Old and New Institutions for Persons with Mental Illness: Treatment, Punishment, or Preventive Confinement?

In 1972, I covertly entered a brutal, inhumane institution for the criminally insane in Eastern North Carolina as a pseudo-patient under a U.S. Department of Justice study. What I experienced during those many weeks would shape how I view what Irving Goffman called total institutions. Since that formative experience as a young law student I have closely observed institutions that warehouse persons with mental illness in many regions of the world ranging from the Americas and Europe to the Indian subcontinent and Asia. Those experiences, together with the careful study of human rights reports and judicial decisions, have led me to one simple conclusion. Despite countless promises for a better life by national commissions, governments, and the international community, there has evolved a vicious cycle of neglect, abandonment, indignity, cruel and inhumane treatment, and punishment of persons with mental illness. This is not true in every place, time, and circumstance -- there are pockets of deep caring and compassion. But for the vast majority, and in most geographic regions, this sad fact remains a tragic reality. The shameful history of benign, and sometimes malignant, neglect of persons with mental illness is well understood: the deep stigma and unredressed discrimination, the deplorable living conditions, and the physical and social barriers preventing their integration and full participation in society. The maltreatment of this vulnerable population has been reinforced by the hurtful stereotypes of incompetency and dangerousness. This article is based on a lecture at the Sheldonian, Oxford University, for Amnesty International. In this article I will show how this vulnerable population has been unconscionably treated. First, I will examine the gross human rights violations that have occurred, and continue to occur, in what I am calling old psychiatric institutions. During the mid-to-late twentieth century, however, many of these old institutions were closed as part of a social compact with mentally ill persons and their families to provide community care. The deinstitutionalization movement, however, resulted in new places of confinement for this population—jails, prisons, and homeless shelters. In the second part of this lecture, I will explore the new realities of criminal confinement of persons with mental illness. As we will see, incarceration of this vulnerable population in the criminal justice system has caused enormous suffering. And, if Dostoyevsky was correct that the degree of civilization … can be judged by entering its prisons, then by that measure we are a deeply uncivilized society