Mary Beth Pfeiffer - Crazy In America
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Articles

The New York Times

Cruel and Unusual Punishment
Sunday, May 7, 2006

Newsday

Mentally ill inmates face a cruel system
Will the state end long solitary confinement and other prison abuses, or go on usu
al? May 6, 2007

The Boston Globe

Prison a wasteland for mentally ill
March 1, 2007

The Miami Herald

Let's care for the weakest among us
Nov. 29, 2006

The Des Moines Register

From Sudan to U.S. to Iowa jail to death
January 7, 2007

Other articles by Mary Beth Pfeiffer

"Prison health care is killing inmates"Albany Times Union
April 1, 2005
http://realcostofprisons.org/blog/archives/2005/04/prison_health_c.html

Feature article: "A Death in the Box"The New York Times Magazine
October 31, 2004
http://www.namiscc.org/Experiences/2004/ADeathInTheBox.htm

"Sentenced to Suicide?"
Hartford Courant
Sunday, July 31, 2005
http://www.justicepolicy.org/article.php?id=530

"Lost Lives and Stories Never Told: When prisoners die by their own hand, the prison system typically responds with silence"Staten Island Advance
Sunday, October 16, 2005
http://www.scaany.org/press/documents/stories_never_told.pdf

"Changing of the Guard"Legal Affairs Magazine, feature article
July/August 2005
http://www.legalaffairs.org/issues/July-August-2005/feature_pfeiffer_julaug05.msp

"Mentally Ill Inmates Need More Help"
Portland Oregonian
Saturday, February 12, 2005
http://www.soros.org/initiatives/justice/articles_publications/articles/pfeiffer_20050228

"Locking up the Mentally Ill" Iowa City Press Citizen
Sunday, November 28, 2004

"Inmate Suicides Point Up Flaws in System"
Columbus Dispatch
Saturday, February 12, 2005

"Death in Prison: Punishing the Mentally Ill" Poughkeepsie Journal, a series of special reports
2001-2003


"Imprisoned and Sick: Punishing the Mentally Ill" Poughkeepsie Journal, a special report.
March 10, 2002.
http://www.poughkeepsiejournal.com/projects/prison2/

"The Prison Explosion" Poughkeepsie Journal, a special report.
November 15-17, 2000
http://www.geocities.com/fancybroccoli/PrisonArticles/PoJo_PrisonExplosion.htm

Prisons punish, not treat, mental breakdowns
''Mentally ill inmates in Pennsylvania and elsewhere are often shunted to disciplinary confinement units because of their inability to cope with the rigors of prison life.'' The Morning Call
May 27, 2007 http://www.mcall.com/news/opinion/anotherview/all-left_col-a.5865799may27,0,2289323,print.story?coll=all-newsopinionanotherview-hed

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Cruel and Unusual Punishment

By MARY BETH PFEIFFER
Sunday, May 7, 2006

Stone Ridge, N.Y.

FOUR years after it was filed, a federal lawsuit against New York State's prisons is exposing some painful truths about a system that locks up people with schizophrenia, bipolar disorder and other serious mental illnesses in isolation in concrete cells around the clock for months and years at a time.

The lawsuit, brought by a legal advocacy group in Albany, Disability Advocates, is the most important against the prison system in decades and could lead to major reforms of, and a more compassionate approach to, the treatment of mentally ill inmates. It could also influence prisons nationwide if a system as big as New York's, the nation's fourth-largest, is made to improve the care of one of the fastest growing and most difficult segments of the inmate population.

Despite the tales of horror told by experts and inmates, the trial received little attention when it opened last month, and the benches were mostly empty in the sixth-floor courtroom of Judge Gerard Lynch of Federal District Court in Manhattan. That illustrates how the treatment of inmates is being ignored by a country that imprisons two million people, including legions of drug addicts, growing numbers of women with young children and at least a quarter-million people who are mentally ill.

The suit centers on the use of what is essentially solitary confinement — prisoners call it the "box" — as a tool to manage the state's 7,300 mentally ill inmates, who are often prone to inappropriate outbursts, fights and disobedience. In depositions, inmates told of harrowing years spent in claustrophobic cells as small as 50 square feet with solid steel doors, little to do and virtually no human contact.

One inmate routinely broke down after long periods in isolation, was sent to the prison hospital to get better and then returned to the box to repeat the process. Another attempted suicide and was punished with more time in confinement. These are not isolated occurrences.

The lawsuit offers a rare peek into a system that for years has zealously protected these secrets. It is not surprising that two weeks into the trial, the parties moved to begin settlement talks. (Disclosure: After the state objected, the judge denied my lawyer's request for me to accompany the judge and the lawyers in the case on tours of four prisons as part of the trial last month.)

Besides the miserable conditions, a major issue in the case is New York's excessive use of these confinement boxes, or what the state calls "special housing units." About 4,300 inmates currently serve time in the special housing units, which were greatly expanded by the Pataki administration from 1998 to 2000. The rationale was to make prisons safer, but a study in three other states has produced little evidence to back that up.

While the state has maintained that the average box sentence is 154 days, an in-house e-mail message released to plaintiffs suggested that seriously ill inmates serve far more in accumulated time: 2.2 years in the unit at Attica State Correctional Facility in western New York and 3.3 years at Five Points Correctional Facility in Seneca County. A prison expert, Steve J. Martin, found that nearly half of the 25 inmates he interviewed had sentences of five years or more. And a psychiatrist, Terry Kupers, concluded that 64 percent of the inmates in maximum-security special housing units are mentally ill.

While New York has reduced inmate suicide in the last two decades with suicide-proof construction and better monitoring, isolated confinement units undoubtedly lead to inmate deaths. New figures assembled for the lawsuit show that 44 percent of the suicides in New York's system from 1995 through mid-2004 occurred among the less than 10 percent of the prison population in isolated confinement, including special housing and another form of 23-hour lockup called "keeplock."

This, as documents from the trial show, is no surprise to state officials. Yet the state continues to use the box to warehouse people with serious mental illness.

As more and more mental hospitals in New York and nationwide close, prisons have become the de facto custodians of people with mental illness. It's an unfortunate reality to which prisons must adapt.

The New York Legislature should move to prohibit the placement of people with serious mental illness in isolated confinement, as has been proposed, and Gov. George Pataki should sign the bill. The state also needs more hospital beds for sick inmates. Beyond this, prisons must develop alternative forms of housing for disturbed inmates and must staff them with people who are trained to understand the difference between insubordination and insanity. Most of all, the state must stop punishing people for being mentally ill.

The use of these boxes to confine mentally ill inmates serves only to make them more paranoid, anxious and ill. These measures indicate that we have a bureaucracy without the tools or know-how to deal with a needy population. Surely New York can do better than this.

Mary Beth Pfeiffer is writing a book about mentally ill people in the criminal justice system.

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Let's care for the weakest among us

Nov. 29, 2006

BY MARY BETH PFEIFFER

An overdue reckoning is taking place in Florida's jails, where the state could face stiff fines if it doesn't come up with psychiatric beds for some 300 seriously mentally ill inmates. The irony is that these inmates, who are so sick that they have been declared incompetent to stand trial, might not be in jail at all if they had received proper mental healthcare in the first place. They are not alone.

