USA: a 'hellish world', the mental health crisis overwhelming America's prisons

In One Flew Over the Cuckoo’s Nest, Ken Kesey describes two kinds of patients in the psychiatric hospital where the story is set: Acutes (“because the doctors figure them still sick enough to be fixed”) and Chronics (who are “in for good, the staff concedes”).

When Kristopher Rodriguez, a 31-year-old man from Florida, first went into the US criminal justice system in 2008, it seemed like he would have been classified as an Acute; now nearly a decade later, he would almost certainly qualify as a Chronic.

A tall, strapping boy whose friends called him Dino, as in “dinosaur”, Rodriguez was diagnosed with schizophrenia when he was around 14. His mother, Gemma Pena, had come home from work one night to find that he had disconnected the hot water heater, convinced that the CIA was using it to spy on him.

n One Flew Over the Cuckoo’s Nest, Ken Kesey describes two kinds of patients in the psychiatric hospital where the story is set: Acutes (“because the doctors figure them still sick enough to be fixed”) and Chronics (who are “in for good, the staff concedes”).

When Kristopher Rodriguez, a 31-year-old man from Florida, first went into the US criminal justice system in 2008, it seemed like he would have been classified as an Acute; now nearly a decade later, he would almost certainly qualify as a Chronic.

A tall, strapping boy whose friends called him Dino, as in “dinosaur”, Rodriguez was diagnosed with schizophrenia when he was around 14. His mother, Gemma Pena, had come home from work one night to find that he had disconnected the hot water heater, convinced that the CIA was using it to spy on him.

More than 50 years after Kesey’s novel, state psychiatric hospitals of the sort he described are, like lobotomies, long gone. Yet if we think that the hellish world Kesey captured belongs to another era, we are deluded. It’s true that the hospitals have mostly disappeared: between 1950 and 2000 the number of people with serious mental illness living in psychiatric institutions dropped from almost half a million people to about 50,000. But none of the rest of it has gone away, not the cruelty, the filth, the bad food or the brutality. Nor, most importantly, has the large population of people with mental illness, like Rodriguez, who are kept largely out of sight, their poor treatment invisible to most ordinary Americans.

The only real difference between Kesey’s time and our own is that the mistreatment of people with mental illness now happens in jails and prisons. Today, the country’s largest providers of psychiatric care are not hospitals at all, but rather the jails in Chicago, Los Angeles and New York City.

Across the country, correctional facilities are struggling with the reality that they have become the nation’s de facto mental healthcare providers, although they are hopelessly ill-equipped for the job. They are now contending with tens of thousands of people with mental illness who, by some counts, make up as much as half of their populations.

Little acknowledged in public debate, this situation is readily apparent in almost every correctional facility in the country. In Michigan, roughly half of all people in county jails have a mental illness, and nearly a quarter of people in state prisons do. In 2016, the state spent nearly $4m on psychiatric medication for state prisoners. In Iowa about a third of people in prison have a serious mental illness; another quarter have a chronic mental health diagnosis.

Meanwhile, nearly half of the people executed nationwide between 2000 and 2015 had been diagnosed with a mental illness and/or substance use disorder in their adult lives. When a legal settlement required California to build a psychiatric unit on its death row at San Quentin the 40 beds were filled immediately.

The mental health crisis is especially pronounced among women prisoners: one study by the US Bureau of Justice Statistics found that 75% of women incarcerated in jails and prisons had a mental illness, as compared with just over 60% and 55% of men, respectively. A more recent study showed that 20% of women in jail and 30% in prison had experienced “serious psychological distress” in the month before the survey, compared with 14% and 26% of men, respectively.

Although the overall number of people behind bars in the US has decreased in recent years, the proportion of prisoners with mental illness has continued to go up. In 2010, about 30% of people at New York’s Rikers Island jail had a mental illness; in 2014, the figure rose to 40% , and by 2017, it had gone up to 43%. Studies of the most frequently arrested people in New York, Los Angeles and elsewhere have found that they are far more likely than others to have mental illness, to require antipsychotic medications while incarcerated and to have a substance use problem.

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