Senator John Cornyn is proposing introducing a poorly informed  legislative proposal  that appears to be in response mental health and criminal science advocacy groups that insist that a high percentage of the inmate population incarcerated in the US are not criminals so much as mentally ill and disabled. 

Psychiatric Nosology (labeling and diagnosis) is not a precise discipline and it’s easy for patients, particularly inmates with motives, to game the system.  Good forensic psychiatrists that I know are careful to search for corroboration before they believe what inmates say but busy psychiatry providers treating people in the corrections system don’t use the tools of forensic psychiatrists, they go with the interview and the complaints of the patient in front of them, the past medication history and limited current information, prescribe meds they think are appropriate and then move on to the next patient, leaving behind a prescription for a psychiatric drug.    

I am an emergency physician, but for civic service reasons have been a jail doctor and medical officer for four sheriffs of my rural central Texas county for 20 of the past 26 years and also a prison physician or medical director for two prisons in the area.

I will admit that a significant percentage of prison and jail inmates are on psychoactive medications, mostly antidepressants, due to their chronic depressive symptoms and troubled mental states.  However anyone with sense would agree that mostly their problems are due to their lifestyle, drug abuse and personal problems.  That doesn’t mean they are mentally ill. 

I keep the medical care costs in our jail down significantly by eliminating the very expensive new psychoactive meds that are used so much in America and other advanced countries.  They are the what are called “atypical” antipsychotics to distinguish them from the original antipsychotic drugs that changed psychiatry, like Mellaril and Thorazine or Haldol that were very effective for seriously psychotic people but not attractive because they had side effects and could cause a terrible movement disorder called tardive dyskinesia, a writhing involuntary movement problem that was sometimes permanent. 

The new atypical antipsychotics are being used for mood disorders and the expanded diagnosis “BIPOLAR” that I think is emblematic of the loose diagnostic process that dominates modern psychiatry.

Most inmates are not seriously mentally ill, but the various meds they are looking for make them feel better, help them forget their miserable situation, unhappy and stressful lives.

A characteristic consideration for purposes of this discussion is that the truly psychotic don’t want medications, because they don’t recognize their mental problems, the manipulators and personality disorders want medications because they are looking for medication cushions and mood alterations.  They want what they were using in “the free” or an alternative. 

Senator Cornyn believes that mental health problems are a major problem for the incarcerated, but that’s not true.  Inmates complain of mental health problems and many are unhappy souls, but most suffer not from serious mental disorders but personality disorders, bad judgment and lifestyle problems, drug and alcohol abuse, and the mood disorders that result.  They are diagnosed as mentally ill, but the tendency of psychiatric professionals is to be caring and generous -- and the inmate population know how to manipulate well-meaning psychiatrists and social workers.

The result is a game—that’s the problem, and Senator Cornyn is enabling the gamers, the criminal manipulators and the mushy headed advocates who feel sorry for criminal population.

Imagine this: if you were a new inmate, but particularly if you were a repeat inmate, and at booking you were offered an opportunity to visit with a psychiatric professional to demonstrate your need for some mood medication or another, things to reduce your anxiety, allow you to sleep, a lot (jail time is down time mostly) something to substitute for your drug habits and substance use in“the free,” and you were experienced and knew the hot buttons for mental health professionals – would you exaggerate your mental problems?  Why sure you would and you would make sure you told mental health advocates with a polticial agenda based “determinism” on the outside would be working for a more liberal approach to making criminal conduct a product of circumstance and environmental factors.  

Senator Cornyn is misinformed by people with an agenda, and so he is making a case for turning a lot of criminal types into people with a diagnosis when the medicalization of deviant and criminal behavior is not appropriate.  True serious mental illness should be a reason for alternatives to incarceration, but that is not about  ginned up diagnoses and exaggerated claims about mentally disabled inmates of jails and prisons.

Eligibility for gun ownership 

Senator Cornyn also proposes in the legislation purging the record of involuntary commitment for people after they are released, and that directly impacts their eligibility to buy firearms, but that approach ignores the fact that being released is only a change in status, and many released mental patients are still suffering.  Would anyone propose purging the record of John Hinckley, the attempted assassin of Reagan, when psychiatrists say he is recovered enough for release? 

Sure, there are involuntarily committed people who are released, but does that mean they no longer have their mental health disorder and are safe to buy a pistol or shoulder arm? 

The essay is so poorly informed on the alternatives and legal issues that that it doesn’t even mention the well-established provisions for alternative adjudication that judges can use to require mental health treatment for people who would otherwise be in the criminal justice system and who have real mental health disorders. 

No jailors, Law Enforcement Administrators or corrections nurses and physicians have any interest in incarcerating a person with a serious mental disability.    However, we have to recognize that there is a problem with psychiatric diagnostic capaciousness and diagnostic aggressiveness in the face of what is an underlying confusing and difficult problem -- personality disorders -- that are not mental illness but well established behavior disorders not amenable to psychiatric treatment, but frequently complicated by  mood and anxiety disorders. 