These inmates, including one who gouged out an eye, are harbingers of a crisis in mental healthcare that extends far beyond Florida's jails. It is evident in emergency rooms crowded with psychotic and suicidal people who have nowhere else to go. It plays out in hospital units from which psychiatric patients are discharged long before they are ready. It crackles over police radios with calls of yet another mentally ill person, adrift or discharged or forgotten, who has lost control.

The 300 inmates who have brought this issue to the fore are but a tiny sliver of the 25,000 mentally ill people in the state's jails and prisons, a micro-subgroup of inmates that is testing the patience of judges in Broward, Miami-Dade, Hillsborough and other counties who want them removed. These inmates are a vivid reminder of the price to be paid when a society overbuilds its prisons and underfunds its mental-health system, a demonstration of how long-term care of the mentally ill has shifted to the place where there is always a bed.

Since 1997, Florida's prison population has swelled by 44 percent, to 89,000 inmates. Meantime, in a state that had 56 state psychiatric beds per 100,000 people in 1990, there are now eight. Squeezed by flagging reimbursements, 36 private psychiatric hospitals have closed in Florida since 1992 -- taking an additional 4,400 beds.

Few would dispute that old, anachronistic mental hospitals needed to close. The idea was to make the community the locus of mental healthcare, with case managers, counselors, clinics and housing to maintain vulnerable mentally ill people outside of hospitals.

A sure sign that the effort has failed is in those 300 insane inmates. Just 5 percent were known to the mental-health system before they were jailed. Had they received care, they likely would not have gotten so sick -- and their prospects for recovery would not be so dim. They also might not have committed crimes that put them behind bars. Now consider that there were 761 severely and 9,197 moderately mentally ill inmates in Florida's prisons in 2005 -- figures that don't count those in shorter-term jails.

Killed by a car

Alice Marsh is one victim of failed community care. In February 2002, Marsh was among the last 10 patients to leave the state's G. Pierce Wood Memorial Hospital in Arcadia, where she had lived on a locked ward for 16 years. A demure woman with severe schizophrenia, she was dispatched to an unlocked room-and-board facility in Pasco County. Within a month, she wandered onto a highway and was killed by a car.

The state has tried. When Pierce closed, $30 million was diverted to a new program, called Florida Assertive Community Treatment, to help people with serious mental illnesses thrive in communities. The results reflect a porous system. Among some 3,100 served in 2005, there were 3,047 hospitalizations; 413 jailings and, most astonishing, 40 deaths. This was the outcome among people receiving the highest level of community care. Imagine the fate of the rest.

Who belongs in prison?

State spending on adult mental healthcare went up 10 percent in real dollars in the last decade -- about a third as much as Florida's adult population. In the first nine months of 2006, meantime, the prison population leaped by another 3,000 inmates, this though Florida crime rates are at their lowest levels since the 1970s. Sure, many people belong in prison, but how many -- and how many more?

When 170,000 seriously ill Floridians go without mental healthcare and roughly one in five inmates is mentally ill, it's time to reconsider what a war on drugs, longer sentences and a tough-on-crime ethic has wrought for the weakest among us. And what that money might buy to help them.

Mary Beth Pfeiffer is author of the forthcoming book Crazy in America: The Hidden Tragedy of Our Criminalized Mentally Ill.

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Prison a wasteland for mentally ill

By Mary Beth Pfeiffer

March 1, 2007

ON THANKSGIVING 2004, a notoriously mad inmate named Richard A. Street hanged himself in a segregation unit at the 800-inmate, maximum-security state prison in Walpole. His death marked the start of a rash of 12 suicides in Massachusetts prisons in 26 months, compared with five in the nearly six years before. A look at Street's prison experience might explain this phenomenon, which is unfortunate but not uncommon in modern prisons.

Street, 53, was a wretched man who had indiscriminately shot two people one night in Boston in 1980 and then went on to exhaust the patience and resources of the Massachusetts prison system. Suffering from schizoaffective disorder and calling himself "Jesus Christ, Future King of the Vampires," he would rant, self-mutilate, and perform naked pirouettes around a basketball in the prison yard.

Recently the state Department of Correction commissioned a report on suicide prevention in Massachusetts prisons and has promised to put its recommendations into practice. Street's chilling case starkly illustrates the need for changes.

I obtained Street's medical records for the spring of 2004, after he had been in the prison's disciplinary detention unit, an alternative form of segregation, for about 10 months. In a six-week period, Street, a thin man with a bushy, reddish-brown beard and long dark hair, was twice found hanging in his cell. He repeatedly gouged his skin, swallowed an 1 1/2-inch piece of metal, and was taken to a local emergency room six times. He smeared feces in his hair and complained that solitary confinement was making him hurt himself.

Photographs show a handcuffed Street displaying a gruesome array of scabbed and mottled wounds on his legs and arms. Nonetheless, his records suggest a skepticism, common on the part of overworked prison clinicians, of Street's pathology. After he had been found "unresponsive" and with gauze tied around his neck, a clinician wrote that Street "is not depressed . . . nor at risk of harm due to mental illness." He had been known to "feign unconsciousness," the record noted.

Five days after Street's death, I toured the so-called Ten Block segregation unit where he died. The unit was four tiers of dingy, claustrophobic cells, a prison slum where Street had been confined around the clock with only his hallucinations and voices as company. My tour guide declined to take me down the rows of inmates in the 60-cell unit, given the proclivity of many to scream or throw bodily fluids. Inmates were so unpredictable that they were shackled when let out of their cells. Clearly, there was more going on with these inmates than sheer criminality, and the conditions were part of the problem.

Twenty-five years before my visit to what is now the Massachusetts Correctional Institution-Cedar Junction, Harvard Medical School psychiatrist Stuart Grassian conducted a study of 14 Walpole inmates who, like Street, had been housed in solitary confinement. He was surprised by what he would later call the "toxic" effects of isolation. Some inmates were hypersensitive to sounds or obsessed with thoughts of torturing guards; others described feelings of panic and fear of suffocation. This was the effect on inmates in general; imagine the impact on those already suffering from mental illness. It is no wonder then that six of the system's 12 most recent suicides occurred in segregation units. That is 50 percent of suicides among about 4 percent of the prison population.

Psychiatric experts say they can judge the quality of a prison system's mental health program by a quick visit to its solitary confinement units. In many states, they are dumping places for the mentally ill.

Street's suicide and those that followed are, in large part, a direct result of a huge influx into prisons of people with mental illness, an inability of prisons to deal with them, and a heavy reliance on isolation as a quick fix to a complex problem. The suicides, many avoidable, represent a failure of policy and compassion.

After Street's death, the sentiment among officers on a union website was that he had belonged not in prison but in a mental hospital.

The rash of suicides is just the latest in a series of crises that beg for better care of the mentally ill -- the 2003 killing in protective custody of defrocked priest John Geoghan and the 1996 suicide of John Salvi among them. Now, after yet another report and another outcry, will the call be heeded?

Mary Beth Pfeiffer is writing a book about mental illness and criminal justice.

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From Sudan to U.S. to Iowa jail to death

Troubled teen's suicide shows what can happen in a nation that imprisons mentally ill people.

