Are State Psychiatric Hospitals Being Transformed into the New Jails and Prisons?

By Glenn J. Egan, PhD and Tomina J. Schwenke, PhD, ABPP
Atlanta Behavioral Health Advocates

The transformation of jails and prisons into America’s mental hospitals for people with mental illness was pointed out in 1992 by the National Alliance on Mental Illness (NAMI) and the Public Citizen’s Health Research Group and was the topic of the 2005 Public Broadcasting System Frontline special, The New Asylums.   In 2006, the Bureau of Justice Statistics reported that more than half of all prison and jail inmates had mental health problems with jail inmates having the highest rate of mental illness (64%). In 2014, the Treatment Advocacy Center reiterated, “Prisons and jails have become America’s new asylums” and reported that a 2012 study found ten times as many people with mental illness in jails and prisons as there were in state psychiatric hospitals.

Although alarming, these statistics do not fully capture the dark underside of the problem for those individuals that are utilizing mental health services.  The majority of patients now treated at state psychiatric hospitals has changed.  It make little sense to do a simple comparison of the number of persons with serious mental illness being held in jails and prisons to with the number of persons being treated in our state psychiatric hospitals when a growing number of the hospitalized patients are there for forensic reasons.

Wik, Hollen, and Fisher (2019) reported that mental health officials are concerned about the impact of the rising number of forensic patients that are present within the state psychiatric hospitals. They note that responses from forensic directors maintained by the National Association of State Mental Health Program Directors Research Institute show a 76% increase in the number of forensic patients in state psychiatric hospitals nationally between the years of 1999 and 2014.  They found that state psychiatric hospitals are spending approximately one-third of their budgets on forensic patients. As the hospital population trends towards serving more individuals that are court involved the shift continues towards increased spending on forensic patients and a proportionate decrease in spending on civil patients.

In Georgia, the number of clinical beds have slowly decreased as the number of forensic beds have increased to the point that forensic units now dominate the mental health services at the state psychiatric hospitals.  Approximately 60% of the hospital beds are now being used for forensic purposes and another 40-bed forensic unit is being built.  However, no new clinical beds are under construction.  The majority of the forensic beds are for persons who lack competency to stand trial, with the rest of these beds for persons found insane at the time of the crime.  Forensic patients on the competency units at the hospital are kept there just long enough to restore their competency to stand trial and not until they are mentally healthy enough to return to society.  

Considering the large number of persons with serious mentally illness who are now incarcerated or homeless, it is doubtful that the state hospitals are giving up beds to forensic patients because they have become more efficient at treating mental illness.  Although the closing of many inpatient hospital services in the late 1960’s and early 1970’s was due to court rulings following genuine concern about the welfare of persons with mental illness, the cost of hospitalization appears to be a leading factor driving the reduction in clinical beds. In Georgia jails, the cost often varies from $45 to $85 dollars per day per inmate; but in Georgia psychiatric hospitals, the cost can be $500 or more per day per patient.  If all persons with serious mentally illness were transferred to state psychiatric hospitals, a massive increase in funding would be needed to keep the mental health system from bankruptcy.  The main protection from further funding cuts, unfortunately, may be the state psychiatric hospital’s role in the criminal justice system.

Without a doubt, the role of state psychiatric hospitals in evaluating and restoring competency to stand trial, doing criminal responsibility evaluations, and caring for those found insane is extremely important and should continue.  However, forensic service should not be provided at the expense of regular clinical services.  The proportion of a state’s psychiatric budget being spent on serving the criminal justice system compared to providing treatment for persons with serious mental illness should be ready available for public scrutiny.  The fact that jails and prisons in this country have largely become the asylums of 21^st century is a tragedy.  However, it is also important to expose and resist the forces that are transforming our state psychiatry hospitals into the new jails and prisons of the 21^st century.