The future of institutions as long-term residences for persons with mental illness is certainly an integral part of the discussion about mental health policy. Usually those discussions focus on state budgets and Medicaid reimbursement and compliance with Olmstead. But, I was intrigued with a recent piece on Scott Hensley's blog on npr.org “A Peaceful War on Mental Institutions”—coverage of a different chapter in the history of mental institutions.

I never realized that many conscientious objectors in World War II were assigned to mental institutions in lieu of military service. Their experiences are documented in a recent piece on NPR ("WWII Pacifists Exposed Mental Ward Horrors") and in two books—Acts of Conscience: World War II, Mental Institutions, and Religious Objectors (by Stephen Taylor and published by Syracuse University Press) and The Turning Point: How Men of Conscience Brought About Major Change in the Care of America's Mentally Ill (by Alex Sareyan and published by American Psychiatric Press).

As I read this tale of the evolution of human conditions within our mental institutions, I was first struck by how much had changed. Then my thoughts wandered to the millions of Americans with mental illness in our corrections system. If we had the same undercover reporting of conditions of these citizens, would the photos be far different?

For more information on mental health in the corrections context, check out:

• Three Times as Many People With Serious Mental Illness in Prisons Than in Psychiatric Hospitals
• Consensus Panel Develops Performance Measures for Correctional Mental Health

We are soon to have a number of states release county and state prisoners early—in order to reduce corrections budgets. While I’m all for ending our practice of incarcerating Americans for lack of available metnal health and addiction treatment, I think the current wave of early releases may actually end up costing us more without some planning.
The ‘Exhibit A’ for my conclusion is a recent report in Psychiatric Services on Bazelon Center's Blueprint for Community Reentry.

The piece has some grim statistics—approximately 16% of all prison and jail inmates have a serious mental illness, and more than half have a clinical diagnosis, a treatment history, or symptoms of mental illness. Within 18 months of release, 64% of those with mental illnesses are rearrested—more than twice the rate of those without mental illnesses. Entitlements such as Medicaid and Medicare, veterans benefits, and Social Security income support enable individuals to obtain mental health care, housing, and other services. Without assistance, released inmates often wait months for benefits—a major factor in their high recidivism rate. However, only a third of inmates receive benefits restoration planning that is essential to preventing reincarceration.

Wired Magazine never fails to make me think. The October 2009 issue featured “The Smart List: 12 Shocking Ideas That Could Change the World.” There were six ideas that have specific relevance to our field:

1. Recruit Autistics. "A preternatural capacity for concentration and near-total recall" makes autistic folks ideal software engineers according to Thorkil Sonne, who founded Specialisterne in Denmark, an IT consultancy that hire mostly people with autism-spectrum disorders.
2. Embrace Human Cloning. Human clones walk among us—identical twins—so why not take in vitro fertilization to its logical conclusion?
3. Make Health Risk Management Meaningful. According to Ralph Keeney, 55% of deaths for people aged15 to 64 are now due to their own decisions—compared to 5% a century ago. Provide people with better calculations of risk (for not using seatbelts, not exercising, bad diets, etc.) and then adjust health premiums accordingly.
4. Release All Nonviolent Offenders in Prison. Incarcerating nonviolent criminals costs us $22,000 per year—and has no social gain. Make nonviolent offenders go to counseling, get an education, do public serivce, and repay their victims.
5. Legalize Assisted Suicide. Ludwig Minelli, founder of Dignitas, a right-to-die organization, believes that prohibiting suicide doesn't keep desperate people from trying. Instead, provide dignified options—and counseling for people considering suicide.
6. Forget Medical Privacy. Guest commentator Jamie Heywood of PatientsLikeMe believes "privacy has been used as an excuse by those who have a vested interest in hoarding" health care information. He wants us to share our personal data on-line in social communities.

You may or may not agree with them—but, if implemented, they certainly will change our world.

I read not long ago that the State of Georgia is sending released sex offenders to live in a camp in the woods near Marietta, Georgia—even those who own their own homes. There are a myriad of factors that have lead to this situation—zoning laws, parole requirements necessitating these individuals to stay a certain distance from children, and lack of suitable housing (the Associated Press reported that "there is only one homeless shelter in Georgia that fulfils the residency requirements for sex offenders, but it only has two beds, which are usually occupied."). I don't think it's acceptable for our leaders to throw up their hands about the inevitability of this situation, as if they were powerless to effect change.