By MARY BETH PFEIFFER
SPECIAL TO THE REGISTER
January 7, 2007

Gabriel Mading's path to America was typical of the so-called "Lost Boys of Sudan": A thousand-mile trek from his war-torn African country to Kenya, several years in a squalid refugee camp there, and, finally, a wrenching goodbye, at age 12, to a mother who believed she was delivering him to a life of privilege and peace.

Gabriel's remarkable journey ended on Nov. 29 at the Polk County Jail in Des Moines, where this lost boy - one among thousands to flee conscription, slavery and death - strangled himself with a torn bit of jail-issue blanket. He was 18.

If Gabriel's life was a commentary on the turmoil that grips the African continent, his death offers lessons about the treatment of mentally ill people in Iowa and America. While this tall, slender young man had food and clothing enough - luxuries in his African homeland - he could not get what he most desperately needed: adequate care for his raging mental illness. Instead, he got a uniform, a number and the four walls of a jailhouse cell.

In a country that has come increasingly to rely on punishment as the answer to a host of social ills, Gabriel Mading is not alone. An estimated 12 percent to 15 percent of the 580 inmates at the Polk County Jail receive medications for mental illness. Meanwhile, 34 percent of the people in Iowa's nine prisons are mentally ill, some 3,000 people in all. Add to that hundreds more in the state's 96 other short-term jails, and thousands on probation and parole.

Years ago, Iowa had psychiatric patients, instead of inmates, in comparable numbers - 5,336 in 1955 in four sprawling public mental hospitals. It is no coincidence that as the numbers of hospital beds shrank - under the admirable but unfulfilled vision to better serve people in their home communities - the ranks soared of people with mental illness behind bars.

From 1994 to 2005, Iowa went from having 513 state psychiatric beds in public mental hospitals to having 267, ranking it 44th in the nation per capita. (It has since added 20 beds.) In the same period, the proportion of mentally ill people in Iowa's prisons rose more than eightfold.

-Few alternatives other than jail

Today, when people like Gabriel Mading become psychotic and violent, when they commit crimes because they cannot control their behavior, they are routinely taken to jails instead of hospitals. The reason is twofold:

-There are too few alternatives to jails in the community.

In 2006, the National Alliance for the Mentally Ill gave Iowa an "F" in a national grading on mental-health care. "Iowa is a prime example of what President Bush's New Freedom Commission on Mental Health meant when it reported [in 2002] that the nation's mental-health-care system is 'fragmented and in disarray,' " the organization reported. While Polk County has more services than the state as a whole, there is little dispute that need far outstrips resources.

- There are too many beds - yes, too many - in jails and prisons.

In the last decade Iowa increased its jail population by 74 percent and its prison population by 50 percent. This was not because of a precipitous rise in crime. The state's index of major crimes has declined 24 percent since 1990. Instead, it stemmed from national trends that did not escape Iowa: longer prison stays for most offenses, greatly reduced chance of parole for certain crimes and an overdone war on drugs that saw the share of inmates serving drug sentences in Iowa's prisons rise from 3 percent in 1983 to 26 percent in 2003.

-Needs not met, but costs high

Frank Cordaro, a Catholic worker and pacifist, spent a month in the Polk County Jail in 2004 on a charge of trespassing at a federal armory. Cordaro saw mentally ill people who needed a helping, rather than punitive, hand: One man soiled himself regularly. Another appeared grossly overmedicated. Others were incarcerated for menial crimes such as disorderly conduct and public lewdness - small infractions on which criminal records are built.

"Jail is such a terrible last resort," he told me, "but it seems to be one that increasingly is the only resort." Why? Because that is where the beds are.

It is an expensive way to provide mental-health care - $21.4 million to run the jail annually, an expense that is sure to rise after Polk County's new 1,500-bed mega-jail is completed. The state, meantime, will spend $313 million this year to run its prisons, twice what it spent a decade ago. Imagine what the $23,000 spent annually to house a single inmate in a state prison could buy in mental-health care, to keep people like Gabriel Mading out of the criminal-justice system in the first place.

-Swings in demeanor disrupt calm at home

Gabriel Mading moved to Des Moines last April, after six rocky years in Richmond, Va., to which a charitable organization had resettled hundreds of Sudanese boys. In Richmond, he had made friends and gone to school. He had tried to assimilate. But a childhood of bloodshed, dislocation and loss - factors in the development of mental illness - had taken its toll. His demeanor swung wildly. He became unmanageable and sometimes destructive. After three years in a facility for mentally and emotionally disturbed adolescents, he was sent to live with an uncle, Michael Madit, in Des Moines. Madit and his wife, Elizabeth Malith, a hard-working couple with two children, are success stories of Sudanese resettlement.

When he was well, Gabriel played lovingly with the couple's two toddlers, preparing bottles for the 18-month-old baby while declining, as many a male his age will, to change his diaper. But these periods of calm invariably ended when Gabriel discontinued his medication and his schizophrenia flared.

He would disappear from the home. He would give away his clothes and his money. He feared that people were poisoning his food, lost 23 pounds and threatened suicide. Missing-persons reports were filed for him twice. Once, he broke the windshield of his uncle's car in a rage. He was ultimately jailed on Oct. 25 after he swung at his uncle with a garden hoe and instead hit a door.

-Briefly hospitalized, but not for long

In the six months before he was jailed, Gabriel had been hospitalized four times, always for brief periods of stabilization, according to Ken McDougall, Madit's sponsor. Intermediate- or long-term psychiatric hospital care is a luxury to which few are afforded in Iowa today. In addition to a shortage of state psychiatric beds, psychiatric units in general hospitals have closed, part of a national trend rooted in inadequate reimbursements and a lack of insurance parity. From 1998 to 2002, the state lost 600 general-hospital psychiatric beds - nearly half the total. The result is waiting lists for state beds and tremendous pressure to move patients through community beds.

Recognizing that he was ill, jail officials had transferred Gabriel Mading to the psychiatric unit at Broadlawns Medical Center, where he was hospitalized for nine days. He was returned to the jail just hours before his suicide, having apparently met the threshold, for a tenuous window in time, of not being a danger to himself or others. He left no note and was alone in a holding cell when he killed himself.

Hospital officials will not comment on Gabriel's case for reasons of patient privacy. But they readily acknowledge what is obvious to the families of and advocates for mentally ill people in Polk County: The hospital's 24-bed unit is small, stressed and almost always full. Said Mikki Stier, Broadlawns' senior vice president of government and external relations: "It's very difficult for patients to get into our hospital." The average stay is just six days, she said, and the typical Medicaid reimbursement covers just 40 percent of the hospital's cost. That might explain why community psychiatric beds are in such short supply.

In the face of this, America has effectively turned its jails and prisons into mini-mental institutions. At the Polk County Jail, mental-health professionals diagnose pathology, dole out medications, conduct group counseling and monitor the suicidal in special padded cells with cameras and a drain in the middle of the floor.

-Facilities ill-suited to offer treatment

How well the jail fulfills this role, which is contracted to a private agency, is an open question. There is little oversight except for inspections by the state and an accrediting agency to see if minimal standards are met. The Sheriff's Department investigates jail suicides but also runs the jail - hardly an arm's-length arrangement.

