Recently, the simultaneous publication of two stories, one in The New York Times and one in The Economist, gave me a unique opportunity to write about a problem I’ve seen in our mental health system.
The first story, "The Woman Who Ate Cutlery," by Dr. Christine Montross, was published in the Times on Aug. 3.
That same day, The Economist published a story headlined, "Locked in."
Both articles started out with a patient vignette. The Economist presented the story of Tracey Aldridge, a jail inmate with 27 incarcerations for misdemeanor offenses (which the article characterized as "typical of the mentally ill"). While incarcerated, Ms. Aldridge required special arm coverings to keep her from ripping her veins out with her teeth. Later, she ate her protective gauntlets.
The Times article similarly began with an anonymized patient vignette about Patient M. Patient M was not psychotic, but did have repeatedly self-injurious behaviors, such as swallowing knives and forks, and inserting sharp objects into her vagina. Swallowed cutlery was the usual reason for her 72 admissions.
Thomas Dart, the sheriff of the jail where Ms. Aldridge was held, expressed anger about her incarcerations, or more specifically, about the cost of her care. He blamed the lack of psychiatric beds and short lengths of stay for the number of inmates with mental illness in his facility. His main responsibility, according to the article, was "to keep people safe while they await trial" rather than act as director of a pseudo-psychiatric hospital. To his credit, he created a novel program to house, supervise, and support misdemeanor mentally ill offenders outside of the jail.
Dr. Montross similarly bemoaned M’s presence on her inpatient unit for her 73rd admission and suggested that M would be better served in the community. In her opinion, failure to provide outpatient services created an unnecessary and costly burden on hospital emergency rooms and inpatient units.
I don’t want to sound like a curmudgeon, so let me be clear that both writers have valid points about the need for well-funded inpatient and outpatient services and about the problems inherent in the incarceration of people with mental illnesses. I agree with their conclusions. Psychiatric patients in jail run the risk of inappropriate segregation, abuse, discrimination, and denial of institutional jobs or rehabilitation programs.
Both writers also vividly portray the challenges inherent in institution-based care for certain patients with severely disruptive, aggressive, or self-injurious behavior. The care of these patients can be both time and staff intensive, thus costly. The physical management required by these patients – the use of seclusion or physical restraint, for example – might draw the scrutiny of external agencies such as the hospital accreditation agency, the Joint Commission, or patients’ rights and inmate advocacy organizations. Physical intervention and seclusion also can draw the attention of the news media, as in the series of articles published in The Atlantic over the use of long-term segregation in a federal control unit prison.
In a worst-case scenario, an adverse treatment outcome could lead to individual or class action litigation.
While I agree with the writers’ conclusions, I also have concern about the implicit messages conveyed in these stories.
The first implicit message is that there is a single, monolithic entity known as "the mentally ill" with clearly demarcated edges separating "us" and "them." This is untrue because of limitations inherent in our diagnostic system but also because of the nature of mental illness. Most psychiatric patients don’t commit crimes, much less misdemeanor offenses "typical of the mentally ill." They also don’t tear out their veins with their teeth or insert sharp objects into their genitalia. Mental illness can strike anyone, and from a statistical standpoint, there is almost certainly a person with a mental illness employed, rather than housed, in Sheriff Dart’s jail – possibly even caring for inmate Aldridge. There are also likely people with mental illness among the policy makers, legislators, and administrators who make funding decisions for correctional and psychiatric facilities.
The patients these stories are really talking about are a small subset of psychiatric patients, people with psychiatric disorders who also happen to have substance abuse problems, legal issues, and poor social supports in addition to their severely maladaptive behaviors. In other words, they are my forensic patients. I know these patients well, because I have worked with them for many years, as a treating clinician in a prison and as a forensic evaluator. I also know how my nonforensic mental health colleagues feel about working with my patients, after release or discharge. They are uncomfortable with them and concerned, reasonably or not, about liability issues and the potential for violence.