Incarceration as "Therapy"

To the Editor: Lamb and Weinberger's April 1998 review (1) of the incarceration of those with severe psychiatric illness was of considerable interest. We would like to add to this discussion a phenomenon we have observed that may contribute to the increased numbers of psychiatric patients in our jails. Specifically, use of law enforcement sometimes takes the place of acute psychiatric intervention when involuntary commitment is not possible. Because of the stringency of our involuntary commitment laws, many families find themselves in the difficult position of having to call on police to intervene in physically volatile situations that result from an ill relative's failure to take medication properly.

A typical scenario is that of a male patient with paranoid schizophrenia who does not take antipsychotic medications properly, regularly, or at all. Psychosis impairs his judgment and insight and often leads him to irritable, hostile, and threatening behavior, yet he is not a sufficient threat to self or others to justify involuntary commitment. At this point, relatives, desperate to obtain treatment but denied access to mental health services, may be forced to resort to police intervention. The ill relative's behavior justifies an arrest on the grounds of, for example, damage against property. In this situation, psychiatric treatment is, paradoxically, more accessible in jail than in the community.

It would be helpful to know how many such individuals are jailed in lieu of being involuntarily committed for treatment, how long such incarcerations last, and the process by which they eventually move from the legal to the mental health system. While we must guard against abusive involuntary commitment, we must also support the treatment of psychosis (2). Further study of this phenomenon is important if we are to provide individuals suffering from psychosis with treatment rather than punishment.

Dr. Lewine is professor of psychiatry and behavioral sciences at Emory University School of Medicine and clinical director of Skyland Trail, a psychiatric rehabilitation program in Atlanta. Ms. Marsh is aftercare coordinator and Ms. Towner is program director at Skyland Trail.