As for the advocacy groups that claim mental illness in 20 percent of inmates – BS.  Depression, reactive or situational, and anxiety from the same sources are common in corrections.  That is not MENTAL ILLNESS, but a normal reaction to an unpleasant turn of events. 

Unhappy criminals should not be a basis for the claim of deterministic criminal psychology, diminishing culpability because of claims of mental illness, when it is just normal reactive distress.  The modern criminal justice advocates are enablers of the deterministic approach to assessing culpability and accountability and are delusional.  Criminals make choices, and then might be unhappy about being caught, prosecuted and imprisoned, but that doesn’t make them candidates for psychiatric care and pity promoted by socialist/postmodernist psychologists and social scientists).

The deterministic moral philosophy theory of the left goes like this: people do things because they must, because they can’t control themselves and are victims of their circumstances, they are a product of their environment or upbringing, and they suffered abuse of some kind or neglect.  IT’S NOT THEIR  FAULT.

In the past 10 years, I have seen a dramatic increase in inmates who claim sexual abuse and domestic abuse as children, much of it contrived to get sympathetic treatment.  Mental health professionals are particularly vulnerable to these tales of woe, and it’s hard asses the truth.  Inmates are often great liars and consistent in that effort.

The abuse claim is similar to the claim of Post Traumatic Stress Disorder, and that is mostly the product of labile and unhappy people trying to claim a stylish mental disability, who suffer not from PTSD but a form of behavior/personality disorder and a psychiatric community quick to make a diagnosis.

In some big city jails all the inmates on intake are offered an opportunity to see a psychiatrist -- imagine that! -- then they are interviewed to determine how troubled they are and what their background is and how much they need the drugs that physicians can provide to make them “better” or “smoother” so they can feel better about themselves and sleep better, be less anxious or unhappy and less depressed.  Imagine, they are living in an orange suit, wearing rubber shoes and confined—and they are anxious or depressed—my my, what a surprise—if they are depressed and anxious that might be a good measure of their sanity and good reality testing.

Under circumstances where there is free and accessible psych attention and medications, do you think people who use mood altering drugs in the “free” won’t try to work the system to get some alternative substances to keep them happy and smooth?   Imagine the level of need for attention and drugs in the inmate population, considering the ubiquitous use of alcohol and marijuana in the criminal population at large.    My experience is that pills are popular in the mainstream and very popular in the criminal sector of society.  No big surprise.

Senator Cornyn probably thinks he is promoting a humane approach and he might think prisons and jails are a terrible thing, and particularly terrible if a person is mentally ill. I agree that mentally ill people, truly mentally ill people must be identified and removed from a general population and considered for treatment and alternative adjudication, but that’s for the truly mentally ill, not the unhappy, anxious, frustrated and manipulative.

When people start throwing around numbers like 20 or 30 percent of incarcerated are mentally ill I object and consider those claims to be junk science based on poor definitions, loose diagnostic criteria and a basic psyschiatric misconception that unhappy is mentally ill.  Unhappy is part of the life of the criminal, due to their bad judgment and decisions. 

Senator Cornyn’s bill begs the question--Mentally ill by whose definition?

This bill is driven by mental health advocates whose agenda is that criminals are just victims, sick and need pity. 

I say BS is a big part of it.

As for the heartburn people get over the proposal to wipe the slate clean for gun ownership if a person is released from involuntary commitment, they have every reason to be uncomfortable with such a thing. 

People need to be assessed for gun ownership by a method better than whether they got out of the mental health slammer.  Very  few seriously mentally ill people are permanently confined.  What should we think about the ones that get released?  As the economists say, it depends.  

I might be psychotic but respond to treatment, and now I am  controlled with treatment.   But what if I stop my meds?  That’s who populates the streets: psychiatric patients who refuse their meds.  Supervised medication is the kind of alternative adjudication that can improve the situation and allow for people to live in the free world, with the constraint they have to take their medications; judges can do that (if they will).   However many judges, steeped in the civil rights ideology, refuse to supervise mental illness treatments.   That is much to the neglect of public safety and civility.

Civil rights fanatics sometimes claim there is no such thing as crazy. I would demur: spend some time with an untreated schizophrenic or a manic psychotic and you will believe there is crazy, there is psychotic, and psychiatry, for all the negative things I have said above about unreliable diagnostic nosology, can provide medications that allow the mentally disabled to be “in the free.”  That’s good -- the truly mentally ill deserve our best efforts to give them a life with some freedom and normalcy.  I argue that I wouldn’t give them guns.  

On the other hand criminals should be incarcerated and punished as provided for by societal agreement even if it makes them anxious, depressed, even angry, especially angry.

John Dale Dunn MD, JD is Consultant, Emergency Services/Peer Review, Civilian Faculty, Emergency Medicine Residency, Carl R. Darnall Army Med Center, Fort Hood, Texas, and Medical Officer, Sheriff Bobby Grubbs, Brown County, Texas