Prince Harry recently spoke movingly about the negative consequences for himself of repressing his grief over the death of his mother when he was twelve years old. Celebrities reveal their anxieties and breakdowns. Such openness is important because it reduces personal isolation and makes people feel that they will not be treated as pariahs if they speak up. Openness and discussion are important, but they skirt the heart of the problem, which is that a proportion of people who are mentally ill cannot look after themselves. The severity and incurability of a mental illnesses are often underestimated and there may be exaggerated expectations of preventing their onset by early intervention. The precise causes and nature of mental illness remains very much a mystery so a large number of people are always going to become desperately ill. Schizophrenia, for instance, is to mental illness what cancer is to physical illness. When Prince Harry talked about psychological troubles, debilitating though these may be, they are still not the same as full-blown psychosis or, in other words, “madness”.
The criminalisation of the mentally ill is one of the cruellest and most easily avoidable tragedies of our era. The prison systems have replaced psychiatric hospitals as the place where people suffering from severe mental illness are most likely to find themselves. It is a process that has been going on since the 1960s, fuelled by a desire to save money, a belief that medication would replace hospitalisation, and a liberal reaction against what was seen as unnecessary incarceration. One of the justifications for closing down the old asylum system was that they were too much like prisons, but the paradoxical result has been that psychiatric patients are now ending up in real prisons.
Between 1955 and 2016, the number of state hospital beds in the US available to psychiatric patients fell by over 97 per cent from 559,000 to just 38,000. An expert noted despairingly that the biggest de facto psychiatric institutions in the US today are Los Angeles County jail, Chicago’s Cook County jail and New York’s Riker’s Island. Those who are not in prison or hospital “become violent or, more often, the victims of violence. They grow sicker and die. The personal and public costs are incalculable,” says a report by the Treatment Advocacy Centre in Virginia. Mentally ill people, usually poor and unemployable because of their condition, are sometimes advised that the only way they will get even the crudest treatment is by being sent to prison.
The same process is happening in Britain. The number of beds available for mental health patients in the UK has dropped by three-quarters since 1986-87 to about 17,000, while the Centre for Mental Health says that 21,000 mentally ill people are imprisoned, making up a quarter of the prison population.
For many mentally ill people, the prospect of incarceration is becoming probable in an unexpected reversion to 18th-century practice. Some are left to wander the streets but most are looked after by their families who may not have the resources to do so. Deceptively progressive sounding words, like “deinstitutionalisation” in the US and “care in the community” in the UK, are used to describe the ending of the vast system that once catered for psychiatric patients.
Some of these institutions were hellholes, and others became unnecessary because medication was available from the 1950s that controlled some of the worst symptoms of mental illness. But the old system did at least provide an asylum in the sense of a place of safety where people who could not look after themselves were cared for. Supposing “care in the community” had been more than an attractive slogan, it might have provided something of a replacement for the old asylums, but the care it provided was always inadequate. The reality of the new system was best described by the writer PD James, an administrator in the NHS in London whose husband was a long-term patient in a mental hospital. She wrote that since the 1970s community care “could be described more accurately as the absence of care in a community still largely resentful or frightened of mental illness”.
Thomas Winsor, the Chief Inspector of Constabulary, who complained that the police are increasingly being used as the “first resort” for people with mental health problems. He said that sometimes they ended up spending the night in police cells even though they had committed no crime because no hospital beds were available. He added that the “inadequacy” of mental health provision should “disturb everyone”.
Marjorie Wallace, the founder and chief executive of Sane, a mental health charity, explains that governments have every incentive to keep mental patients out of hospital, since “providing a single bed costs the same as ‘treating’ 44 people in the community”. She welcomed Theresa May’s intention expressed in a speech earlier this year to do something about “the burning injustice of mental health and inadequate treatment”, but says that this will remain a utopian vision unless there is more ring-fenced money for psychiatric services which are already close to breakdown. The present system has failed and the result is the creeping criminalisation of mental illness.