America's Criminal Treatment of Mental Illness


By Alisa Roth

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An urgent exposéf the mental health crisis in our courts, jails, and prisons

America has made mental illness a crime. Jails in New York, Los Angeles, and Chicago each house more people with mental illnesses than any hospital. As many as half of all people in America’s jails and prisons have a psychiatric disorder. One in four fatal police shootings involves a person with such disorders.

In this revelatory book, journalist Alisa Roth goes deep inside the criminal justice system to show how and why it has become a warehouse where inmates are denied proper treatment, abused, and punished in ways that make them sicker.

Through intimate stories of people in the system and those trying to fix it, Roth reveals the hidden forces behind this crisis and suggests how a fairer and more humane approach might look. Insane is a galvanizing wake-up call for criminal justice reformers and anyone concerned about the plight of our most vulnerable.



NEAR THE BEGINNING OF KEN KESEYS 1962 novel, One Flew Over the Cuckoo’s Nest, the narrator recalls seeing a public relations man give a tour of the psychiatric hospital where the story is set. Boasting of how far things have come from the “old-fashioned cruelty” that used to reign in such places, he tells a group of visiting teachers, “What a cheery atmosphere, don’t you agree?… Oh when I think back on the old days, on the filth, the bad food, even, yes, brutality, oh, I realize ladies that we have come a long way.”1

As Kesey’s novel makes devastatingly clear, however, this new-and-improved institution simply offers the same old abuse in a different package. The book centers around the struggle between Randle McMurphy, a rebellious small-time criminal who feigns mental illness to avoid prison time—memorably played by Jack Nicholson in the 1975 film adaptation—and Nurse Ratched, the sadistic manager of the psych ward where he has been sent. McMurphy convinces the other patients to support him in an insurrection against Ratched’s control; she eventually puts an end to it by having McMurphy lobotomized.

Few other works of fiction or nonfiction have so indelibly captured the horrors of psychiatric hospitals in the mid-twentieth century, from the lack of any real effort to cure patients to outright abuse of the kind the public relations man promised had disappeared; the overmedication of the patients; the forced inactivity; the humiliating and unsanitary conditions (“[one patient] stood so long in one spot the piss ate the floor and beams away under him”).2

More than fifty years later, state psychiatric hospitals of this sort are, like lobotomies, long gone. Yet when we think that the hellish world Kesey captured belongs to another era, we are just as deluded as his fictional PR man. It’s true that the hospitals have mostly disappeared: between 1950 and 2000 the number of people with serious mental illness living in psychiatric institutions dropped from almost half a million people to about fifty thousand.3 But none of the rest of it has gone away, not the cruelty, the filth, the bad food, or the brutality. Nor, most importantly, has the large population of people with mental illness who are kept largely out of sight, their poor treatment invisible to most ordinary Americans.

The only real difference between Kesey’s time and our own is that the mistreatment of people with mental illness now happens in jails and prisons. Today, the country’s largest providers of psychiatric care are not hospitals at all, but rather the jails in Chicago, Los Angeles, and New York City. Across the country, correctional facilities are struggling with the reality that they have become the nation’s de facto mental health care providers, although they are hopelessly ill-equipped for the job. They are now contending with tens of thousands of people with mental illness who, by some counts, make up as much as half of their populations.

Little acknowledged in public debate, this situation is readily apparent in almost every correctional facility in the country. In Michigan roughly half of all people in county jails have a mental illness, and nearly a quarter of people in state prisons do. In 2016 the state spent nearly $4 million on psychiatric medication for state prisoners.4 In Iowa about a third of people in prison have a serious mental illness; another quarter have a chronic mental health diagnosis.5 Meanwhile, nearly half of the people executed nationwide between 2000 and 2015 had been diagnosed with a mental illness and/or substance use disorder in their adult lives.6 When a legal settlement required California to build a psychiatric unit on its death row at San Quentin, the forty beds were filled immediately. The mental health crisis is especially pronounced among women prisoners: one study by the US Bureau of Justice Statistics found that 75 percent of women incarcerated in jails and prisons had a mental illness, as compared with just over 60 and 55 percent of men, respectively.7 A more recent study showed that 20 percent of women in jail and 30 percent in prison had experienced “serious psychological distress” in the month before the survey, compared with 14 percent and 26 percent of men, respectively.8

