This is part 2 of the series “Asylum Was Once a Place of Safe Haven.” Don’t miss Part 1.
Hear the Rattle and Click as the Door Slams Home. Welcome to Prison.
Without true understanding of how many people were touched by mental illness and what actions needed to be taken to help care for their personal welfare upon release from healthcare facilities, a concurrent rise in homelessness and surge of patients into correctional facilities began to unfold. (11) In a 2013 report to Congress on nationwide homeless it was stated that 1.4 million people used a homeless shelter in a given year and a headcount of about 600,000 were sleeping on the street in a single night. (12) Approximately 40% of these individuals are believed to have a severe mental illness or chronic substance use disorder.
Today it is estimated that over 60% of all persons in U.S. state, local, and federal prisons have at least one mental health condition. (13) This poses a huge ethical issue where incarceration of the mentally ill bleeds the lines of not permitting basic human rights, let alone proper healthcare, for those with disabilities. What if a person with cognitive disability has a behavioral episode or is unable to understand that their decision making could ultimately lead to interaction issues with the broader public or law enforcement? Is it fair to use imprisonment as punishment? Could this exacerbate symptoms, leading to further degradation of health and behavior?
According to a major study by the National Institute of Corrections, suicide has been the leading cause of death for prison inmates over the last 20 years. This review of 700 suicide cases also found that roughly 40% of these victims had a history of mental illness. (14) The initial thought may be that some prisoners feel guilty for their crimes, but that is naively narrow considering the large population of those with mental health issues living in prisons instead of long-term care facilities.
The United Nations Convention for the Rights of People with Disabilities describes rehabilitation in the context of basic human rights, requiring governments to take “effective and appropriate measures” to “enable persons with disabilities to attain and maintain maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life.” (15) For those living with mental health problems, that has hardly been the case for well over 60 years.
A licensed creative arts therapist working in a forensic psychiatric facility within New York’s largest correctional system remarks, “Mental illness is the result of social transgenerational trauma transmission that damages a person’s brain development, cognition, and capacity for safe attachment to other human beings. Insurance companies don’t look into trauma theory, they only want measurable standards that are fueled by financial reasons and do not understand that therapists need to spend months to years working with someone who is severely mentally ill. The hope to create a different kind of relationship where trust is developed is difficult when insurance will only pay for the first five days of service.” Due to the complex nature of the work, this therapist has asked to remain anonymous.
Creative arts therapies are promoted in this facility given the positive impact on prisoners, namely those with serious mental illness who would normally not join in group activities. “Especially in a traumatized society, keeping people locked up damages their bodies in many ways. I find that my patients are incredibly receptive to the work we do and it is so interesting that some of those who are severely impaired enjoy it the most. They don’t have anything else expect their bodies and if you give them different opportunities to shape their anger, they don’t become self-destructive or destructive of others.”
These types of therapies are generally not covered by private insurance, but are slowly being integrated into correctional facilities and hospital systems. After decades of being unnoticed, a body of scientific research now exists to greatly support the efficacy of movement/dance, fine arts, and music therapies for certain populations, namely those with mental illness and incarcerated individuals. (16,17)
Money — Share It Fairly, But Don’t Take a Slice of My Pie
Generating services to provide help is possible, yet seems to not be as easy in practice in our society. First, the stigma needs to be removed. Fear and the lack of understanding that many mental health-related problems can undergo treatment and achieve full recovery creates a huge barrier. Then there’s the money…
When investigating the current financial state of mental healthcare in the U.S., the details are not easy to uncover. There have been decades of inappropriate decision making by individuals across many industries, including admittance of misconduct by the associations that were created to help the healthcare system. Today, care costs continue to rise and funding to aid mental health services falls, leaving a wake of hopeless victims stuck in the middle.
