How Prisons Trap the Mentally Ill

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Standing in the middle of his prison cell in Poughkeepsie NY, Masai Giardino Stewart could touch the walls if he outstretched his arms. Throughout one sweltering summer, Stewart was confined in this space for at least 23 hours a day.

The banging and yelling that echoed in the corridors, the constant chaos, made Stewart anxious, and [his days without sleep] brought frightening flashbacks of trauma from early childhood.

[His mother Tami Bell knew that trauma well]. In 2002, when her son was 10 years old, Tami Bell worked up the strength to drive away with her children to a local domestic violence shelter [after years in which they had suffered constant emotional and physical abuse at the hands of their father, which she believed had taken a toll on her son’s mental health.]

Stewart has received at least six diagnoses, including PTSD, intermittent explosive disorder, bipolar disorder, and dissociative disorder. The one considered most serious by mental health professionals is bipolar, a condition marked by extreme shifts in mood and energy levels.

Bell especially began to fear for her son when he turned 18 and became a legal adult, meaning she could no longer compel him to get treatment. When he struggled to adhere to treatment on his own, Bell fought to enroll her son into the state’s Assisted Outpatient Treatment (AOT) program, the only way to compel treatment for an adult living in the community.

Her efforts were ultimately unsuccessful.

Bell was forced to look on as her son’s illness was left largely untreated over the course of the next several years. When he landed in prison, Bell struggled to secure him sufficient mental health care, fearful again that her son’s illness would worsen while in solitary confinement.

Stewart’s life offers a glimpse into how the inadequacies of our mental health system tend to funnel the mentally ill into our jails and prisons. His crime stemmed in the first place from his illness: He punched a delivery man and stole food while he was homeless and off treatment, for which he served six months in jail.

When he violated probation terms of attending regular mental health appointments, he landed a longer term in prison.

Our country’s jails and prisons house 356,000 people with serious mental illnesses, such as schizophrenia, schizoaffective disorder, bipolar disorder, major depression, and psychotic disorder, according to a 2014 estimate by the nonprofit Treatment Advocacy Center.

Awareness of the mental health crisis in our criminal justice system has grown in recent years. In the past year alone, cities like Chicago and New York launched new programs to identify and treat people with serious mental illness who are at risk of arrest or jail time. Public attention heightened after The Associated Press and the New York Times exposed the deaths of several mentally ill inmates after they were left unsupervised or beaten by corrections guards.

Stewart’s experience in the penal system is emblematic of how prison staff struggle with diagnoses and care for the mentally ill—where those with mental illness can end up in solitary confinement, despite extensive scientific research on the detrimental mental health effects.

His bipolar diagnosis prior to going to prison would have protected him under law from serving time in solitary; but prison mental health authorities did not concur with the prior diagnosis, and he served three months locked in a small cell alone.

Stewart is now 24. He was released on parole in September 2015 after serving one year and eight months….

Turning 18

[Six years earlier], as Stewart approached his 18th birthday—the age when he would become a legal adult and make all treatment decisions on his own—Tami Bell grew concerned that her son would go off treatment and pose a danger to himself and the people around him.

She reached out to AOT coordinators in Dutchess County to enroll him.  Created in 1999 by law, an AOT is a court-ordered treatment plan for qualifying individuals with a violent history or multiple hospitalizations stemming from treatment noncompliance.

Allowing patients to continue living in the community, AOT’s treatment plans can include medication, therapy, enrollment in counseling programs, and case management. Outside of inpatient hospital commitment, AOT is the only way adults with mental illness can be compelled into treatment.

But Bell’s application was repeatedly rejected.

“They said he ‘wasn’t ill enough.’ Or they said, ‘Yes, yes, he does qualify. But he has an apartment. You have to be homeless.’ When he was homeless, they said, ‘We have to be able to find them.’ They always had an excuse for why they wouldn’t file an AOT,” Bell said.

Meanwhile, Stewart turned to a life on the streets, selling drugs and “hanging out with the wrong crowd,” as he put it. He became homeless, couch-surfing at his friends’ apartments. While adrift, he often witnessed violence in the tough neighborhoods of Poughkeepsie. His good friends were shot and killed.

“I was immature and didn’t know what life was,” Stewart recalled.

Stewart visited his assigned therapist (provided by the county mental health system) to try discussing his trauma, but he said she brushed off his problems. “She didn’t record my stress. She wrote that I was a gang member,” he said.

Studies have shown that poor relationships with mental health providers can lead to people dropping off their treatment, according to the Treatment Advocacy Center. Conversely, a 2013 study published in the Journal of Clinical Psychopharmacology, found that a bipolar patient’s positive perception of the relationship, including showing empathy, accessibility, and willingness to collaborate on treatment decisions, was positively associated with medication adherence.

Feeling that therapy did not help address his mental health issues, he dropped treatment. He also did not consistently take his medications because they made him feel dull, Stewart said.