Although the overall number of people behind bars in the United States has decreased in recent years, the proportion of prisoners with mental illness has continued to go up. In 2010, about 30 percent of people at New York’s Rikers Island jail had a mental illness; in 2014, the figure rose to 40 percent, and by 2017, it had gone up to 43 percent.9 Studies of the most frequently arrested people in New York, Los Angeles, and elsewhere have found that they are far more likely than others to have mental illness, to require antipsychotic medications while incarcerated, and to have a substance use problem.

That there are so many people with mental illness locked in our jails and prisons is but one piece of the crisis. Along with race and poverty, mental illness has become a salient feature of mass incarceration, one that must be accounted for in any discussion about criminal justice reform. Mental illness affects every aspect of the criminal justice system, from policing to the courts to prisons and beyond. Nor are the effects limited to the criminal justice system; many people with mental illness cycle back and forth between jail or prison and living in the community. The racial inequity of the criminal justice system has been widely noted: it is estimated that one out of every three African American men and one of every six Hispanic men born in 2001 will be arrested in their lifetimes.10 But for Americans with serious mental illness, it is estimated that as many as one in two will be arrested at some point in their lives.11 It’s not just arrests. One in four of the nearly one thousand fatal police shootings in 2016 involved a person with mental illness, according to a study by the Washington Post. The Post estimated that mental illness was a factor in a quarter of fatal police shootings in 2017, too.12

People with mental illness are among the most disadvantaged members of our society, and when they end up in the criminal justice system, they tend to fare worse than others. People with mental illness are less likely to make bail and more likely to face longer sentences.13 They are more likely to end up in solitary confinement, less likely to make parole, and more likely to commit suicide.14 Yet jail and prison have become, for many people, their primary means of getting mental health care. Their experiences offer an especially eye-opening view of a criminal justice system that today houses more than two million people and costs us hundreds of billions of dollars a year.

Diagnosing and treating mental illness is complicated. Unlike physical diseases like diabetes or cancer, there is no definitive test, and our assumptions about what constitutes “craziness” have continued to shift over the centuries. In biblical times and still today in some cultures, seeing visions or hearing voices is an indication of holiness, not madness. I spoke to the mother of a man with severe mental illness who recalled telling her son that the voice he heard couldn’t be Jesus because Jesus would never say such awful things. Others might consider it a sign of mental illness to hear Jesus saying anything, good or bad. Even medical understanding of sanity is ever-changing: as recently as 1973, the Diagnostic and Statistical Manual of Mental Disorders—the preeminent guide to psychiatric diagnosis and treatment—listed homosexuality as a disease. (It was not until 1987 that homosexuality was completely removed from the DSM.)

Beyond the difficulties of diagnosis, finding an effective way to treat serious diseases such as bipolar disorder or schizophrenia is often a matter of trial and error. Sometimes, a medication regimen stops working. Many psychotropic medications have severe side effects. The likelihood of side effects emerging increases the longer a person takes these medicines; sometimes the side effects are so bothersome that patients decide to quit taking them.

In One Flew Over the Cuckoo’s Nest, Kesey describes the two kinds of patients in the hospital as Acutes (“because the doctors figure them still sick enough to be fixed”) and Chronics (who are “in for good, the staff concedes”).15 When Kristopher Rodriguez, a thirty-one-year-old man from Florida, first went into the criminal justice system, it seemed like he would have been classified as an Acute; now nearly a decade later, he would almost certainly qualify as a Chronic. A tall, strapping boy whose friends called him Dino, as in “dinosaur,” he was diagnosed with schizophrenia when he was around fourteen. His mother, Gemma Pena, had come home from work one night to find that he had disconnected the hot-water heater, convinced that the CIA was using it to spy on him. At first she thought his behavior was simply evidence of grief over his grandmother’s death a few months earlier; Rodriguez had been especially close to her. But when he continued to act strangely, saying he was hearing voices, Pena called the police and had him hospitalized against his will.

