Preserving mental-health care for prisoners: A life-and-death budget issue

State officials and the Concerned Lifers Organization, a prisoners' group, have a common goal: better psychiatric care in prisons and on the outside.

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Washington state's Monroe Correctional Complex

State officials and the Concerned Lifers Organization, a prisoners' group, have a common goal: better psychiatric care in prisons and on the outside.

Seventeen Washingtonians have been murdered over the past 13 years by men whose violent psychiatric disorders were known to authorities before they committed the crimes.

Of the nine men who killed those people, the most recent and notorious is Maurice Clemmons, who shot four Lakewood police officers a year ago after being paroled despite a documented history of mental illness.

Before Clemmons' murder spree, in a scathing 2008 article headlined “State pays in blood for flawed mental health system,” the Seattle Post-Intelligencer described 11 of the “preventable tragedies.” Award-winning reporter Carol Smith (now a senior writer at Investigate West), wrote that state laws combined with an “overburdened, ineffective mental health care system” enabled the homicides.

Chad Lewis, a family services specialist with the state Department of Corrections (DOC), agrees. “The common thread in those cases is mental illness,” Lewis said, and marshaling resources to deal with mentally ill offenders is a top priority for DOC Secretary Eldon Vail: “We're not oblivious” to the need for improvement. “We're more than just aware.”

The Concerned Lifers Organization at Monroe Correctional Complex is equally concerned. The group is currently trying to improve mental health care inside prison walls, through a series of presentations to visitors including UW Medical School residents in psychiatry and others interested in ensuring better treatment of people with mental illnesses.

Earlier this fall a friend who has led CLO religion seminars for many years asked me to join a group of five people invited to attend one of these presentations. At the prison's front desk we turned our pockets inside out, gave officials our car keys, and filed through a metal detector. A woman who manages family services programs joined our group and led us through a series of locked doors and yards, where razor wire coiled atop fences between guard towers, into a room with a circle of chairs. Forty inmates straggled in, greeted each of us in turn, and sat down with us.

The CLO was founded at Monroe in 1978 by prisoners “doing ‘life without,’” as they aptly call serving their sentences of life without possibility of parole. Members mentor shorter-term convicts in life skills and values that could help keep them from re-offending after completing their sentences. They host visiting groups of at-risk teens and tell them about the life behind walls that looms ahead of lawbreakers. They sponsor religion classes, lead a book club, and raise funds to provide poor students in the surrounding community with college scholarships.

Last December, shocked by the Clemmons murders, the CLO wrote a collective letter of sympathy to relatives of the police officers who died. Through their labor at the prison rate of 42 cents per hour they raised enough to donate about $2,000 to the families.

Prisons like Monroe have become America’s de facto new asylums. It’s a truth so often repeated that the phrase has become a cliché. As rising numbers of Americans with chronic psychiatric disorders are incarcerated, the total share of prison inmates in the U.S. with serious mental illnesses has climbed to 16 percent. This is the most conservative estimate, according to "Confronting Confinement," a 2006 report of a national commission on safety and abuse in America’s prisons. Many estimates put the number closer to 36 percent, or even 54 percent when individuals with anxiety disorders such as PTSD are counted in.

The unintended and awkward medical role of prisons debuted with the steady release of patients from big mental hospitals, a shift that began half a century ago. By 1996 this “deinstitutionalization” had reduced hospital populations by 90 percent. During the Reagan years many state asylums were shut down entirely to save public funds, and few of the community clinics that were promised as replacements got built. Since then, despite the fact that most people with mental illness can recover and live productive lives if they receive proper care, public programs for treating psychiatric disorders have been chronically underfunded across the country and in Washington state.

The consequences are visible on our city sidewalks and in our parks. People with untreated mental illnesses wander around disoriented and incapable of insight into their actions. Most are harmless (statistically speaking, they’re far less dangerous to your health than a ride in a car), and street thugs prey on them. Some try to medicate their disturbing symptoms with alcohol or street drugs, and some break the law. A 2003 report from Human Rights Watch, "Ill-Equipped: U.S. Prisons and Offenders with Mental Illness," quotes a former lead psychiatrist at Washington’s McNeil Island Corrections Center as saying, “The severity of the mental illness of those coming in is increasing…. The prisoners often have no idea how they ended up here.”

Monroe superintendent Scott Frakes summed up today's situation: “Too often people get the help they need only because they step over the line, have a law enforcement encounter, go to prison, and get assessed.” Necessary medical treatment follows those assessments because, Frakes said, “There are two groups in the United States with a Constitutional right to health care: veterans and prisoners.”

So although Americans in general have no right to mental health care, some get it as a belated sort of fluke — dragged in hooked to punishments for helplessly irrational actions.

The night I visited Monroe, a panel of inmates summed up prison policies regarding the diagnosis and treatment of mental illness and questioned whether prison staff always follow recommended policy. They also spoke about the fears that lead prisoners to mask their symptoms.

