Insane: America's Criminal Treatment of Mental Illness

by Alisa Roth

An urgent exposé of the mental health crisis in our courts, jails, and prisons


America has made mental illness a crime. Jails in New York, Los Angeles, and Chicago each house more people with mental illnesses than any hospital. As many as half of all people in America's jails and prisons have a psychiatric disorder. One in four fatal police shootings involves a person with such disorders.


In this revelatory book, journalist Alisa Roth goes deep inside the criminal justice system to show how and why it has become a warehouse where inmates are denied proper treatment, abused, and punished in ways that make them sicker.


Through intimate stories of people in the system and those trying to fix it, Roth reveals the hidden forces behind this crisis and suggests how a fairer and more humane approach might look. Insane is a galvanizing wake-up call for criminal justice reformers and anyone concerned about the plight of our most vulnerable.

Genres: Nonfiction, Psychology, Mental Health, History, Politics, Social Justice, Sociology

320 pages, Hardcover

First published April 3, 2018

Reviews

[Barbara · Rating 4 out of 5]

4.5 stars

As a 2014-2015 'Soros Justice Fellow', investigative journalist Alisa Roth spent a year studying the plight of mentally ill prisoners in the U.S. Criminal Justice System. Roth visited jails and prisons in New York, Illinois, California, Georgia, and Oklahoma. She also interviewed mentally ill subjects and their families; consulted experts; perused medical and jail records; inspected court reports and other public documents; and read newspaper articles, books, and other source materials.


Alisa Roth

Roth found that almost every correctional facility in the country has a large number of prisoners with mental illness. Mental illness is a term that includes a wide array of disorders that affect a person's mood, thinking, and behavior. Examples are anxiety disorders; addictive behaviors; bipolar disorder; and schizophrenia.

Diagnosing and treating mental illness is difficult because there is no definitive test, and finding reliable drugs is often a matter of trial and error. Medical professionals have found that it's difficult to find the correct dosages; medications sometimes stop working; and there can be serious side effects.

Mental illness is a challenge even in the civilian community - with insufficient treatment centers and the like - but the problem is exacerbated in jails and prisons. Mentally ill people who are incarcerated generally get little or no treatment, and - upon release - are often sicker than when they went in.

One reason for this is the difficulty of diagnosing mental illness in the jail population. Some institutions - especially large ones - often try. In Cook County Jail in Chicago, for instance, a social worker oversees intake exams for new arrivals, looking for clues about mental health. This is frequently difficult, since mentally ill detainees often don't know - or don't want to talk about - their mental health issues. One tactic is to talk about medical problems, like blood pressure or diabetes, and ask, "Where did you get help?" The individual might then accidently mention a psychiatric hospital.

Administrators at Cook County Jail assert that - with recent improvements in the facility - a mentally ill prisoner can now get individual therapy, group therapy, and special housing.....and that many of the institute's corrections officers are trained to work with people with mental illness. This is not typical, however, of most prisons in the country.




Cook County Jail


A therapy session

*****

The author was permitted to observe the Twin Towers Correctional Facility at the Los Angeles County Jail, which is one of the biggest providers of psychiatric care in the country. The Twin Towers Facility houses the sickest inmates in Los Angeles - people who can't share a cell with another person and who aren't permitted to wear regulation jail attire - baggy pants and a scrub shirt. Instead, the mentally ill prisoners wear shapeless smocks made of quilted cloth that is supposed to be indestructible, so they can't be torn or tied into a noose. Patients are not offered any therapy, and mental health care consists entirely of medication and medication management.


The Twin Towers Correctional Facility


Inside the Twin Towers

When Roth peered into one of the cells in the Twin Towers Facility, she saw a prisoner wrapped in a dark blue blanket-cocoon lying on the lower bunk. The inmate's unit was covered in feces, which was spattered on the edge of the top bunk; rubbed on the floor; smeared in circles on the walls, and used as paste to stick sheets of paper towels to the wall - like a row of artworks. This wasn't an isolated incident, as many mentally ill prisoners 'decorate' their cells with feces. Even worse, one corrections officer described a prisoner who ate his feces, then drank water from the toilet.


