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Honors Theses Student Research
From prisons to asylums, and back : mental health
policy in the age of neoliberalism
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Martin, Michele, "From prisons to asylums, and back : mental health policy in the age of neoliberalism" (2015). Honors Theses. Paper 807.
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From Prisons to Asylums, and Back: Mental Health Policy in the Age of Neoliberalism By: Michele Martin Honors Thesis Submitted to Department of Political Science University of Richmond Richmond, VA May 1, 2015 Advisor: Dr. Rick Mayes Table of Contents Introduction
What does justice for people with mental illness require?
Participatory Parity and Severe Mental Illness
History of Civil Rights for the Mentally Ill
The Current State of Mental Health Care
Bifurcation between Wellness and Illness
The Unique Nature of Severe and Persistent Mental Illness (SPMI)
Mental Health Exceptionalism vs. Mainstreaming
Criminalization of the Mentally Ill: A Consequence of the Current System
Prisons to Asylums
Asylums Back to Prisons
“Command and Control” Culture
Overreliance on Psychotropic Medications
Sexual Victimization of Mentally Ill Inmates
Revolving Door Phenomenon
Why is the system the way it is?
Community Mental Health and how it failed to establish a Continuum of Care
Initial Attempts to Remedy the Disconnect Between Hospital and Community Care.......... 38 The 1980s and the Rise of Neoliberalism
Moving Forward: Towards Participatory Parity
Limitations of Mental Health Parity and the Need for Systemic Reform
Recommendation 1: Improved Case Management
Recommendation 2: Alter Mental Health Block Grant (MHBG)
This thesis seeks to explain why rates of severe mental illness in the criminal justice system have risen steadily throughout the past three decades, despite an increasing acknowledgement of the importance of mental health to overall health. Legislative, scientific, and societal advances have aimed at increasing access to and bolstering the quality of mental health care. Yet, the large numbers of severely mentally ill persons residing in the criminal justice system imply care in the community is not adequately serving their needs, or that, for whatever reason, they are not seeking care. I begin my analysis by considering mental health care through a justice lens, laying out three conditions that must be met if justice is to be served for persons with severe mental illness. The first is material-based and is that persons with severe mental illness should have access to the material resources necessary for them to thrive on par with the rest of society.
The second two are value-based and have more to do with the recognition this group receives.
First off, there should not exist institutionalized stigma attached to persons with severe forms of mental illness, and, second, policies should reflect the unique needs of this population. When all three of these conditions are met, parity of participation is achieved. This justice framework guides the rest of my paper, as I explore the current state of the United States mental health system, the consequences of its focus on mainstreaming, and the historical reasons why the system developed in the way it did. I end by looking forward to small-scale policy changes that move persons with severely mental illness closer to participatory parity. I ultimately conclude that, although these policies likely will aid in achieving some degree of participatory parity for this highly marginalized population of individuals, we as a society have a long way to go before such an ideal can be reached.
Introduction The primary research question this thesis seeks to answer is why, despite mental health parity legislation and an increasing awareness of the importance of mental health care in America, the rates of persons with mental illness in the criminal justice system continue to rise.
According to a November 2014 report by the Treatment Advocacy Center, a non-profit organization advocating for the improvement of treatment laws for mental illness, approximately 20 percent of inmates in jails and 15 percent of inmates in state prisons have been diagnosed with a severe mental illness.1 This statistic stands in stark contrast to the much lower 6.4 percent of inmates reportedly suffering from such illnesses in 1983. Although I recognize that mental illness is more frequently diagnosed today than it was 30 years ago, research unequivocally shows a definite switch from state mental hospitals to prisons and jails as the primary providers of inpatient mental health care for persons with severe mental illnesses.2 This marked increase is surprising given the host of legislation passed during this same time period to increase access to mental health services. On April 8, 2008, the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act (MHPAEA) was signed into law. This piece of legislation, which requires that insurance companies treat mental health the same way they do physical health, was viewed as a major milestone by mental health advocates in Congress, as it would supposedly increase access to treatment for individuals with all forms of mental illness.3 Following the passage of the MHPAEA, Patrick Kennedy, a United States Senator with a
history of mental illness is quoted as saying:
Treatment Advocacy Center, “How Many Individuals with Serious Mental Illness are in Jails and Prisons?” Treatment Advocacy Center, November 2014, accessed February 2, 2015, http://www.treatmentadvocacycenter.org/problem/consequences-of-non-treatment/2580.
Ibid Colleen Barry L. Barry, Haiden A. Huskamp and Howard H. Goldman, “A Political History of Federal Mental Health and Addiction Insurance Parity,” The Milbank Quarterly, 88 (2010): 406, accessed October, 2014, doi:10.1111/j.1468-0009.2010.00605.x.