For example, they’re afraid that staff use antipsychotic medications not for therapeutic purposes but to tranquilize and control, and that inmates who seek treatment will be branded as weaklings who “can’t handle their time” or as crazy “dings” (“dingalings”). Others fear losing their eligibility for conjugal visits, for opportunities to transfer to units with more privileges, or for Family Sunday, an event like a fair, which one panelist summed up as “for fathers, one of the best things going.”

One speaker told us how he came to be serving a life sentence under the Three Strikes statute. When he was 12 his two sisters were killed before his eyes in a bizarre attack. He started drinking to forget, but remained functional enough as an adult to hold a job as a union ironworker. “I married a woman who helped me stay drunk and out of trouble for years,” he said, but when the marriage ended he lost his job and committed robberies while intoxicated. He said that staff during his first two confinements failed to follow a Western State Hospital directive printed on the record he showed us: With proper treatment, it is unlikely [this man] would re-offend. He concluded, “The system could have fixed me 30 years ago but didn’t.”

A shy man in his 20s who committed a murder when he was 15 told the audience that counseling at Green Hill School juvenile center helped him develop some of the skills he needed to start managing terrors and antisocial impulses born of what he called “family issues.” But when he aged out of Green Hill, he said, a friend he made at Monroe who had paranoid schizophrenia hanged himself after staff stopped his prescription for antipsychotic medications. The young man said the suicide terrified him, but when he asked for psychiatric help, he was basically told to get over it. Now he’s “scared of asking” for therapy.

The theme of needing time with counselors dominated several other speakers' stories. The panel moderator commented: “Talking is a skill of how to deal with stuff in your life. Guys who can’t feel they communicate have just one recourse: [reverting to] past behavior.” Fortunately, as one panelist said, the CLO is “a circle of life, a group that reaches out. We can talk with each other about anything.”

The mission of a prison is public safety, said Dr. Bruce Gage, DOC chief of psychiatry. “We take that seriously as the context,” he told me, but within that context, “the quality of the mental health service we provide is really very good.” Compared to care at a state hospital, “we measure up in active programming, meds education, all sorts of things except that we don’t have round-the-clock nursing staff.”

However, “As in any managed-care system, we have limits," said Gage. "We don’t treat everybody who asks for services. Plenty of people who think they need or deserve services don’t have anything that psychiatric treatment can do anything about." Still, Gage said, it's "unacceptable” for health care personnel to refuse an inmate's request for counseling unless a psychological evaluation supports such a refusal. “I have never seen an example of that [breach of protocol], and we have a grievance process. If I didn’t believe that we provided a level of service that I was comfortable with, I wouldn't work here. I believe in what we’re doing.”

So does Human Rights Watch, at least when comparing mental-health care in Washington state prisons with programs in many other states. According to the analysis in "Ill-Equipped," University of Washington researchers who were invited to monitor the success of the McNeil Island mental-health program, which later moved to Monroe, found inmates "substantially less symptomatic when they left the program than when they entered.” In addition, “staff and prisoners appeared to have a far less antagonistic relationship than was the case in most prisons we have visited.”

Still, a prison is not a clinic. Even in a corrections facility with staff who are sincerely trying to “correct” their charges, a mentally ill person needing to change his ways must have specialized help. And no prison deploys trained medical professionals in a patient-to-staff ratio like a hospital’s. When treatment hours are scarce, they will naturally go to inmates with severe psychoses. Yet inmates with milder disorders need professional care, too, said David Lovell, professor of psychosocial and community health at the UW and one of the researchers cited in "Ill-Equipped."

Lovell conceded that “'Just someone to talk to' needs to be rationed.” (Prison groups like the CLO can offer some companionship of this kind.) But conversations with a trained counselor can prevent “situational-adjustment kinds of problems from becoming a full-blown mental health crisis,” he said. Besides, prison staffers don’t always know which prisoners are seriously ill, because “systems of diagnosis are also overloaded.”

Another problem is that a prison's safety mission trumps mental health care when the two collide. Lovell explores what he calls "the excruciating treatment versus custody conflict" in the August 2008 issue of Criminal Justice and Behavior. Custodial staff are trained to go by the book when disciplining bad behavior, and even when they have mixed feelings because the person behaving badly is ill, exceptions are hard to make.

One extreme form of prison discipline is confining inmates who become unmanageable in so-called Supermax units, where individuals posing the highest risk to staff and fellow prisoners are segregated, sometimes long-term. Inmates in isolation who are mentally ill get worse, and healthy inmates can become psychotic, as Atul Gawande showed in his 2009 New Yorker essay “Hellhole.”

