OCTOBER 15, 2018
ONE NIGHT, a man was pounding on a Dunkin’ Donuts window. Dreadlocked and in dirty clothes, he yelled incoherently as I walked home in Brooklyn. Inside, the tired staff kept serving customers, immune to the noise. I thought of the homeless guy, toothless, who lurches into the local bodega and gets cussed out. And of the New York subway cars, routinely cleared out by a filthy man, defecating, urinating, or masturbating in his seat. The delusional woman who once pushed a stranger onto the tracks. And the boy with a knife.
Where I live, the helpless sick often live on the street. This is true across the United States: the “battered bleak of brain,” as Allen Ginsberg called them, are homeless or incarcerated. Bedford-Stuyvesant in Brooklyn tells a story common from here to Chicago to Los Angeles.
Fathers are missing from many homes near mine. Most are black, like most of our neighborhood and 37 percent of US prisoners. Today, New York is home to more African Americans than almost any other state. This wasn’t always so: In 1900, 90 percent of black Americans lived in places like Virginia, where I grew up, and Alabama, where my family has lived for centuries. But when six million descendants of slaves left the South, between World War I and 1970, they were trailed by poverty and prejudice: by bias in real estate, schools, and policing. Drained by white flight, Bedford-Stuyvesant was blighted by heroin and crack. The area’s leafy streets became scenes of gang violence. In 1990, Bedford-Stuyvesant saw 120 murders, one every third day. The race riot of 1991 was nearby in Crown Heights. More common than violence, though, were drugs and arrests of young black men. In New York, black men are arrested at eight times higher rates for marijuana possession than whites, The New York Times found. In 2016, Harper’s published an exposé, quoting a Nixon aide: “Did we know we were lying about the drugs? Of course we did,” John Erlichman told an interviewer years before. “[B]y getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities.” So they did.
One in three black men in the United States will spend time incarcerated, the Bureau of Justice Statistics predicted in 2001. This is old news. What gets less attention is another injustice: the gap in how America treats — or, more often, punishes — the mentally ill. Today in the United States, the three biggest providers of mental health care are not hospitals, but prisons.
One recent morning my neighbor walked in behind me at our local cafe. A fortysomething father, with a teenage daughter bound for boarding school, he and his wife are friends of mine — stoop-chat, neighbor-dinner friends. As we stirred our coffees, I showed him the cover of Kanye West’s new album: the words “I hate being Bi-Polar its awesome” handwritten across a photo of Wyoming mountains. “Good to see,” he said. “In our community, it’s not possible; you can’t have any mental weakness.” On the sidewalk outside, he paused a moment. Then he added, “I remember the first time I had a panic attack. The EMTs kept asking me was I on drugs. I’ve never taken drugs in my life!”
The fact is that mental illness in our country is criminalized, if you happen to be poor or black — if you are the homeless man on the subway, rambling about God or the CIA; or the shouting black youth, gunned down by police; or the white fireman in a hotel elevator, manic and naked, but otherwise harmless. We no longer have a place for such people, not since the 1960s. That’s when we quit housing the mentally ill in hospitals, allegedly to spare them bedlam. We’ve come full circle: in colonial times, the insane were housed with criminals, until reformers pushed for something more humane. Now, our prisons are packed once again with the mentally ill.
What’s wrong with us? This question drives Alisa Roth’s new book, Insane: America’s Criminal Treatment of Mental Illness. One in five Americans has a mental illness; and one in 25 a “serious” condition like schizophrenia or bipolar disorder. Yet 50 percent of the mentally ill go untreated — half of them because they can’t afford it. Access to treatment is varied: black and Latino people are far less likely to seek help or get treated than whites. And when they do see doctors, minorities are more likely to be misdiagnosed. In black men especially, mental illness is often taboo or misunderstood: see Kanye West. Bipolar disorder was similarly stigmatized in jazz musicians like Thelonious Monk, Nina Simone, and Charles Mingus. The place where the poor are likely to get treated, if anywhere, is prison. Roth gets inside these places, from Los Angeles to Chicago to Rikers Island in New York, and tells us what she sees. With an eye not toward shaming but toward progress, she gestures at solutions.
The medical journal JAMA published an article in 2015 with a provocative subtitle: “Bring back the asylum.” Its authors argued that moving away from long-term mental hospitals had created a national crisis. The severely mentally ill are not treated “in the community,” as was intended in 1963, when Kennedy signed his policy of deinstitutionalization into law. Instead, they’re often treated as criminals, when they blunder into trouble with police. As the authors point out, even if forensic psychiatry were well funded, jails and prisons are ill equipped to serve as clinics. These prisons are more akin to torture chambers than curative asylums, with inmates essentially warehoused in cages. Meals are erratic, and sleep is restricted. Hardly a recipe for peace of mind.
