Prisons have become a substitute for state-run mental hospitals, German Lopez argues, but Scott Alexander offers a deeper explanation:
Lopez seems to be working off a model where there is a population of mentally ill people who can’t make it in normal society, and so will inevitably end up either in a long-term mental hospital or a prison. Since mental hospitals are good places where people get treatment, and prisons are bad places where people get punishment, we should “catch” these mentally ill people before they end up in prison so that they can be in nice hospitals instead.
Needless to say I disagree with pretty much every part of this assessment.
Between all of this talk of “the tragic collapse of America’s public mental health system” and “the US’s largely gutted mental health system” and “the country pulled back and defunded its mental health system” and so on, you might get the impression that less money is being spent on mental health. This is not really true. The share of GDP devoted to mental health is the same as it was in 1971, although this looks worse if you compare it to rising costs in other areas of health care. There hasn’t been a “gutting of the mental health system”, there’s been a shift from long-term state-run mental hospitals to community care. It hasn’t “left the criminal justice system as the only system that can respond to people with mental illness”, it helped create an alternate and less restrictive system of outpatient psychiatry. In my opinion, this was a positive development, and the share of mentally ill people in prison is not an argument against it. Let me explain.
“Mentally ill people in prison” conjures up this lurid image of psychos who snap and kill their families, followed by “well, what did you expect leaving a person like that on the street?” The reality is more mundane. There are lots of mentally ill people in prison because there are lots of mentally ill people everywhere. Remember, 20% of the population qualifies as mentally ill in one sense or another. If a depressed guy sells some marijuana and gets caught, he is now a “mentally ill person in prison”.
There are disproportionately many mentally ill people in prison partly because people’s illnesses lead them to commit crimes, but mostly because some of the factors correlated with mental illness are the same factors correlated with criminality. Poverty? Check. Neighborhood effects? Check. Genetic load? Check. Education? Check. IQ? Check. Broken families? Check. Drug abuse? Definitely check. The factors that gave that pot dealer depression might be the same factors that drove him to sell pot instead of becoming an astronaut. Treating the depression might help a little, but it’s not guaranteed to keep him on the good side of the law.
In my model, the overwhelming majority of mentally ill people can live okay lives outside of any institution, hopefully receiving community care if they want it. If they commit crimes they will go to prison just like anyone else; if not, we should hardly be clamoring to bring back the often-horrifying state-run mental hospitals and lock them up there.
What about that graph? It’s very suggestive. You see a sudden drop in the number of people in state mental hospitals. Then you see a corresponding sudden rise in the number of people in prison. It looks like there’s some sort of Law Of Conservation Of Institutionalization. Coincidence?
Yes. Absolutely. It is 100% a coincidence. Studies show that the majority of people let out of institutions during the deinstitutionalization process were not violent and that the rate of violent crime committed by the mentally ill did not change with deinstitutionalization. Even if we take the “15% of inmates are severely mentally ill” factoid at face value, that would mean that the severely mentally ill could explain at most 15%-ish of the big jump in prison population in the 1980s. The big jump in prison population in the 1980s was caused by the drug war and by people Getting Tough On Crime. Stop dragging the mentally ill into this.
Lopez himself wrote a nice piece on how most mentally ill people are not violent, and another nice piece on how most people in prison are there for violent offenses. But put these together, and you get that most mentally ill people do not end up in prison. Most of the people who got out of the mental hospitals during deinstitutionalization are getting by. Some of them are homeless, and that’s bad. But if you want to solve homelessness among the mentally ill, build homeless shelters, not state-run long-term mental hospitals.