The state Office of Citizens' Aide/Ombudsman plays a watchdog role, but it is stretched thin. The state's jails and prisons account for just a fifth of its responsibility. In 2005, the ombudsman received 39 complaints regarding health care at the Polk County Jail. As of last week, it had received 61 for 2006, a troubling increase.

Correctional facilities are ill-suited to serve as hospitals. Gabriel was one of 12 people to kill themselves in Iowa's jails since mid-2002 and was among 212 who tried. Those statistics are likely to get worse as counties find money to build more cells even as they cut mental-health programs, a looming outgrowth of Iowa's cap on property taxes.

Gabriel Mading desperately missed his family and fervently wished to return home. Although he came from a faraway place and spoke thickly accented English, Gabriel was not so different from the estimated 116,000 Iowans with serious mental illness. These are people who suffer debilitating maladies and live with the risk that their illness could take them to a place they never thought possible: the inside of a jail cell.

MARY BETH PFEIFFER, who lives in upstate New York, is author of the forthcoming book, "Crazy in America: The Hidden Tragedy of Our Criminalized Mentally Ill." The book includes a chapter on Iowan Shayne Eggen, who gouged out her eyes while incarcerated. Contact Pfeiffer at marybeth@crazyinamerica.com

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Mentally ill inmates face a cruel system
Will the state end long solitary confinement and other prison abuses, or go on as usual?

BY MARY BETH PFEIFFER
May 6, 2007

In 1998, 11 years after a federal judge ordered improved mental health care for prisoners at New York State's Attica Correctional Facility, a psychotic 28-year-old man identified as Inmate A hanged himself in an Attica solitary confinement unit.

The inmate had tried suicide several times before and was experiencing delusions and hallucinations - clear signs of mental illness - but this did not affect how his keepers viewed him: as a "malingerer," according to court documents, who deserved round-the-clock lockup in a veritable closet for his prison misdeeds. Nor did it matter that the prison was operating under the watchful eye of a federal court that had sought to avoid this kind of outcome.

Now, nine years later, such abusive long-term isolated confinement of mentally ill inmates is at the center of another, more far-reaching federal lawsuit recently settled by New York State, alleging dismal inmate mental health care across its 71 prisons. With the state's pledge to add 400 treatment beds and curbs on how mentally ill inmates are disciplined, the settlement has the potential to lift hundreds of prisoners out of miserably punitive conditions. Nonetheless, caution is advised.

One need only look at Inmate A and others who died long after the state had agreed to improve their lot - even as court monitors kept a regular vigil - to know the limits of judicial reach. The settlement is a good development, to be sure, but it fails to go far enough.

The court reports that tell the checkered history of settlements of class-action prison lawsuits - those, for example, that revealed the fate of Inmate A - will not, under this new settlement, be made public. So who will know if the state reneges?

It's an urgent question, as New York's prisons, like those in other states, have become de facto mental institutions in an era of shuttered mental hospitals and inadequate community care. While the prison population has expanded by about 9 percent since 1991, the number of inmates with mental illness - currently estimated at 8,400 - has nearly doubled. The system has its own 189-bed psychiatric hospital and specialized units for mentally ill inmates, but its resources are dwarfed by the need.

Unable to conform and offered few treatment alternatives, mentally ill inmates often are isolated in cells as small as 50 square feet for an average of three years. The most recalcitrant are fed cold loaves of flour, milk, potato and carrot - with a side of raw cabbage - a punitive practice frowned upon by the accrediting American Correctional Association.

The lawsuit settlement places limits on use of the "loaf" and on punishment of mentally ill inmates who hurt themselves in violation of prison rules. It also provides two hours of therapy a week for inmates in isolation. What it will not do, however, is exclude schizophrenic and other intensely ill inmates from the dehumanizing, psychologically battering rigors of isolated confinement.

Prisons in at least seven other states now ban isolated confinement for inmates with serious mental illness. Under a bill pending in the State Legislature - vetoed last August by then-Gov. George Pataki but reintroduced and now in committee - New York would follow suit. Crucially, the bill would let a state commission monitor mental health care behind prison walls, providing badly needed, and permanent, oversight.

Settlements in federal lawsuits undoubtedly have improved prison conditions. But the path to change has been tortuous and long. After a settlement involving the Green Haven Correctional Facility in Dutchess County, a frustrated court monitor wrote 13 reports from 1992 to 2000 in which he described care as "wretched," "callous" and "dangerous." Five inmates died needlessly, including one from a staph infection that wasn't treated for six months; others were transferred under the monitor's nose to prisons not covered by the settlement.

In 1999, after the suicide of another Attica inmate under conditions almost identical to those involving Inmate A, a court expert reported that "no substantively meaningful improvement" had occurred. This was about 19 years after the filing of the suit pertaining to inmate care at Attica. By 2002, when advocates decided to take their case against corrections officials systemwide, half of prison suicides were occurring in isolated confinement - and Attica's count was among the highest.

Given a cooperative state bureaucracy with an enlightened view of mental health care, advocates believe that the outcome in the most recent case - Disability Advocates Inc. v. Office of Mental Health - will be different from the outcome in other cases. Maybe. Maybe not. The track record isn't good.

Without legislation, I fear that someone else may be writing this very article in a decade or two. Or - denied progress reports under a confidentiality clause that keeps them under wraps - maybe she won't.

***

Mary Beth Pfeiffer is author of "Crazy in America: The Hidden Tragedy of Our Criminalized Mentally Ill," which includes a chapter on the New York State prison system.




Book Review: Crazy in America:
The Hidden Tragedy of our Criminalized Mentally Ill
by Mary Beth Pfeiffer
Reviewed by: Joel A. Dvoskin, Ph.D.
American Psychology-Law News, Summer 2007

It is a tired cliché in our business that people sometimes “fall through the cracks.” But this cliché is not only hackneyed; it is dangerously misleading. As we learn in Crazy in America, the gulf that exists between America’s mental health and criminal justice systems is a vast canyon. When people fall, it is not through a crack but into an abyss.

Great teachers are almost always great story-tellers, and with this book, Mary Beth Pfeiffer cements her credentials as both. Relying on her natural gifts as a story-teller, buttressed by years of painstaking research, Pfeiffer tells a now all-too-familiar tale in a powerful way that might just make a real difference in American public policy. That this public policy failure involves at least two vast systems is exactly the point, and it is a point that is made with surgical precision.

After only a few pages, it becomes clear to the reader that Pfeiffer is a skillful journalist. She must have been an excellent reporter, as evidenced by her ability to gather an impressive amount of information about her subjects and her subject. But here, Pfeiffer is working not as a reporter but as a columnist. She tries hard to be fair, but makes no pretense of objectivity; this book has an unabashed point of view. Her goal is to convince, to educate, and to advocate. Reporters convey facts; Pfeiffer’s goal is to communicate meaning, and to instigate action.

Like Bruce Perry’s recent classic, The Boy Who Was Raised as a Dog, Pfeiffer interlaces the tragic stories of six flawed but likeable human beings -- Shayne, Luke, Alan, Peter, Jessica, and Joseph – with an impressive analytical critique of America’s equally flawed but far less likeable policy shifts in the public provision of mental health and criminal justice.