Mental hospitals, on the other hand, are not the nefarious places portrayed in movies and novels. Roth points out the irony of laws meant to keep the mentally ill safe by limiting forced hospitalization. For a poor family, these laws make it very difficult to get a psychotic relative treated. They are in fact far more likely to get him arrested. A mental hospitalization, in any case, is rarely the long-term sentence it once was. Today, the average stay is one week — just long enough to stabilize patients who may be paranoid, agitated, or suicidal.
On the day I got committed, I was a 27-year-old grad student. As many manic patients do, I fought the decision. Every bit as manipulative as I was well spoken, I argued at intake with a young psych resident, drawing on my neuroscience degree. I desperately wanted to be at my college roommate’s wedding that weekend. Ignoring the fact that I’d been a sleepless wreck for weeks, with darting eyes and stuttered speech, I belligerently debated with the staff, my eyes rolling, fists pounding, hands shaking. Nobody asked if I was on drugs; they could see that I was sick. And scared. “Involuntary hospitalization” may sound like a violation of rights, but it is often the easiest path to recovery. “Intake” is done by a psychiatrist, with experience and access to a patient’s medical history. It beats the hell out of the alternative facing many poor black men: a judge without medical expertise, often lacking context for the prisoner’s illness, decides within minutes of first meeting him if he is competent to be tried in a court of law.
On Rikers Island today, there are 4,500 mentally ill inmates, out of 10,000. Seven hundred have a “serious” illness, like schizophrenia or bipolar disorder. Twenty-five percent of the United States’s incarcerated need mental health care. Forty percent of female prisoners do. At the country’s biggest women’s prison, in Oklahoma, a full 90 percent of prisoners are mentally ill. As one state legislator told Alisa Roth: “Basically, in Oklahoma, we’re just warehousing people in prison, and we’re not trying to rehabilitate anybody because of budget constraints.”
Life as a prisoner is, as Roth puts it, psychotogenic: it exacerbates psychosis in someone prone to it, and can trigger suicidal thoughts. For the most part, Roth is quick to note, prisons do not actively abuse prisoners. Rather, they are understaffed, underfunded, and untrained to treat them. The result: Passive neglect, and solitary confinement as a form of expedient discipline. Solitude, of course, stokes mental illness, like kindling on a flame.
One summer night, another neighbor told me about her father. Walking under sycamores past the brownstones, bodegas, and bars, she told a familiar story. She described mood swings and charismatic highs; rage and booze. She said that she only lately realized that her father, despite a career more stable than his personal life, probably suffers from untreated mental illness. In communities like ours, her family’s story is hardly rare.
What her family and mine have in common is a legacy of mental illness. She and I also both went to Ivy League schools, lived in Japan and France, and studied foreign languages. But our similarities end there. I’m white, she’s black. I grew up well off in the leafy suburbs of Richmond, Virginia; she in the housing projects of Queens. Her male relatives, involved with drugs, were in and out of prison. A nephew stayed with her once when he finished his sentence. Idle and surly, he seemed depressed.
Mental illness does not often make people violent. Police, however, do shoot mentally ill people nearly every day. One in four police shootings in 2015 and 2016, Roth writes, struck mentally ill people. Some precincts report much higher rates. Of those killed by San Francisco police in 2016, a full 60 percent were mentally ill. A SWAT team in Atlanta in 2012 responded to a call about a suicidal 16-year-old boy by surrounding his home. Decked out in riot gear, a sniper on a nearby roof assassinated him. Last year, US police added 230 sick people to the body count of mentally ill Americans killed by cops.
Those most likely to be victimized by police, according to criminologists, are men with bipolar disorder who are addicted to drugs or alcohol. Substance abuse, common in bipolar people, seems to put them at somewhat higher risk of committing crimes. This summer, a study by Seattle researchers found that 50 percent of those shot by police were hospitalized or incarcerated in the two years prior to being shot; those shot by cops were 22 times more likely to have an impulsivity or conduct disorder than car crash survivors. One 2018 report found that mania or psychosis combined with substance abuse increased the chances of a run in with the law by 7.47 times (as compared to the mentally healthy without addiction). Manic men are more likely to act in an aggressive manner that attracts police attention. As Kanye West raps on his latest album, “This the kind of high that don’t come down, this the kind of high that gets you gunned down.”
Families often call 911 when a relative is having a mental crisis. Instead of an ambulance, police show up, in part because mental health calls are not high priority from a medical perspective. The tools of law enforcement then perpetuate, as Roth puts it, the notion that people with mental illness are dangerous.
