Journal of Criminal Law and Criminology
Volume 75
Issue 2 Summer
Article 7
Summer 1984
(e Impact of State Mental Hospital
Deinstitutionalization on United States Prison
Populations, 1968-1978
Henry J. Steadman
John Monahan
Barbara Du'ee
Eliot Hartstone
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Recommended Citation
Henry J. Steadman, John Monahan, Barbara Du;ee, Eliot Hartstone, <e Impact of State Mental Hospital Deinstitutionalization on
United States Prison Populations, 1968-1978, 75 J. Crim. L. & Criminology 474 (1984)
0091-4169/84/7502-474
THE
JOURNAL
OF
CRIMINAL
LAW
&
CRIMINOLOGY
Vol.
75,
No.
2
Copyright
©
1984
by
Northwestern
University
School
of
Law
Ainted
in
SA.
THE
IMPACT
OF
STATE MENTAL
HOSPITAL
DEINSTITUTIONALIZATION
ON
UNITED
STATES
PRISON
POPULATIONS,
1968-1978*
HENRY
J.
STEADMAN,"
JOHN
MONAHAN,***
BARBARA
DUFFEE,****
ELIOT
HARTSTONE*****
AND
PAMELA
CLARK
ROBBINS******
In
a
1939
study
of
several
European
countries,
L.
Penrose
reported
that
"as
a
general
rule,
if
the
prison
services
are
extensive,
the
asylum
population
is
relatively
small
and
the
reverse
also
tends
to
be
true."'
Since
then,
the
belief
that
the
criminal
justice
and
mental
health
sys-
tems
are
functionally
interdependent
has
gained
widespread
acceptance
among
commentators
and
researchers.
2
This
hypothesized
interdependence
is
frequently
invoked
in policy
debates
about
the
process
of
state
mental
hospital
"deinstitutionaliza-
*
The
authors
are
grateful
to
Thomas
Lalley,
Jacques
Quen,
and Donald
Lunde
for
their
comments
on
an
earlier
draft
of
this
manuscript,
and
to Lawrence Greenfeld,
Sharon
Kantorowski
Davis,
Sheldon
Messinger,
Thomas Clannon,
and
Park
Dietz
for
their
assistance
in
conducting
the
research.
Research
was
supported
in
part
by
National
Institute of
Justice
grant
No.
79-NI-AX-0216.
Address
reprint
requests
to
Dr.
Steadman.
**
Director,
Bureau
of
Evaluation
Research,
New York
State
Office
of
Mental
Health.
Ph.D.,
University
of
North
Carolina,
1971;
M.A., Boston
College,
1967;
B.A.,
Boston
College,
1966.
***
Professor,
University
of
Virginia
School
of
Law.
Ph.D.,
Indiana
University,
1972;
M.A.,
Indiana
University,
1970;
B.A.,
State
University
of
New York,
Stony
Brook,
1968.
****
Research
Analyst,
The
United
States
Secret Service. M.A.,
State
University
of
New
York,
Albany,
1984;
B.A.,
Pennsylvania
State
University,
1977.
*****
Research
Associate,
URSA
Institute.
Ph.D.,
New York
University,
1979;
M.A.,
New
York
University,
1975;
B.A.,
University
of
Massachusetts, Amherst,
1971.
******
Research
Scientist,
New
York
Office
of
Mental Health.
B.A.,
William
Smith
College,
1979.
1
Penrose,
Mental
Disease
and
Crime.-
Outline
of
a
Comparative Study
ofEuropean
Statistics,
18
BRIT.
J.
MED.
PSYCHOLOGY
1
(1939).
2
See,
e.g.,
K.
MILLER,
THE
CRIMINAL
JUSTICE
AND
MENTAL
HEALTH
SYSTEMS:
CON-
FLICT
AND
COLLUSION
(1980).
IMPACT
OF
DEINSTITUTIONALIZA
TION
tion"
and
its
impact
upon
state
prison
populations.
