Psychotherapy Bulletin

Psychotherapy Bulletin

Clinical Impact Statement: This manuscript provides information to professionals in mental health, corrections, law enforcement, and the judiciary to better understand the link between persons with mental illness and the criminal justice system. The manuscript details prevalence rates and challenges faced by persons with mental illness in jails and prisons, and offers suggestions for alternative approaches.

As I’ve reflected on the question of what made me choose forensic psychology as a profession, I realize that the answer may be a surprising one: heavy metal music and horror movies. The 1980s were a great time to be in high school and college. For an adolescent male with grief and loss (and subsequent latent anger) issues, heavy metal and horror movies provided a perfect outlet. This was the era of the slasher movie—Halloween, Friday the 13th, Nightmare on Elm Street. I watched every horror movie I could get my hands on, and I found myself increasingly curious about the character development of the killer. Why did he turn out that way? How did his mind work? Why wouldn’t poor Jason Voorhees be angry at the camp counselors who let him drown? Michael Myers spent 15 years in a dank, horrifying insane asylum as a child, for goodness’ sake. The Silence of the Lambs, released in 1991, was the best of the bunch in terms of exploring the “mind of the maniac.”  

Horror is to film as heavy metal is to music. Heavy metal is fueled by themes of mental illness and violent crime. These songs were formative in my earliest understanding of the criminal mind. Metallica’s “Welcome Home (Sanitarium)” and Anthrax’s “Madhouse” describe being unjustly placed in an asylum (a common theme shared across many metal songs). Slayer’s “Criminally Insane,” “Dead Skin Mask,” and “Killing Fields” all describe the mind and behavior of the psychopathic killer in gruesome detail, with many other metal artists creating entire catalogs out of these types of themes. And I was all in. Channeling the words of Quiet Riot’s singer Kevin DuBose, pictured wild-eyed in a straitjacket on the album cover, I just knew that “metal health will drive you mad.”

So here I was, my understanding of psychology informed and titillated by the stories I watched and heard in movies and music. It didn’t take long for me to find forensic psychology in graduate school, focusing on a career in which I could see these movies and songs come to life. I created an external rotation at my internship in which I shadowed a forensic psychologist in private practice, which piqued my interest in forensic assessment and evaluation. Walking into jail the first time, ready to evaluate a defendant who was charged with a violent assault, was the culmination of years of training, study, schooling – and yes, movies and metal. My postdoctoral fellowship at St. Elizabeth’s Hospital cemented my focus on forensic evaluation.

My first job as a psychologist was at New Jersey State Prison (NJSP), the state’s featured maximum security institution. At that time, it held more than 2000 men, all sentenced to at least 30 years, with most serving life sentences. Nicknamed “The Wall” because of its imposing exterior multi-story walls, NJSP housed New Jersey’s death row, management control unit, several mental health units, and (to my excitement) many of the state’s most infamous inmates. My job as a staff psychologist was to provide acute mental health emergency care, conduct risk assessments for internal and external transfers, check the mental health status of inmates in Administrative Segregation, and oversee mental health care for certain units.

For the first six months, I was like a kid in a candy store. I pored over case files that read like Hollywood B-movie scripts—heinous criminal offenses, offenders with brutal histories. I interviewed the same offenders at their cell doors, trying to understand how and why they committed the crimes they had been accused of. Many of these offenders were diagnosed with various mental illnesses—the songs and movies of my adolescence were truly living and breathing before me. Between St. Elizabeth’s and NJSP, I was working in the world of the “criminally insane,” and like any good voyeur, I was fascinated by the stories around me. In fact, several movies and songs had been written about the very offenders I was working with.

But an interested thing happened about six months into my job. Within one particular week, I had a spate of jarring experiences that challenged my voyeuristic fascination. I was asked to complete a suicide assessment on a depressed offender serving a multi-year stint in Administrative Segregation who pointedly and genuinely asked about the point of spending the rest of his natural life in his cold, dark cell. Another inmate, diagnosed with paranoid schizophrenia, told me his story—he had killed his father while in the midst of a delusional psychosis (essentially to stop his father from “taking over the world,” since he believed his father had been plotting to eradicate the world’s population one nation at a time); despite having no previous criminal record, he was sentenced to life in prison by a jury skeptical of the insanity defense. Another inmate was given an institutional charge of “destroying state property” for smearing feces inside his cell while psychotic.

The most significant event, however, occurred on a Friday afternoon. Things were winding down for the work week. Most professional staff didn’t work weekends, so most of the mental health and medical operations were moving toward “maintenance mode” until we returned the following Monday. However, we received a call from an officer in a general population unit. He asked us to come to the unit immediately. Upon our arrival, the officer told us about a potentially lethal situation. The unit was composed of more than 40 cells, each with two inmates per cell. One of the cells housed an unlikely pair: a prototypical, tattooed, muscle-bound man with a history of high-level biker gang membership, and a lithe, emaciated man with schizophrenia. Both were serving life sentences. We arrived at the unit during rec time. While the first inmate was pumping iron outside in the yard, his schizophrenic cellmate experienced an acute psychotic episode. He began defacing his cellmate’s television in a bizarre cleansing ritual, carving symbols into the tv and covering it with milk. The correctional officer stated gravely, “Yard ends in 10 minutes. When that guy comes back and sees his tv destroyed, he’s gonna want to kill that guy.” We managed to move the man with schizophrenia to the mental health unit just before the close of the day—potentially saving his life.

