Consider the case of Harvey. Harvey experiences paranoid delusions, and one evening, he can’t shake the feeling that someone is watching him from his closet. In his panic, he calls the police to come investigate the intruder. When the officers arrive, they do not find anyone besides Harvey, who is agitated and experiencing significant mental distress. This is the third time he has called in with similar complaints in the past 24 hours.

It is evident to the responding officers that Harvey is experiencing some sort of delusion, and since they cannot calm him down or convince him of his safety, they opt to detain him. The officers can do so, as in the United States, while the Fourteenth Amendment provides some guardrails to involuntary commitment, there is no federal statute regarding detention, and it is up to their discretion to detain him if they believe he could be a threat to himself or others. They attempt to bring him to the nearby hospital for care, but the emergency room and psychiatric unit are both at capacity. As Harvey is still exhibiting signs of distress, the officers do not want to release him and opt instead to take him to jail for the night.

While the case of Harvey is a hypothetical scenario, it is not a far stretch from the reality of many living with a mental illness in the United States. With limited mental health services available, especially in emergency situations, law enforcement officers have become de facto clinicians. While police have little to no mental health training, approximately one-third of individuals living with severe mental illness have their first contact with mental health treatment through a law enforcement encounter. It is up to the responding police officer to determine whether the individual will go to a hospital or to jail.

Yet, even if the police officer wants to assist the individual in receiving care, there is a chronic shortage of care available. While data is scarce, one estimate suggests that there are only about 20,000 beds in civil state psychiatric hospitals, yet 1.8 million people living with mental illnesses are booked into jail annually, meaning 25 times as many people who need mental health care are in correctional facilities as there are available civil state treatment facilities combined. This phenomenon has grown so prevalent that it has earned a name: “compassion arrest,” denoting the practice of detaining individuals experiencing mental illness when no appropriate treatment options are available.

Further, living with a mental illness has proven to significantly increase the chances of a fatal encounter with police. Individuals who live with an untreated serious mental illness are at 16 times greater risk of being killed when approached or stopped by law enforcement than other civilians—at least one in four fatal law enforcement encounters involves an individual with serious mental illness (note: this is a conservative estimate).

Within the carceral system, untreated mental illnesses are rampant in prison populations. Around 56% of individuals in state prisons were found to have indications of mental health problems. Yet, only one-fourth (around 26%) of this population has received any professional mental health treatment once entering prison.

The criminalization of mental illness is unfortunately not a new phenomenon (ex., Foucault’s Madness and Civilization); however, in the recent history of the United States, there was a historic benchmark set that paved the way for this precedent. In 1963, the Community Care Act was passed as an effort to shift mental health treatment away from abusive asylums and into community centers. While the institutions were shuttered, federal funding was never dispersed, leaving thousands of individuals without the proper care they needed. The lack of adequate resources, coupled with the rise of mass incarceration fueled by the intense focus on drug-related crimes since the 1980s, has led to law enforcement and carceral facilities to be the primary arbiters of mental health care.

Bioethics, Incarceration, and Mental Illness

In recent years, scholars, clinicians, and activists have voiced concerns about mass incarceration as a public health issue, including calls for public policy to end mass incarceration from a public health standpoint. Bioethicists have joined these efforts by emphasizing the pressing need to engage in issues related to mass incarceration and policing. Further, scholars have called for bioethicists to contribute to addressing racially-motivated violence, which is deeply embedded in the role the legal system plays in promoting inequities in Black communities.

However, little attention, particularly in bioethics, has been paid to the treatment of individuals with mental illness in the police and justice context, from initial police encounter to long-term imprisonment or institutionalization. In my recent work, I have called attention to how the interplay of the courtroom and the clinic in determining responsibility can lead to discriminatory treatment, as well as the role of law enforcement in coercive psychiatric interventions. As I continue to work on these pressing issues, I aim to connect and collaborate with others who are developing interdisciplinary approaches to addressing these concerns, both within and beyond the realms of bioethics and philosophy. 

The post Criminalizing Mental Illness: Cops as Clinicians and Incarceration as Health Care in the United States first appeared on Blog of the APA.