A prisoner in his cell

Roth notes that prisoners in the Twin Towers are only allowed out of their cells in handcuffs or handcuffs and leg shackles - and some refuse to come out of their cells at all. These restrictions are necessary because corrections officers are not medically trained specialists schooled to manage the mentally ill; instead, they're law enforcement personnel taught to maintain safety.


A prisoner being handcuffed


A prisoner chained to a table

The Los Angeles County Jail does have a hospital unit, called the Forensic Inpatient Unit (FIP), which is a licenced acute psychiatric ward for the very sickest inmates. Unfortunately, the FIP doesn't have nearly enough beds to accomodate all the prisoners who belong there.

*****

The most debilitating form of incarceration in any corrections institute is solitary confinement - the practice of keeping a person alone in a small cell for 23 or more hours per day for weeks, months, years, or even decades at a time. Prisoners are generally placed in solitary for bad behavior.....and people with severe mental illness are among the most likely prisoners to end up there. Being alone and cut off from human interaction can cause or aggravate symptoms of psychosis such as hallucinations, paronoia, sleeplessness, and self-harm.....and mental health treatment in 'the hole' is minimal or non-existent.


A solitary confinement cell

The author mentions Brian Nelson, who spent 23 years in solitary confinement (mostly at the now closed supermax Tamms Correctional Center in Illinois) after being convicted of accessory to murder. Other harsh disciplinary measures used in prisons are hog-tying or cutting off water to cells.....and again the mentally ill are the most likely recipients.

There are many stories about the shoddy mental health care that people get in jails and prisons. In a 2017 class action lawsuit, prisoners at the federal penitentiary in Lewisberg, Pennsylvania claimed that the Bureau of Prisons provides little one-on-one counseling and that the 'supposed' counseling mostly consists of conversations through cell doors, which could easily be overheard by others. Even worse: "care for people with mental illness at Lewisburg consist of staff passing out coloring books and puzzles and calling it 'treatment'."

The author found similiar stories in almost all the instutions she investigated. The reasons prisons can't effectively deal with mentally ill people include:
- Overcrowding. A large population of very sick people are jammed into facilities that weren't designed for so many individuals.
- Lack of staff. There aren't enough medical personnel and corrections officers because the working conditions are difficult; prisons are often in inconvenient or remote locations; and the pay is low.

It's also important to note that race and poverty overlap with mental illness in the criminal justice system, creating a downward trajectory. The result is that once an indigent mentally ill person is arrested, he/she can't make bail, can't cope with being incarcerated, becomes disruptive, gets a longer sentence, becomes sicker....and so on. It's a vicious cycle. This is especially troubling among African-Americans and Hispanics, because they make up a large percentage of the prison population.

*****

To illustrate her points about mentally ill people in the criminal justice system, the author presents a number of case studies. I'll give some examples.

- In March, 2006 former firefighter and family man Bryan Allen Sanderson was arrested for indecent exposure in a South Carolina motel. At the time of his arrest Sanderson was manic and hearing voices in his head. Being in jail made Sanderson's symptoms worse, and he smeared feces around his cell and threatened officers and other prisoners. Sanderson was put in solitary confinement where he continued to cause trouble by throwing his food instead of eating it. Finally, five months after he was arrested, Sanderson appeared before a judge and accepted a plea for time served. However, the ordeal and its aftermath resulted in Sanderson losing his family, his livelihood, and his middle-class life.

- In 2012 Darren Rainey was serving a sentence for cocaine possession in a Florida prison. Being diagnosed with schizophrenia, Rainey was housed in a unit for mentally ill inmates. When corrections officers found that Rainey had smeared his cell with feces he was taken to a 'special shower' to clean up. At 160 degrees, the water temperature in the shower far exceeded the legal limit of 120 degrees. The officers left Rainey in the scalding water for two hours, by which time he was dead and his reddened skin was peeling 'like fruit roll-ups.' Prisoners and ex-convicts claim that abuse like this is the norm (though it doesn't usually go as far as murder).