Deinstitutionaliza-
tion
is
really
a
shorthand
term
for
a range
of
procedural,
statutory, and
ideological
changes
that
attempt
to
transfer
the
care
of
the
chronically
mentally
ill
from
institutional
to
community
settings.
3
State
mental
hospital
populations
are
reduced by discharging
long-term
residents,
shortening
hospital
stays,
and attempting
to reduce
the
number of
ad-
missions.
One
hypothesized
impact
of
these
processes
is
that
the
flood
of
former
mental patients
shifted
to
community
care
in
newly
created
(or,
more
often,
nonexistent)
"community mental
health
centers" leads
to
a
drastic
increase
in
deviant
behavior
in
the
community,
to
which
the
criminal
justice
system
is
forced
to
respond.
4
Indeed,
the
epidemiologic
data
on
population
shifts
in
the
criminal
justice
and
mental health
systems
in
the
U.S.
appear
to
confirm
an
in-
terdependent
relationship.
At
the
end
of
1968,
there
were
399,000
pa-
tients
in
state
mental
hospitals
and
168,000
inmates
in
state
prisons.
5
Within
a
decade,
the
hospital
population
fell
64%,
to
147,000,6
while
the
prison
population
rose
65%,
to
277,000.
7
Indeed,
the
correlation
be-
tween
the
annual
resident
census
of
state
mental
hospitals
and
state
pris-
ons
in
the
United
States
between
1968
and
1978
was
a
dramatic
-.
87.
Although
the
fact
of
the
covariation
of
prison
and
mental
hospital
populations
is
indisputable,
the
precise
nature of
their
interdependence
is
unclear.
Several
commentators
have
suggested
that
released
mental
patients
who
cause
trouble
in
the
community
often
are
arrested
to
get
them
off
the
streets;
they
then
may
be
treated
for
their
disorders while
incarcerated.
8
This
would imply
not
only
the
covariation
that
has
been
noted
between
population
rates,
but
also
that
the
composition
of
the
prison
population
is
changing
in
the
direction
of
a
greater
incidence
of
mental
disorder.
At
the
same
time
that
these
commentators
claim
that
state
prison
populations
have
become
more
"disordered,"
there
is
evidence
that
state
mental
hospital
populations may
have
become
more "criminal."
In
3
Bacharach,
A
ConceptualApproach
to
Deinstitutionalization,
29
Hosp.
COMMUNITY
PSYCHI-
ATRY
573
(1978);
Morrissey,
Deinstitutionaliing
the
Mentally
Ill:
Processes,
Outcomes,
and
New
Directions,
in
DEVIANCE
AND
MENTAL
ILLNESS
(W.
Gove
ed.
1982).
4
Abramson,
The
Criminalization
of
Mental'y
Disordered
Behavior:
Possible
Side-Effect
of
a
New
Mental
Health
Law,
23
Hosp.
COMMUNITY
PSYCHIATRY
101
(1972).
5
Goldman, Adams
&
Taube,
Deinstitutionaliation
The
Data
Demythologized,
34
HosP.
COMMUNITY
PSYCHIATRY
129
(1983).
6
Id
7
Personal
communication
with
National
Institute
of
Mental
Health,
Division
of
Biome-
try
(1982);
PRISONERS IN
THE
U.S.
(Bureau
of
Justice
Statistics,
1979).
This
is,
of
course,
precisely
the
shift
that
Penrose,
supra
note
1,
would
have
predicted.
8
Abramson,
supra
note
4;
Geller
&
Lister,
The
Process
of
Criminal
Commitment
for
Pretrial
Ps.ychiatric
Examination:
An
Evaluation,
135
AM.
J.
PSYCHIATRY
53
(1978);
Lamb &
Grant,
The
Mentaly
Ill
in
an
Urban
County
Jail,
39
ARCHIVES
GEN.
PSYCHIATRY
17
(1982).
1984]
STEADMAN,
ET
AL.