Bell appealed to staff, counselors, and therapists in the state’s Office of Mental Health (OMH), and her county mental health system to put her son back on track. But Bell said their response was that Stewart did not want the treatment himself, and was thus “hard to serve.”

At least six mental health providers and officials at both the state and local county levels told Bell that her son had a better chance of getting help if he committed a crime and went to prison.

Nowhere to Turn for Help

The 1999 law that created the AOT program, known as Kendra’s Law, was drafted after a mentally ill man pushed a woman onto the subway tracks, killing her. The program would secure treatment for people with serious mental illness who could deteriorate if left untreated, while protecting public safety.

According to the latest estimates by the National Institute of Mental Health, about 10 million of the 43.6 million American adults diagnosed with a mental illness have a “serious mental illness,” which the Institute defines as a mental, behavioral, or emotional disorder that leads to impairment of daily functional activities.

The program not only requires the individual to take treatment; it also requires the mental health system to give treatment, and if the patient violates the court-ordered conditions, the person will be brought to a hospital for an evaluation to determine if commitment is necessary.

Prior to the 1960s, the mentally ill were regularly institutionalized at state hospitals. But with the introduction of antipsychotic medication, as well as President John F. Kennedy’s push for creating community mental health programs under the Community Mental Health Act of 1963, the mentally ill were moved out of hospitals.

The intention was for people with mental illness to be integrated back into society.

But in reality, funding for mental health services was on the decline. Most recently in New York, for example, the state mental health budget dropped 5.4 percent between fiscal year 2009 to fiscal year 2012, from $3.77 billion to $3.57 billion, according to the National Alliance on Mental Illness.

In Poughkeepsie, the Hudson River Psychiatric Center, where Stewart was once treated, closed down in 2011 and transferred its patients to other local facilities.

Furthermore, landmark Supreme Court cases like O’Connor v. Donaldson in 1975 ruled that a state cannot confine a patient against his will if he is not an imminent danger to himself or others. Many states today, including New York, have laws that only permit involuntary commitment if the patient will seriously harm himself or others.

In the absence of resources and legal responsibility for assisting the seriously ill, many are left untreated: in any given year, there are about 3.9 million adults with an untreated serious mental illness, according to the Treatment Advocacy Center.

Short of inpatient hospitalization (which itself is difficult to obtain), and a nationwide shortage of 100,000 hospital beds, the AOT is often the only safety net available—though there are civil liberties advocates who criticize AOT programs for restricting a patient’s right to refuse treatment.

Studies have shown AOT programs are effective at preventing the seriously ill from having their conditions worsen. A 2010 evaluation of New York’s AOT program, published in the Psychiatric Services journal, found that patients with serious mental illness who received services under AOT had arrest rates that were two-thirds lower than those who did not use AOT.

A 2010 study by Columbia University’s Mailman School of Public Health also found that New Yorkers enrolled in AOT were four times less likely to “perpetrate serious violence,” compared to a control group.

DJ Jaffe, a local mental health advocate and executive director of the nonprofit think tank Mental Illness Policy Org., estimates that in New York State there are 8,012 adults with severe mental illness who can benefit from AOT. But he says the program is underutilized. At the time of writing, there are 2,723 people under court order to be on AOT.

According to Jaffe, who was part of the coalition of advocates who helped craft the AOT law in New York, federal and state policies prioritize treating high-functioning patients over the most seriously ill because the latter are often more difficult to stabilize.

“Getting into AOT is very difficult. The mental health system doesn’t want responsibility for the most seriously ill,” he said.


Jaffe said that … a result, many of the seriously ill end up in the criminal justice system.

“When someone goes to jail, that’s a success for the mental health system, because it’s one less person to treat,” Jaffe said.

In Stewart’s case, his mom’s persistence with local authorities had finally won them a verbal agreement from New York’s Office of Mental Health that she could file for an AOT petition, which she promptly did. Unfortunately, the opportunity came too late.

Stewart was picked up just two weeks later on a parole violation that resulted in a long-term prison sentence. When Bell later checked on the application, she was told it had not been processed.

Stewart believes the AOT program could have kept him from leading a life on the streets.

“I think it would’ve kept me out of prison,” he said.

Condemned to Solitary

Although the Office of Mental Health (OMH), which also provides mental health care to all inmates in the state prison system, kept a long psychiatric record of Stewart’s mental illness and psychiatric treatments, the agency did not diagnose him with a “serious mental illness” (SMI)—a designation that would prevent an inmate from receiving a solitary confinement sentence, under the rationale that people with a severe condition can experience their illness worsening under the duress of solitary.

But Stewart did not get that designation.