It was the first of perhaps a dozen times that she had him “Baker Acted,” as it is known in Florida. (The Baker Act was named for Maxine Baker, a member of the Florida state legislature who pushed for the 1971 law that today governs involuntary commitments in the state.) The next few years were a blur of doctors’ appointments, drug use, homelessness, arrests, and voluntary and involuntary hospitalizations, a history that his mother has documented in four overstuffed shopping bags she keeps hidden away in her rented efficiency apartment in Hialeah, a Miami suburb that has a large Cuban population.

The papers and mementos she spreads on the neatly made double bed include photos of her son as a dark-haired baby with fat cheeks and dark eyes, the remnants of his baseball card collection, certificates of achievement from the taekwondo class he took in middle school, the footprint the hospital took when he was born, letters from mental health clinics following up on missed appointments, worn snapshots of him as a twelve-year-old in his Navy Cadets uniform, and old prescription bottles, some with medication to manage his mental illness still inside: Abilify, Clozaril, Benzotropine. When a hurricane threatened to flood her ground floor apartment recently, she put all the documents into plastic bins, which she wrapped in plastic bags and set on the high bar table in her kitchen alcove. “I had to save my son’s records,” she said. “That was my main concern.”

She keeps them all as if sheer existence of this detritus, this catalog of his long-ago accomplishments might somehow propel him back on track. She hopes the medical records will help him re-qualify for Social Security Disability when he gets out of prison. The pills she keeps as evidence in case he ever decides to join one of the lawsuits alleging that the medication leads to compulsive gambling and other problems.

The dusty artifacts, infused with cigarette smoke, also serve as evidence of her devotion to what could be called the Kristopher Project, the frustrating and years-long effort to manage his illness: all the times she went to court to have him committed to the psychiatric hospital, the pillbox she bought and filled in a vain attempt to help him take his medication, and scraps of paper scrawled with phone numbers of doctors, lawyers, and social workers. Pena, who trained as a medical technician and currently works as an administrative assistant in the maternity clinic at a hospital near her home, attributes her tenacity to maternal love. “I decided to be a mother,” she says frequently. “God gives us choices, and I chose to be a mother.”

Rodriguez is currently serving a ten-year sentence in a Florida state prison for trying to rob somebody at gunpoint in 2008, when he was twenty-two. He spent five years in jail before he took the plea bargain; people with mental illness often spend far longer in jail waiting for their cases to be resolved. During his time in jail, he was sick enough that he had to be hospitalized three separate times—twice for psychiatric crises and once because he was so psychotic that he mutilated his genitals. His mother said the second psychiatric hospitalization was the last time she saw him lucid.

Nevertheless, after he accepted a plea bargain, he was transferred to prison. His first few months there, he lived in general population. (One wonders how Florida’s department of corrections was not notified of the extent of his illness before he arrived.) After a few months of occasional run-ins with prison staff, he was moved to a unit for prisoners with mental illness. About a year ago his condition deteriorated to such an extent that he was moved to the Lake Correctional Institution, a prison northwest of Orlando that is equipped with an inpatient psychiatric unit. Even so, his mother says, her son remains severely psychotic, an assessment apparently shared by the Florida Department of Corrections, which regularly denies Pena visits on the basis that Rodriguez is too sick to see her.

Pena says that she writes her son regularly but that it’s been years since he’s written back. She sent him pictures of herself and his brothers and nieces, but he tore them up. When she does get to visit him, the son who used to take pride in being a natty dresser smells terrible and is often visibly dirty, as if he hasn’t bathed in weeks, even though she regularly puts money into his commissary account so that he can buy toiletries. (Prisoners who want basic items, from potato chips to a radio to toothpaste and shampoo, have to use the money in their commissary accounts, usually provided by family and friends.) During their last visit he got so agitated, yelling and pounding his fists on the table, that the corrections officers handcuffed and shackled him, and took him away strapped into a wheelchair. His medical records show that his medication compliance has been spotty; sometimes Rodriguez refuses to take it, and other times it hasn’t been available because the supplier didn’t deliver it to the prison.