Decades of cuts in funding has led to degradation of the system, leaving little incentive for many qualified clinicians or specialized providers to actively participate. Payment would need to be made in order for complex care to be facilitated, but where would this money come from? According to 2015-2016 budget reporting from the National Alliance on Mental Health (NAMI), state funding for mental health services fell or remained unchanged in more than half of U.S. states for the second year in a row. (18)
The National Institute of Mental Health (NIMH) is the largest source of funding for mental health research, yet represents only 5% of the budget appropriated to the National Institute of Health (NIH). Looking back, the NIMH has had relatively flat annual funding levels since 2003 regardless of rises in medical inflation and the U.S. population. (19) This gives the NIMH practically the same purchasing power — how much services can be bought with each dollar — as they had in 1999. (20)
These are likely contributing factors to findings that nearly 60% of adults with mental illness do not receive any treatment. (21) Similarly, over half of sufferers admit that lack of insurance coverage or inability to afford care is the main reason for not receiving mental health services. (22) In 2013, the final ruling of the Mental Health Parity and Addiction Equity Act of 2008 was written into federal law, requiring financial coverage of services for mental health, behavioral health, and substance-use disorders to be equal or better than physical/surgical medical costs. (23) This is certainly a step in a positive direction, however there are some notable caveats — insurance companies can still limit services under what they believe is “medically necessary,” Medicare is not covered by this law, and it does not force providers to cover mental healthcare if they already do not provide it.
This is the second of a three-part series about the state of mental health care in America. Continue reading the end of the series in Part 3. Or read Asylum Was Once a Place of Safe Haven, Part 1 now.
11. Kim, D. (2014, August 13). Psychiatric Deinstitutionalization and Prison Population Growth: A Critical Literature Review and Its Implications. Criminal Justice Policy Review, 27(1), 3-21. doi:10.1177/0887403414547043
12.The U.S. Department of Housing and Urban Development. (2014). The 2013 Annual Homeless Assessment Report (AHAR) to Congress, Part 2, Estimates of Homelessness in the United States (Rep.). Retrieved from https://www.hudexchange.info/onecpd/assets/File/2013-AHAR-Part-2.pdf
13. National Council for Behavioral Health. (2015). Mental Health, Drug Use, and Prisons. Retrieved from http://www.thenationalcouncil.org/consulting-best-practices/national-council-shareables
14. National Center on Institutions and Alternatives, & Hayes, L. M. (2010). National Study of Jail Suicide: 20 Years Later. Washington, DC: U.S. Department of Justice, National Institute of Corrections. Retrieved from https://s3.amazonaws.com/static.nicic.gov/Library/024308.pdf
15. United Nations. (2006, December 6). Convention for the Rights of People with Disabilities (United States of America, United Nations, Department of Economic and Social Affairs). Retrieved from http://www.un.org/esa/socdev/enable/rights/convtexte.htm
16. Gussak, D. E. (2016, August 06). The Continuing Emergence of Art Therapy in Prisons. Emerging Issues in Prison Health, 67-84. doi:10.1007/978-94-017-7558-8_5
17. Tuastad, L., & O’grady, L. (2013, January). Music therapy inside and outside prison – A freedom practice? Nordic Journal of Music Therapy, 22(3), 210-232. doi:10.1080/08098131.2012.752760
18. AMI, the National Alliance on Mental Illness. (2015, December). State Mental Health Legislation, 2015: Trends, Themes and Effective Practices (Rep.). Retrieved from https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/State-Mental-Health-Legislation-2015/NAMI-StateMentalHealthLegislation2015.pdf
19. United States Census Bureau. (2015). Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2010 to July 1, 2015 (NST-EST2015-01) [XLSX]. Population Estimates, Population Change, and Components of Change. http://www.census.gov/popest/data/national/totals/2015/index.html
20. Insel, T. R., M.D. (2015). The Anatomy of NIMH Funding. Retrieved from http://www.nimh.nih.gov/funding/funding-strategy-for-research-grants/the-anatomy-of-nimh-funding.shtml
21. Smith, K., Ph.D., M.S.W., Kuramoto-Crawford, J., Ph.D., & Lynch, S., Ph.D., L.C.S.W. (2016, March 23). Availability of Payment Assistance for Mental Health Services in U.S. Mental Health Treatment Facilities (Rep.). Retrieved http://www.samhsa.gov/data/sites/default/files/report_2123/ShortReport-2123.html
22. The Substance Abuse and Mental Health Services Administration (SAMHSA). (2013, September 24). Affordability Most Frequent Reason for Not Receiving Mental Health Services (Rep.). Retrieved from http://www.samhsa.gov/data/sites/default/files/spot075-services-affordability-2013/spot075-services-affordability-2013.pdf
23. Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008; Technical Amendment to External Review for Multi-State Plan Program, Federal Register § 78 FR 68239 (2013).