Every day, about 3,800 people spend their days in solitary confinement in New York—including about 650 to 700 of whom are OMH patients, according to the nonprofit organization mandated by law to monitor and inspect New York prisons, the Correctional Association.two girls

The detrimental effects of solitary confinement on one’s psychological state are well-studied and documented. The Correctional Association found that inmates held in solitary confinement were admitted into mental health crisis treatment units—meant for people who are suicidal or suffering a serious mental health crisis—at rates almost four times the general inmate population.

Inside solitary, Stewart grew increasingly anxious. He told OMH clinicians that he was feeling more irritable, sleeping in the daytime and keeping awake at night. He reported feeling hyper-vigilant and easily startled when officers slammed the gates, triggering flashbacks to his childhood abuse.

…His mother appealed to OMH to conduct another, more thorough evaluation, given his long history of mental illness. In December 2014, another OMH clinician [concluded that] Stewart did not show signs of “manic or major depressive episodes,” or “significant mood symptoms,” while not taking any medications.

Bell says this contradicts the explosive behavior she witnessed at home before Stewart was incarcerated, or the shopping splurges Stewart sometimes indulged in, which were consistent with bipolar.

“We know what’s wrong with our loved ones. We don’t have a diagnosis, but we live with these people and we understand their illness,” Bell said.

In 2014, despite an increase in the proportion of inmates on OMH’s caseload (712 out of 53,197 total inmates, compared to 657 out of 54,142) from the year prior, the number of SMI designations actually dropped by one (32 to 31), according to records from the state prison system, Department of Corrections and Community Supervision (DOCCS). 

…Sarah Kerr, a lawyer with the Prisoners Rights Project at the Legal Aid Society, regularly receives letters from prison inmates seeking help to amend their diagnoses. Some inmates were initially classified as “seriously mentally ill,” but later got their diagnosis changed and were no longer considered “serious.”

Kerr regularly writes appeals for inmates who were recognized as “serious and persistent mentally ill” by the Social Security Administration to qualify for disability benefits (prior to incarceration), but in prison did not receive the “seriously mentally ill” designation. Stewart had received disability benefits due to his mental illness.

Kerr said OMH will occasionally amend its diagnosis as a result of her advocacy. But the agency rarely explains its rationale for its diagnoses.

“We don’t always get what we ask for,” Kerr said. “They will say, the person has been evaluated and does not qualify. They won’t be explicit [with why],” she added.

….Joseph Galanek, a former researcher at Case Western Reserve University studying the mentally ill population in the criminal justice system, says that mental health staff need to establish trust, while working with corrections officers, so patients feel safe sharing their therapeutic needs.

“Just seeing someone in an office once a week, that doesn’t work,” said Galanek, who now works for SciMetrika, LLC, a public health consultation firm.

“Mental health staff have to interact with the inmate and officers. They have to be trusted by inmate and officers,”

Stewart said he found it difficult opening up to OMH staff. “I pleaded with mental health to help me but they said to me you’ll do fine here in the box and were very dismissive,” he said.

He added that during his time in solitary confinement, mental health staff did daily rounds to check on inmates, but “they speed-walk right by with no form of acknowledgment and act as though they don’t hear your calls for help.”

Officers also need mental health training to know how to properly identify symptoms.

“For example, people are yelling and screaming—criminals do that to get what they want,” Galanek said. “They’ll manipulate, scream and yell, threaten people violently. But someone with schizophrenia who needs treatment is also yelling and screaming, because of what they’re hallucinating.”

Prison staff have a tough job on their hands. But Galanek stressed that effective treatment begins with respecting patients.

“Trying to work with them like human beings, explaining what treatment is, what symptoms are, and how treatment can help them,” he said.

A Chance to Start Again

In September 2015 Stewart was released on parole. Shortly after his release, Bell suggested that they go to the mall together. But Stewart felt overwhelmed when he entered the space, unaccustomed to the huge crowds.

Bell is determined to find the right diagnosis for her son. Through successfully raising money on an online crowd-funding campaign, she was able to pay for a new psychiatric evaluation from a psychiatrist at Columbia University, Dr. Jonathan Slater.

Based on Dr. Slater’s evaluation, she hopes the county and OMH mental health providers will craft a treatment plan that will truly help Stewart. Bell still has yet to hear back about her latest AOT application.

But Stewart’s experience in prison made him realize the importance of managing his illness. He now attends all his mental health appointments, with Bell helping to drive him there. He sees his appointed doctor twice a month, for 20 to 30 minutes per session.

And despite his troubled childhood, Stewart has forgiven and reconciled with his father, who occasionally visits. Stewart now considers him a role model.

“He taught me a sense of humility and humanity, what it is to be a man,” Stewart said.

Stewart has big plans for the future. His dream is to go back to school for a business degree and then start his own small business.

“I want to take care of my family, and deal with my demons,” he said.

Annie Wu, a 2014-2015 John Jay/Tow Reporting Fellow, is a staff writer for Epoch Times. This is a condensed version of a story published March 3 for her Fellowship project. The complete story can be accessed HERE.  Annie welcomes comments from readers.

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