In jails and prisons across the United States, mental illness is prevalent and psychiatric disorders often worsen because inmates don't get the treatment they need, says journalist Alisa Roth.

In her new book Insane: America's Criminal Treatment of Mental Illness, Roth investigates the widespread incarceration of the mentally ill in the U.S., and what she sees as impossible burdens placed on correctional officers to act as mental health providers when they're not adequately trained.

"It's unpleasant, it's loud, it's claustrophobic," she tells NPR's All Things Considered. "You see people who are desperately sick. I mean, desperately sick. One time when I was [at the Los Angeles County jail], corrections officers came out with a man who had been strapped into a wheelchair and was bleeding from his arm because he had scratched out a piece of his own flesh."

Another day she accompanied officers as they tried to get inmates to come out for recreation time or for a shower.

"And they opened the little door in the cell where you hand food trays through, and there was this almost overpowering smell of feces," Roth says, "because this man had smeared the walls of his cell."

By some counts, Roth says, as many as half of all inmates suffer from some sort of psychiatric disorder; jails in New York, Los Angeles and Chicago are now the three largest institutions providing psychiatric care in the U.S.

Some correctional institutions refused Roth's requests when she was researching her book to see their facilities. Others, including L.A. County's jail, allowed her inside — to see firsthand what happens there.



Interview Highlights

On what Roth learned about mental health care in the criminal justice system

It's easy to portray these people as monsters or otherworldly, and I think we need to remember they're real people who are just not getting the treatment they need. The officers, too, are legitimately concerned about having things thrown at them or being attacked. ...

Another thing that struck me there was this sense of people cycling through. We talk about the civilian mental health care system and the criminal justice system as two separate entities; [but] really, in a lot of cases, the patients in both of them are going back and forth between the two.

One day when I was there, there was a man who acted up in court and was sent back to the jail. He was strapped into a restraint chair for transport from the court to the jail, and I went with the officers to retrieve him and bring him back to a cell. And they kept talking to him because they knew him. He had been there a bunch of times before, and they kept saying, "Hey, what happened? What's going on?" And the man didn't say anything until we were getting off the elevator, and then he started asking if he could be sent back to his old cell.

On the scarcity of mental health treatment

It is astonishing to me how difficult it can be to access mental health care in this country. In Oklahoma, I visited community clinics – outpatient clinics in the community. What happens in Oklahoma is that if you come in with symptoms of mental illness, or somebody brings you in for symptoms of mental illness, you're given a score from one to four. And basically, if you are not actively suicidal or actively psychotic, you're going to be diverted to some other form of treatment. You're not going to get in to see a psychiatrist — or you're not going to get in to see a psychiatrist for months, and months and months.

Even figuring out where to go for treatment can be difficult. At one point, I was following somebody here in New York who had been in and out of the mental health care system, and in and out of jail and prison. And I wanted to see how many people — how many psychiatrists — in New York City alone accept Medicaid and how many of those would be accepting new patients at any given time.

I spent probably two days making phone calls. I should add that I made those calls without worrying about losing time from my job; I wasn't worried about running out of money on my cellphone; I wasn't worried about where I was going to sleep that night; I wasn't worried about getting my medication; I wasn't worried about where my next meal was coming from. And I finally gave up – I went to one of the public hospitals here in the city. I went to the Medicaid office; I explained to the very nice clerk what I wanted to do. She handed me a sheet of paper. She said, "Well, it really depends which Medicaid plan you're on." And there were, I forget, five or six different options. She said "You need to go online and look up the psychiatrist, and then you need to call the office, and see if they're accepting patients." It's just, it's so – who's going to do that? Who has the time or the wherewithal or even just the brainpower to do that?

On how she sees these issues improving

One of the heartening things I've found in all this very upsetting reporting is that there is a consensus that what we're doing is wrong. Whether we're talking about the people who are locked up and their families, or the corrections officers, or the prosecutors, the defense attorneys, the judges, the doctors — you name it. They're in agreement that what we're doing is not working, that it's counterproductive, that we need to change. We need to figure out how to come to a consensus about what that change looks like, but at least we're all on the same page – that this is not the way it should be and that nobody is benefiting from this situation.

Noah Caldwell and Renita Jablonski produced and edited the audio of this story. Sydnee Monday adapted it for the Web.



Copyright 2018 NPR. To see more, visit http://www.npr.org/.

AILSA CHANG, HOST:

To get a picture of the horrors of this country's psychiatric institutions in the mid-20th century, you can read or watch "One Flew Over The Cuckoo's Nest."

(SOUNDBITE OF FILM, "ONE FLEW OVER THE CUCKOO'S NEST")

SYDNEY LASSICK: (As Charlie Cheswick) I ain't no little kid.

LOUISE FLETCHER: (As Nurse Ratched) You sit down.

LASSICK: (As Charlie Cheswick) I ain't no little kid.

CHANG: Or you can do what Alisa Roth did - spend time in our present-day jails and prisons.

ALISA ROTH: We have recreated those asylums almost point-by-point.

CHANG: The journalist says that includes the brutality, the cruelty and the filth.

ROTH: Understaffing on the security side, understaffing on the medical side, under-trained mental health care workers, overmedication - it's like we've just rebuilt them and call them something else, but it's all the same problems.

CHANG: Alisa Roth investigates the widespread incarceration of the mentally ill in her new book "Insane: America's Criminal Treatment Of Mental Illness".

