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As the healthcare debate rages in the US, the fate of the hundreds of thousands of mentally ill people in American jails and prisons has been absent from the agenda.
In a special report, Fault Lines' Josh Rushing visited detention facilities in Texas and discovered how inmates with mental illness are treated.
Homelessness has become a part of the landscape of every major city and town in the US, but it is often more than poverty that is to blame for the plight of the homeless.
While there are no exact figures, advocacy groups estimate that as many as 80 per cent of homeless people suffer from mental illness.
For many, this eventually leads to confrontations with the law - which explains how the mentally ill have come to make up more than half of the US prison population.
Houston in Texas has one of the nation's largest homeless populations.
Incidents in which police officers have shot and killed mentally ill individuals have forced law enforcement officials here to re-think their approach.
"As the years passed, we decided to take advantage of the resources of the mental health community," Chief Harold Hurrt of the Houston police says.
"And now, we are much more professional in our response in that we realise that jail is not the answer."
Houston is home to the nation's largest Crisis Intervention Team (CIT) unit. By partnering police officers with mental health clinicians, this programme aims to allow distressed mentally ill individuals to recover in hospitals rather than detention facilities.
However, long term psychiatric facilities have all but disappeared throughout the US and the under-funded and over-crowded public hospitals can offer only short term services.
Fewer than 40,000 Americans currently reside in psychiatric hospitals. But, according to the Department of Justice, 30 times that number - 1.25 million mentally ill people - are serving time in US prisons.
|Psychiatrists say jail is not an ideal environment to treat inmates
"There's no question jails are the new asylums," says Dr E Fuller Torrey, the author of The Insanity Offence.
"I have tried to find a single county in the United States - we have over 3,000 counties in the United States - where the hospital still has more mentally ill people than the jails. In every country that I can find, the jail has more mentally ill people than the hospital."
Harris County jail in Houston is no exception.
Each year 130,000 inmates pass through the facility and at any given time it doses 2,500 inmates with psychotropic drugs, making it the largest mental health facility in Texas.
The jail's authorities have recently made significant changes to improve conditions for the mentally ill.
Andre Bonier has been living on the streets for 15 years. Diagnosed as schizophrenic, he is in Harris County jail for the 31st time.
"When he got here a week ago, he was a completely different person from what you were able to see today," says Dr Jackie Bickham.
"He was extremely aggressive, so aggressive that he had to be brought over directly from processing, had been on office meds, was combative, threatening, hostile, throwing faeces."
Andre has been charged with assaulting a family member, although he claims to have no recollection of it or any understanding of the legal process he faces.
The problems for Harris staff go beyond treating Andre - they also have to prepare him for a trial, after which, if found guilty, he could be transferred into the Texas prison system.
"This is intended to be a jail, not a treatment centre ... We create an environment that's as therapeutic as possible, it's staffed with professionals ... But it's still not a hospital setting," says Dr Patrick Seale.
At the Luther Unit in Texas, two psychiatric staff are responsible for more than 1,300 inmates.
|Charlie Brink says his
treatment in prison 'sucks'
Charlie Brink, who is serving a seven year sentence for drug charges, says that his treatment "sucks" and that he only sees a doctor once every six months.
"You go into a room and you look at the big screen TV and he's there on the TV and he can see you, but it's just not the same as talking to someone in person.
"To me prison is for people like child-molesters and rapists and murderers and stuff like that. It seems like we're not even treated like people here."
While direct contact with a doctor may be rare, prescription medications seem to flow through the corrections system without a problem.
The Texas Department of Criminal Justice refused numerous requests to speak with Fault Lines about its mentally ill population behind bars.
At the heart of the issue is the crucial question of whether, if mentally ill people break the law, jails should help or punish them.
The origins of the problem can be traced to institutions such as the Rosewood Center, near Baltimore in Maryland.
Founded in 1888 as an "Asylum and Training School for the Feeble Minded", such places were later criticised for holding and medicating people against their will.
Starting in the 1960s, these institutions fell victim to political pressure from both the left and right.
Conservatives such as Ronald Reagan, the then governor of California, pressed for state budget cuts to reduce the size of what they called the welfare state.
At the same time, civil liberties groups began an aggressive campaign against involuntary commitment, calling it a violation of patients' civil rights.
Lawyers and politicians argued that the mentally ill would be better treated as out-patients by community mental health centres, but the idea never got off the ground.
"The whole idea behind de-institutionalisation turned out to be very well-meaning, but a disaster because there was not a plan for what was going to happen to people when they left the hospitals," says Dr Torrey.
"It's a major black mark. And I think the whole de-institutionalisation movement will go down in history as one of the great social disasters of the 20th century."
Healthcare has dominated the domestic agenda in the US recently, but advocates say mental illness has been conspicuously absent from the conversation.
|Dr Torrey says the treatment of the mentally ill in prisons is a 'black mark'
Instead the administration has been touting so-called "parity" legislation, which will require private insurance companies to cover mental illness.
But critics point out that people who are homeless or in prison often do not have access to insurance, and that the legislation does not address the real problem.
Kathryn Power is the director of the Center for Mental Health Services and the highest-ranking federal official responsible for protecting the interests of the mentally ill.
"My jail diversion programme is a $10 million programme - that's not a very big programme," she says.
"[With a] $10 million programme we can perhaps fund five or six communities in the United States."
The Huntsville Unit, the oldest prison in Texas, releases dozens of prisoners every day.
Bill Kleiber, a former inmate with bipolar disorder, greets them and trains volunteers to be the first point of contact for newly released prisoners as they prepare to step out into the world.
He is assisted by Eric Strawhacker who was released from prison in April. In addition to coping with his mental illness, Eric now faces the additional stigma of being a convicted felon.
"It is really a travesty that we would take mentally ill people and cycle them through incarcerations," Kleiber says. "They're just cycled through there as big human warehouses.
"Come spend a day with me at the bus station. And see the human garbage we have created. A lot of those men were not like that when they went in there. And I'll take you in to some of these prisons and they walk around like zombies."
The healthcare discussion has become as ugly of a partisan debate as any in recent US history. Yet when it comes to treatment for the mentally ill, it is clear that the status quo is both potentially dangerous and inhumane.
"I think our era will be regarded with a great deal of wonderment as to why they allowed all those mentally ill people to be on the streets," Dr Torrey says.
"You need leadership, you need professional leadership within the psychiatric profession and you also need political leadership. You need governors or someone in the White House or someone in the Department of Health and Human Services who says this is a problem that we can solve and we're going to solve it."
Josh Rushing's special investigation into the treatment of the mentally ill in US prisons can be seen on Fault Lines from Thursday, September 17, at the following times GMT: Thursday: 0600, 1630; Friday: 0130, 0830; Saturday: 1130, 2330; Sunday: 0630, 2030; Monday: 1430; Tuesday: 1230, 1930; Wednesday: 0300.