BY DEFAULT, JAILS BECOME MENTAL INSTITUTIONS

In This Article
THE JAIL: Faulting System In Los Angeles
THE DELINQUENT: Young, Mentally Ill And Bound for Jail
THE ASYLUM: Well-Meaning Plan To Close Hospitals

LOS ANGELES -- Michael H. had not had a shave or haircut in months when he
was found one recent morning sleeping on the floor of St. Paul's Episcopal
Church in suburban Lancaster, next to empty cans of tuna and soup from the
church pantry.

There was little to suggest that he had once been a prosperous college
graduate with a wife and two children -- until he developed schizophrenia,
lost his job and, without insurance, could no longer afford the drugs
needed to control his mental illness.

Charged with illegal entry and burglary, Michael H. was taken to the Los
Angeles County Jail. The jail, by default, is the nation's largest mental
institution. On an average day, it holds 1,500 to 1,700 inmates who are
severely mentally ill, most of them detained on minor charges, essentially
for being public nuisances.

The situation in the jail, scathingly criticized as unconstitutional by the
United States Justice Department last fall, is the most visible evidence
that jails and prisons have become the nation's new mental hospitals.

On any day, almost 200,000 people behind bars -- more than 1 in 10 of the
total -- are known to suffer from schizophrenia, manic depression or major
depression, the three most severe mental illnesses. The rate is four times
that in the general population. And there is evidence, particularly with
juveniles, that the numbers in jail are growing.

Some of these people have committed serious, violent crimes. But many more
are homeless people like Michael H., charged with minor crimes that are
byproducts of their illnesses. Others are picked up with no charges at all,
in what police call mercy arrests, simply for acting strange.

They include adults like Helen Rose Akanni, a woman with paranoid
schizophrenia who was mistakenly charged with drunken driving and held for
a week before a psychiatrist saw her. They include teen-agers like Jason
E., a manic-depressive whose violence gives his father the choice of having
him jailed or endangering his family.

"Part of mental illness in America now is that you are going to get
arrested," said Laurie M. Flynn, executive director of the National
Alliance for the Mentally Ill, an advocacy group of relatives and friends
of people with mental disorders.

What experts call the criminalization of the mentally ill has grown as an
issue as the nation's inmate population has exploded and as corrections
officials and families of the emotionally disturbed have become alarmed by
the problems posed by having the mentally ill behind bars.

But the trend began in the 1960s, with the mass closings of public mental
hospitals. At the time, new antipsychotic drugs made medicating patients in
the community seem a humane alternative to long-term hospitalization.
States also seized the chance to slash hospital budgets. From a high of
559,000 in 1955, the number of patients in state institutions dropped to
69,000 in 1995.

But the drugs work only when they are taken -- and when they work, patients
are tempted to stop, because of the unpleasant side effects. As states
lagged in opening a promised network of clinics and halfway houses to
monitor patients, obtaining treatment became harder. Health insurers
restricted coverage, for-profit hospitals turned away the psychotic, and
new laws made it more difficult to commit disturbed people. Thousands began
to fall through the cracks.

Coincidentally, with voters willing to spend freely to fight rising crime
rates, states were building more jails and prisons. Jails became the only
institutions left open to the mentally ill 24 hours a day.

Homelessness was the most public sign of the problem. But for growing
numbers of people, the price of mental illness was arrest.

Ms. Akanni, for example, became upset when she could not find her
2-year-old daughter; the girl had fallen asleep under a bed. To calm
herself, Ms. Akanni went for a drive, but she got in an accident. When she
gave her name as the Lord God Almighty, an officer arrested her for drunken
driving. A week passed before a psychiatrist saw her and she was able to
explain that she had a 2-year-old at home, alone.

When Ms. Akanni was released, she was arrested again, for abandoning her
child. The girl had survived by eating garbage.

"The inmates we see in jail today are the same people I used to see in
psychiatric hospitals," said Dr. Eugene Kunzman, the former medical
director of the mental health program at the Los Angeles jail.

In many states, so many public hospitals have closed, or the laws
regulating admission to hospitals have been made so tight, that sometimes
the only way to get care is to be arrested. Resources are especially scarce
for juveniles.

In Dallas, social workers advised Jason E.'s family to have him jailed to
get treatment. He had assaulted both parents and his brother, and hospitals
were too expensive or refused him because he was violent. Jason's father
rejected the advice and kept him at home -- only to be warned he could be
charged with endangering his other son.