By some counts, she writes, as many as half of all inmates suffer from a psychiatric disorder. Some correctional institutions turned her away. Others, including the LA County jail, allowed her to see firsthand what goes on inside.

ROTH: What you see in Los Angeles County is a jail which is scary. It's unpleasant. It's loud. It's claustrophobic. You see people who are desperately sick - I mean, desperately sick. So one time when I was there, corrections officers came out with a man who had been strapped into a wheelchair and was bleeding from his arm because he had scratched out a piece of his own flesh.

I was walking around with officers one day, trying to get people to come out for recreation time or for a shower, what have you, and they opened the little door in the cell where you hand food trays through, and there was this almost overpowering smell of feces because this man had smeared the walls of his cell with feces like plaster.

CHANG: Wow. I was also struck by the attitude of some of the officers you talked to. I remember the nonchalant way one of the officers showed you his special knife for cutting down people trying to hang themselves. It was just like, yeah, this is just part of my uniform.

ROTH: Yeah, and it was just part of his job. Suicide is the leading cause of death in jails. And it was part of his job the same way as taking people out of their cells and bringing them for out-of-cell time.

CHANG: Yeah.

ROTH: At the same time, you know, it's easy to portray these people as monsters or otherworldly. And I think we need to remember that they are real people who are just not getting the treatment that they need. The officers, too, are legitimately concerned about having things thrown at them or being attacked. You know, the officers post signs on the cells saying, this man is a spitter or this one is will hold his door open when you try to put him back.

CHANG: Or throw feces at you.

ROTH: Or throw feces at you. I mean, another thing that struck me there was this sense of people cycling through. So we talk about the civilian mental health care system and the criminal justice system as two separate entities. And really, in a lot of cases, the patients in both of them are going back and forth between the two.

One day when I was there, there was a man who had acted up in court and was sent back to the jail. He was strapped into a restraint chair for transport from the court to the jail, and I went with the officers to retrieve him, bring him back to a cell. And they kept talking to him because they knew him. He'd been there a bunch of times before, and they kept saying, hey, what happened; what's going on? And the man didn't say anything until we were getting off the elevator, and then he started asking if he could be sent back to his old cell. And it sounded for all the world like somebody, you know, a businessman coming back to his favorite hotel in some city, saying, can I have...

CHANG: Right.

ROTH: ...You know, this room?

CHANG: The room, the penthouse, yeah.

ROTH: Exactly, exactly.

CHANG: You have this very amazing statistic that LA, New York and Chicago - the jails in those three cities are the three largest providers of mental health care now in the country.

ROTH: It's ridiculous, but it's true in just about every jurisdiction in the country. So LA and Chicago and New York are enormous, but it's true if you go to Rochester. It's true if you go to Albuquerque. This is truly a national crisis that's playing out at a very local level.

CHANG: The enormous numbers of mentally ill people you see in jails and prisons - for them, the story begins actually outside of jail or prison - right? - much earlier in a community where they just weren't given enough access to mental health care and then went along and did things that got them arrested. And the story goes on for them.

ROTH: It's astonishing to me how difficult it can be to access mental health care in this country. In Oklahoma, I visited community clinics - so, you know, outpatient clinics in the community. So what happens in Oklahoma is that if you come in with symptoms of mental illness or somebody brings you in with symptoms of mental illness, you're given a score. And basically if you are not actively suicidal or actively psychotic, you're going to be diverted to some other form of treatment. You're not going to get in to see a psychiatrist, or you're not going to get in to see a psychiatrist for months and months and months.

Even figuring out where to go for treatment can be difficult. At one point, I was following somebody here in New York who had been in and out of the mental health care system and in and out of jail and prison. And I wanted to see how many psychiatrists in New York City alone accept Medicaid and how many of those would be accepting new patients.

CHANG: And what did you find?

ROTH: I spent probably two days making phone calls. I should add that I made those calls without worrying about losing time from my job. I wasn't worried about running out of money on my cellphone. I wasn't worried about where I was going to sleep that night. I wasn't worried about getting my medication. I wasn't worried about where my next meal was coming from. And I finally gave up.

I went to one of the public hospitals here in the city. I went to the Medicaid office. I explained to the very nice clerk what I wanted to do. She handed me a sheet of paper. She said, well, it really depends which Medicaid plan you're on. And there were - I forget - five or six different options. She said, you need to go online and look up the psychiatrists, and then you need to call the office and see if they're accepting patients.

CHANG: Oy.

ROTH: It's just - it's so - who's going to do that?

CHANG: Right.

ROTH: Who has the time or the wherewithal or even just the brainpower to do that?

CHANG: Right - and persistence and focus to see it all through.

ROTH: Exactly.

CHANG: So who's paying attention to all of this? How is this all going to change?

ROTH: One of the heartening things I found in all this very upsetting reporting is that there is a consensus that what we're doing is wrong. Whether we're talking about the people who are locked up and their families or the corrections officers or the prosecutors, the defense attorneys, the judges, the doctors - you name it - we are in agreement that what we're doing is not working, that it's counterproductive, that we need to change. We need to figure out how to come to a consensus about what that change looks like. But at least we're all on the same page that this is not the way it should be and that nobody is benefiting from this situation.

CHANG: Alisa Roth is author of "Insane: America's Criminal Treatment Of Mental Illness." Thank you very much for joining us.

ROTH: Thank you for having me. Transcript provided by NPR, Copyright NPR.