Darren Rainey Illustration by Mark Espinosa

- Edgar Coleman, a former football player and teacher, was arrested by the University of Minnesota police over 200 times between 1996 and 2012....and that doesn't include the myriad times he was just shooed along. Coleman would stay in the school's buildings at night and steal food from buffet lines. Sometimes the police would take Coleman to jail, sometimes to a homeless shelter, but he was soon back on the streets. Coleman is dubbed a 'super-utilizer' - a person who cycles in and out of jail, getting re-arrested shortly after being released.

*****

There may be a light at the end of a (very long) tunnel since some communities are trying to improve conditions for mentally ill prisoners, including Cook Country and Los Angeles (mentioned above) and Riker's Island in New York City - which is increasing the number of special mental health units called the 'Program to Accelerate Clinical Effectiveness (PACE).'


Mental Health Unit at Riker's Island

According to Roth, what may really turn the tide "is the consensus that what we're doing is wrong. Whether we're talking about the people who are locked up and their families, or the corrections officers, or the prosecutors, the defense attorneys, the judges, the doctors — you name it. They're in agreement that what we're doing is not working, that it's counterproductive, that we need to change. We need to figure out how to come to a consensus about what that change looks like, but at least we're all on the same page – that this is not the way it should be and that nobody is benefiting from this situation."

This is a well-researched and well-written treatise on mental illness and the U.S. Justice System. Recommended to people interested in the topic.

You can follow my reviews at https://reviewsbybarbsaffer.blogspot....

[Jaidee · Rating 3 out of 5]

3 "torn, appreciative, mixed" stars !!

Thank you to Netgalley, the author and Perseus Books for an e-copy. This book was originally published in 2018. This edition was released June 2020. I am providing my honest review.

This is a book that is very hard to both rate and review. I have so many feelings and opinions in this subject matter. I do not wish to discuss why in this review.

The author has done a hell of a lot of research, as well as interviews and getting quite involved in the very interesting and compelling case studies she presented so well in this book. She appears to do her very best to remain neutral and non-partisan in her approach. She also does not lay blame with any particular group as to why the system is so broken not only for severely mentally ill prisoners but also the general forensic population, the workers in the system, the judicial system and the medical/ psychiatric system. For many readers this will be very eye-opening and educational. For me, not so much.

What would have been very helpful additions to this book:

1. a more clear understanding on the effects of gender, socioeconomic status and race on treatment in prison
2. a clearer definition of the population studied....mental health ranges from generalized anxiety disorder to paranoid schizophrenia....huge numbers are included in the percentages yet the book focused on those with severe psychotic disorders
3. some focus on the victims of both violent and non-violent crimes and the effects that is has on them both from a mental health and quality of life perspective
4. how brain injuries, neurological disorders, learning disabilities and developmental delays interplay with mental health conditions in this population
5. the role of substance misuse
6. the contribution of malignant personality disorders to the commission of crimes and their interplay with those with co-exisitng severe mental health disorders
7. the information is often scattered....a synopsis at the end of each chapter as well as charts and flow charts would have also added to absorbing the info in the book
8. more emphasis on possible solutions that would be helpful for all....severely mentally ill prisoners, the general prison population and very importantly victims of violent crime as well.

A valiant attempt at presenting an extremely important subject matter. Certainly a pretty good book for those with little knowledge of the subject area.

[JEN A · Rating 4 out of 5]

I received an advanced copy of this book from Net Galley and the publisher in return for an honest review. The release date for this book is 9 June 2020

Full disclosure with this, I have suffered with mental illness my entire life so any work that deals with it draws my attention. Luckily, I have never been diagnosed with bipolar disorder or schizophrenia which is talked about a lot in this book nor have I been incarcerated. That being said, I found the author’s correlations with regards to mental health and the penal system to be very eye-opening. It is definitely a shame in how our country deals with mental illness and this is just one more point of reference. I feel the author was very concise in making their point.

