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In 2013, at California’s Salinas Valley State Prison’s inpatient psychiatric hospital, which houses high-security level inmates with severe mental and physical impairments, Desmond Watkins drank enough water to kill himself. He suffered from a condition called psychogenic polydipsia, a mental illness that causes someone to believe they are thirsty all the time. People with this condition must be carefully monitored and have their water intake limited to prevent water intoxication. Reports indicate that authorities knew that Watkins was a risk to himself—he’d been hospitalized for polydipsia only a few months before. Yet, he somehow gained access to enough water to kill himself.
His death raises questions about the quality of care mentally ill inmates receive in prison facilities. In 2012, thirty-two inmates in California’s thirty-four state prison facilities committed suicide, and many of these deaths, like Watkins’s, were likely preventable with proper psychiatric care. (California considered Watkins’s death an accident, not a suicide.) California’s state prisons have one of the highest suicide rates of prisons in the United States. One inmate commits suicide approximately every eleven days, nearly 1.5 times the national average, and that rate has increased steadily since the early 2000s.
As many as half of the U.S. prison population suffers from mental illness. How can the system adapt?
To talk about mental illness is to encroach on territory that is at best confusing, even for those with resources and support. For individuals with severe impairments who face homelessness, unemployment, limited educational opportunities, and strained family ties, the system seems doomed to fail. When they are not properly equipped to cope with symptoms, these individuals tend to come into contact with police and the judicial system (for instance, many choose to medicate with street drugs or may lash out at strangers), and their behavior can be difficult for untrained staff to interpret.
So, America’s prison system has become a convenient place to hold the mentally ill. Some reports estimate that as much as half of the U.S. prison population suffers from mental illness. This comes at a substantial cost. Right now, independent sources estimate that California spends about $60,000 per inmate per year, which means that California spends more than four times as much per prisoner as it does per K–12 student. Mental health care adds over $15,000 to this figure.
Furthermore, the unique stressors that prisons place on the mentally ill make their treatment particularly challenging. During a visit to California State Prison, Sacramento—another state prison with facilities for the care of the mentally ill—, I spoke with Chief Psychologist Dr. Ralph Wheeler, who described how prison life makes clinical work more difficult. Outside prison, one treatment strategy for people with certain mental illnesses is to avoid, or remove themselves from, situations that may provoke symptoms. But in prison there is often no escape from stressors—ranging from cellmate conflict to riots, alarms, and crowds. The mentally ill are also more disproportionately more likely to be affected by the loss of freedom and enhanced sense of vulnerability than the non–mentally ill population.
Of course, prisons put regulations in place to protect inmates, and to prevent them from committing suicide. Different units provide varying levels of care, which dictate how often an inmate sees a psychologist or physician. In the Psychological Services Unit (PSU), inmates are not permitted to walk around unshackled; they must be restrained in hand and foot cuffs or in cages. A man in the PSU white uniform shuffled down the hall, attended by two guards—another requirement. Inmates in the PSU receive a level of care known as EOP (Enhanced Outpatient Care). They have weekly meetings with a therapist and participate in group therapy, albeit in individual cages because they cannot be unshackled in the presence of others. I was informed that inmates in the PSU are quite violent and have proven themselves to be rule-breakers. The “rule-followers” are instead housed in an EOP gen-pop; they are able to meet in small groups without shackles.
People suffering from “mental health crisis” are housed in a rubber room for short durations—usually about 2–3 weeks, depending on a physician’s recommendation. Inmates in crisis see someone every day. The rooms—the walls of which are lightly padded in a pink gel-like substance rather than rubber—have no furniture except for a metal toilet in the corner. Other rooms contain beds with straps to tie people down. Inmates are sometimes required to don a “tear-proof” smock, the modern equivalent of a straightjacket. Certain rooms are labeled “NO CUPS” to prevent “gassing”—inmates collecting and throwing urine, feces, or semen in the eyes of visitors and correctional officers. But, even with these structures in place, an officer off-handedly commented that it is extremely difficult to stop someone hell-bent on hurting himself.
• • •
Watkins’s case was part of an expert’s report in Coleman v. Brown, a decades-long class action suit alleging that the California Department of Correction and Rehabilitation (CDCR) has failed to care for the mentally ill in prison. As a result of the latest ruling in Coleman, the state of California is under court order to improve the conditions of its mental health care within state prisons. In the spring of 2013 Governor Jerry Brown sought to lift the order, but the court denied his request.
The Coleman complaint was followed by several special expert reports detailing the ways in which the CDCR’s procedures and training fail to detect and appropriately treat the mentally ill, but the latest report shows that these conditions have not yet improved. Deaths such as Watkins’s are more likely to happen when there is a shortage of trained medical professionals. At facilities like Salinas, staff psychiatrists frequently had nearly sixty patients to manage. (At PSU, the caseload is eleven inmates per clinician.) A report by Dr. Raymond F. Patterson, one of the experts assigned to Coleman, finds that inmates in segregation units are more than thirty-three times more likely to commit suicide. Numerous other studies have documented that solitary confinement has an extreme adverse effect on mentally ill patients, exacerbating adverse psychiatric conditions by further isolating those individuals who most need attention. And the prison system is so resistant to change that Patterson stated in his fourteenth and final report that he would no longer participate in the process: “It has become apparent that continued repetition of these recommendations would be a further waste of time and effort.”