This legislation is one more step in the long civil rights struggle to ensure that all Americans reach their potential. For far too long, health insurance companies have used the stigma of mental illness and substance abuse as an excuse to deny coverage for those biological disorders.4 Such quotes, uttered by fellow Congressional leaders, sufferers of mental illness and other mental health advocates in the days and weeks following the law’s passage, imply victory for Americans diagnosed with mental illness. Given the significant strides our country has made in the way we view and treat mental illness, this is a believable assumption. Organizations like the National Alliance on Mental Illness (NAMI) and Mental Health America (MHA) have worked tirelessly to reduce the stigma traditionally attached to these illnesses. And, although there is still a long way to go, medical researchers have discovered much about the causes of mental illnesses and thus have developed new and better methods for treating them.5 Despite these legislative and scientific victories, prisons and the streets continue to serve as the dumping grounds for many people with these illnesses. This paradox forms the basis of my inquiry. Medical professionals and the general public have agreed that prisons and jails are not suitable environments for persons with mental illness. So why does the criminal justice system today house nearly as many persons with severe mental illnesses as it did over 150 years ago? 6 This thesis seeks to unpack the historical and political forces that have created and sustained the above-explained paradox. I do so by identifying problems with the public mental health system and exploring its development. I then address the question of whether the achievement of federal mental health parity legislation is likely to improve the quality of life for those Americans suffering from severe mental illnesses. I argue that the concept of community Fred Frommer, “After 12 Years, Wellstone Mental Health Parity Act is Law.” MPR News, October 8, 2008.
Retrieved from http://www.mprnews.org/story/2008/10/03/parity_finalpassage.
Richard G. Frank and Sherry A. Glied, Better But Not Well: Mental Health Policy in the United States Since 1950 (Baltimore, Maryland: The Johns Hopkins University Press), 44.
E. Fuller Torrey, Aaron D. Kennard, Don Eslinger, Richard Lamb, and James Pavle, “More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States,” Treatment Advocacy Center, May 2010. Retrieved from http://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf.
mental health care, although well founded, was not effectively implemented. A lack of organization and neoliberal policies of the 1980s impeded the realization of a community-based continuum of care for mental illness. Furthermore, policymakers did not account for the fact that releasing mentally ill persons into the community would not automatically lead to freedom in a substantive sense. Given these realities, I provide suggestions for policymakers moving forward.
I begin my inquiry with a discussion of what justice looks like for persons with mental illness.
What does justice for people with mental illness require?
Capability is primarily a reflection of the freedom to achieve valuable functionings. It concentrates directly on freedom as such rather than on the means to achieve freedom…in this sense it can be read as a reflection of substantive freedom.
-Amartya Sen Introduction Justice for persons with mental illness requires a different kind of parity than that which has garnered so much attention in the policy realm over the course of the last two decades.
Although parity under insurance is an important piece of mental health reform, it alone cannot achieve justice for the mentally ill. A set of normative requirements for the treatment of mentally ill individuals in a democratic society like the United States is needed to ensure that justice is served for this group of citizens. I have developed such a set, relying heavily on concepts put forth by two prominent scholars, Amartya Sen and Nancy Fraser. Through a discussion of freedom, political agency and participatory parity, I lay out the ideological foundation for my argument for greater continuity of care in mental health. This section will proceed in three parts. In the first part, I outline the history of civil rights for the mentally ill.
This will be followed by a discussion of procedural versus substantive equality and the unfreedoms often associated with the former. The third section explains Nancy Fraser’s concept of participatory parity and its potential application in mental health policy.
Amartya Sen’s Capabilities Approach Amartya Sen, a development economist who advocates for a comprehensive view of development, provides a good starting point for uncovering the type of public policy that would lead to justice for the mentally ill. Sen’s capabilities approach to the evaluation of individual and social well-being is more inclusive than some of the more traditional approaches. While theorists like John Rawls and Ronald Dworkin tend only to focus on whether a person has the instrumental means to achieve well-being, the capabilities approach looks at whether that person is able to use those instruments.7 More broadly, Sen’s approach differs from three oft-cited schools of thought in ethics and economics: classical economics, utilitarianism and libertarianism. Unlike classical economists, Sen conceptualizes development as more than an increase in income or economic standing. For instance, Sen would say that rich countries in which some citizens lack access to basic healthcare should not be labeled as fully developed.8 Utilitarianism, on the other hand, in prioritizing the importance of mental satisfaction, does not leave room for the kind of constructive dissatisfaction that Sen views as a necessary prerequisite for positive social change. I focus mainly on Sen’s criticism of the libertarian approach; out of which I argue today’s approach to mental health policy emerged.
The libertarian school of thought emphasizes procedures for liberty, while virtually ignoring the consequences of such procedures. This approach to social evaluation focuses on whether a person has the instruments needed to achieve well- being but pays scant attention to whether a person has the ability to use these instruments.9 Sen’s capabilities approach goes a step further, taking into account substantive outcomes. He illustrates the idea in a book about freedom and Amartya Sen, Inequality Reexamined (New York: Russell Sage Foundation, 1992): 42.
Amartya Sen, Development as Freedom (Knopf Doubleday Publishing Group, 2011): 16.
Sen, Inequality Reexamined, 42.
inequality, drawing a comparison between “well-being freedom” and “achieved well-being.”10 While the former is procedural in nature and focuses only on the “levers of control,” the latter is a product of effective freedom.11 For those individuals who possess constraints that may interfere with their capacity to provide for their needs and pursue their ambitions, procedural freedom can be quite limiting.12 In essence, Sen’s approach to social evaluation reminds us that procedural equality does not always lead to substantive equality. It is important to recognize that Sen’s vision of freedom, although it serves a primer for thinking about how justice for the mentally ill might be achieved, is still highly individualistic and does not provide a call for collective action. For this reason, I have chosen Nancy Fraser’s concept of participatory parity as the primary model to guide my discussion of justice. Fraser ties to provide a way of uniting procedure with substance in a manner that is appropriate for a democracy and thus gives the nonill a reason to care about individuals with mental illness.