[Jake · Rating 5 out of 5]

Some sources say, upon his journey to the continent of north America the famous British writer, Charles Dickens, creator of Oliver twist, defender of humanity, had sworn to himself to see two things in this once new world.
1. Niagara falls
2. Eastern state penitentiary. (The famous Philadelphia based prison.)
While I can not comment on his experiences at the famous waterfall, I will present a musing of his - upon visiting the prison:

“I hold this slow and daily tampering with the mysteries of the brain to be immeasurably worse than any torture of the body; and because its ghastly signs and tokens are not so palpable to the eye and sense of touch as scars upon the flesh; because its wounds are not upon the surface, and it extorts few cries that human ears can hear; therefore the more I denounce it, as a secret punishment which slumbering humanity is not roused up to stay.”

Within this prison, each person was made to sit alone. To suffer and to mourn for their crimes. “In penitence” .
In short, after being defined by the law as a criminal, the punishment was intense isolation.
But what becomes of a man when alone in his head? Madness. Obviously.
Dickens noted this. And many others have spoken the words of man's inherent sociability as a fundamental psychological trait. As it says in genesis, “man is not meant to be alone”.
Or as Aristotle said in his politics "Man is by nature a social animal".
Such truisms are oft repeated so let us not pretend they do not exist.

Now of course, this book is not about the social state of man’s existence. It is rather about some deeply disturbing ideas we sweep under the rug. I will convey these ideas in isolated sentences. Numbered.

1. Mental illness is an illness .

It is not cancer, it is not diabetes, but is nevertheless serious. I do not need to repeat this. It is a biological malady. An actual physical, mechanical array of cause and effect. It is not simply a conceptual issue, “just in one’s head”, but one that is rooted within physicality.
This is - at this point within our modern state of scientific inquiry - an undeniable fact.

2. Mental pain, is real pain.

Pain - whether caused from a stabbing, or a heartbreak from thy beloved - is real.
Yes. I mean physiologically,or mechanically . The neuro chemistry is a thing. It releases “pain chemicals” to use absurdly crude neuroanatomy. It is by all metrics physical responses in both mental and bodily pain. To deny such thing is to forget your own memories.

3. The American judicial system is prejudiced, and has many issues. Many people suffer needlessly due to our institutions.

4. Many people who suffer have mental illness.
To paraphrase a line near the start of the book, one of the main groups in our society to suffer within america’s wacky penal system is the mentally ill.

Keep points 1, 2, and 4 in mind.
These people, who dream of suicide- like Lenny for his farm in of mice and men - who suffer the whims and chaos of their brains. Who receive no sympathy simply because the “ghastly signs and tokens are not so palpable to the eye and sense of touch as scars upon the flesh; because its wounds are not upon the surface” suffer. Dearly and horribly.

Despite modern advancements in psychology, and neuroscience we let them continue to suffer - with little to no remorse.
We proceed to stigmatize them only because we simply do not feel their pain. It is like the story told in Smith’s theory of moral sentiments where the man hears of the many that died of an earth quake across the world.
Why the hell should that man hearing of tragedy care when he DOES NOT FEEL THEIR PAIN. He does not need to care. And as such. He usually will not.

This wonderful book has a humanist undertone. Its title starts with the irony of our system . We must be “insane” to treat these “crazy” people so poorly. The writing is full of the stories and examples of these men and women that suffered from our shitty institutions. The author does a phenomenal job conveying the suffering of these poor souls by telling the stories of the ills we have done. It saddens me that there are not more books to recognize the clear human tragedy within our own society, but as a flip side, it deeply impresses me that this author is gifted with such a keen eye. Well done.

With no reluctance at all - I highly recommend this book to anyone that cares about human suffering. And to those that give a shit regarding many of our deeply existential societal issues. For those, it will serve to be a gut wrenching read, but one worthwhile nonetheless.