The recent hunger strikes at Pelican Bay called attention to the use of solitary confinement, known within the system by its official names “SHU” (Secure Housing Unit) and “Ad-Seg” (Administrative Segregation). Yet when I visited CSP-Sacramento, which houses a large segment of inmates who require constant psychiatric attention, the CDCR told me that solitary confinement did not really exist there, and that even in SHU inmates have bunkmates. In EOP or PSU inmates may be housed individually, but only for significant and chronic illnesses.
• • •
The history of Coleman parallels another recent lawsuit brought by inmates against the CDCR, Plata v. Brown. Plata alleges that the delivery of mental health services, among other services, is seriously impeded by overcrowding. The Supreme Court held in 2010 that California must reduce its prison population to 137.5 percent of capacity in order to bring the CDCR within compliance with the Eighth Amendment’s prohibition against cruel and unusual punishment. Although the prison population has steadily declined, the CDCR has yet to comply.
One of the state’s strategies for dealing with overcrowding is an initiative called “realignment,” defined by Assembly Bill (“A.B”) 109. At its core, A.B. 109 kicks back responsibility to the counties, which are now responsible for housing certain types of offenders called “N3s” or “triple-nons” in correctional lingo, meaning their most recent crimes were non-serious, non-violent, and non-sexual. Contrary to some popular misconceptions, A.B. 109 does not simply order that inmates be released. Nevertheless, “N3” status applies even to offenders who have committed violent crimes in the past. This aspect of A.B. 109 has drawn some criticism, especially after an A.B. 109-er murdered someone in Hollywood shortly after his release.
As a result of realignment, the overcrowding problem has shifted from state prisons to county jails, many of which have simply reduced sentences or built more jails. It is even more difficult for clinicians to provide health services in jail than it is for them to provide services in prison, and, perhaps more tellingly, people who are serving jail terms, which are generally shorter stints than state prison sentences, must both transition into the jail system and then transition out of it more quickly. In the meantime, mental health care is subject to interruption, making a prisoner more likely to offend again.
Despite realignment, which has reduced the number of inmates in California state prisons from a high of around 170,000 to about 130,000 (still well above the court-ordered number of under 120,000 inmates, 137.5 percent of design capacity), the number of inmates with a severe mental illness has remained about 33,000. As a result, realignment has simply resulted in a higher ratio of mentally ill inmates in California state prisons. While a lower prison population alleviates housing and intake concerns, the CDCR cannot adequately address the Coleman issue without substantially increasing mental health services.
Instead, California has simply thrown money at the problem. The CDCR has invested tens of millions into improving health care for the mentally ill within its facilities, increasing spending on mental health care per inmate from $13,212 in 2010–11 to $15,726 for 2013–14. The CDCR has also built new facilities such as a 22,158-square-foot, LEED-certified facility in Sacramento designed to treat mentally ill inmates. But, it’s not entirely clear how these capital investments are actually improving the care of the mentally ill.
To be fair, it is difficult to look at mental illness in prison from a purely clinical view. The prison system operates on a different paradigm, one that is always forced to balance public safety with the humanity of the inmates. From the CDCR’s point of view, vast shifts have been made due to realignment, from an accommodation model to that of treatment and rehabilitation. Culture takes a long time to change.
San Francisco established a Behavioral Health Court, which offers an alternative to jail time.
Treatment and rehabilitation for the mentally ill is a long process without a quick fix. When I asked Dr. Wheeler whether some individuals could be fully rehabilitated, he told me that rehabilitation may not look the way we think it should: those with severe impairments are doing the best they can. But who decides what is “best”? The Coleman plaintiffs argue that the CDCR’s “best” simply is not good enough. While no information on the exact costs of defending Coleman is available, defending these lawsuits arguably does more good than harm by funneling more money into a prison system that is rife with problems. That money should be reinvested back into community services that prevent the mentally ill from falling into the prison system in the first place.
• • •
How can the prison system be calibrated to respond to the needs of mentally ill offenders? In 2002, San Francisco established a Behavioral Health Court (“BHC”), which offers an alternative to jail time and aims to provide mentally ill offenders comprehensive care and treatment to help them establish and maintain sustainable regimens. To qualify for BHC, someone must have a diagnosed Axis 1 illness, and the mental illness must have been a motivating factor in the crime at issue. (Axis 1 illnesses include depression, schizophrenia, PTSD; Axis 2 are personality disorders, such as borderline personality disorder.) The people the BHC helps are high-need and high-risk: they are homeless and lack the means and support system to get help. They are also highly likely to commit more crimes.