These events were not uncommon in the prison, nor were they endemic to NJSP. Similar events and experiences occurred throughout my two years at the prison—and no doubt were occurring at other correctional facilities around the country. Like many institutions before and after, NJSP was in the midst of a class-action lawsuit in which inmates had successfully sued on the grounds of inadequate mental health care. In fact, that was the primary reason I had the job in the first place. The lawsuit created a slew of mental health positions at the prison. I had eagerly taken the position, unaware of the context that had led to the creation of the job in the first place. But I soon learned that the job, like those of my hard-working counterparts, was only a salve for a gaping wound. I was totally unprepared for the overwhelming need for mental health care at the prison—the sheer scale of chronic mental illness as well as acute mental health emergencies was unlike anything I had been trained for.

That was, in a phrase, my turning point. I unwittingly transformed from a thrill-seeking forensic psychologist into a justice-seeking one. I could no longer work in the metaphorical dark, simply reading case files or talking with inmates for my own selfish excitement. I became aware of the troubling yet pervasive reality in which people with mental illness had filled the prison largely by default. Of course, most inmates had committed terrible crimes and were justifiably being held accountable for their actions. This should never change. However, I began to understand that much of the misery I witnessed as a correctional psychologist was significantly exacerbated by the failings of our country’s misguided approach to mental illness. My entire career since that week has therefore been rooted in the pursuit of social justice for people with mental illness—through applied research, teaching, consultation, legislative action, policy advocacy, and clinical work.

I should say that this was not a problem exclusive to NJSP. The state’s entire correctional system was captured under the lawsuit and its subsequent ramifications. Nor was the state of New Jersey alone in this challenge. Nearly every state has faced these barriers. In my opinion, it’s become the number one mental health issue in our country and can be summed up succinctly: We have abdicated care for people with mental illness from people with licenses to people with badges.

Now for a few statistics that help tell the real story about mental health care in America. Persons with mental illness are more than three times as likely to be arrested than people without mental illness for the same behavior (Qureshi, Liefman, Coffey, & Carney, 2015; Teplin, 1984). Nearly 60% of all persons with a serious and persistent mental illness will come into unwanted contact with law enforcement at least once in their lifetimes, and 40% have spent at least one day in jail (Steinwachs, Kasper, & Skinner, 1992). Especially tragic is the reality that people with serious and persistent mental illnesses are 4-10 times more likely to be victims of violence and crime than perpetrators—a harsh reality for group of people with a life expectancy in the sixties (Gundaya, Crisanti, Steffen, & Gowensmith, 2009; Treatment Advocacy Center, 2016; Walker, McGee, &, Druss, 2015).

However, the sad story only worsens after arrest. Jails and prisons have become our nation’s largest inpatient mental health facilities. County jails far outpace state hospitals in terms of numbers of persons with mental illness served and housed. Los Angeles County Jail treats approximately 3000 men with mental illness each day, with other large urban jails rivaling that total. Most of these men—now labeled as criminal defendants—are facing misdemeanor charges after being arrested for low-level, quality of life transgressions that come as a byproduct of living on the streets with a major mental illness. Criminal courts order them to state hospitals for mental health treatment, but wait times are enormous. Persons with mental illness wait in jails for weeks to months for transfer, because state hospitals operate at a meager eight percent of previous capacities (Beachum, 2016). Persons ordered by the criminal court in Colorado, for example, now wait more than 100 days on average for admission, as compared to 25 days in 2017 (Sherry, 2018). As state hospitals become increasingly filled with court-ordered forensic patients, space for voluntary and civil admissions evaporate. Individuals with serious and persistent mental illness thus have fewer and fewer options when experiencing acute symptoms. Behavior then becomes increasingly erratic and disruptive, the police are called—and the cycle continues.