I find this to be part of a troubling change in our view of the acceptability of treating ‘undesirable’ fellow citizens inhumanely. I think this change in thinking is a threat—a slippery slope in the floor of acceptable treatment—for the consumers we serve. One day it's okay to send people to jail because they have no mental health treatment (they need to exhibit some self control and not act in ways that will land them in jail); the next day it's acceptable to close critical health care services that will result in the death of uninsured persons (who should work hard enough to have insurance); and then we can sentence people (dastardly people who prey on children) to living in encampments without even the human supports of leper colonies of old.

In the behavioral health and social service niche, we serve and advocate for a group of individuals unattractive in popular culture. Runaway teens living on the streets, drug addicts, "the retarded", and more. I caution us all to not stand by when this growing acceptance of inhumanity occurs. For those of you who are not swayed by dewy-eyed humanitarian thinking, you can ponder the immortal words of Ronald Reagan who said, "Protecting the rights of even the least individual among us is basically the only excuse the government has for even existing…”

September 3, 2009

I rarely weigh in on forensic issues in our field; my view is that this is the province of lawyers and politicians. However, I recently received an opinion piece, "Morning Bell: Adult Times for Adult Crimes," from The Heritage Foundation that I couldn’t let pass without comment. The long and the short of The Heritage Foundation position is that the U.S. should not reconsider its policy of sentencing juveniles to life in prison without the possibility of parole. The support for their position is based on a study, "Adult Times for Adult Crimes: Life Without Parole for Juvenile Killers and Violent Teens" by legal scholars Charles D. Stimson and Andrew M. Grossman, of The Heritage Foundation's Center for Legal and Judicial Studies.

To buttress their argument, The Heritage Foundation cites the fact that eleven other countries in the world allow juveniles to be sentenced to life in prison without parole. However, after viewing the United Nations Human Rights Council's 2009 Statement on Juvenile Sentencing (cited in The Heritage Foundation's article), I’m not so sure. The statement includes the following passage, "Eleven countries have laws with the potential to permit the sentencing of child offenders to life without possibility of release: Antigua and Barbuda, Argentina, Australia, Belize, Brunei, Cuba (legislation pending), Dominica, Saint Vincent and the Grenadines, the Solomon Islands, Sri Lanka (legislation pending), and the United States. Currently, there is no evidence of any country, besides the United States, with child offenders sentenced to life without the possibility of release." So much for that evidence.

Some more interesting facts on juvenile life imprisonment come from the same UNHRC statement:

8. The Convention on the Rights of the Child (“CRC”), ratified by every country in the world except the United States and Somalia, codifies an international customary norm of human rights that recommends against life sentences and forbids the sentencing of child offenders to life in prison without possibility of release.14 There are now 135countries that have rejected the sentence through domestic legal commitments and 185 countries that have voted for the resolution in the General Assembly.15 The prohibition, arguably, has now reached the level of a jus cogens norm. As such, it is binding on all states, including those that have not formally ratified it themselves.

10. Customary international law is part of domestic law in the United States and, therefore, juvenile life sentences without the possibility of parole should be prohibited.19 Juvenile life sentences have not been consistently and historically applied. 20 The sentence was not used on a large scale until the 1990s when at least 40 states passed laws increasing the options for sending juveniles to adult courts.21

11. In the United States, there are an estimated 2,484 juveniles serving life sentences without parole. 22 Nationally, 59% of children were sentenced to life without the possibility of release for their first ever criminal conviction. Of these children, 16% were between the ages of 13 and 15 when they committed their crimes, and 26% were sentenced under a felony murder charge, where they did not pull the trigger or carry the weapon.23 In addition, African American youth are disproportionately represented through every stage of the juvenile justice process, including among those children serving life sentences without the possibility of release.24

Regardless of the policies of other countries, the reason for my commentary is that this flies in the face of emerging research on brain development. At this year's Chautauqua Institution, "State of Mind” conference, I attended the update on new brain research from John J. Ratey, Associate Clinical Professor of Psychiatry at Harvard Medical School. One of my takeaways from his update is that new science tells us human brains do not mature until the age of 25 or so. It seems to me that—despite how horrific the crime—to sentence juveniles with not-yet-fully-developed brain functioning to prison sentences with no opportunity for societal repatriation in their later, mature years is indeed cruel and unusual punishment.