For years now, Rodriguez has been stuck in this sad limbo: according to the state, he is well enough to stay incarcerated but far too sick to live in the general prison population or even to get regular visits from his mother. Lawyers who have examined his case say his story is typical. Florida’s prisons have been the subject of repeated investigations for their treatment of prisoners with mental illness; so have jails and prisons in other states, including California, Illinois, and Alabama. Indeed, jails and prisons across the country are filled with thousands of people like Kristopher Rodriguez.

Tom Dart, the sheriff of Cook County, Illinois, which encompasses the greater Chicago area, says there is a fundamental mismatch between the legions of people with mental illness who inhabit jails and prisons and the services that those jails and prisons are able to provide. So critical is the problem that in 2015, Dart appointed a clinical psychologist to run the Cook County Jail, one of the largest in the country, which he oversees. (It’s far more typical for wardens to rise through the ranks of corrections officers or other law enforcement.) “It would be no different if you were to populate college calculus classes with… preschool kids,” he told me. “You would imagine, the professor doesn’t know how to deal with it, it’s the wrong population for this class, but you keep filling the class with four-year-olds.”

When I first started reporting on mental illness in the criminal justice system, I believed the oft-heard explanation that this crisis was the result of closing the state psychiatric hospitals: beginning in the 1960s, we took people out of asylums, and because there was no place else for them to go, they moved, more or less directly, into jails and prisons. But I quickly discovered that the story was far more complicated. The severe neglect of community mental health care in the United States has certainly contributed to the extraordinary number of people with mental illness behind bars. But far worse than that, I came to realize, we have re-created much of the same dysfunction that pervaded the asylums of the nineteenth and twentieth centuries and the very abuses we sought to end by shutting them down. Overcrowding is common, oversight is poor, and abuse is widespread. There is also a more fundamental problem than the sheer number of people with mental illness who get arrested and end up in jails and prisons, or the ways they are treated when they get there. In many cases, they shouldn’t be there at all.

The patchwork of institutions and entities—cops, courts, and correctional facilities—that together make up our criminal justice system is deeply fragmented and bureaucratic. Throughout our history we have struggled to figure out what transgressions should be considered crimes: for a brief period within my grandparents’ lifetimes, it was against the law to drink a glass of wine; within my parents’ lifetimes, interracial marriage was illegal. In my adult life, I have watched marijuana become legal in state after state. Over the last forty years, the War on Drugs, in combination with aggressive policing tactics like broken windows—cracking down on small crimes to deter people from committing larger ones—drove millions of people into the criminal justice system. And mandatory sentencing laws kept them there for longer and longer periods. State after state has looked to redefine crimes, in part as a way to manage overcrowding in prisons: in 2010, for example, South Carolina raised from $1,000 to $2,000 the threshold at which theft was considered a felony so that fewer people would go to prison for the crime, one of at least thirty-five states to make similar changes since 2001.16 Where marijuana use was once a punishable offense, seven states and DC have now legalized it for recreational use.17 And several states have begun to view possession of smaller amounts of drugs as misdemeanors, not felonies.

There is still little consensus about the rationale for incarceration: is it deterrence, rehabilitation, or retribution? Given the dramatic overrepresentation in our jails and prisons of people of color and low-income people, it could be argued that the reality has as much to do with oppression and social control as it does with any coherent theory of punishment. Regardless, we have created a system that has left the United States with by far the highest per capita incarceration rate of any large nation in the world.

It’s important to acknowledge how often race, poverty, and mental illness overlap in the criminal justice system, creating a mutually reinforcing downward spiral. But of all the gross imbalances of our current approach to criminal justice, perhaps no group has been hurt as much as people with mental illness. Once they are caught in the criminal justice system, they are far less able to cope with its demands and are at much higher risk for exploitation and abuse. This book seeks to understand why we are shunting some of the most vulnerable people in America into jails and prisons—and why have they been so mistreated when they get there.

In examining the complicated forces behind this crisis, I hope to spur action to end the abuses and to bring more compassion and common sense into the way we approach mental illness in our society. In the course of my research, I have found that people in one jurisdiction or even one area of the criminal justice system are often unaware of what their counterparts in other places or other parts of the system are doing. This book is addressed to the general reader. But I hope that the links made here will encourage practitioners of both law and medicine and others who are involved with mental illness and criminal justice to see that any true reform will require coordination and engagement on many levels and, ultimately, in many places.