"It's tragic," said Judge Hal Gaither of the Dallas County Juvenile Court.
"If you are a young person and mentally ill, you have to get arrested to
receive treatment."

Though some people do benefit from regular medication while in jail, others
suffer as the stress deepens their depression, intensifies delusions or
leads to a psychotic break. Suicide is a risk: 95 percent of those who
commit suicide in jail or prison have a diagnosed mental disorder, a study
in the American Journal of Psychiatry found.

Locking up the mentally ill also has high costs for the nation's crowded
prisons and jails.

Because judges are often reluctant to grant bail to the mentally ill, and
because they need special treatment, they tend to stay in jail much longer
than other inmates.

On Rikers Island, New York City's jail, where 15 percent of new inmates
have serious mental disorders, the average stay for all inmates is 42 days,
but it is 215 days for the mentally ill, said Dr. Arthur Lynch, the
official in the New York City Health and Hospitals Corp. who oversees
treatment in the jail.

Jails and prisons often find themselves unprepared to deal with the
mentally ill. Guards may not know, for example, how to respond to disturbed
inmates who simply are not capable of standing in an orderly line for
meals; a common result is that the inmates are put in solitary confinement.

"We are doing the best we can, but it is definitely frustrating for the
officers," said Gayle Ray, the county sheriff for Nashville, where 142
inmates o antipsychotic medication -- 8.6 percent of her jail system's
1,630 inmates -- are housed on one floor of the Criminal Justice Center.
"Jails were not designed to be mental hospitals, and what's happening is a
real passing of the buck to another part of the system."

Advocates for the mentally ill say the clock is being turned back to the
19th century, when it was common in the United States to confine people
with mental illness in jails. Mental hospitals, or asylums, grew out of a
crusade in the 1840s by Dorothea Dix, the Boston reformer, who warned that
"insane persons" were being confined in "cages, closets, cellars, stalls,
pens: chained, naked, beaten with rods and lashed into obedience."

"Criminalization," said Dr. E. Fuller Torrey, a leading researcher of
schizophrenia in Washington, D.C., "has been both a personal disaster for
the mentally ill, and an institutional disaster for the criminal justice
system."

THE JAIL: Faulting System In Los Angeles

In Los Angeles, an average of 1,000 new offenders a day are brought to the
county jail system, seven separate jails spread across 4,000 square miles
housing a total of 22,000 inmates. It is a logistical nightmare.

When the Justice Department investigated the jail last year, this was the
screening procedure it found: On entering, each prisoner was issued a sheet
and towel and was shown an informational video. Among other questions, the
video asked new arrivals to tell jailers if they had a mental health problem.

Many of the sickest new arrivals did not, because they were in denial.
Others did not respond because they had been to the jail before. They knew
that if they did, they would be issued yellow jumpsuits, which made them
easy targets for guards or other inmates. They might be locked 23 hours a
day in dirty isolation cells. And any medication they had would be
confiscated until a jail psychiatrist saw them -- which could take weeks.

"Unconstitutional conditions exist at the Los Angeles County Jail," the
report by the Justice Department's Civil Rights Division concluded,
"including a deliberate indifference to the inmates' serious mental health
needs."

The study, prompted by relatives of people who had been jailed, was the
first federal review of the predicament of the mentally ill in jail. It
produced a case study of the forces that draw the mentally ill into jails,
and of the problems that they pose for jails and that jails pose for them.

"The problem I see is that the whole concept of treatment of the mentally
ill in jail is an oxymoron," said David Myer, who directs the Los Angeles
Mental Health Department's programs in the jail. "Jail is a horrible place.
It isn't good for people who are well. For someone who is mentally ill, it
is terrible."

The troubles begin with the fact that the county jail is a jail, not a
hospital. It is run by the sheriff's department to keep discipline among
its large population and to process inmates for court.

In addition, most deputies have little training in dealing with the
emotionally disturbed, said Anita Dunsay, a recently retired clinical
psychologist who worked in the jail. "The deputies tend to be fresh
graduates of the sheriff's academy, and baby-sitting isn't what they joined
up for, so they easily get angry at the mentally ill," she said.

One result, the Justice Department charged, was that even though l,700
inmates a day got some form of treatment, many more had mental illnesses
that were going undetected. This was particularly true of those who were
quietly depressed or had personality or anxiety disorders, illnesses for
which California law does not mandate care.

The report also charged that record-keeping was so haphazard that some
mentally ill inmates were lost in the system, while many illnesses were
misdiagnosed and patients were given the wrong medication.