I do hope that we can change these issues soon.

Thank you Alisa Roth!

[JEN A · Rating 4 out of 5]

Full disclosure with this, I have suffered with mental illness my entire life so any work that deals with it draws my attention. Luckily, I have never been diagnosed with bipolar disorder or schizophrenia which is talked about a lot in this book nor have I been incarcerated. That being said, I found the author’s correlations with regards to mental health and the penal system to be very eye-opening. It is definitely a shame in how our country deals with mental illness and this is just one more point of reference. I feel the author was very concise in making their point.

[Lmcelebre · Rating 4 out of 5]

Roth does a great job of exposing some of the real inadequacies in our criminal justice system as they relate to mental health and I think her appraisal of the situation is fair and accurate. While I don't think she necessarily brings us any closer to resolution, I think her book may help to open up a dialogue that needs to happen if we're ever going to find solutions.

[Michael B. Morgan · Rating 3 out of 5]

When I picked up this book, I had an idea of what to expect. But nothing prepared me for how Roth's storytelling cut through and into my mind. Roth introduces you to people whose "crime" is to live with mental illness in a society that doesn't know what to do. Some cases reminded me of faces I have seen myself: faces of confusion, despair and anger. People completely out of touch with reality, but their illness wasn't a choice. How can we really face the depths of mental illness?
However, there was something about the reporting of the events that felt forced to me, as if the author was trying to get into my brain and inject ideas into it. That was my perception, but it still made me uncomfortable. Still a good book.

[Patricia Baker · Rating 3 out of 5]

as someone who used to work in the medical field, I can say this author has it right. the treatment of those who are mentally ill should not be placed in a jail, but in a separate facility that can oversee the mentally ill and help them get back on their feet. so often there is no place to put a person on the edge of insanity. mental health establishment are usually full and not accepting any new person. the jail is wrong because it does not address the central issue of why the person is in custody. do like the idea of more mental health training for those first responders whether they are EMT, police or fire. also like the idea of having a continued oversight from the time they are first encountered to the time they are released to housing and medical followup. I wish the general public would view mental health the same way it views cardiac, diabetes, or any other disease. there will be times of abatement of symptoms and there will be flareups. no one turns their back of the person needing another cardiac cath or med change. so there should be no back turning of the person with mental illness.

[Kristen · Rating 4 out of 5]

This was a hard, hard, HARD book to read, but I wish we were having more conversations about the topic. This was a really in-depth look at the prison system in America and how prisons treat and are sometimes asked to care for those with mental illness. With very little mental health care being affordable or available for a number of Americans, prisons are overflowing with inmates who have some type of mental illness for a number of reasons. And the state of prisons also exacerbates mental illness for most of the prisoners there. In addition, Roth does a fabulous job examining how the police treat those with mental illness. It's scary and disturbing and sad - and we need to do something about it. If you aren't motivated to learn more about these issues and/or do something to advocate for better policies around mental illness and the criminal justice system after reading this book, I can't imagine what would move you.

[John-andrew · Rating 5 out of 5]

Whatever you think life is like behind bars, think again. Roth's intimate yet powerful look at how our prison system handles mentally ill inmates will take you through the pits of hell and back again. This left me with more questions than answers, and more frustrated than angry. We are the richest country in the world yet we are unable to afford adequate mental health care for those who need it most? Are we so bereft of a common social conscience that we're unable to care for our fellow citizens? These are among the myriad questions I wrestled with while reading her detailed accounts of prisoners, the system in which they're caught, and the families on the outside who suffer. Many of our mentally ill wind up there because they're mentally ill, not because they're criminals. But once inside the system, their lives are forever broken.

[RhS · Rating 4 out of 5]

Meticulously researched, packed with stats, and oh so depressing. Not gonna lie, it was hard for me to get through. The writing is highly academic, and the subject matter is bleak.

I mostly agree with the author. Mental health care should be focused on delivering what the patient needs.

