016-03-07) Alexander Reverse Voxsplaining Prison And Mental Illness

Scott Alexander: Reverse Voxsplaining: Prison and Mental Illness. German Lopez of Vox writes that “America’s criminal justice system has in many ways become a substitute for the US’ largely gutted mental health system”.

“the number of people with mental illness in prisons/jails outnumber those in state hospitals 10 to 1.”

Lopez seems to be working off a model where there is a population of mentally ill people who can’t make it in normal society, and so will inevitably end up either in a long-term mental hospital or a prison.

Needless to say I disagree with pretty much every part of this assessment.

you might get the impression that less money is being spent on mental health. This is not really true. The share of GDP devoted to mental health is the same as it was in 1971,

there’s been a shift from long-term state-run mental hospitals to community care. It helped create an alternate and less restrictive system of outpatient psychiatry.

There are lots of mentally ill people in prison because there are lots of mentally ill people everywhere. Remember, 20% of the population qualifies as mentally ill in one sense or another.

There are disproportionately many mentally ill people in prison partly because people’s illnesses lead them to commit crimes, but mostly because some of the factors correlated with mental illness are the same factors correlated with criminality. Poverty? Check. Neighborhood effects? Check. Genetic load? Check. Education? Check. IQ? Check. Broken families? Check. Drug abuse? Definitely check.

In my model, the overwhelming majority of mentally ill people can live okay lives outside of any institution, hopefully receiving community care if they want it. If they commit crimes they will go to prison just like anyone else; if not, we should hardly be clamoring to bring back the often-horrifying state-run mental hospitals and lock them up there.

So when we talk about the number of mentally ill people in prison, we should be trying to distinguish between Lopez’s model and mine. That means asking: exactly how mentally ill are we talking about here?

Lopez’s source for the claim that “ten times more mentally ill people are in prisons than hospitals” is a report by the Treatment Advocacy Center – note the less-than-neutral name.

First, “psychotic” is not the same thing as “severely mentally ill”.

Describing a survey that shows 15% of people as admitting one symptom of psychosis as showing 15% of people are severely mentally ill is really sketchy.

The prison survey provides a perfect example. It looks like the prisoners were asked fixed questions about their symptoms

a lot of short mental health screening questions get false positives from perfectly healthy people

also, Scientific American says that about 5-15% of perfectly ordinary people hear voices. Meanwhile, 4-6% of prisoners in the survey admitted to it

But this is the stricter of the two criteria that the survey uses! The other one counts depressed people, bipolar people, and psychotic people. I don’t want to trivialize non-psychotic illnesses like depression

So I don’t think this survey shows the majority of the mentally ill prison population is in need of institutionalization. Yes, ten times more mentally ill people are in prison than in state mental hospitals, but consider the base rates! The prison population is huge. The population of people who need to be committed to mental hospitals 24-7 is tiny.

So when Vox says that ten times more mentally ill people are in prison than in psychiatric hospitals, I will shoot right back at them that ten times more mentally ill people are in the Los Angeles metropolitan area than in state mental hospitals. You want more meaningless statistics?

What about that graph? It’s very suggestive. You see a sudden drop in the number of people in state mental hospitals. Then you see a corresponding sudden rise in the number of people in prison.

Coincidence? Yes. Absolutely. It is 100% a coincidence. Studies show that the majority of people let out of institutions during the deinstitutionalization process were not violent and that the rate of violent crime committed by the mentally ill did not change with deinstitutionalization.

The big jump in prison population in the 1980s was caused by the drug war and by people Getting Tough On Crime. Stop dragging the mentally ill into this.

most mentally ill people do not end up in prison. Most of the people who got out of the mental hospitals during deinstitutionalization are getting by. Some of them are homeless, and that’s bad. But if you want to solve homelessness among the mentally ill, build homeless shelters, not state-run long-term mental hospitals.

In case you haven’t noticed, I really don’t like state-run long-term mental hospitals. There is a really amazingly great thing about prison, which is that you don’t go there unless you’re convicted of a crime. Mental hospitals do not have that advantage. The commitment process kind of sucks

I think long-term state-run mental hospitals are better than prison, but not by very much. The Rosenhan participants described it as: …an overwhelming sense of dehumanization, severe invasion of privacy, and boredom while hospitalized.

The idea of potentially saving a couple of people from prison by pre-emptively committing way more people to a mental hospital does not appeal to me at all, and I still think closing the institutions was the best thing Reagan ever did.

But prison and institutions aren’t the only two options! There’s a six month waiting period for psychiatrists in most parts of the country

There are a bunch of patients who are having trouble affording their medications

There are omnipresent underfunded community mental health systems

All of these things are doing great work right now. Indeed, the plan for closing the state-run long-term facilities was to gradually transition care to all of these other systems, and where that was supported it worked well, and insofar as it didn’t work well it was because it wasn’t supported.

we shouldn’t be making our mental health decisions based on worries about criminality and prisons. Most people who are mentally ill will never end up on the wrong side of the law, and many (most?) mentally ill people who do end up in prison will do so for reasons not directly related to their illness

And if mentally ill people do end up in prison? There is a forensic health system dedicated to treating mentally ill prisoners. It’s not perfect, but with more funding and attention it could be better.