New
York
State,
for
example,
the
percentage
of
male
admittees
with
prior
arrest
records
increased
from
15%
in
1947,
to
32%
in
1968,
and
to
40%
in
1975.
9
Further,
hospital
staffs
perceive
increasing
assaultiveness
and
hostility in
patients
over
time.
10
Although
the
population
of
state
mental
hospitals
may
have
precipitously
declined,
the
"criminality"
of
those who
remain
may
be
increasing.
This
may
be
due, in
part,
to
the
tightening
of
commitment
procedures
and
the
development
of
the
"dan-
gerousness"
criterion
for
commitment
that
began
in
the
late
1960's.
n
In
addition
to
these
theoretical
issues,
the functional
interdepen-
dence
of
prisons
and
mental
hospitals may explain
a
wide
variety
of
pragmatic
ills
in
both
the
criminal
justice
and
mental
health
systems.
Some
researchers
attribute
the
severe
and unanticipated
overcrowding
of
U.S.
prisons in
the
1980's,
for
example,
to
failure
to
account
for
the
effects
of
the
collapse
of
the
state
mental
hospital
system.1
2
Beyond
sim-
ple overcrowding,
researchers
claim
that
the
perceived influx
of
former
mental
patients
into
the
prison
population
presents
special
management
needs
that
prisons
are
ill-equipped
to
meet
and
disrupts
the
"program-
ming"
of
more
normal
offenders.
13
In
the
mental
health
system,
the
purported
transformation
of
mental
hospitals
into detention
facilities
for
"dangerous"
persons
prone
to commit
crimes has
been
held
responsible
for
a
drastically
increased
need
for
security
that
the
hospitals
were
not
designed
to
meet.
Commentators
also
claim
that
hospital
staffs
have
been
thrust
into
the
untenable
position
of
treating
antisocial
behavior,
a
task
for
which
few
current treatments
have
been
demonstrated
as
effective.
14
Despite
the
frequency
with
which
the
correlation
between
prison
and
mental
hospital
populations
and
its
implications
for
institutional
composition
has
been
invoked
by commentators,
attempts
to
verify
it
have
been
rare
and partial.
No
study
has
employed
both
a
comparative
framework,
to simultaneously
assess
changes
in
prison
and
mental
hospi-
tal
size
and
composition,
and
a
longitudinal
one, to
measure
these
changes
over
time.
The
present
study
does
both.
9
Steadman,
Cocozza
&
Melick,
Explaining
the
Increased
Arrest
Rate
Among
Mental
Patients:
The
Changing
Clientele
of
State
Hospitals,
135
AM.
J.
PSYCHIATRY
816
(1978).
10
H.J.
Steadman,
J.
Braff,
P.
Castellani, R.
Ingalls
&
A.
Weinstein,
Staff
Perceptions
of
Factors
Affecting
Changes
in
New
York
State
Psychiatric
Center
Inpatient Trends
(Bureau
of
Special
Projects
Research,
New
York
State
Office
of
Mental
Health,
January
1979)
(unpub-
lished
manuscript).
11
A.
STONE,
MENTAL
HEALTH
AND
LAW:
A
SYSTEM
IN
TRANSITION
(1975).
12
Grabosky,
Rates
of
Imprisonment
and
Pychiatric
Hospitalization
in
the
United
States,
7
Soc.
INDICATORS RESEARCH
63 (1980).
13
Wilson,
Who
Will Carefor
the
'Mad
and
Bad,'
6
CORRECTIONS
MAG.
5
(1980).
14
Bonovitz
&
Guy,
Impact
of
Restrictive
Civil
Commitment
Procedures
on
a
Prison
Psychiatric
Service,
136
AM.
J.
PSYCHIATRY
1045
(1979).
[Vol.
75
IMPACT
OF
DEINSTITUTIONALIZA
TION
At
first
blush,
the
methodology
for
such
an undertaking
seems
straightforward:
administer
diagnostic
interviews
and
tests
to
prison
ad-
mittees to
ascertain
levels
of
psychopathology
at
various
points
in
time.