But. When it comes to violent criminals, rapists, human traffickers, and pedophiles, many of them qualify as mentally ill. And (it's ugly so I'll just say it) - I don't care. For me, once you cross over into that territory, you're irredeemable to society, and no tax dollars should be wasted catering to your needs.

For all the OTHER mentally ill patients / prisoners out there, yes, we can and should do much better than this.

[Psychonaut · Rating 4 out of 5]

As a jail therapist, I can say that, unfortunately, every bit of this is accurate.

[Thomas Edmund · Rating 4 out of 5]

It's hard to pick who to recommend Insane to - one the one hand as a new introduction to the connections between mental health, criminal activity and incarceration I imagine the tome would be illuminating and harrowing at once. For people with experience in the field etc, even non-US citizens there isn't too much surprising contained within the pages. The issues facing the mental health field and people experiencing challenges are fairly similar across Western nations.

What I think Roth does particularly well is explain the good, the bad and the ugly of the situation, while the content is predominantly negative in terms of poor outcomes for people with mental illnesses, and major challenges for professionals within the field Roth does explain some success stories, and offer hope for the future.

My only beef with the book is that at times it felt mired in the statistics that ultimately told the same story over and over again. I realize of course that is part of the point, however it did feel that some of the first sections could have been shortened and focused more on the harrowing individual tales.

Overall a timely book and a good chronicle of the ongoing challenges for people with mental illnesses and the heavy conundrums that face people making decisions in the justice system.

[Deanna · Rating 4 out of 5]

This book tore me up. I had to stop reading multiple times because a lot of these stories are just so heartbreaking. This book was so eye opening to how the criminal justice system treats people with severe mental illness. They are subject to horrible acts of abuse and neglect only making their diagnosis more severe. You can see not only how the criminal justice system but also how mental health care system has failed so many people. This is a great read for those interested in this topic.

[Wendi Lee · Rating 4 out of 5]

While at times dry, this was an informative and sometimes wrenching book about how and why prisons across America have such large populations of mentally ill inmates.

[O · Rating 5 out of 5]

This book is horrifying, but such a necessary read. Another example of how "the greatest country in the world" can be extremely backward and evil in the way we treat certain groups of people.

[Angela Michelle · Rating 4 out of 5]

This book got me thinking about our current policies and procedures regarding mentally ill criminals and it seemed very well-researched. There are some disturbing stories and many of the situations were like ones my husband encountered while working at a state-run mental hospital. With his experiences there, the information seemed all the more believable and flabbergasting at the same time.

[Steven Pugh · Rating 5 out of 5]

This is an important book that tells about people hidden behind bars, struggling with mental illness, the criminal justice system, and the needs of jails and prisons for strict control. This book also relates the stories about the valiant, dedicated people trying to change an awful system.

The author does a wonderful job taking an emotionally taxing and disturbing topic and making it readable. A less skilled author may have written a book about an important topic like this and sounded too preachy and continuously condemned the society that allows such horrors to take place. Alisa Roth told these silenced peoples' stories with both heart and stinging truth.

I hope this book helps fulfills Churchill's quote about America "You can always count on Americans to do the right thing - after they've tried everything else" regarding people with mental illness trapped in jails and prisons, because we sure seem to be wrong thing right now.

[David Provost · Rating 4 out of 5]

As someone who has worked in the supportive housing field for the past ten years, I can say that Ms. Roth has captured the essence of one of the United State's largest social blunders - the criminalization of mental illness, accurately and sympathetically. The book is objective in style. It's a bit of page turner to boot.

This is a must read for anyone who is interested in the welfare of the mentally ill and homeless among us.

[Madison Lands · Rating 2 out of 5]

Wanted a lot more from this text, especially in the conclusions that it arrived at. Particularly very disturbed that it lacks a meaningful engagement with the role that race plays in who is incarcerated, who is diagnosed as mentally ill, and how we treat patients and/or incarcerated people with mental illness based on race.