We will hear stories of unbearable cruelty, abuse, and neglect. We will also see countless kind acts and unlikely heroes—including corrections officers and judges, attorneys and doctors, family members and social workers—who have, like Kesey and nineteenth-century reformer Dorothea Dix, made the mistreatment of people with mental illness their cause. And we’ll see the courage and determination of people who, despite varying degrees of “sanity,” struggle to fight the system and improve their lives.

The first part of the book, “Ensnared,” shows how and why people with mental illness are so easily swept into the criminal justice system. It begins with the story of Bryan Sanderson, a former firefighter and amateur comedian whose bipolar disorder ruins his career, destroys his marriage, and lands him in the criminal justice system, where, untreated and increasingly psychotic, he is driven to unspeakable acts of self-harm; he now devotes his time to teaching police how to deal with people with mental illness. This section also visits the special mental health units at the Los Angeles County Jail, showing the dark reality of care at one of the nation’s largest jails and the extraordinary challenges faced by the medical and security personnel who work there. A third chapter then looks back at the history of mental health care and criminal justice in this country, showing the extent to which the problems we confront today have been with us since the establishment of the first jails and hospitals in the colonial era.

The second part of the book, “Locked Up,” looks at how jails and prisons have taken on the job of providing mental health care. It explores the difficulties of providing quality care in this setting and the abuses—both official and unofficial—that can result. The tragic story of Jamie Wallace, a young man incarcerated in the Alabama prison system—which some have called the worst in the country—shows how the combination of mental illness and a dysfunctional system can be deadly.

The third part, “Breaking Free,” shows how difficult it is for people with mental illness to get out of the system once they are in it. It looks at the ways that mental illness puts people at a disadvantage in interactions with both law enforcement and the courts, as well as some nationwide efforts to keep people out of the jail and prison to begin with, by disrupting the structures seen in the first two parts of the book. Much of this is examined through the story of Kyle Muhammad, a man who has tried over and over again to stay on the right side of the law. His mother has, more than once, called the police on him to ensure his safety despite the risk of his getting caught in the criminal justice system again.

Our understanding of mental illness has come a long way over the past two centuries. Thanks to brain scans, we now know that the brains of some people with bipolar disorder respond differently to lithium than others.18 Researchers have found genes that are linked to an increased likelihood of developing schizophrenia, so in the future we may be able to help people mitigate their risk of developing these illnesses, much as we already can with things such as diabetes, heart disease, and many cancers.19 The pharmaceuticals we have today, while imperfect, are much more effective at treating symptoms of the diseases than earlier ones, and they are a far cry from early, often cruel treatments such as lobotomies or water immersion—a therapy that involved suspending patients in tubs of water for days on end.

Yet in so many other ways, we continue to treat people with mental illness almost exactly as we did before electricity was invented, before women had the right to vote, and before the abolition of slavery. We still lock sick people away from the rest of society. We still keep many of them in solitary confinement. We still fail to provide adequate treatment for them. And we have known almost since the beginning that all of this is wrong. It’s wrong because it doesn’t cure mental illness or prevent people with mental illness from committing crimes when they get out. And it’s wrong because locking up vulnerable people in inhumane conditions is fundamentally immoral.

That we know all this but continue to relegate sick people to our courts, our jails, and our prisons shows how irrational—how insane—our approach to both mental health care and criminal justice remains.

Author’s Note

REPORTING ON THE CRISIS OF mental health illness in our prisons and jails has taken me deep into two of the most closed worlds—mental health care and criminal justice—in the United States. In addition to official rules that limit information flow—HIPAA and sealed court records, among others—the stigma of both mental illness and a criminal record is very real. As a journalist, I have struggled to reconcile my deep-seated belief in open records and information sharing with a desire not to harm people or expose them to unnecessary discrimination.