This is not to say that the mentally ill are never violent. Mass shootings are often committed by people with brain disorders: the United States’s first, in 1970 at the University of Texas, Austin, was by a 25-year-old man whose autopsy revealed a brain tumor. The shooters at Columbine High School in 1999 were depressed; one died with a drug like Prozac in his blood. Adam Lanza at Sandy Hook in Connecticut had autism. The “Batman shooter” at the movie theater in Aurora, Colorado, was a PhD student in neuroscience who had attempted suicide multiple times since age 13. He told his therapist he was having homicidal fantasies before he shot up a theater. (Ruling: Not insane; Guilty. Currently serving 12 consecutive life sentences.) If someone had helped these sick people in time, many lives would have been saved.
Black Southern history runs deep in Bed-Stuy. In the 1930s, during the Great Migration, many black families moved up here from the South, bringing accents, jazz, and soul food. In 1838, one of America’s first free black towns was founded in the area by a freedman from Virginia. Caribbean immigrants came, along with Harlem families. Meanwhile, white people like me — Irish, Germans, Italians — moved away. And Bed-Stuy became poor and rough. The area’s crime, immortalized by local rappers like Jay-Z and Biggie Smalls, sometimes involved guns. More often, it involved petty drugs, policed with prejudice. The cocaine snorted by white bankers was never punished like crack among the black urban poor. Then, as crime declined a decade ago, white young people like me started moving in, drawn by the historic homes, eclectic culture, and rising rents elsewhere. But Bed-Stuy remains among the largest majority-black neighborhoods in the United States. At the cafe where I once worked, our regulars had relatives in Georgia, North Carolina, Alabama, or Louisiana. We’d talk about towns we knew in common, and music. No place in New York feels more Southern to me than Bed-Stuy, or more like home.
The place my neighbors are from is where I’m from, too. The food, the warm voices, sweet tea, and folksy pace of life make us nostalgic for the South. Other traditions we’re glad to leave behind. As one advocate told Alisa Roth about Southern prisons, “What I believe is that in the decades to come, mental illness will be the new Jim Crow.”
Southern states treat their mentally ill worse than anywhere else. Alabama, where my family has lived for two centuries, is no exception. Fond of guns and capital punishment, the state executes more people per capita than any other. It has high rates of mental illness, but spends less on mental health care than nearly any other state. Alabama ranks 46 out of 50 states in unmet mental illness need, according to a yearly survey by the advocacy group Mental Health America. Alabamians often get defensive if outsiders bring up racism — lynching, George Wallace, and civil rights groups like Southern Poverty Law Center and Equal Justice Initiative, based in Montgomery. They insist that Alabama has changed, and that prejudice is a thing of the past. But given the rate of incarcerated black people in Alabama, it’s clear that racism thrives in Dixie. One of Alabama’s most powerful politicians, US Attorney General Jeff Sessions, wants the death penalty for drug dealers, and backs the laws that fill our prisons with black fathers. Even ignoring race, the state’s treatment of the mentally ill is as bigoted as any prejudice.
Alabama executed a mentally ill man this year, as it has done at least three times in recent years. This year’s victim, Michael Eggers, a white man, was on anti-psychotic medications, and his brother was institutionalized with schizophrenia. The Equal Justice Initiative reports that
Mr. Eggers believed that the Mexican Mafia and other outlaw groups, law enforcement agencies, and the government were conspiring to persecute him — following him from California as he fled to eight different states to evade them; checking into the psych ward to torment him when he was involuntarily committed for emergency psychiatric care; and even killing his father in retaliation for the killing of his former employer in Walker County, Alabama, in 2000.
Eggers’s original run-in with law enforcement came from a sting operation, when he was tricked into buying marijuana.
Alabama’s prisons in 2016 operated at 175 percent capacity, freakishly understaffed and overbooked. The violence among inmates is remarkable: hundreds of assaults in 2016, and at least eight dead in 2017. Prisoners staged hunger strikes 27 times in four years to protest abhorrent conditions: rat infestations; lack of care; assaults.
What Charles Dickens wrote in 1842 of an American mental asylum describes our prisons depressingly well:
Everything had a lounging, listless, madhouse air […] The moping idiot, cowering down with long disheveled hair; the gibbering maniac, with his hideous and pointed finger; the vacant eye, the fierce wild face, the gloomy picking of the hands and lips, and munching of the nails.
Dickens described the man in solitary confinement as a torture victim: “He never hears of wife or children; home or friends; the life or death of any single creature […] He is a man buried alive; to be dug out in the slow round of years; and in the meantime dead to everything but torturing anxieties and horrible despair.” What Dickens damned, we have not fixed.
