California Prison Mental Health – A Failed Delivery System

I have just received the following email from a reader, who introduces him/herself as "a concerned prison mental health clinician" and who prefers to remain anonymous. I am publishing it verbatim.

A suicidal inmate with a diagnosis of Major Depression with Psychosis is handcuffed for up to three hours before he is transferred to a crisis bed.
A correctional officer yells out “you are full of it” to an inmate who requests permission to return to his cell from the yard, because he says he feels that “people are watching him, and he is feeling paranoid.” This inmate has a diagnosis of Schizophrenia, Paranoid Type.
A correctional counselor (CC) says to an inmate diagnosed with rapid cycling bipolar disorder, “you are just a con, you were up and about yesterday, I saw you, and today you won’t come out of your cell.”
A psych tech refuses repeated requests of an inmate to see a psychiatrist, for nearly three weeks, this inmate suffered from racing, and obsessive thoughts – because this psych tech decided that the inmate was “playing.” This inmate is diagnosed with Obsessive Compulsive Disorder.
A mental health clinical supervisor says to his clinical team, that these are all criminals, and they know what to say.
A sergeant in response to an inmate yelling at the TV (because he believes that the TV is talking to him) decides to “clean out his cell” because inmates are not allowed to yell.

These are just a few examples from just one week at a California correctional facility that is supposed to be complying with the Mental Health Service Delivery System, based on the Coleman v. Schwarzenegger decisions. The current prison mental health system is one horror story after another, and here we are talking not about “general population,” but about units that are supposed to specialize in providing mental health treatment.

There are many reasons for this, but primarily it has to do with the way prisons are designed, and the custody culture, that, for the most part, does not consider mental illness to be legitimate. The misperceptions, and stigma that exists in the larger society is hugely magnified inside a prison. Further, the custody staff, and even some of the clinical administration staff do not seem to understand mental health treatment, and the course of recovery.

An example of this stigma, and lack of understanding about mental health treatment is the statement by Department of Corrections and Rehabilitation Secretary Matt Cate:
"... We don't need a treatment room and a yoga room and a music room and a basketball court for our most seriously ill inmates — we need to get those inmates better so they can return to the general population." From Oakland Tribune by Josh Richman, February 3, 2009

Fact is that most of those with serious mental illness are not going to return to the “general population.” Most of the tens of thousands of seriously mentally ill inmates, if in the community, would qualify for disability (SSI) and would only be expected to work part-time at the very most. They would be living in supportive housing, such as licensed board and care facilities, or supported independent living, with onsite case management. The prison general population is a very high stress environment, and many of the mentally ill inmates would decompensate, and end up being hospitalized, or in crisis within a matter of weeks, if not days.

I was heartened to read by U.S. District Judge Lawrence Karlton’s statement that he is considering placing the mental health services also under a receivership. CDCR does not have the capacity, or understanding to provide effective mental health care. Their role is custody, not mental health treatment.

With 40-50% of California inmates seriously mentally ill, we need to enter into a process of rethinking, and redesigning prison mental health treatment. A few recommendations/suggestions that I, as a prison mental health clinician, have are as follows:

1. Under a future receiver’s office create a clinical oversight body within each prison-institution, comprising of both administrative and line clinical staff (psychiatrists, clinical psychologists, and clinical social workers) that would be charged with addressing clinical/treatment issues and obstacles.

2. Recognize that with such high numbers of seriously mentally ill inmates, prisons are effectively locked mental health institutions. The custody staff must re-think their roles as security, and mental health providers. Develop a new classification of “mental health custody” that would specialize in working within mental health units. A very small number of custody staff do have this kind of specialization, and where we have such staff, the units operate smoothly, and some level of mental health services are delivered. Where we do not have this level training, and/or interest, the services are spotty at best – and that would be the case in the vast majority of cases.

3. Begin developing a separate agency outside of the CDCR that would be charged with providing mental health services. This agency would then be held accountable for standards and practices, and would relieve the CDCR from trying to implement services that are outside of its custody role and scope.

4. Mental Health services in prison should be held at the same, or higher level of standard as those delivered in the community in California. This would include confidentiality, and clear protection against abusive or stigmatizing treatment.

5. And finally, but no means least, construct new facilities designed to provide mental health care.

The above recommendations are by no means exhaustive, but we need a public open conversation, and implementation of mental health treatment at the same time. We cannot continue to wait, while the civil and constitutional rights of California prisoners are violated daily. Such stigmatizing treatment would not be tolerated in the community, and there is no reason why such abuse is being tolerated in prisons.

It is time to take mental health out of the hands of the an incompetent state body, and placed in the hands of mental health receivership who would have the necessary mental health background to implement immediate change to the delivery system.