Frakes, the Monroe superintendent, said his staff is very careful about putting sick prisoners who break the rules in Supermax cells. “Sometimes a guy goes to segregation because of a mental-health issue, but we try not to keep them there if that’s the case," he said. "We can do involuntary medications, but there’s a process, and we don’t do that lightly. What we don’t want to do is leave somebody isolated in segregation, suffering.” He mentioned incidents in other states that were reported in "Ill-Equipped," in which mentally ill prisoners suffered harsh punishments or injured themselves, were left in unsupervised isolation, and were later found dead. When those stories made headlines, "We challenged ourselves to say whether we're doing anything like that, like ignoring someone until they could die. We were confident we would never do that, but at the same time it’s reasonable to think the Minnesota guys thought the same thing. We keep our vigilance up.”

Clearly, then, mental health care in a prison, even at its best, has serious limitations. They are imposed by its mission of public safety, which naturally means channeling more of the available funds and staffing to custodial matters and less of it to therapy for mentally ill prisoners. But this short-term frugality is a false economy in the long run. Even though effective treatment can't guarantee recovery from psychiatric disorders in every case (any more than chemotherapy can guarantee recovery from every cancer treated that way), when prisoners receive the kind of treatment that will help them manage their symptoms and be productive after returning to society, public safety is strengthened.

After returning to society, though, individuals with mental illnesses require ongoing recovery support. So according to psychiatric chief Gage, the biggest problem the DOC faces is not inside the walls. “Where do we send people when they're released?" he asked. "We get them into pretty good shape,” but after they leave, “mental health services in the community are so limited. The community needs clinics! There is a total under-funding of public needs. We’re not doing anything nearly enough for the mentally ill.”

Mike Walls, director of mental health for the Washington Health Services Administration, agreed. His major concern regarding state budget shortfalls is about “cuts that reduce community resources and community mental health programs. This will send more people into the Department of Corrections. We’ll have the same amount of services, but a bigger need, which means you have less to go around.”

Frakes also lamented the lack of public mental health support. “It’s tough for people in the community living with mental illness who have no money. And when our guys go back home, 'home' is all over the state. Outside any city they’re going to struggle getting mental health resources.”

They're going to struggle within city limits, too. Earlier this month Ari Kohn, director of the Post-Prison Education Program in Seattle, told me, “Right now the DOC is ready to release a guy with schizo-affective and bipolar disorders. They’re calling us up to help him, but how can a program like ours do that? What he needs is intensive case management as well as meds, or he’ll re-offend and go back to prison the way he did before. It’s time for the electorate to hold the Governor and legislature responsible for adequately funding the mental health system.”

The Governor may soon call a special session of the legislature, in an effort to close a budget gap estimated at more than $5 billion for the coming biennium. The DOC is charged with cutting $53 million from its budget on top of a $221 million cut the previous biennium. Corrections services considered nonessential are already getting the ax. Deputy prisons director Dan Pacholke said in an email that state support was canceled two weeks ago for the Sustainable Prisons Project, which won an environmental award this year from the Kennedy School of Government at Harvard.

However, state support for basic DOC services, which include health care for prisoners, is mandatory under law. Walls predicted that the budgetary impact on prison psychiatry programs will be “more consolidation than reduction” — for instance, housing the programs in four Washington facilities instead of 10. "Knock on wood," he added.

Reductions in prison services that some might not consider "basic" worry DOC Secretary Vail. For example, one-day lockdowns will be scheduled at prisons each month to eliminate staff hours given to training inmates in anger management and mental-health strategies. Commenting on News about having to cut programs that prepare inmates for life after release, with the goal of reducing recidivism, Vail expressed sharp frustration. “More crimes will result in the 'out' years as a result of reducing those programs now,” he said.

An increase in future crimes, of course, means diminished safety for citizens as well as more arrests, which in turn create a more costly, more challenged corrections system — and the expensive, scary cycle continues.

Washington residents won't tax themselves to pay for services that can keep many mentally ill individuals from becoming offenders and can help mentally ill offenders become law-abiding citizens. Yet many call for stricter laws after tragedies like the Clemmons homicides. They are not making themselves and their neighbors safer. Don Pierce, executive director of the Washington Association of Sheriffs and Police Chiefs, criticized some proposed laws that the Governor and legislature contemplated in the aftermath of the Clemmons shootings. In an Associated Press article he was quoted as saying that new draconian measures would be undermined unless mental health treatment and community services are adequately funded. "If we don't have the money to fix those things,” he said, “let's not make ourselves feel good by passing legislation that doesn't do anything." 

Ninety-seven percent of the inmates in our prisons are eventually released to live in our communities. A mental-health system so crippled that it sets sick people up for confinement in institutions that can't compare to hospitals, and then denies them care once they've served their time, is not only unjust and inhumane. It also costs citizens far more in the long run than an adequate mental-health system would cost, and it threatens their security.

Lewis ended his conversation with me by saying: “It’s a crisis. I’ve never seen this level of funding cuts. It makes it hard to do what’s best for public safety.”


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