The crime of mental illness

The current push to get tough on crime will likely increase rates of incarceration 1 — and consequently increase the numbers of prisoners with mental illnesses. If we want to stop jails and prisons from becoming mental health warehouses, we have an urgent medical–legal–societal conundrum to solve.

Correctional facilities have long been known to contain many more people with serious mental problems than the general population 2 — as many as three times more, according to a recent Canadian study. 3 One major reason for this is the lack of awareness of the needs of and support for people with manageable, or curable, mental illnesses in the community.

And there’s the crux: People with difficult but potentially manageable medical conditions — such as chronic schizophrenia, depression, or mood and anxiety disorders, made worse by abuse, neglect or ignorance — who have no support systems can act out in ways society deems unacceptable and even come to be viewed as criminal.

Consider Ashley Smith. The New Brunswick teen committed a series of minor offences over several years that took her through the provincial jail system and, because of escalating behavioural problems, into the federal prison system. In 2007, Ashley, age 19, killed herself while in custody. Her unsuitable behaviour became a death sentence.

This isn’t about the court system. It does what it can within the confines of legal definitions and pretrial diversion programs. But it cannot address clinical needs or determine best placement for the mentally ill. If we accept the premise that serious illnesses should be treated, the only question left is where: in correctional institutions, the community or both?

The Mental Health Commission of Canada has proposed a framework that aspires to destigmatize mental illness, provide comprehensive, accessible person-centred prevention and care programs for all, and justify these programs with appropriate evidence. 4 For the mentally ill who commit crimes, this framework should lead to programs focused on people rather than on institutions.

As a next step, strong advocacy and support from the medical community would go a long way to raise awareness, thus leading to concrete plans and resources to address this complex issue.

To understand exactly what needs to be done, governments must mandate the collection of accurate and comprehensive data on the prevalence and consequences of mental health problems among the incarcerated — not only behavioural problems well-known to correctional personnel but also all mental illnesses.

Corrections staff need training on how to care for prisoners with mental illness. Whether in a remand centre, a provincial jail or a federal prison, the staff needs to know how to recognize symptoms so they can quickly identify distressed inmates with poorly controlled mental health problems. The acting-out behaviour that can escalate if symptoms are not addressed can destabilize cell block routines, frustrate guards, irritate other inmates and lead to serious confrontations.

More research and novel approaches to treatment and care of mentally ill prisoners are needed. Whether within existing systems or in pilot programs, evaluation of short- and long-term outcomes must focus on success of treatment and reintegration into society. The evaluation should include cost-effectiveness —to advance sound public policy based on evidence not ideology.

Part of the solution is outside the justice system: incarceration would not be the only solution if prevention programs were available that tackle problems long before someone gets in trouble with the law. Reintegration programs could stop, or at least slow down, the revolving door that leads people back into the correctional system. Integrated community-based care could try to deal with the many issues after release. These programs could be far more cost-effective than building more prisons.

At present, there are few peer-reviewed evaluations of mental health courts, diversion programs, and community treatment orders and programs, such as British Columbia’s integrated forensic mental health system, which is designed to enhance service delivery to mentally ill inmates. 2 Without proper studies, how are we to determine best practices, especially with ever-escalating costs?

Having people with treatable mental health disorders fall into the criminal justice system serves neither society nor the individual. That so many inmates in jails and prisons have mental health disorders — often untreated — is an indictment of society’s values and understanding of mental health disorders.