The criminalisation of the mentally ill is one of the cruellest and most easily avoidable tragedies of our era. In the next few days, the state of Arkansas is intending to execute by lethal injection a 60-year-old man called Bruce Ward who showed signs of insanity at the time of his conviction for murder and was diagnosed by a court-recognised psychiatrist in 2006 as being a paranoid schizophrenic.
Ward is one of seven men facing execution in Arkansas after the first death sentence in the state since 2005 was carried out on Thursday. “He appears not to understand that he is about to die, believing instead that he is preparing for a ‘special mission’ as an evangelist,” says a report by the Harvard University Fair Punishment Project. A second man scheduled for execution is Jason McGehee who suffers from bipolar disorder and possible brain damage.
The prison systems in the US and UK have replaced psychiatric hospitals as the place where people suffering from severe mental illness are most likely to find themselves. It is a process that has been going on since the 1960s, fuelled by a desire to save money, a belief that medication would replace hospitalisation, and a liberal reaction against what was seen as unnecessary incarceration. Between 1955 and 2016, the number of state hospital beds in the US available to psychiatric patients fell by over 97 per cent from 559,000 to just 38,000. An expert noted despairingly that the biggest de facto psychiatric institutions in the US today are Los Angeles County jail, Chicago’s Cook County jail and New York’s Riker’s Island. Those who are not in prison or hospital “become violent or, more often, the victims of violence. They grow sicker and die. The personal and public costs are incalculable,” says a report by the Treatment Advocacy Center in Virginia. Mentally ill people, usually poor and unemployable because of their condition, are sometimes advised that the only way they will get even the crudest treatment is by being sent to prison.
The same process is happening in Britain. One of the justifications for closing down the old asylum system was that they were too much like prisons, but the paradoxical result has been that psychiatric patients are now ending up in real prisons. The number of beds available for mental health patients in the UK has dropped by three quarters since 1986/87 to about 17,000, while the Centre for Mental Health says that 21,000 mentally ill people are imprisoned, making up a quarter of the prison population.
For many mentally ill people, the prospect of incarceration is becoming probable in an unexpected reversion to eighteenth century practice. Some are left to wander the streets but most are looked after by their families who may not have the resources to do so. Deceptively progressive sounding words, like ‘deinstitutionalisation’ in the US and ‘care in the community’ in the UK, are used to describe the ending of the vast system that once catered for psychiatric patients.
Some of these institutions were hellholes, and others became unnecessary because medication was available from the 1950s that controlled some of the worst symptoms of mental illness. But the old system did at least provide an asylum in the sense of a place of safety where people who could not look after themselves were cared for. Supposing ‘care in the community’ had been more than an attractive slogan, it might have provided something of a replacement for the old asylums, but the care it provided was always inadequate.
The reality of the new system was best described by the detective-story writer P.D. James, an administrator in the NHS in London whose husband was a long-term patient in a mental hospital. She wrote that since the 1970s community care “could be described more accurately as the absence of care in a community still largely resentful or frightened of mental illness.”
Not much has changed for the better since P.D.James was writing, as was made plain this week by the report of the Sir Thomas Winsor, the Chief Inspector of Constabulary, who complained that the police are increasingly being used as the “first resort” for people with mental health problems. He said that sometimes they ended up spending the night in police cells even though they had committed no crime because no hospital beds were available. He added that the “inadequacy” of mental health provision should “disturb everyone”.
Marjorie Wallace, the founder and chief executive of SANE, a mental health charity, explains that governments have every incentive to keep mental patients out of hospital, since “providing a single bed costs the same as ‘treating’ 44 people in the community.” She welcomed Theresa May’s intention expressed in a speech earlier this year to do something about “the burning injustice of mental health and inadequate treatment”, but says that this will remain a Utopian vision unless there is more ring-fenced money for psychiatric services which are already close to breakdown.
There is more open discussion than there used to be about mental illness, with a campaign against stigmatisation and exhortations for people to seek counselling or simply speak up about their mental troubles before they become chronic and irreversible. Prince Harry spoke movingly about the negative consequences for himself of repressing his grief over the death of his mother when he was twelve years old. Celebrities reveal their anxieties and breakdowns. Such openness is important because it reduces personal isolation and makes people feel that they will not be treated as pariahs if they speak up.
When I first began to write about schizophrenia in 2002, I found that my friends and relatives divided into those who knew nothing about mental illness and those who knew all too much about it. But the latter had often never mentioned previously that they were looking after a sister with schizophrenia or a brother who could not leave his flat without having a breakdown. One friend disclosed a terrible story of a sister-in-law who had poured petrol over herself and set it alight, suffering burns over three quarters of her body from which she took weeks to die in agony.
Openness and discussion are important, but they skirt the heart of the problem, which is that a proportion of people who are mentally ill cannot look after themselves. The severity and incurability of a mental illnesses are often underestimated and there may be exaggerated expectations of preventing their onset by early intervention. The precise causes and nature of mental illness remains very much a mystery so a large number of people are always going to become desperately ill. Schizophrenia, for instance, is to mental illness what cancer is to physical illness. When Prince Harry talked about psychological troubles, debilitating though these may be, they are still not the same as full blown psychosis or, in other words, madness.
The present system has failed and the result is the creeping criminalisation of madness. The only way to reverse this is to build a core of dedicated hospitals that will care for and protect psychiatric patients who cannot do this for themselves and are a potential danger to themselves and others.