Right now, the BHC maintains about 140 people in its system. These people were already on the very fringe of society before being arrested, the sorts of people that exist and are ignored in every community, but are particularly vulnerable in the Bay Area, a region now dominated by tech giants and start-up billionaires. When I visited the courtroom, it immediately felt out of the ordinary: designed to manage and treat mentally ill criminal defendants, providing some hope of treatment and assimilation into the community.
The judge’s involvement is much higher and more paternal than in regular court proceedings. “You should put that paper in a plastic bag so it doesn’t get wet,” Judge Ronald E. Albers advised one of the clients, who offered a wilted piece of paper as evidence of her compliance. The last few days have included much-needed torrential rainfall in the Bay Area. She is supposed to keep a sign-in sheet, which she uses to certify that she has been attending group sessions for anger management and addiction, but the paper got soaked in the rain.
And, participants are rewarded for achieving goals and attending meetings, rather than penalized for violating parole. Judge Albers urged the next defendant to get a cell phone so that he could call ahead if he needs to cancel or reschedule appointments with his social worker. Another defendant was given a round of applause and added to the “honor roll” for successfully attending job-preparedness seminars and landing a second interview at Trader Joe’s. Before dismissing defendants, the D.A. offers a Reese’s Peanut Butter Cup. “Take more!” she encouraged them.
Lawyers and social workers work together, rather than in an adversarial nature, to find the best solution for each client. Before a day’s court session, Judge Albers meets with representatives from social services divisions, defense attorneys, and the district attorney’s office to review the cases on his daily calendar and determine the proper course of action. During these case management meetings, Judge Albers takes extensive notes.
“It’s like children,” Judge Albers told me before court was in session. He explained to me that the role of the judge is perhaps one of the most important ones in the defendant’s case management. He sees his job as to encourage those who are on the right path, making appointments, attending group sessions, and not to overly-punish those who are not following the program. “If you punish too heavily, then there’s nowhere to go,” he says. “You can’t cut off a kid’s hand for stealing candy.”
The BHC operates on a similar principle. If someone qualifies, she can opt into BHC, which will suspend her jail time. Most BHC individuals spend a few years moving through the system. They often come to court every week or every two weeks to check in with Judge Albers. The consistency is particularly important: if someone misses a caseworker meeting or a doctor’s appointment or doesn’t pick up a prescription, time is of the essence. Intervention must come quickly.
The BHC is one way to deal with the “N3s” resulting from A.B. 109. “N3” status doesn’t apply only to offenders who haven’t committed serious crimes—they may have pled out to a lesser crime or committed a more serious crime in the past. And even if the crimes they commit are not life-threateningly violent, many are despicable—punching an elderly man in the face, stealing wallets, attacking city employees. The BHC recognizes that those who commit such crimes while suffering from an untreated mental illness need support and assistance, rather than punishment. But like many such public services, the BHC suffers from the twin challenges of money and time. Many administrators explained that with more resources, departments like the BHC could fund full-time staff.
Some other counties are making headway with similar programs. Contra Costa County, for example, has had success with its split sentencing program. I spoke with Philip Kader, the head of probation in Contra Costa, who enthusiastically described “split sentencing,” where A.B. 109-ers serve a shorter jail time in exchange for counseling and mental health services to help them acclimate to life after being released. More recently, the Affordable Care Act has provided health coverage for inmates, allowing for some continuity upon release. (One role of case managers in the BHC is to help participants sign up for Medi-Cal and receive health benefits.) But even though realignment has thrown some money at the problem, not every county in California is as progressive as San Francisco or Contra Costa. Other counties continue to send more people to state prison or use the realignment money to build bigger jails.
Perhaps what is most remarkable about the BHC is that it questions the entire penal system by decriminalizing mental illness, taking into consideration the fact that defendants who are mentally ill have diminished culpability. Rather than looking at mentally ill offenders as a people requiring punishment or a quick fix, the BHC tries to treat the problem in a way that considers public safety, the society at large, and the individual all at once. While long-term data is not yet available to explain how well the BHC works to reduce recidivism, a Texas study found that mental health courts reduce recidivism by about a third and substantially increase compliance with a psychiatric regimen.
Certainly, the BHC does raise new questions. One is whether mental health courts can force those who would not ordinarily accept medication for mental illness into compliance with a psychiatric regimen. San Francisco, for example, has a provision that allows for mandatory psychiatric treatment in extreme cases. Those who comply with the BHC must adhere to strict regimens, which usually include psychotropic medications, as well as outpatient therapy and support groups. Despite the problems they raise, these programs do offer support, and seem more humane than prison sentences.
• • •
More creative solutions are required to help the mentally ill currently trapped within the criminal justice system. As realignment indicates, their numbers are unlikely to decrease without substantial changes in sentencing laws. The high rate of suicides in California prisons—as well as the high percentage of mentally ill in prison—reflects trends that exist outside of the penal system. Inmates come from the communities where we live, after all. Without substantially increasing treatment and access to services for the mentally ill both inside and outside prison, there can be no real change. Once someone is contemplating suicide at a state prison, it may be too late.
Image: Thomas Hawk
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