Allen Frances, M.D.
Prison Or Treatment For the Mentally ill
We should be supporting mental health, not punishing patients.
March 10, 2013
The public revulsion over repeated mass shootings has
placed mental health in the spotlight. This is both good and bad.
Bad because focusing on the mentality of the shooter diverts attention
away from the lethality of the weapon -- and from the fact that many
mass shooters had no history of mental health involvement. We will never
be able to predict who will commit random acts of violence, but we can
reduce our ridiculously high rates of gun death by having a sane
gun control policy.
Good because our current (non)system of mental health care is badly
broken and cries out for fixing and better funding. The problems are
spelled out by Amanda Pustilnik, associate professor of law at
University of Maryland and an expert on the relationship of law,
neuroscience, and mental health policy.
"Today, our largest mental hospitals are our
jails. The jail at New York's Rikers' Island functions as the
nation's largest psychiatric facility. Los Angeles' jails -- not its
hospitals - are California's largest providers of mental health
care. State prisons alone spend nearly $5 billion annually to
incarcerate mentally ill inmates who are not violent."
"According to the Department of Justice, nearly
1.3 million people with mental illness are incarcerated in state and
federal jails and prisons -- compared to only about 70,000 people
being served in psychiatric hospitals.
"The current psychiatric hospital inpatient population is only 5
percent of what it was at its height. We have about the same number
of psychiatric hospital beds now as we did in 1850. Some of this 'deinstitutionalization'
comes from the availability of medication and improved outpatient
treatment, but most of the change is no more than a switch of
institutions from hospital to prison."
"Every year, tens of thousands of people try in vain to get access
to mental health treatment. It can take months just to get an
outpatient appointment and people desperately in need are routinely
turned away at the hospital door because there is so little funding
for psychiatric beds."
"Where has the money for treatment gone? Much of it has been
funneled directly into, and wasted on, our prison system. Prisons
and jails have taken on behemoth proportions, bloated with
nonviolent and even non-offending people who in earlier times would
have been treated in hospitals -- we are the poorer for it and no
"The mentally are far more likely to be the victim of a crime or to
harm themselves. Their over-representation in the criminal system
results from their poor ability to communicate with police, lack of
adequate legal representation, self-medication with drugs and
alcohol, enacting symptoms in public, and lack of any other place to
put them. As a Florida judge pointed out- jails are the one
institution that can't say no to admitting someone -- so the
mentally ill are dumped there, often without treatment, and then
have a criminal record to boot."
"And some mentally ill people spend time in jails without having
committed any offense at all. Several states authorize the police to
arrest mentally ill people who have not broken any law, simply to
promote public order. More commonly, hospitals transfer patients to
jails to handle overflow. Even children may be confined in criminal
detention centers because there are so few treatment facilities for
severely mentally ill children. This reliance on the criminal
justice system as a surrogate mental health system wastes life and
treasure, and conflicts with basic notions of justice."
"So, why are we so irrational in our misallocation of resources? Why
don't we invest instead in proven alternatives to prison, like
assertive community-based treatment programs and access to
"The problem is that housing and treatment sound like 'entitlements'
-- while prison sounds like (and is) punishment. As a culture that
prizes self-reliance, we are cautious about extending benefits and
suspicious of rewarding people for what looks like bad behavior. The
punishment of people with mental illnesses who act out in public
might also seem to fit with a certain notion of public order and
"And it fits with our fears: We look at a handful of national
tragedies and conclude that mentally ill people are irresponsible
and dangerous - that a law-and-order response is appropriate and
necessary. With visions of school shooters before our eyes, we don't
see the typical mentally ill person- - someone who is mostly likely
to be poor, female, and non-violent."
"According to the Bureau of Justice Statistics, three out of four
women in state prisons have a mental health problem, compared to
just over half of male prisoners. Yet women are not driving the mass
violence problem in our country.
"Our current moment is reminiscent of 1998, when New York State
Governor George Pataki responded to the tragedy of a schizophrenic
man pushing a woman to her death in front of a subway train. 'What
can we as a people,' the governor asked, 'do to protect individuals
from themselves and to protect us as a society?'"
"It's time to turn that question around and ask how we can protect
mentally ill people from our dangerous preference for punishment
over treatment, for prisons over hospitals, for cleaning up
tragedies rather than preventing them."
"Let's provide effective treatment for people with mental illnesses,
not make them the stalking horse of our fears. If we focus on access
to treatment instead of punishment, we may all be safer and live in
a better society."
Thank you, Professor Pustilnik, for a compelling
presentation of a national nightmare. "A society will be judged on the
basis of how it treats its weakest members." We are failing that
judgment in the most shameful and costly way possible.
To reduce gun violence, we must have saner gun control policies AND
saner care of the mentally ill. These are not competing alternatives -
they are both desperately needed.
My fear is that we will get neither. As Mark Twain said, "history doesn't
repeat itself, but it sure does rhyme."
The rhyme here is political inaction. After each tragedy, the
politicians hypocritically mourn and harrumph, but wind up buckling
under pressure from the NRA, fiscal constraints, and the prison and gun
We now have the best chance in decades of breaking out of the all too
familiar past patterns, but the smart money is that the politicians will
once again take no, or only symbolic, actions and that we will continue
the insane military arming of the civilian population and the cruel
shunting of the mentally ill to jail. If mass incarceration of the
mentally ill could solve mass gun violence, we'd be safe already. But we
It seems that only the constant toll of repeated dramatic tragedies will
eventually shake the complacency and cowardice of a stalemated Congress
and the backward looking state legislatures.
Allen Frances is a professor emeritus at Duke University and was the
chairman of the DSM-IV task force.