Wherever possible, I have sought to use in my accounts the real names and identifying characteristics of those interviewed. Unless otherwise noted, I have identified public officials, jail and prison employees, and law enforcement officers by their real names. In some cases I have chosen to refer to a person who only appears once or twice by a generic reference—“a physician who works in a jail,” for example—rather than by naming her. Unless otherwise noted, this is simply to avoid bogging down the stories with extraneous detail.

For the prisoners and former prisoners themselves, I have approached the question on a case-by-case basis. Bryan Sanderson and Brian Nelson have both generously agreed to let me use their real names. The person I call Kyle Muhammad shared his stories and his records with me in exchange for anonymity, which I have granted him. Jamie Wallace is dead, but many details of his life and his case are in the public record; other information has been provided to me by his family members and friends. The generous access I was given to the commitment hearings at Bellevue Hospital and at the restoration-to-competency classes at the Fulton County Jail was in both cases contingent on my maintaining the anonymity of the participants.

Some situations were less clear-cut: during my time at the Los Angeles County Jail, for example, I learned the names of a number of the people being held there. With that information I was often able to use public records to learn more details of their cases. However, because they did not know why I was there and they were not given an opportunity to object to my presence, I have chosen not to identify them by their real names. Finally, in the Epilogue my own connection to the story meant that I have been privy to many more details than I would have been otherwise, and I chose not to use the real name of the person I refer to as “Matthew,” or that of “Mr. Johnson,” out of respect for this family. In none of these cases have I changed identifying details beyond the name; where there is information about a crime or a person that might compromise the person’s privacy, I have simply omitted it.


  • "Chilling...Roth writes movingly of the human toll of incarceration...She convincingly diagnoses the glaring inadequacies of mental health treatment in prison but she is not out for scapegoats...Insane is rife with sharp, brutal details that pull the reader beyond the realms of abstract policy debates."—New York Times Book Review
  • "This essential exposé, which includes tragic case histories, tells of legions of prisoners put in solitary confinement or subdued with medication...At the heart of the problem, Roth notes, is the changing landscape of mental-health care."—New Yorker
  • "Superb...Roth stresses America's failure to provide the vital community mental health services first promised in the Kennedy years...Some of the most revealing sections of Insane deal with the officers who patrol these wards...Burnout is inevitable."—New York Review of Books
  • "Roth got rare access, including at mental health units inside the Los Angeles County Jail and a women's prison in Oklahoma, and dove deep into the stories of a handful of individuals whose florid mental illness led them to prison, was badly managed and resulted in awful outcomes...[She] navigates it with grace."—Marshall Project
  • "Alisa Roth's powerful new book...calls into question such simplistic solutions to the current crisis in our mental health-care system...Based on in-depth interviews and observations, the book provides revealing snapshots of conditions at New York City's Rikers Island, the Los Angeles County jail, and Chicago's Cook County jail, the nation's de facto three largest mental health-care providers."—Democracy Journal
  • "50 percent of the mentally ill go untreated-half of them because they can't afford it...The place where the poor are likely to get treated, if anywhere, is prison...With an eye not toward shaming but toward progress, [Roth] gestures at solutions."—San Antonio Express-News
  • "Powerful, heart-wrenching...A summons to action to correct a system that inflicts needless suffering on people in custody."—Time Free Press
  • "Deep, broad and well documented. Roth has provided an eye-opening book about mental health care in the U.S."—Missourian
  • "A searing exposé about the criminalization of mental illness...Though the subject matter dictates that much of the book is relentlessly depressing, the author is such a talented information gatherer and fluid stylist that the narrative becomes compulsive reading. An eye-opening book that cries out for change."—Kirkus (starred review)
  • "Roth strikes a powerful balance between big picture analysis and individual stories to make this searing account of America's misguided treatment of the mentally ill hard to ignore."—Publishers Weekly (starred review)

On Sale
Jun 9, 2020
Page Count
336 pages
Basic Books

Alisa Roth

About the Author

Alisa Roth is the mental health correspondent for Minnesota Public Radio and frequent contributor to various NPR programs. A Soros Justice Fellow, her work has also appeared in the New York Review of Books and New York Times. She lives in St. Paul, Minnesota.

Learn more about this author