[Carrie · Rating 4 out of 5]

An important topic presented in a well-researched manner. Our system definitely needs reform. Good to see some cities have started to implement new strategies, but we still have a long way to go.

[Alexis · Rating 5 out of 5]

We often hear about mental illness in connection with criminal justice when there's a high profile crime and people rush to offer explanations (usually when the defendant is white). But the intersection of the two is much greater, and more tragic.

While people often link the issue of mental illness in correctional institutions to deinstitutionalization, the problem is much more complex and fragmented, as Alisa Roth outlines in her heartbreaking, enraging book. She goes through a variety of settings to show how decisions and policies, often made in isolation, combine to create a horror. Jails are our largest provider of mental health care. In 2017, 43% of inmates at Rikers Island had a mental illness. 1/4 of fatal police shootings involve a person with mental illness. Suicide is the leading cause of death in jails.

Jails are expected to fulfill contradictory functions: to control inmates, and also to treat their illness. They lack the capacity to do the latter, even in better run institutions or where improvements are being made. In some states, like Alabama, it's arguable as to whether they are trying. The desire to control inevitably results in restrictions on inmates that are counterproductive to treatment, even when the officers are actually trained in dealing with mental illness. The desire to punish also means that inmates lose "privileges" such as visits and exercise which are shown to improve treatment outcomes.

The ways in which bureaucracy frustrates itself are also evident. HIPAA means that corrections staff cannot be given medical information, even though they are effectively present for therapy and could use the information to treat inmates better. The 1965 Medicaid law prohibits federal funds from being used for large institutions. This means that when inmates are hospitalized, the state must pay for it themselves--increasing the incentive to keep costs down. States spend, on average, only $105 per capita on mental health, and there is a significant shortage of mental health care. 40% of psychiatrists do not accept insurance (though Roth cautions that since psychiatrists may operate dual practices, this may only reflect their private practice). Since prisons are often in remote locations they struggle to recruit staff, and even better located institutions don't pay competitively.

Politically, mental health is not a high priority, much less for those who have committed crimes. Many of those crimes are not significant, but mentally ill inmates are less likely to get bail. The long process of pretrial detention, waiting for competency hearings, and the slow wheels of the system worsen their illness. One of the more blackly comic episodes involves inmates watching Law & Order so they can pass their competency hearings. When they get out of jail, they don't have good access to mental health care, and so a cycle repeats. Some of the bright spots in the story involve departments that are making an effort to retrain officers and cities that are improving mental health care.

There is so much to this book--even though it's not exceptionally long. Roth visited institutions in various parts of the country and uses inmate stories--some graphic--to show the workings of the system. There are so many problems, and so many intersecting parts, that I didn't even know where to begin to start solving it.

[April Helms · Rating 4 out of 5]

I finished this book this afternoon (for my book club), and still trying to absorb everything. Roth's book is fairly short, but packs a heck of a punch in terms of exposing at so many levels how poorly this country handles mental health issues, especially when it comes to incarceration. We do so many things in this country that actually fuel the various prison pipelines, and those who have a mental illness especially get caught up in a vicious cycle of imprisonment and release because resources are so scant and scattered. One story, for example, relates how one person awaiting sentencing waited four months for a psychiatric evaluation. Basically, everything from what is criminalized, to solitary confinement, to bail issues, to how prisons are set up, how law enforcement often has as much — if not more — of a voice when it comes to deciding who gets care in what environment (and this is something the vast majority of corrections officers or police officers really don't have the training for) — it sets out most vulnerable up for failure. Not to mention the lack of training (or incentive) for deescalating a situation, and having trained mental health providers on site at prisons and hospital facilities. Roth does show some bright spots by illustrating promising programs that seem to be working at reducing the numbers of mentally ill who spend time in a prison, and how many go back to prison, such as the Restoration Center in San Antonio and CIT training for police. But obviously, much still needs to be done on many fronts. Roth includes numerous interviews with those who have mental illness who have gone through the criminal justice system, as well as their families.

