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More Mentally Ill Persons Are in Jails and PrisonsThan Hospitals: A Survey of the States

- Treatment Advocacy Center

In the United States, the first public outcry against putting mentally ill individuals into jails and prisons occurred in the early years of the 19th century. Louis Dwight, a Congregationalist minister in Massachusetts, was shocked by what he saw when he began taking Bibles to prisoners in jails. In response to Dwight’s advocacy, in 1827 the state legislature appointed a committee to investigate; the committee recommended that confinement in jails of mentally ill persons be made illegal and that those in jails be transferred to hospitals. Shortly thereafter the legislature approved the erection of the State Lunatic Asylum at Worcester for 120 patients.62

Dorothea Dix, the most famous and successful psychiatric reformer in American history, picked up where Dwight left off. During 1841 and 1842, she visited every jail in Massachusetts and documented the mistreatment of mentally ill prisoners. The following year, she presented her findings to the state legislature: “Men of Massachusetts, I beg, I implore, I demand . . . Raise up the fallen; succor the desolate; restore the outcast; defend the helpless.”63 Dix extended her crusade to many other states and by 1847 had visited 300 county jails and 18 state prisons. Her efforts led to the building of many new state mental hospitals.

At the time Dix was advocating on behalf of mentally ill persons incarcerated in jails and prisons, there was approximately 1 public psychiatric bed available for every 5,000 people in the population (the 1850 census, the first reliable enumeration of mentally ill persons in the United States, counted 4,730 insane persons in the total population of 23,261,000). A century later, in 1955, prior to the beginning of deinstitutionalization of mental patients in the United States, there was approximately 1 public psychiatric hospital bed available for every 300 people in the population (559,000 patients in state and county mental hospitals in a total population of 165,000,000).64 During those 100 years, there were some changes in diagnostic nomenclature, but public psychiatric hospital beds were largely reserved for individuals with serious mental illnesses, specifically schizophrenia, schizoaffective disorder, bipolar disorder, and major depression.

The advocacy efforts of Dorothea Dix and her colleagues to move mentally ill persons from jails and prisons to mental hospitals were largely successful. The 1880 census of mentally ill persons, the most complete survey ever carried out in the United States, identified 40,942 “insane persons” in “hospitals and asylums for the insane.” It also reported finding only 397 “insane persons” in jails and prisons, constituting less than 1 percent (0.7 percent) of the jail and prison population.65 Other studies done between 1880 and 1960 also found comparatively low prevalence rates of mentally ill persons in jails and prisons. For example, a 1930 study of almost 10,000 arrestees reported that just 1.5 percent of them were psychotic at the time of arrest.66 Thus, for almost 100 years, the problem of mentally ill persons in jails and prisons appeared to have been solved. These individuals were treated as patients, not as criminals, and were sent to mental hospitals, although the hospitals had little treatment to offer them at that time.

In 1939 Lionel Penrose, a British psychiatrist and mathematician, published a paper on the relationship between the population of psychiatric hospitals and that of prisons. He postulated that the two populations were inversely correlated: as one decreases, the other increases.67 It has become known as the balloon theory—push in on one side and the other side bulges out. What Penrose did not know when he published his paper was that the United States was about to embark on a grand social experiment— deinstitutionalization—that would test his theory.

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