On a tour of the Central Jail three months after the report's release,
mentally ill inmates in yellow jumpsuits could be seen meeting with a
psychiatrist on a steel bench in a busy corridor. A stench from the jail's
blocked sewer caused people to cover their noses and mouths. Cells reserved
for the mentally ill were so crowded that some men had to sleep on the
floor. Some babbled; others complained they could not sleep because of rats
in their quarters.

The physical conditions improved dramatically in January, when the
sheriff's department, under threat of a Justice Department lawsuit, moved
most of the mentally disturbed inmates to the county's new Twin Towers
jail. There, inmates are housed in clean, modern, one- and two-man cells.

The screening process was also updated: deputies now directly ask new
arrivals if they are on medication. Already the number identifying
themselves as mentally ill has increased, and Myer said he expected it
would eventually climb by 50 percent.

"The moral of the story," Myer said, "is that if you want to get something
done you need to bring the power of the federal government in and threaten
to take over your jail."

But even as the Los Angeles jail moves toward, in effect, creating its own
mental hospital, there are still problems inherent in dealing with the
mentally ill in any jail. Inmates, said Kunzman, the former medical
director, are seldom in jail long enough to stabilize them on the right
medication, to offer them adequate therapy or to plan for their care after
release.

And so far the changes at the Los Angeles County Jail affect mainly
physical conditions, not treatment, said Marianne Baptista, an
administrator at Step Up on Second, a mental health agency in Santa Monica
whose caseworkers often search the jail for missing clients. "On our end,
nothing's changed," she said.

Her agency's clients still often disappear into the jail after being
arrested, without any notification to the clinic. "More often than not,
once in jail, their medications are taken away from them or they are given
something different, and then their symptoms come out again," she said.
"Being in jail may make them more crazy."

That cycle can cause long-term physical damage, said Kay Redfield Jamison,
a professor of psychiatry at Johns Hopkins School of Medicine. "Every
relapse you have increases the odds that your brain is being damaged and
that you will have another relapse faster, just like with heart attacks,"
she said.

Without the state hospitals, experts say, a revolving door has been
created, in which many mentally ill people cycle from clinics to
homelessness to jail.

In Los Angeles, more than 70 percent of the severely mentall ill homeless
have been arrested at least once, according to a report prepared for the
Los Angeles County Board of Supervisors by Carla Jacobs, a board member of
the National Alliance for the Mentally Ill.

Many mentally ill people do manage to get treatment and do not end up in
jail, of course, especially those with higher incomes. But the magnitude of
the problem is suggested by a survey by the National Alliance for the
Mentally Ill of families with a seriously mentally ill member; 40 percent
of the ill individuals had been arrested.

On an average day, said Linda A. Teplin, a professor of psychiatry at
Northwestern University Medical School, 9 percent of men and 18.5 percent
of women in local jails -- about 56,000 people -- are severely mentally
ill. An estimated 10 percent of all inmates in state and federal prisons, ,
or 122,000 people, are severely mentally ill, said Allen J. Beck of the
Justice Department's Bureau of Justice Statistics.

And about 20 percent of juveniles in criminal justice facilities, or 20,000
people, are that ill, said Joseph Cocozza, director of the GAINS Center, a
research organization in Delmar, N.Y.

It was Professor Teplin's research that first demonstrated that the
mentally ill are arrested much more often than people in the general
population. But the problem, she said, is not police callousness. "The
police arrest the mentally ill because they have no other alternative," she
said.

She recalled riding with the police in a Midwestern city one night when
they received a call about a crazy man on a bus. The man, named Charlie,
was both schizophrenic and a drunk. They took him to a detoxification
center, where he fell asleep. But the detox center recognized him and
insisted he was crazy, not drunk, so the police drove him to a hospital.

At the hospital the doctors also knew Charlie. Regarding him as difficult,
they said he was an alcoholic to avoid admitting him.

Finally, the police arrested Charlie, Professor Teplin said. It was a cold
night and they did not want him to freeze to death. He was charged with
disorderly conduct.

THE DELINQUENT: Young, Mentally Ill And Bound for Jail

The 16-year-old girl suffered from delusions and hallucinations. The
diagnosis was "psychotic, not otherwise specified." Her father was in
prison for sexually abusing her sister. Her mother was an alcoholic. Not
surprisingly, the girl began skipping school. She got pregnant. She
assaulted her mother.

Before most state hospitals were closed, the girl would probably have been
committed to a state psychiatric hospital. But in Texas, where she lives,
the juvenile court declared her a delinquent and sent her to the state's
juvenile justice agency, the Texas Youth Commission. The commission sent
her to its Corsicana Residential Treatment Center for seriously emotionally
disturbed youths.