The only nit I have is that the book goes into how a lot of medical personnel working a prisons are later found to have rap sheets themselves. However, it is not addressed whether they were effective at their jobs. If they were doing a good job, I'd say they probably had qualifications that made them well-suited to helping out prisoners, especially since there is a paucity of professionals willing to go into this field. Later in the book, it goes into the difficulties that those with a record- particularly those with a mental illness- have in finding housing and jobs. How nearly impossible it is to get a second chance. I found it an odd condemnation for a book that seeks to bring empathy for the incarcerated and formerly imprisoned. If there were issues in general, that's one thing, but to say a medical professional was a problem because he or she had a record (and not go into job performance, save in one case where it did seem to be an issue) was a small fumble. Aside from this, I highly recommend this for anyone interested in how deeply flawed our criminal justice system is.

[Georgie · Rating 4 out of 5]

!! Please note: This book does include a number of trigger warnings- namely it discusses topics such as self-harm and suicide. It is also somewhat graphic, as there are detailed descriptions of self-mutilation and bodily fluids. !!

Roth provides an extensive and well-researched analytic overview pertaining to the over-representation of mental illness in the American prison system. I particularly appreciated the inclusion of numerous case studies from a range of states - it clearly highlights current decrepit prison conditions and the ill-preparedness of the justice system (as a whole) to adequately treat individuals in a manner that is fair and humane. Although this book focuses on the American prison system (statistically in particular), such issues are evident worldwide.

I would have liked more discussion around potential initiatives regarding improvement, particularly community- based, as this was only lightly touched upon.

Regardless, I think this is a must-read (particularly for those in the criminology and law sectors).

[Tait Gould · Rating 4 out of 5]

"The definition of insanity is doing the same thing over and over again and expecting a different outcome"

This was a very informative read about the treatment of mental illness in the prison system and in everyday life. Alisa Roth writes in an engaging way with just enough history, personal stories, and well-done research to the topic. I was constantly thinking while reading and being challenged to see parallels in 2022. Unfortunately, it seems that the position surrounding mental illness is only getting worse. Roth writes that "incarceration is yet another form of abuse for people who have, in many cases, spent a lifetime being abused". She reiterates how the basics of the system, not only in prison but how the justice system handles mental health, is a continuous cycle of letting people down.

One of my reading goals for the year is to read more non-fiction and this was a good choice! The topic was interesting and it didn't read like a textbook. Would recommend!

[Literatures Movies · Rating 3 out of 5]

Interesting as this book was, it was an absolute slog to get through. For some reason getting through this book just felt immensely slow for me.

The author went in depth in regards of how criminals in America are being treated very badly, especially those with mental health issues. Their mental health aren't taken seriously, causing it to exacerbate in prison. The author also talked about how the system is set to work against those with mental health issues rather than with them. While all this point was all very valid points, I don't think one needs 50% of the book to get their point across.

The author provides a lot of examples and reasoning as to why, but 50% of the book (that I read) could really be summarized in a few sentences. This book really ran way way way too long without much substance.

DNF 50%

[Erika Skarlupka · Rating 5 out of 5]

A must read for anyone concerned with mental health and prison systems in America. The failings of the healthcare and criminal justice systems in this country have lead to an outright crisis for those with mental illness. Often neglected and abused in jails and prisons they are left to suffer, unable to advocate for themselves. This is a shocking investigation into how some changes are being made, but the glaring short comings of what is, in truth, many broken systems.

Thanks to Netgalley for this copy in return for my honest review.

[Hailey · Rating 4 out of 5]

Insane was a nonfiction novel by Alisa Roth that gives an AMAZING background for people interested in the prison sysetem and mental health. I liked this book a lot, and the onle reason I gave it a 4 star rating was because I wished it would have had more stories like in the beginning.

[Rachel Willis · Rating 4 out of 5]

A tough but necessary read. Roth details the funneling of the mentally ill into the criminal justice system and why this is a problem.

[Monica · Rating 4 out of 5]

Narrative could have been better but topic is fascinating and horrifying.