Where
shifts
from
mental
hospitals
to prisons
were
occurring,
the
rate
of
disorders
would
be expected
to
rise.
Unfortunately,
there
is
no
available
reliable
baseline
data
from psychological interviews
and
tests
on
the
prevalence
of
mental
disorder
in
prison
populations
for
the
period
before
the deinstitutionalization
of
mental
hospitals.
I5
A
direct
test
of
the
hypothesis, therefore,
is
not
feasible.
In our current
study,
we
have
attempted
to
test
by
more
indirect
means
the
degree
of
reciprocity
between
the
criminal justice
and
mental
health
systems.
The
extent to
which
an individual
has
a
history
or
ca-
reer
I6
of
involvement
with
the mental health
system
may
be
taken
as
an
index
of
his
or
her
disordered
mental
status. Indeed,
numerous studies
suggest
that
a
history
of
mental
hospitalization
weighs
heavily
in
the
actual determination of current
disorder
by
psychiatrists
and
psycholo-
gists.'
7
Similarly,
researchers
generally
take
a
history
of
arrest
and
im-
prisonment
as
the
definition
of
a
"career"
criminal,
and
also
take
it
into
account
in
assessing
the
criminal
justice
system's
treatment
of
such
of-
fenders.'
8
Should
data
reveal
that
the proportion
of
prison
admittees
with
a
history
of
mental
hospitalization
rose
at the
same
time
that
the
populations
of
state mental
hospitals
fell,
the
theory
that
deinstitutional-
ization
has
contributed
significantly
to
the
rise
in prison
populations
would
be
supported.
19
Our
data
also
permit
an
analysis
of
the type
of
functional interdependence
between
these
two
systems
that
can
reflect
changes
in
institutional
composition.
With
the
confinement
career
data,
it
is
possible
to
test
more
broadly
the
prior
New York
State
finding
that
15
Monahan
&
Steadman,
Crime
and
MenalDisorder.
An EpidemiologicalApproach, in
CRIME
AND
JUSTICE:
AN
ANNUAL
REVIEW
OF
RESEARCH
145
(M.
Tonry
and
N.
Morris
eds.
1983).
16
HJ.
STEADMAN
& J.
COCOZZA,
CAREERS
OF
THE
CRIMINALLY
INSANE
(1974).
17
R.
ROESCH
&
S.
GOLDING,
COMPETENCY
To
STAND
TRIAL
(1980).
Certainly,
if
the
research
focus
had
been on
the
prevalence
of
specific
types
of
mental
illness,
more
direct
clinical
indicators
would have
been
essential. Because
this research
was
not
a
prevalence
study,
however,
but
one
of
how
institutional
career
patterns
may have changed,
the
history
of
mental
hospitalization
was
appropriate.
Furthermore,
there
are
no
baseline
data
available
on
clinical measures
that
would
permit
a
retrospective
study
of
system
changes.
18
Greenwood,
The
Violent
O
nder
in
the
CriminalJustice
System,
in
CRIMINAL VIOLENCE
320
(M. Wolfgang
and
N.
Weiner
eds.
1982).
19
This approach
assumes
that
the
proportion
of
the
general
population
that
is
seriously
mentally
ill
remains relatively
constant
over
time.
Based
on
Dohrenwend,
et
al.'s
1980
com-
prehensive
review
of
the
extant
epidemiological
data,
that
assumption
is
empirically
support-
able.
B.
DOHRENWEND,
B.S.
DOHRENWEND,
M.S.
GOULD,
B.
LINK,
R.
NEUGEBAUER,
R.
WUNSCH-HITZIG,
MENTAL ILLNESS
IN
THE
UNITED
STATES: EPIDEMIOLOGICAL
ESTIMATES
(1980).
Accordingly,
should the
proportion
of
prisoners
with
a
history
of
mental
hospitaliza-
tion
increase,
it
would
not
be
attributable
to changes in
the population
rates
of
serious
mental
disorders.
1984]