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In this series of six case studies, Mary Beth Pfeiffer provides a critique of mental health care in the United States, including clinical services, police, administrators and policy makers. Crazy in America recounts the experiences and fate of six individuals, selectively chosen to illustrate Pfeiffer's central arguments: that the criminal justice system is the final refuge for many people with mental illness, and that prisons are de facto asylums. More than that, Pfeiffer's argument is that prisons and police are not equal to this responsibility, and that the needs of the mentally ill are neglected as a result, leading to inhumane incarceration and sometimes death.
Over the past three decades several factors have coalesced to create the situation described in Crazy in America. These are: deinstitutionalization, a policy marked by closure of psychiatric hospitals and reductions in state funded beds; restrictive mental health legislation which in many jurisdictions limits committal to narrow dangerousness criteria; massively increased rates of criminal incarceration; withdrawal of rehabilitation and treatment programs in prisons, and increasing use of illicit drugs.
The case studies involve people such as Shayne Eggen who had many contacts with various mental health services prior to coming to the attention of the police, and others such as Joseph Maldonado whose mental health needs only came to official attention in police custody. For Jessica Roger her existing mental health problems were exacerbated by her incarceration, especially by the practice of twenty three hour a day confinement to a tiny isolation cell. The facilities Pfeiffer describes have woefully inadequate standards of mental health care, poorly trained staff and in some cases a punitive institutional attitude towards people showing signs of distress.
The overall point is that there is simply not enough of the right sorts of services available, with the result that the criminal justice system is the last resort of the state. Various social agencies, including the police, could have done more in several of these cases. Jessica Roger was transferred to a psychiatric facility many times throughout her time in prison, on each occasion with the paradoxical consequence that in a more humane environment she improved enough to be returned to prison. In prison her regime of punishment resumed, with inevitably negative consequences for her mental health. Her suicide was her own desperate way of ending this vicious cycle. As in other cases there were some alternatives that might have made a difference but staff were not disposed to take those options. Pfeiffer cites the Iowa mental health legislation as contributing to the fate of Shayne Eggen, but it is clear that even under Iowa's minimalist dangerousness criteria a case could have been made for her committal. Alan Houseman was an introverted individual with a diagnosis of schizophrenia. He didn't see the police cruiser in the car park when he stopped to relieve himself. He was shot by the police officer who stopped him for questioning.
Crazy in America is written in a racy journalistic style. Pfeiffer has an endless list of examples to cite in support of her arguments. Few words are wasted in theorizing or exploring the wider background to these cases. The focus of the book is the lives of the individuals affected, and the details of what happened in each instance. Pfeiffer leaves the reader in no doubt as to her interpretations. She is forthright in her criticisms of law enforcement personnel, whether police or custodial staff, although she is not without understanding of the difficulties they face. She is skeptical of many of the official reports, especially as they typically focus on immediate events and don't consider the pattern contributing to these tragedies.
Pfeiffer rounds off the book with a commentary on the more systemic issues contributing her case studies, and with a prescription for change. Her ten-point list to keep people with mental illness out of the criminal justice system reflects many other commentators' views on this issue. It includes social interventions, policy initiatives, and improved service provision for the mentally in prison. While there may be many who identify with the stories she tells, it is to be hoped the book is read by clinicians, policy makers and planners as it is clear that there are changes necessary at many levels of the mental health and criminal justice systems.
© 2008 Tony O'Brien
Tony O'Brien, RN, MPhil., Senior Lecturer, Mental Health Nursing, University of Auckland, firstname.lastname@example.org
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