In One Flew Over the Cuckoo’s Nest, Ken Kesey describes two kinds of patients in the psychiatric hospital where the story is set: Acutes (“because the doctors figure them still sick enough to be fixed”) and Chronics (who are “in for good, the staff concedes”).

When Kristopher Rodriguez, a 31-year-old man from Florida, first went into the US criminal justice system in 2008, it seemed like he would have been classified as an Acute; now nearly a decade later, he would almost certainly qualify as a Chronic.

A tall, strapping boy whose friends called him Dino, as in “dinosaur”, Rodriguez was diagnosed with schizophrenia when he was around 14. His mother, Gemma Pena, had come home from work one night to find that he had disconnected the hot water heater, convinced that the CIA was using it to spy on him.

At first she thought his behavior was simply evidence of grief over his grandmother’s death a few months earlier; Rodriguez had been especially close to her. But when he continued to act strangely, saying he was hearing voices, Pena called the police and had him hospitalized against his will.

It was the first of perhaps a dozen times that she had him “Baker Acted”, as it is known in Florida – after the 1971 law governing involuntary hospitalizations. The next few years were a blur of doctors appointments, drug use, homelessness, arrests and voluntary and involuntary hospitalizations.

Rodriguez is currently serving a 10-year sentence in a Florida state prison for trying to rob somebody at gunpoint when he was 22. He spent five years in jail before he took the plea bargain; people with mental illness often spend far longer in jail waiting for their cases to be resolved.

During his time in jail, he was sick enough that he had to be hospitalized three separate times – twice for psychiatric crises and once because he was so psychotic that he mutilated his genitals. His mother said the second psychiatric hospitalization was the last time she saw him lucid.

Nevertheless, after he accepted a plea bargain, Rodriguez was transferred to prison. His first few months there, he lived in general population. (One wonders how Florida’s department of corrections was not notified of the extent of his illness before he arrived.) After a few months of occasional run-ins with prison staff, he was moved to a unit for prisoners with mental illness.

About a year ago, his condition deteriorated to such an extent that he was moved to the Lake Correctional Institution, a prison north-west of Orlando that is equipped with an inpatient psychiatric unit.

Even so, his mother says, her son remains severely psychotic, an assessment apparently shared by the Florida department of corrections, which regularly denies Pena visits on the basis that Rodriguez is too sick to see her.

More than 50 years after Kesey’s novel, state psychiatric hospitals of the sort he described are, like lobotomies, long gone. Yet if we think that the hellish world Kesey captured belongs to another era, we are deluded.



It’s true that the hospitals have mostly disappeared: between 1950 and 2000 the number of people with serious mental illness living in psychiatric institutions dropped from almost half a million people to about 50,000. But none of the rest of it has gone away, not the cruelty, the filth, the bad food or the brutality. Nor, most importantly, has the large population of people with mental illness, like Rodriguez, who are kept largely out of sight, their poor treatment invisible to most ordinary Americans.

The only real difference between Kesey’s time and our own is that the mistreatment of people with mental illness now happens in jails and prisons. Today, the country’s largest providers of psychiatric care are not hospitals at all, but rather the jails in Chicago, Los Angeles and New York City.

Across the country, correctional facilities are struggling with the reality that they have become the nation’s de facto mental healthcare providers, although they are hopelessly ill-equipped for the job. They are now contending with tens of thousands of people with mental illness who, by some counts, make up as much as half of their populations.

Little acknowledged in public debate, this situation is readily apparent in almost every correctional facility in the country. In Michigan, roughly half of all people in county jails have a mental illness, and nearly a quarter of people in state prisons do. In 2016, the state spent nearly $4m on psychiatric medication for state prisoners. In Iowa about a third of people in prison have a serious mental illness; another quarter have a chronic mental health diagnosis.

Meanwhile, nearly half of the people executed nationwide between 2000 and 2015 had been diagnosed with a mental illness and/or substance use disorder in their adult lives. When a legal settlement required California to build a psychiatric unit on its death row at San Quentin the 40 beds were filled immediately.

The mental health crisis is especially pronounced among women prisoners: one study by the US Bureau of Justice Statistics found that 75% of women incarcerated in jails and prisons had a mental illness, as compared with just over 60% and 55% of men, respectively. A more recent study showed that 20% of women in jail and 30% in prison had experienced “serious psychological distress” in the month before the survey, compared with 14% and 26% of men, respectively.

Although the overall number of people behind bars in the US has decreased in recent years, the proportion of prisoners with mental illness has continued to go up. In 2010, about 30% of people at New York’s Rikers Island jail had a mental illness; in 2014, the figure rose to 40% , and by 2017, it had gone up to 43%. Studies of the most frequently arrested people in New York, Los Angeles and elsewhere have found that they are far more likely than others to have mental illness, to require antipsychotic medications while incarcerated and to have a substance use problem.

That there are so many people with mental illness locked in our jails and prisons is but one piece of the crisis. Along with race and poverty, mental illness has become a salient feature of mass incarceration, one that must be accounted for in any discussion about criminal justice reform.

Mental illness affects every aspect of the criminal justice system, from policing to the courts to prisons and beyond. Nor are the effects limited to the criminal justice system; many people with mental illness cycle back and forth between jail or prison and living in the community.

The racial inequity of the criminal justice system has been widely noted: it is estimated that one out of every three African American men and one of every six Hispanic men born in 2001 will be arrested in their lifetimes.

But for Americans with serious mental illness, it is estimated that as many as one in two will be arrested at some point in their lives. It’s not just arrests. One in four of the nearly 1,000 fatal police shootings in 2016 involved a person with mental illness, according to a study by the Washington Post. The Post estimated that mental illness was a factor in a quarter of fatal police shootings in 2017, too.

People with mental illness are among the most disadvantaged members of our society, and when they end up in the criminal justice system, they tend to fare worse than others. People with mental illness are less likely to make bail and more likely to face longer sentences. They are more likely to end up in solitary confinement, less likely to make parole and more likely to commit suicide.

Yet jail and prison have become, for many people, their primary means of getting mental healthcare. Their experiences offer an especially eye-opening view of a criminal justice system that today houses more than two million people and costs us hundreds of billions of dollars a year.

Gemma Pena says that she writes her son regularly but that it’s been years since Kristopher has written back. She sent him pictures of herself and his brothers and nieces, but he tore them up.



When she does get to visit him, the son who used to take pride in being a natty dresser smells terrible and is often visibly dirty, as if he hasn’t bathed in weeks, even though she regularly puts money into his commissary account so that he can buy toiletries. (Prisoners who want basic items, from potato chips to a radio to toothpaste and shampoo, have to use the money in their commissary accounts, usually provided by family and friends.)

During their last visit he got so agitated, yelling and pounding his fists on the table, that the corrections officers handcuffed and shackled him, and took him away strapped into a wheelchair. His medical records show that his medication compliance has been spotty; sometimes Rodriguez refuses to take it, and other times it hasn’t been available because the supplier didn’t deliver it to the prison.

For years now, Rodriguez has been stuck in this sad limbo: according to the state, he is well enough to stay incarcerated, but far too sick to live in the general prison population or even to get regular visits from his mother.

Lawyers who have examined his case say his story is typical. Florida’s prisons have been the subject of repeated investigations for their treatment of prisoners with mental illness; so have jails and prisons in other states, including California, Illinois and Alabama.

The investigations are critical, as are the changes to policy and protocol that they can produce. But jails and prisons are filled with thousands of people like Kristopher Rodriguez. And as long as we continue to lock them up, the problem is going to keep getting worse.