In 2016, Sheriff Tom Dart of Chicago’s Cook County Jail penned an open letter to sheriffs and jail directors. “[A]bsolutely none of us signed up to run the largest mental health institutions in our respective communities,” he wrote. “Yet that is where we find ourselves.” Dart, whom Roth calls “a trailblazer,” told her, “If they’re going to make it so that I am going to be the largest mental health provider, we’re going to be the best ones. We’re going to treat ’em as a patient while they’re here.” But Dart’s attitude is rare in law enforcement. And resources are limited.
We’re talking cell walls smeared with feces. Prisoners who routinely hurl foul blasts of urine, semen, spit, and feces at guards, risking a new assault charge and longer sentences. Mentally ill prisoners are not allowed to have toilet paper in their cells, for fear they will suffocate. Dazed, many never talk, like dementia patients. They are often sloppily dressed, or not at all. At the L.A. County Jail, Roth writes, “a man in a cell on the second tier stands naked, openly masturbating in front of his cell door. Nobody tries to stop him; nobody even really seems to notice. When I comment, [an officer] says, ‘He does it all the time.’” The guards, when moving a psychotic prisoner who is uncooperative, get decked out in riot gear regalia: knee and elbow pads, helmets, plastic shields, and pepper spray to “encourage” the inmate to “cuff up” — that is, to get handcuffed. Guards on these wards carry “cut-down tools” to deal with hangings — the most common type of prison suicide, itself the most common cause of death among inmates.
Guards aren’t trained as health-care workers, but as enforcers. How they react to sick inmates is often callous. Sometimes it’s sickening. Florida officers once abandoned a mentally ill prisoner in a shower until he burned to death, Roth reports. Suicide attempts by inmates often earn punishment, including solitary confinement. This backfires; inmates who have spent time in solitary, one study found, are seven times more likely to self-harm. Officers in some jails are known to hand out razors to suicidal prisoners. Others mock the mentally ill, or feed them at strange times, like at three in the morning.
Of the many stories in Roth’s book, two stuck with me the most. Together, they tell a tale of two boys with bipolar disorder who landed in very different places.
The lucky boy was a star student, artist, and musician, the son of a chemistry professor. On winter break from his liberal arts college, the boy returned home to Maryland in a manic agitation. He was weirdly obsessed with songwriter Sting; arguing about a feminist academic; talking fast, disjointedly, paranoid, and grandiose. The apocalypse was near, the boy thought, and the only way to rescue his mother was to kill her. So the son took a hammer and beat her to death. Thanks to the efforts of his PhD father to get him deemed legally insane, the lucky boy served his time in a hospital. Today, diagnosed with bipolar disorder, he is on medication and fully rehabilitated. He lives as an artist, independent in a home of his own. The brother of one of Roth’s childhood friends, he inspired her book.
Another boy wasn’t so lucky. The son of a trucker in my family’s home state, Jamie Wallace was also bipolar, as well as ADHD and schizophrenic, according to various psychiatrists. He was born unlucky in Alabama, with mania in both sides of his family. His father, known for his fiery temper, sometimes whipped him. Growing up poor outside of Birmingham, occasionally on food stamps, Wallace had learning disabilities that made school hard for him. His mother reportedly called him “retard” and preferred her younger son. According to one uncle, Jamie’s parents would host rowdy drug- and alcohol-fueled parties at their house with the kids around. Jamie once showed his uncle how to roll a joint, saying his father had taught him. The boy had physical disabilities, too, that required multiple surgeries. On the day of the shooting, Jamie had recently been released from a mental hospital, with a change in the pills he took to stabilize his mood.
Like the professor’s son, Wallace ended up killing his mother — shooting her with a gun he took from his grandmother. (Alabama, a state of hunters, is full of guns; in a place rife with untreated mental illness, guns are a strange and often fatal way to keep people safe.) Lacking the advantages of the chemist’s son, or of a family like mine, Wallace ended up neglected in a cell, without therapy of any kind. In the class-action lawsuit against Alabama’s Department of Corrections for its incompetent mental health care, he was a star witness. A week after testifying, he committed suicide in his cell.
Alabama outsources its prison mental health care. So do 23 other states. But Alabama, once again, stands out. The counter-proposal Alabama offered a contractor required the company to cut psychiatrists’ hours by 12 percent and psychologists’ by 25 percent. At Bullock Correctional Facility near Birmingham, writes Roth, “as many as 70 percent of mental health appointments” are canceled because there are not enough officers to escort therapists. When inmates complained about inadequate treatment, a class-action lawsuit took Alabama to court. Testifying in the trial, one prisoner said that mental health staff “ain’t come see me worth a damn,” just “once in a blue moon,” every two months or so, for a five- to 10-minute visit. A federal judge ruled that the mental health care Alabama provided its inmates was so poor it was unconstitutional. Alabama must double or triple staffing in prison mental health care to meet the needs of its sickest citizens.
