Stepping Up to Address Our Nation’s Shame

We first saw San Quentin State Prison well before our bus arrived at the prison. At a distance, it’s unmistakable and distinctive, mixing architectural styles with some dating back to the 1850s. Fifteen minutes later, our bus arrived at the main gate. The members of APA’s Board of Trustees were likely not fully prepared for what they would see once we crossed onto the grounds.

In June, I arranged for the Board of Trustees to tour San Quentin in northern California. It was a powerful, moving, and formative experience, and I’m thankful to Dr. Paul Burton, the chief psychiatrist, and to the California Department of Corrections and Rehabilitation for giving us that access. Our visit was important because, if one wants to understand firsthand the toll mental illness is taking on our country, one just needs to peer beyond the bars of our nation’s jails and prisons. It’s also important to have a detailed and nuanced understanding of the situation.

Our tour was a no-holds-barred look at San Quentin State Prison. For three hours, we were shown various aspects of prison life.

The first part of our tour took us to the execution chamber, where over 200 men have died. We also saw California’s “Condemned Row”—the largest in the nation. And we saw the grounds’ oldest and obsolete cells, located in what can only be called a dungeon. The cell doors have been removed so that these cells will never be used again.

The most recent major addition to the grounds came in January 2010: a 50-bed hospital that offers inmates the medical, dental, and mental health care they need. It was as formidable as the other buildings we saw. But the inside felt much, much different.

We specifically saw the psychiatric facilities, which are highly used by the inmates. In many ways they are state of the art. As you’d expect, sharp angles in the halls and cells, down to the door hinges and door handles, were filed smooth to prevent inmates from using them to aid in a suicide attempt. Many cells provided a sanctuary for inmates, nearly always curled up on a plain bed with a blanket covering them head to toe.

Jason Young

But the rooms that captivated our group were the group therapy rooms. Separate enclosures or “modules” formed a semi-circle for people who are at once both dangerous and needing and deserving of help. We briefly observed one group. Those participating highly praised the care they were getting. One patient’s body language told us when he had enough of our interruption; in a visceral way, it was clear he valued his treatment.

The four psychiatrists with whom we interacted were obviously compassionate and concerned about each of their patients. At each stop, it was abundantly clear that the care provided by the staff psychiatrists was superb and professional. Even if incarceration itself is likely a detriment to many individuals’ mental health, the physician-patient interactions we witnessed gave us hope.

Tragic Scenario Plays Out Across the U.S.

Nationally, the numbers are staggering. Each year, roughly 2 million adults with serious mental illness such as schizophrenia, bipolar disorder, and major depression are admitted to our jails, and many of these also suffer from drug and alcohol use problems.

Jails and prisons have become the front lines of treatment for mental illness. The data indicate that San Quentin is an anomaly in the quality of care that’s available in such a setting. This is likely due to its proximity to a highly desirable metropolitan area and its affiliation with the University of California, San Francisco, Department of Psychiatry.

According to a 2010 study by the Treatment Advocacy Center and the National Sheriff’s Association, there was one psychiatric bed for every 300 Americans in 1955. By 2005, that rate dropped to one psychiatric bed for every 3,000 Americans. Over time mental illness has been criminalized, and our jails and prisons take up the slack, despite being seriously ill-equipped to do so. Our jails and prisons have turned into warehouses for those with mental illness; the number of people with mental illness in jails is three to six times higher than that of the general public.

This is why APA and the American Psychiatric Association Foundation have joined forces with the National Association of Counties and the Council of State Governments Justice Center in the “Stepping Up” Initiative. The initiative seeks to reduce the number of people with mental illness in our prisons and jails by promoting the use of mental health courts and diverting minor offenders who have mental illness to treatment resources rather than incarceration.

Stepping Up is a great start, but we will and must do more.

This is a problem that is truly national in its scope: In 44 states, the largest institutions housing people with severe psychiatric illness are prisons or jails. The costs are high and increasingly are understood to be unsustainable. Worse still, the toll on patients and on our communities is unacceptable.

This is why I’m announcing that APA, as part of my work as your president, will step up and do more in this arena. One thing we will do is raise awareness, with policymakers, opinion leaders, news media, and partners. We will hold a major national event on this issue in the coming months, and I urge you to join us as we focus on care, not incarceration, in every case where it is appropriate.

Fyodor Dostoyevsky once said, “The degree of civilization in a society can be judged by entering its prisons.”

We must reduce the use of our jails and prisons as warehouses for Americans with mental illness, partly to help our patients, but also because of what this tragedy says about the kind of nation we are. This is an effort for our patients, for our profession, and for our nation. ■