Editor’s Note: Dr. Kenneth Paul Rosenberg is the director of the PBS film “Bedlam,” author of the Penguin Random House book “Bedlam,” and a psychiatrist at Weill Cornell Medical Center. Patrisse Cullors is a co-founder of Black Lives Matter and founder of Yes on R, the mental health initiative in Los Angeles. The views expressed in this commentary are their own. View more opinion on CNN.
On Super Tuesday, Los Angeles voters approved a seemingly small ballot measure that is a first step toward fixing our broken mental health system.
Rather than build more jails, which are increasingly responsible for caring for Americans with Serious Mental Illness (SMI), the approved ballot initiative authorizes Los Angeles County’s Sheriff Civilian Oversight Commission to develop a plan to reduce the jail population by improving mental health and drug abuse prevention, care, and treatment. It also gave the commission subpoena power to investigate complaints.
But change is not just happening in California. From New Orleans, Louisiana, to Dane County, Wisconsin, mental health advocates are fighting for mental illness treatment and protesting the construction of new jails. And in New York City, one of the country’s largest jails, Rikers Island, is being closed, partly based on the scandalous care of incarcerated people with mental illness, about 43% of the jail’s population as of 2017.
The movement from incarceration to treatment couldn’t come soon enough for family members like ours. One of us is a black activist, an artist in Los Angeles, and an architect of Measure R, the recently passed Los Angles ballot measure. The other, a white psychiatrist and documentary filmmaker in New York City, has spent seven years chronicling the mental health crisis in Los Angeles. Aside from our interest in mental illness treatment, what we share is the experience of having a sibling with SMI, a disease that has kept them from realizing that they are sick and need treatment.
After 35 years of psychiatric illness, Ken’s sister Merle lived alone in Philadelphia, shunning visitors and refusing treatment, despite Ken’s urging. When he sought help from police to go to her home and force her into care, they found her dead in her bed at age 55.
Patrisse’s brother rotated through jail, prison and short stays in local hospital psychiatric emergency departments, from which he was quickly discharged. Patrisse has since managed to become her brother’s legal conservator, meaning that she can force him to get care — a bitter pill for a civil rights activist to accept, but one that saved his life. Securing this legal authority required a herculean effort that included posting an open letter on social media begging county officials to keep him in a hospital instead of jail.
This is not just someone else’s problem. Nationally, according to the National Institute of Mental Health, nearly one in five adults live with a mental illness; 4.5 % of adults in the US have SMI. Nearly 15% of the US population will struggle with substance abuse, according to a 2016 Surgeon General report.
Meanwhile, on any given day in Los Angeles, about 25% of the men and 40% of the women housed in the county jail require mental health treatment, according to Alisa Roth, a reporter and author of “Insane: America’s Criminal Treatment of Mental Illness.”
The problem on the streets and jails is fueled by an epidemic of substance abuse, said Dr. Colin Dias, former director of Emergency Services at the Los Angeles County + University of Southern California Medical Center, which afflicts as many as 80% of the people he evaluates in the emergency department with mental illness.
How did America come to abandon people with debilitating psychiatric diseases? Many point to President John F. Kennedy’s landmark Community Mental Health Act, signed into law in 1963, as a starting point for disaster. Affected by his own sister’s prefrontal lobotomy at 23 and subsequent institutionalization, Kennedy promised that the “cold mercy of custodial care would be replaced by the open warmth of community.”
Community mental health facilities were established to take care of less severely ill people. In fact, they were more geared to preventing new cases of SMI as opposed to addressing the needs of chronic patients who were leaving the asylums. The centers also became less medically oriented and more community oriented, meaning less able to address very sick people.
Despite Kennedy’s good intentions, patients fell not into the welcoming arms of community, but rather into the unprepared arms of law enforcement, given the lack of resources available for those who were released onto local streets.
Mental illness crises are among the few health emergencies in which law enforcement are the first responders and become the overseers of treatment. But there is another side to this.
For family members, calling the police or sheriff’s deputies may be the only option for getting help for a loved one who doesn’t know they’re sick. (Anosognosia, or lack of insight about one’s illness, is a common feature of psychosis.)
Even when an individual is brought to a hospital (at considerable time and expense to police and sheriff deputies) they will likely be discharged within a few hours because of severe bed shortage, just as Patrisse’s close family member has been — time and time again.
The jail bed, on the other hand, is the bed that never says no. Transports to jail are processed more quickly, with officers waiting an average of just 37 minutes for a transfer of custody, versus the three-hour average for a medical facility handoff, according to the Treatment Advocacy Center, a nonprofit that works to promote policies that support people with severe mental illness.
Once incarcerated, people are treated, yet often only kept locked up until they’re deemed sane enough to be released, often only to continue being spun through the revolving door of madness, jail, streets and emergency room visits.
We know from the history of deinstitutionalization that when it comes to mental illness, the road to hell is paved with good intentions. If we take away the jails, we need to replace them with something better. Today, we have about 3% per capita of the public psychiatric beds that were available in 1955, according to a 2016 report from the Treatment Advocacy Center.
In addition to inpatient beds, we need viable outpatient, community-based treatment centers — like the kind we see at the World Health Organization exemplar in Trieste, Italy — which offers 24/7 psychiatric outreach care, with little need for costly confinement in a hospital.
We also need laws that allow families to get help for their loved ones who resist treatment, without involving law enforcement, which has its hands full dealing with real crime. Arrest itself poses serious risks given that at least 25% of fatal police shootings involve an encounter with a person with a mental illness.
Since the data isn’t tracked properly, the Treatment Advocacy Center says it could be as high as 50%. Easier access to conservatorships, like the one that Patrisse got for her family member, are a crucial tool for families. Above all else, we need humane and effective treatments, because the best solution would be better medical management and cure.
The fact is that getting and keeping people with SMI out of jail is necessary but insufficient. If we allow history to repeat itself, we could even make one of our country’s greatest social crises worse. The success of the March 3 ballot measure in Los Angeles has not solved the mental health crisis.
However, it marks a watershed moment for mental illness advocacy, giving us the opportunity to move one crucial step closer to helping people with SMI to pursue what every American wants for ourselves and our loved ones — to live with dignity and health.