My family has lived in Alabama since 1817, faring far better than most of our neighbors. Our kin ran a lumber company there for 60 years. They include a Rhodes scholar, alums of Oxford, Princeton, Yale, and Stanford; doctors, lawyers, business owners. The psychotic illness in my family is as clear as our pedigree. If one of us ever got in trouble with the law when insane, chances are we would be treated as sick — sent to a hospital, and hopefully rehabilitated. But if our neighbors in the county — poor, rural, African American — commit a violent crime in the midst of a manic confusion or psychosis, history shows what our state is likely to do: punish without mercy. The death penalty has a clear racial bias: black inmates make up 41 percent of death row inmates in America, though the country’s black population is just 13 percent. A black Alabamian is 38 percent more likely to be sentenced to death for murder than a white one. Near the acre where my mother was born, a black defendant with mania would be treated as a felon. Without access to mental health care, he’d likely end up alone in a solitary cell, possibly hanging from the ceiling. He may breathe his last while the state of Alabama, as religious as it is vindictive, injects poison into his veins, and watches him die.
If you lose your mind and get it back, what you feel most is gratitude. The feeling, for me, was overpowering, nearly religious. I hadn’t been to church since I was a kid, and I didn’t consider myself a believer. But when I first became manic, in St. Louis, I started going weekly. The preachers were ex-crack addicts. A portrait of Martin Luther King Jr. hung on the wall. I couldn’t stop singing. How sweet the sound that saved a wretch like me. In this shelter for men alienated from their families, where I’d been invited by a stranger who said she thought I could use it, I watched people speak in tongues and collapse to the ground, and I saw what some must get out of religion. How welcoming to be back in a loving community: connected, no longer estranged. Today, I’m still secular, and I’ve been mercifully sane for years. But I’ve never lost that sense of gratitude.
“Asylum,” before earning its ugly reputation, meant “sanctuary; a place of retreat and security: SHELTER.” We need places like this, and we’ll keep needing them until scientists develop drugs to fix the worst of what ails us — drugs we certainly don’t have now. If the last century’s efforts are any indication, we will wait a long time.
Prisons are not the answer to mental illness, as Roth’s book makes clear. We don’t need to lock people up for longer stays. We need hospitals, more of them and better equipped to deal with the sickest among us. Decriminalizing drugs would help: our prisons are packed with nonviolent drug offenders, many of whom are sick. We must also prevent crime by treating the conditions that create it: poverty and trauma along with mental illness. We need smart, kind professionals to harbor those exiled furthest from home.
Psychiatrists today offer pills, but precious little asylum. Take it from one who’s seen many! The medicine of the mind, as practiced nowadays, is usually not about listening to a patient’s stories, or empathizing with his experience, but fitting him to a questionnaire. Next comes the parade of prescriptions for drugs, often ineffective and rife with side effects. One reason black patients are thought to be misdiagnosed at higher rates than whites is that psychiatrists, usually white, either don’t listen or don’t understand a patient’s way of expressing himself: mania looks like psychosis. For those of us with the privilege of access to mental health care, finding treatment that works can still take years. While we wait, it’s not a doctor who helps us deal intelligently with our shipwrecked self-esteem, or with the strangers we’ve become; this is not how doctors see their job anymore. Asylum work falls instead to talk therapists. My own, whose PhD is in Classics, has a mask of Agamemnon on her wall, beside a painting of Achilles and Patroclus; below is a shelf of books on attachment theory and relationships. She is interested in narrative, and interpersonal dynamics, not in reducing people to disorders. We need more people like her.
If crime is to be prevented, we also need more doctors in psychiatry. Psychiatrists make less than other doctors for mostly thankless work, so theirs is not a popular field, nor as respected as, say, oncology or surgery. Prison psychiatrists are paid even less to work in difficult places. Therapists and social workers don’t make much, either, and often, like teachers, aren’t respected. If we celebrated mental health workers for what they do — not so much for “comforting the weak” but for treating brain illnesses and trauma, and, just as importantly, for preventing crime — the field might attract more ambitious young people. Curious about the mind, eager for meaningful work, these experts could fill asylums with competent, curious humanity in the manner of, say, Oliver Sacks. Crime might be prevented not by guns but by safe havens: by asylums.
Here, at least, is one insanity we know how to cure.