Pfeiffer’s characters were repeatedly told that they were too unstable -- too sick -- to qualify for treatment. In other words, the Catch-22 of Joseph Heller’s fiction had come to horrifying life in the jails of Iowa, Texas, and Florida – you can get mental health treatment as long as you don’t need it too badly. In fiction, such obscenities are comedy; in real life they are too tragic to fathom.

The book is not perfect. Pfeiffer, for example, uncritically cites flawed research that supports her point of view about segregation, and ignores the realistic needs of correctional administrators to occasionally remove some extremely violent inmates from general population to protect the staff and other inmates they endanger.

But these flaws are small, and do nothing to weaken the book’s overarching premise, that punishment is not and never will be a useful or humane treatment for serious mental illness. For these inmates with the most severe forms of mental illnesses, segregation to punish inmates for behaviors that are obviously beyond their control. For people with serious mental illness in the community, police practices that are other wise sensible result in tragedy – for the officers and the people whose lives they ended – when applied rigidly to people who needed something flexibility and skills that are not always part of police training.

In the book’s most shocking and infuriating scene, Shayne is accused of “manipulating” her captors, even after she has plucked out her own eyes in response to her demons. Human beings confined alone in 5’ by 8’ cells for years on end are accused of “attention-seeking,” in spite of the rather obvious rebuttal that attention is the one thing they almost never receive. It is almost impossible to believe that this book is not a work of fiction, the perverse musings of a gifted, twisted writer of horror stories. But you can’t make this stuff up. Pfeiffer grabs us not with imagination, but with truth.

In other words, this horror story is all too real. Pfeiffer, to her credit, fights off easy answers. She writes of Shayne tragic story as “a litany of a person, a family, and a system that was helpless against an illness.” Instead of blaming the correctional officials who have been forced to treat illnesses that they do not understand, instead of blaming understaffed and under-funded mental health centers for turning people away, instead of blaming police officers who truly believed that deadly force was required, Pfeiffer’s finger of blame is pointed squarely at each and every one of us.

Americans are not stupid, even if we often act as though we are. Politicians tell us that they will cut taxes. They don’t tell us that our roads will crack, our bridges will collapse, our infants will die, and our surviving children will be ignorant. They don’t tell us that some of those among us with mental illness will be callously allowed to spiral into preventable misery and death. They don’t tell us, and we pretend that we don’t know. Americans are not stupid, but we have become increasingly greedy and selfish, and it’s not the fault of politicians. They are not the cause of our greed; they are the result. We elect the ones who lie to us, and who tell us what we want to hear. Meanwhile, for Shayne and Luke, for Alan and Peter, for Jessica and Joseph, the costs of our greed are too troubling to witness.

A witness, of course, is exactly what is needed. Ultimately, Mary Beth Pfeiffer’s gift to us is to witness these unspeakable crimes against humanity, and to witness them in a well-informed manner. She is not pessimistic; quite the contrary. It is her well informed optimism – the absolute knowledge that we can and must do better – that fuels her anger. If enough people read this book, it will be impossible to sustain the delusion that we can have a humane and sensible society for free. If enough people read this book and pick up the phone or write a letter, it will be impossible to sustain the myth that this is the best that we can do for our most disabled citizens, their families, and ultimately ourselves.

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Articles

American Psychology-Law News,

Book Review: Crazy In America : The Hidden Tragedy of our Criminalized Mentally Ill Summer 2007

The New York Times

Cruel and Unusual Punishment
Sunday, May 7, 2006

Newsday

Mentally ill inmates face a cruel system
Will the state end long solitary confinement and other prison abuses, or go on usu
al? May 6, 2007

The Boston Globe

Prison a wasteland for mentally ill
March 1, 2007

The Miami Herald

Let's care for the weakest among us
Nov. 29, 2006

The Des Moines Register

From Sudan to U.S. to Iowa jail to death
January 7, 2007

Other articles by Mary Beth Pfeiffer

"Prison health care is killing inmates"Albany Times Union
April 1, 2005
http://realcostofprisons.org/blog/archives/2005/04/prison_health_c.html

Feature article: "A Death in the Box"The New York Times Magazine
October 31, 2004
http://www.namiscc.org/Experiences/2004/ADeathInTheBox.htm

"Sentenced to Suicide?"
Hartford Courant
Sunday, July 31, 2005
http://www.justicepolicy.org/article.php?id=530

"Lost Lives and Stories Never Told: When prisoners die by their own hand, the prison system typically responds with silence"Staten Island Advance
Sunday, October 16, 2005
http://www.scaany.org/press/documents/stories_never_told.pdf

"Changing of the Guard"Legal Affairs Magazine, feature article
July/August 2005
http://www.legalaffairs.org/issues/July-August-2005/feature_pfeiffer_julaug05.msp

"Mentally Ill Inmates Need More Help"
Portland Oregonian
Saturday, February 12, 2005
http://www.soros.org/initiatives/justice/articles_publications/articles/pfeiffer_20050228

"Locking up the Mentally Ill" Iowa City Press Citizen
Sunday, November 28, 2004

"Inmate Suicides Point Up Flaws in System"
Columbus Dispatch
Saturday, February 12, 2005

"Death in Prison: Punishing the Mentally Ill" Poughkeepsie Journal, a series of special reports
2001-2003


"Imprisoned and Sick: Punishing the Mentally Ill" Poughkeepsie Journal, a special report.
March 10, 2002.
http://www.poughkeepsiejournal.com/projects/prison2/

"The Prison Explosion" Poughkeepsie Journal, a special report.
November 15-17, 2000
http://www.geocities.com/fancybroccoli/PrisonArticles/PoJo_PrisonExplosion.htm

Prisons punish, not treat, mental breakdowns
''Mentally ill inmates in Pennsylvania and elsewhere are often shunted to disciplinary confinement units because of their inability to cope with the rigors of prison life.'' The Morning Call
May 27, 2007 http://www.mcall.com/news/opinion/anotherview/all-left_col-a.5865799may27,0,2289323,print.story?coll=all-newsopinionanotherview-hed

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Cruel and Unusual Punishment

By MARY BETH PFEIFFER
Sunday, May 7, 2006

Stone Ridge, N.Y.

FOUR years after it was filed, a federal lawsuit against New York State's prisons is exposing some painful truths about a system that locks up people with schizophrenia, bipolar disorder and other serious mental illnesses in isolation in concrete cells around the clock for months and years at a time.

The lawsuit, brought by a legal advocacy group in Albany, Disability Advocates, is the most important against the prison system in decades and could lead to major reforms of, and a more compassionate approach to, the treatment of mentally ill inmates. It could also influence prisons nationwide if a system as big as New York's, the nation's fourth-largest, is made to improve the care of one of the fastest growing and most difficult segments of the inmate population.

Despite the tales of horror told by experts and inmates, the trial received little attention when it opened last month, and the benches were mostly empty in the sixth-floor courtroom of Judge Gerard Lynch of Federal District Court in Manhattan. That illustrates how the treatment of inmates is being ignored by a country that imprisons two million people, including legions of drug addicts, growing numbers of women with young children and at least a quarter-million people who are mentally ill.