The girl personifies the problems facing many young people with mental
disorders, said Linda Reyes, a psychologist and assistant deputy executive
director of the TYC. "Unless you are wealthy and can afford private
doctors, you have to get arrested to get treatment," she said.

Even so, the commission is limited in what it can do. The girl refuses to
take antipsychotic medication, and because Corsicana is not a hospital, its
staff cannot make her take it. She is not making progress -- she walks
around naked and urinates on the floor -- but by law, when her term
expires, she must be released.

Incarcerating mentally ill adolescents is "tragic and absurd," Dr. Reyes
said. "The system we have created is totally ineffective. It doesn't
rehabilitate the kids. And it doesn't even take care of public safety,
because when she is sent home, she will just get picked up again."

Of the 4,791 juveniles in the Texas agency's custody, 22 percent suffer
from schizophrenia, manic depression or major depression. The national
figure is similar: an estimated 20 percent of incarcerated juveniles are
seriously emotionally disturbed.

When other psychiatric disorders are included, the percentages rise
sharply. A recent survey by the California Youth Authority found that 35
percent of boys in its custody and 73 percent of girls need treatment, said
its director, Francisco Alarcon.

One reason for the higher percentage of young people with mental illness in
jail, specialists say, is that many states have cut budgets for adolescent
psychiatric hospitals even more than those for adults.

"I had a 15-year-old girl who was hallucinating and psychotic," said Cathy
Brock, a supervisor at the Letot Center in Dallas for runaway children.
"And a staff member from Mental Health and Mental Retardation agreed she
needed hospitalization. But then she said they were over budget for the
year -- so couldn't I find an offense that would get her arrested, like an
assault?"

The Dallas County Juvenile Department has as large a budget for psychiatric
hospitalization, $6.6 million this year, as the county's mental health
department.

As a result, Ms. Brock said, "When I have a kid who is severely mentally
ill and has been arrested, and the family has no resources, I will do
everything I can to make sure that kid gets adjudicated." But urging judges
and families to convict children, she said, "presents all kinds of ethical
binds.".

Another reason these young people are incarcerated disproportionately is
that they act out their illnesses more than adults, usually in aggressive
and impulsive ways that can get them arrested, said the president of the
National Mental Health Association, Michael Faenza.

There is evidence that the number of disturbed young people being arrested
is increasing. At Corsicana, Dr. Reyes said, the proportion of juveniles on
antipsychotic drugs has doubled to 80 percent since 1990.

But it is unclear whether this trend indicates more mental illness, or
reflects tougher sentencing laws that are driving greater numbers of all
young people behind bars.

Torrey, the schizophrenia expert, said he does not believe that social
conditions, like the breakdown of the family and bad parenting, cause young
people to become mentally ill. "What we are seeing," he said, "is the
breakdown of the public mental health system."

THE ASYLUM: Well-Meaning Plan To Close Hospitals

For a growing number of the mentally ill, it has come to this, said Dr.
Michael Pawel, executive director of the August Aichhorn Center for
emotionally disturbed juvenile offenders in Manhattan: "Jail has become the
place where, when you have to go there, they have to take you in."

As thousands of the mentally ill end up behind bars, no one has estimated
the cost of shifting so many of the mentally ill from one kind of
institution, hospitals, to another, jails and prisons. At New York state's
rate of $30,000 a year per inmate, the annual cost to prisons alone would
be $3.7 billion, not counting the extra expenses of treating the mentally ill.

But because of the price exacted on the mentally ill themselves, some
therapists and mental health advocates are reconsidering what they did in
helping to close state hospitals.

"I was not wrong that antipsychotic medications were good," said Dr.
Richard Lamb, a professor of psychiatry at the University of Southern
California School of Medicine. Lamb worked in a state hospital in the 1960s
and was among those pushing for treating people outside hospitals. "But I
was wrong about discharging so many people with severe problems."

Part of the premise, he recalled, was that governments would build places
in communities where discharged patients could continue to take their drugs
and get therapy. But, largely for economic reasons, this was never done.

Now, Lamb said he realizes, "Some people just need more structured care."

Thinking over what seemed at the time like a wonderful reform, he likened
himself to the British colonel in "The Bridge Over the River Kwai." The
colonel built a bridge for his Japanese captors because the idea was so
magnificent. "What have I done?" he asked himself.

Copyright 1998 The New York Times Company