Door Number Three

If we had to point at one major flaw in our society for the unspeakable tragedy in Newtown - what would it be?  Would we blame our 2nd amendment and the ability of Americans to own guns?  Would we point the finger at a culture that is saturated with violence and degradation in our media and entertainment?  Or would we perhaps look at how we changed the treatment and care of the mentally ill among us?

I vote for Door Number Three.

Curiously, during the period before deinstitutionalization, the mentally ill seem to have been less likely to be arrested for serious crimes than the general population. Studies in New York and Connecticut from the 1920s through the 1940s showed a much lower arrest rate for the mentally ill.⁶⁴ In an era when involuntary commitment was relatively easy, those who were considered a danger to themselves or others would be hospitalized at the first signs of serious mental illness. The connection between insanity and crime was apparent,⁶⁵ and the society took a precautionary approach. Mentally ill persons who were not hospitalized were those not considered a danger to others. This changed as deinstitutionalization took effect.

As early as 1976, studies of deinstitutionalized New York City mental patients showed that they had disproportionate arrest rates for rape, burglary, and aggravated assault.⁶⁶ A study of San Mateo County, California mental hospital patients also showed disproportionate arrest rates for murder, rape, robbery, aggravated assault, and burglary: for murder, 55 times more likely to be arrested in 1973, and 82.5 times more likely in 1972. Mental patients were about nine times more likely to be arrested for rape, robbery, aggravated assault, and burglary than the general population of the county.⁶⁷ Even patients with no pre-hospitalization arrests were five times as likely to be arrested for violent crimes as the general population.⁶⁸ Studies in Denmark and Sweden similarly show that psychotics are disproportionately violent offenders.⁶⁹ Recent surveys in the United States also show that “violence and violent victimization are more common among persons with severe mental illness than in the general population.”⁷⁰

Deinstitutionalization played a substantial role in the dramatic increase in violent crime rates in America in the 1970s and 1980s. People who might have been hospitalized in 1950 or 1960 when they first exhibited evidence of serious mental illness today remain at large until they commit a serious felony. The criminal justice system then usually sends these mentally ill offenders to prison, not a mental hospital.

The result is a system that is bad for the mentally ill: prisons, in spite of their best efforts, are still primarily institutions of punishment, and are inferior places to treat the mentally ill. It is a bad system for felons without mental illness problems, who are sharing facilities with the mentally ill, and are understandably afraid of their unpredictability. It is a bad system for the victims of those mentally ill felons, because in 1960, a mentally ill person was much more likely to have been hospitalized before victimizing someone else. It is a bad system for the taxpayers, who foot the bill for expensive trials and long prison sentences for the headline tragedies, and hundreds of thousands of minor offenses, instead of the much less expensive commitment procedures and perhaps shorter terms of treatment.

Deinstitutionalization of the mentally ill was one of the truly remarkable public policy decisions of the 1960s and 1970s, and yet its full impact is barely recognized by most of the public. Partly this was because the changes did not happen overnight, but took place state-by-state over two decades, with no single national event. While homelessness received enormous public attention in the early 1980s, the news media’s reluctance to acknowledge the role that deinstitutionalization played in this human tragedy meant that the public safety connection was generally invisible to the general public. The solution remains unclear, but recognizing the consequences of deinstitutionalization is the first step.