The suit centers on the use of what is essentially solitary confinement — prisoners call it the "box" — as a tool to manage the state's 7,300 mentally ill inmates, who are often prone to inappropriate outbursts, fights and disobedience. In depositions, inmates told of harrowing years spent in claustrophobic cells as small as 50 square feet with solid steel doors, little to do and virtually no human contact.

One inmate routinely broke down after long periods in isolation, was sent to the prison hospital to get better and then returned to the box to repeat the process. Another attempted suicide and was punished with more time in confinement. These are not isolated occurrences.

The lawsuit offers a rare peek into a system that for years has zealously protected these secrets. It is not surprising that two weeks into the trial, the parties moved to begin settlement talks. (Disclosure: After the state objected, the judge denied my lawyer's request for me to accompany the judge and the lawyers in the case on tours of four prisons as part of the trial last month.)

Besides the miserable conditions, a major issue in the case is New York's excessive use of these confinement boxes, or what the state calls "special housing units." About 4,300 inmates currently serve time in the special housing units, which were greatly expanded by the Pataki administration from 1998 to 2000. The rationale was to make prisons safer, but a study in three other states has produced little evidence to back that up.

While the state has maintained that the average box sentence is 154 days, an in-house e-mail message released to plaintiffs suggested that seriously ill inmates serve far more in accumulated time: 2.2 years in the unit at Attica State Correctional Facility in western New York and 3.3 years at Five Points Correctional Facility in Seneca County. A prison expert, Steve J. Martin, found that nearly half of the 25 inmates he interviewed had sentences of five years or more. And a psychiatrist, Terry Kupers, concluded that 64 percent of the inmates in maximum-security special housing units are mentally ill.

While New York has reduced inmate suicide in the last two decades with suicide-proof construction and better monitoring, isolated confinement units undoubtedly lead to inmate deaths. New figures assembled for the lawsuit show that 44 percent of the suicides in New York's system from 1995 through mid-2004 occurred among the less than 10 percent of the prison population in isolated confinement, including special housing and another form of 23-hour lockup called "keeplock."

This, as documents from the trial show, is no surprise to state officials. Yet the state continues to use the box to warehouse people with serious mental illness.

As more and more mental hospitals in New York and nationwide close, prisons have become the de facto custodians of people with mental illness. It's an unfortunate reality to which prisons must adapt.

The New York Legislature should move to prohibit the placement of people with serious mental illness in isolated confinement, as has been proposed, and Gov. George Pataki should sign the bill. The state also needs more hospital beds for sick inmates. Beyond this, prisons must develop alternative forms of housing for disturbed inmates and must staff them with people who are trained to understand the difference between insubordination and insanity. Most of all, the state must stop punishing people for being mentally ill.

The use of these boxes to confine mentally ill inmates serves only to make them more paranoid, anxious and ill. These measures indicate that we have a bureaucracy without the tools or know-how to deal with a needy population. Surely New York can do better than this.

Mary Beth Pfeiffer is writing a book about mentally ill people in the criminal justice system.

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Let's care for the weakest among us

Nov. 29, 2006

BY MARY BETH PFEIFFER

An overdue reckoning is taking place in Florida's jails, where the state could face stiff fines if it doesn't come up with psychiatric beds for some 300 seriously mentally ill inmates. The irony is that these inmates, who are so sick that they have been declared incompetent to stand trial, might not be in jail at all if they had received proper mental healthcare in the first place. They are not alone.

These inmates, including one who gouged out an eye, are harbingers of a crisis in mental healthcare that extends far beyond Florida's jails. It is evident in emergency rooms crowded with psychotic and suicidal people who have nowhere else to go. It plays out in hospital units from which psychiatric patients are discharged long before they are ready. It crackles over police radios with calls of yet another mentally ill person, adrift or discharged or forgotten, who has lost control.

The 300 inmates who have brought this issue to the fore are but a tiny sliver of the 25,000 mentally ill people in the state's jails and prisons, a micro-subgroup of inmates that is testing the patience of judges in Broward, Miami-Dade, Hillsborough and other counties who want them removed. These inmates are a vivid reminder of the price to be paid when a society overbuilds its prisons and underfunds its mental-health system, a demonstration of how long-term care of the mentally ill has shifted to the place where there is always a bed.

Since 1997, Florida's prison population has swelled by 44 percent, to 89,000 inmates. Meantime, in a state that had 56 state psychiatric beds per 100,000 people in 1990, there are now eight. Squeezed by flagging reimbursements, 36 private psychiatric hospitals have closed in Florida since 1992 -- taking an additional 4,400 beds.

Few would dispute that old, anachronistic mental hospitals needed to close. The idea was to make the community the locus of mental healthcare, with case managers, counselors, clinics and housing to maintain vulnerable mentally ill people outside of hospitals.

A sure sign that the effort has failed is in those 300 insane inmates. Just 5 percent were known to the mental-health system before they were jailed. Had they received care, they likely would not have gotten so sick -- and their prospects for recovery would not be so dim. They also might not have committed crimes that put them behind bars. Now consider that there were 761 severely and 9,197 moderately mentally ill inmates in Florida's prisons in 2005 -- figures that don't count those in shorter-term jails.

Killed by a car

Alice Marsh is one victim of failed community care. In February 2002, Marsh was among the last 10 patients to leave the state's G. Pierce Wood Memorial Hospital in Arcadia, where she had lived on a locked ward for 16 years. A demure woman with severe schizophrenia, she was dispatched to an unlocked room-and-board facility in Pasco County. Within a month, she wandered onto a highway and was killed by a car.

The state has tried. When Pierce closed, $30 million was diverted to a new program, called Florida Assertive Community Treatment, to help people with serious mental illnesses thrive in communities. The results reflect a porous system. Among some 3,100 served in 2005, there were 3,047 hospitalizations; 413 jailings and, most astonishing, 40 deaths. This was the outcome among people receiving the highest level of community care. Imagine the fate of the rest.

Who belongs in prison?

State spending on adult mental healthcare went up 10 percent in real dollars in the last decade -- about a third as much as Florida's adult population. In the first nine months of 2006, meantime, the prison population leaped by another 3,000 inmates, this though Florida crime rates are at their lowest levels since the 1970s. Sure, many people belong in prison, but how many -- and how many more?

When 170,000 seriously ill Floridians go without mental healthcare and roughly one in five inmates is mentally ill, it's time to reconsider what a war on drugs, longer sentences and a tough-on-crime ethic has wrought for the weakest among us. And what that money might buy to help them.

Mary Beth Pfeiffer is author of the forthcoming book Crazy in America: The Hidden Tragedy of Our Criminalized Mentally Ill.

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Prison a wasteland for mentally ill

By Mary Beth Pfeiffer

March 1, 2007

ON THANKSGIVING 2004, a notoriously mad inmate named Richard A. Street hanged himself in a segregation unit at the 800-inmate, maximum-security state prison in Walpole. His death marked the start of a rash of 12 suicides in Massachusetts prisons in 26 months, compared with five in the nearly six years before. A look at Street's prison experience might explain this phenomenon, which is unfortunate but not uncommon in modern prisons.

Street, 53, was a wretched man who had indiscriminately shot two people one night in Boston in 1980 and then went on to exhaust the patience and resources of the Massachusetts prison system. Suffering from schizoaffective disorder and calling himself "Jesus Christ, Future King of the Vampires," he would rant, self-mutilate, and perform naked pirouettes around a basketball in the prison yard.