Statistics tell part of the story. Human stories tell the rest. In January 2017, a defendant waiting 12 days for his transfer to competency restoration services died in the San Luis Obispo County Jail from complications due to his mental illness (McGuinness, 2017). A few years earlier, a northern California man previously adjudicated as IST (Incompetent to Stand Trial) hanged himself in jail awaiting transfer to Napa State Hospital (Shafer, 2015). In Washington state, one woman with deteriorating mental health was eventually deemed “gravely disabled” after waiting in jail for more than five months for competency-related services to materialize; she was transferred to a civil hospital as an emergency measure (Trueblood v. State of Washington Department of Human and Social Services (DSHS), 2015). Across the country in the Philadelphia county jail, a homeless man awaiting inpatient competency restoration services for more than seven months was beaten to death in his cell by another inmate – while in a separate nearby facility, a different homeless man accused of stealing candy from a Dollar Store remained in jail awaiting competency-related services for nearly one year (Moraff, 2015). Finally, Mr. Jaymichael Mitchell died in his cell, covered with feces and urine, after spending more than three months in a Virginia county jail while psychotic. Mr. Mitchell was facing misdemeanor charges after allegedly stealing a bottle of Mountain Dew, a Snickers bar, and a Zebra Cake from a convenience store (Swaine, 2018).

These stories are incomprehensibly tragic, and they should hold us accountable. In the most powerful and wealthiest nation in history, we have relinquished the care of our most vulnerable citizens to retributive correctional systems built on deterrence and punishment. We would never allow these sorts of realities to beset people with heart disease or diabetes, yet as a society we turn a blind eye while it’s happening to people with treatable mental illness.

The stories above are the same stories that got me into the field of forensic psychology. It’s the stuff that horror movies and heavy metal are made of. It fueled my early fascination with this field. But after witnessing these events, one after another after another after another, I experienced a turning point that switched me from voyeur to advocate. People with serious and persistent mental illness are often marginalized and misunderstood, and they deserve better than jail cells from the professionals and systems working to serve them.

I hope this has been informative. Please feel free to contact me at [email protected].

Cite This Article

Gowensmith, W. N. (2018). Thrills, chills, and social justice in forensic psychology. Psychotherapy Bulletin, 53(4), 32-36.

References

Beachum, L. (2016, July 1). Nation’s psychiatric bed count falls to record low. The Washington Post. Retrieved from https://www.washingtonpost.com/news/to-yourhealth/wp/2016/07/01/nations-psychiatric-bed-count-falls-to-record-low/?noredirect=on&utm_term=.c626eae899e5 on October 28, 2018.

Gundaya, D. M., Crisanti, A., Steffen, J., & Gowensmith, W. N. (2009, October). Forensic involvement and victimization among Adult Mental Health Division consumers. Poster presentation at the Hawaii Psychological Association conference, Honolulu, HI.

McGuinness, C. (2017, May 31). No place to go: Inmates declared mentally unfit to stand trial languish in jails. New Times SLO. Retrieved from https://www.newtimesslo.com/sanluisobispo/no-place-to-go-inmates-declared-mentally-unfit-to-stand-trial-languish-in-jails/Content?oid=2978784

Moraff, C. (2015, November 2). Pennsylvania’s mentally ill spend years in jail without trial or treatment. Daily Beast. Retrieved from https://www.thedailybeast.com/pennsylvanias-mentally-ill-spend-years-in-jail-without-trial-or-treatment

Qureshi, S., Leifman, S., Coffey, T., & Carney, R. M. (2015, June). Outcomes of the Miami-Dade County Forensic Alternative Center: A diversion program for mentally ill offenders. Poster presentation at the University of Miami’s Miller School of Medicine Annual Research Day, Miami, FL.

Shafer, S. (2015). Long, dangerous wait for hospital beds for those incompetent to stand trial. KQED News. Retrieved from: https://ww2.kqed.org/stateofhealth/2015/10/20/long-dangerous-wait-for-hospital-beds-for-those-incompetent-to-stand-trial/

Sherry, A. (2018, July 23). Colorado faces growing legal jeopardy over dealing with mentally ill inmates. Colorado Public Radio. Retrieved from http://www.cpr.org/news/story/colorado-faces-growing-legal-jeopa on July 24, 2018.

Steinwachs, D., Kasper, J., & Skinner, E. (1992). Patterns of use and costs among severely mentally ill people. Health Affairs, 11(3), 178-185. doi: org/10.1377/hlthaff.11.3.178

Swaine, J. (2015, August 25). Young black man jailed since April for alleged $5 theft found dead in cell. The Guardian. Retrieved from https://www.theguardian.com/us-news/2015/aug/28/jamycheal-mitchell-virginia-jail-found-dead?CMP=share_btn_tw

Teplin, L. A. (1984). Criminalizing mental disorder: The comparative arrest rate of the mentally ill. American Psychologist, 39(7), 794-803. http://dx.doi.org/10.1037/0003-066X.39.7.794

Treatment Advocacy Center. (2016). Victimization and serious mental illness. Publication retrieved at http://www.treatmentadvocacycenter.org/evidence-and-research/learn-more-about/3630-victimization-and-serious-mental-illness on October 28, 2018.

Trueblood v. State of Washington Department of Human and Social Services, 101 F. Supp. 3d 1010 (W.D. Wash. 2015).

Walker, E. R., McGee, R. E., & Druss, B. G. (2015). Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. JAMA Psychiatry, 72(4), 334-41. doi: 10.1001/jamapsychiatry.2014.2502

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