Recently the state Department of Correction commissioned a report on suicide prevention in Massachusetts prisons and has promised to put its recommendations into practice. Street's chilling case starkly illustrates the need for changes.

I obtained Street's medical records for the spring of 2004, after he had been in the prison's disciplinary detention unit, an alternative form of segregation, for about 10 months. In a six-week period, Street, a thin man with a bushy, reddish-brown beard and long dark hair, was twice found hanging in his cell. He repeatedly gouged his skin, swallowed an 1 1/2-inch piece of metal, and was taken to a local emergency room six times. He smeared feces in his hair and complained that solitary confinement was making him hurt himself.

Photographs show a handcuffed Street displaying a gruesome array of scabbed and mottled wounds on his legs and arms. Nonetheless, his records suggest a skepticism, common on the part of overworked prison clinicians, of Street's pathology. After he had been found "unresponsive" and with gauze tied around his neck, a clinician wrote that Street "is not depressed . . . nor at risk of harm due to mental illness." He had been known to "feign unconsciousness," the record noted.

Five days after Street's death, I toured the so-called Ten Block segregation unit where he died. The unit was four tiers of dingy, claustrophobic cells, a prison slum where Street had been confined around the clock with only his hallucinations and voices as company. My tour guide declined to take me down the rows of inmates in the 60-cell unit, given the proclivity of many to scream or throw bodily fluids. Inmates were so unpredictable that they were shackled when let out of their cells. Clearly, there was more going on with these inmates than sheer criminality, and the conditions were part of the problem.

Twenty-five years before my visit to what is now the Massachusetts Correctional Institution-Cedar Junction, Harvard Medical School psychiatrist Stuart Grassian conducted a study of 14 Walpole inmates who, like Street, had been housed in solitary confinement. He was surprised by what he would later call the "toxic" effects of isolation. Some inmates were hypersensitive to sounds or obsessed with thoughts of torturing guards; others described feelings of panic and fear of suffocation. This was the effect on inmates in general; imagine the impact on those already suffering from mental illness. It is no wonder then that six of the system's 12 most recent suicides occurred in segregation units. That is 50 percent of suicides among about 4 percent of the prison population.

Psychiatric experts say they can judge the quality of a prison system's mental health program by a quick visit to its solitary confinement units. In many states, they are dumping places for the mentally ill.

Street's suicide and those that followed are, in large part, a direct result of a huge influx into prisons of people with mental illness, an inability of prisons to deal with them, and a heavy reliance on isolation as a quick fix to a complex problem. The suicides, many avoidable, represent a failure of policy and compassion.

After Street's death, the sentiment among officers on a union website was that he had belonged not in prison but in a mental hospital.

The rash of suicides is just the latest in a series of crises that beg for better care of the mentally ill -- the 2003 killing in protective custody of defrocked priest John Geoghan and the 1996 suicide of John Salvi among them. Now, after yet another report and another outcry, will the call be heeded?

Mary Beth Pfeiffer is writing a book about mental illness and criminal justice.

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From Sudan to U.S. to Iowa jail to death

Troubled teen's suicide shows what can happen in a nation that imprisons mentally ill people.

By MARY BETH PFEIFFER
SPECIAL TO THE REGISTER
January 7, 2007

Gabriel Mading's path to America was typical of the so-called "Lost Boys of Sudan": A thousand-mile trek from his war-torn African country to Kenya, several years in a squalid refugee camp there, and, finally, a wrenching goodbye, at age 12, to a mother who believed she was delivering him to a life of privilege and peace.

Gabriel's remarkable journey ended on Nov. 29 at the Polk County Jail in Des Moines, where this lost boy - one among thousands to flee conscription, slavery and death - strangled himself with a torn bit of jail-issue blanket. He was 18.

If Gabriel's life was a commentary on the turmoil that grips the African continent, his death offers lessons about the treatment of mentally ill people in Iowa and America. While this tall, slender young man had food and clothing enough - luxuries in his African homeland - he could not get what he most desperately needed: adequate care for his raging mental illness. Instead, he got a uniform, a number and the four walls of a jailhouse cell.

In a country that has come increasingly to rely on punishment as the answer to a host of social ills, Gabriel Mading is not alone. An estimated 12 percent to 15 percent of the 580 inmates at the Polk County Jail receive medications for mental illness. Meanwhile, 34 percent of the people in Iowa's nine prisons are mentally ill, some 3,000 people in all. Add to that hundreds more in the state's 96 other short-term jails, and thousands on probation and parole.

Years ago, Iowa had psychiatric patients, instead of inmates, in comparable numbers - 5,336 in 1955 in four sprawling public mental hospitals. It is no coincidence that as the numbers of hospital beds shrank - under the admirable but unfulfilled vision to better serve people in their home communities - the ranks soared of people with mental illness behind bars.

From 1994 to 2005, Iowa went from having 513 state psychiatric beds in public mental hospitals to having 267, ranking it 44th in the nation per capita. (It has since added 20 beds.) In the same period, the proportion of mentally ill people in Iowa's prisons rose more than eightfold.

-Few alternatives other than jail

Today, when people like Gabriel Mading become psychotic and violent, when they commit crimes because they cannot control their behavior, they are routinely taken to jails instead of hospitals. The reason is twofold:

-There are too few alternatives to jails in the community.

In 2006, the National Alliance for the Mentally Ill gave Iowa an "F" in a national grading on mental-health care. "Iowa is a prime example of what President Bush's New Freedom Commission on Mental Health meant when it reported [in 2002] that the nation's mental-health-care system is 'fragmented and in disarray,' " the organization reported. While Polk County has more services than the state as a whole, there is little dispute that need far outstrips resources.

- There are too many beds - yes, too many - in jails and prisons.

In the last decade Iowa increased its jail population by 74 percent and its prison population by 50 percent. This was not because of a precipitous rise in crime. The state's index of major crimes has declined 24 percent since 1990. Instead, it stemmed from national trends that did not escape Iowa: longer prison stays for most offenses, greatly reduced chance of parole for certain crimes and an overdone war on drugs that saw the share of inmates serving drug sentences in Iowa's prisons rise from 3 percent in 1983 to 26 percent in 2003.

-Needs not met, but costs high

Frank Cordaro, a Catholic worker and pacifist, spent a month in the Polk County Jail in 2004 on a charge of trespassing at a federal armory. Cordaro saw mentally ill people who needed a helping, rather than punitive, hand: One man soiled himself regularly. Another appeared grossly overmedicated. Others were incarcerated for menial crimes such as disorderly conduct and public lewdness - small infractions on which criminal records are built.

"Jail is such a terrible last resort," he told me, "but it seems to be one that increasingly is the only resort." Why? Because that is where the beds are.

It is an expensive way to provide mental-health care - $21.4 million to run the jail annually, an expense that is sure to rise after Polk County's new 1,500-bed mega-jail is completed. The state, meantime, will spend $313 million this year to run its prisons, twice what it spent a decade ago. Imagine what the $23,000 spent annually to house a single inmate in a state prison could buy in mental-health care, to keep people like Gabriel Mading out of the criminal-justice system in the first place.

-Swings in demeanor disrupt calm at home

Gabriel Mading moved to Des Moines last April, after six rocky years in Richmond, Va., to which a charitable organization had resettled hundreds of Sudanese boys. In Richmond, he had made friends and gone to school. He had tried to assimilate. But a childhood of bloodshed, dislocation and loss - factors in the development of mental illness - had taken its toll. His demeanor swung wildly. He became unmanageable and sometimes destructive. After three years in a facility for mentally and emotionally disturbed adolescents, he was sent to live with an uncle, Michael Madit, in Des Moines. Madit and his wife, Elizabeth Malith, a hard-working couple with two children, are success stories of Sudanese resettlement.

When he was well, Gabriel played lovingly with the couple's two toddlers, preparing bottles for the 18-month-old baby while declining, as many a male his age will, to change his diaper. But these periods of calm invariably ended when Gabriel discontinued his medication and his schizophrenia flared.

He would disappear from the home. He would give away his clothes and his money. He feared that people were poisoning his food, lost 23 pounds and threatened suicide. Missing-persons reports were filed for him twice. Once, he broke the windshield of his uncle's car in a rage. He was ultimately jailed on Oct. 25 after he swung at his uncle with a garden hoe and instead hit a door.

-Briefly hospitalized, but not for long

In the six months before he was jailed, Gabriel had been hospitalized four times, always for brief periods of stabilization, according to Ken McDougall, Madit's sponsor. Intermediate- or long-term psychiatric hospital care is a luxury to which few are afforded in Iowa today. In addition to a shortage of state psychiatric beds, psychiatric units in general hospitals have closed, part of a national trend rooted in inadequate reimbursements and a lack of insurance parity. From 1998 to 2002, the state lost 600 general-hospital psychiatric beds - nearly half the total. The result is waiting lists for state beds and tremendous pressure to move patients through community beds.

Recognizing that he was ill, jail officials had transferred Gabriel Mading to the psychiatric unit at Broadlawns Medical Center, where he was hospitalized for nine days. He was returned to the jail just hours before his suicide, having apparently met the threshold, for a tenuous window in time, of not being a danger to himself or others. He left no note and was alone in a holding cell when he killed himself.

Hospital officials will not comment on Gabriel's case for reasons of patient privacy. But they readily acknowledge what is obvious to the families of and advocates for mentally ill people in Polk County: The hospital's 24-bed unit is small, stressed and almost always full. Said Mikki Stier, Broadlawns' senior vice president of government and external relations: "It's very difficult for patients to get into our hospital." The average stay is just six days, she said, and the typical Medicaid reimbursement covers just 40 percent of the hospital's cost. That might explain why community psychiatric beds are in such short supply.

In the face of this, America has effectively turned its jails and prisons into mini-mental institutions. At the Polk County Jail, mental-health professionals diagnose pathology, dole out medications, conduct group counseling and monitor the suicidal in special padded cells with cameras and a drain in the middle of the floor.

-Facilities ill-suited to offer treatment

How well the jail fulfills this role, which is contracted to a private agency, is an open question. There is little oversight except for inspections by the state and an accrediting agency to see if minimal standards are met. The Sheriff's Department investigates jail suicides but also runs the jail - hardly an arm's-length arrangement.

The state Office of Citizens' Aide/Ombudsman plays a watchdog role, but it is stretched thin. The state's jails and prisons account for just a fifth of its responsibility. In 2005, the ombudsman received 39 complaints regarding health care at the Polk County Jail. As of last week, it had received 61 for 2006, a troubling increase.

Correctional facilities are ill-suited to serve as hospitals. Gabriel was one of 12 people to kill themselves in Iowa's jails since mid-2002 and was among 212 who tried. Those statistics are likely to get worse as counties find money to build more cells even as they cut mental-health programs, a looming outgrowth of Iowa's cap on property taxes.

Gabriel Mading desperately missed his family and fervently wished to return home. Although he came from a faraway place and spoke thickly accented English, Gabriel was not so different from the estimated 116,000 Iowans with serious mental illness. These are people who suffer debilitating maladies and live with the risk that their illness could take them to a place they never thought possible: the inside of a jail cell.

MARY BETH PFEIFFER, who lives in upstate New York, is author of the forthcoming book, "Crazy in America: The Hidden Tragedy of Our Criminalized Mentally Ill." The book includes a chapter on Iowan Shayne Eggen, who gouged out her eyes while incarcerated. Contact Pfeiffer at marybeth@crazyinamerica.com

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Mentally ill inmates face a cruel system
Will the state end long solitary confinement and other prison abuses, or go on as usual?

BY MARY BETH PFEIFFER
May 6, 2007

In 1998, 11 years after a federal judge ordered improved mental health care for prisoners at New York State's Attica Correctional Facility, a psychotic 28-year-old man identified as Inmate A hanged himself in an Attica solitary confinement unit.

The inmate had tried suicide several times before and was experiencing delusions and hallucinations - clear signs of mental illness - but this did not affect how his keepers viewed him: as a "malingerer," according to court documents, who deserved round-the-clock lockup in a veritable closet for his prison misdeeds. Nor did it matter that the prison was operating under the watchful eye of a federal court that had sought to avoid this kind of outcome.

Now, nine years later, such abusive long-term isolated confinement of mentally ill inmates is at the center of another, more far-reaching federal lawsuit recently settled by New York State, alleging dismal inmate mental health care across its 71 prisons. With the state's pledge to add 400 treatment beds and curbs on how mentally ill inmates are disciplined, the settlement has the potential to lift hundreds of prisoners out of miserably punitive conditions. Nonetheless, caution is advised.

One need only look at Inmate A and others who died long after the state had agreed to improve their lot - even as court monitors kept a regular vigil - to know the limits of judicial reach. The settlement is a good development, to be sure, but it fails to go far enough.

The court reports that tell the checkered history of settlements of class-action prison lawsuits - those, for example, that revealed the fate of Inmate A - will not, under this new settlement, be made public. So who will know if the state reneges?

It's an urgent question, as New York's prisons, like those in other states, have become de facto mental institutions in an era of shuttered mental hospitals and inadequate community care. While the prison population has expanded by about 9 percent since 1991, the number of inmates with mental illness - currently estimated at 8,400 - has nearly doubled. The system has its own 189-bed psychiatric hospital and specialized units for mentally ill inmates, but its resources are dwarfed by the need.

Unable to conform and offered few treatment alternatives, mentally ill inmates often are isolated in cells as small as 50 square feet for an average of three years. The most recalcitrant are fed cold loaves of flour, milk, potato and carrot - with a side of raw cabbage - a punitive practice frowned upon by the accrediting American Correctional Association.

The lawsuit settlement places limits on use of the "loaf" and on punishment of mentally ill inmates who hurt themselves in violation of prison rules. It also provides two hours of therapy a week for inmates in isolation. What it will not do, however, is exclude schizophrenic and other intensely ill inmates from the dehumanizing, psychologically battering rigors of isolated confinement.

Prisons in at least seven other states now ban isolated confinement for inmates with serious mental illness. Under a bill pending in the State Legislature - vetoed last August by then-Gov. George Pataki but reintroduced and now in committee - New York would follow suit. Crucially, the bill would let a state commission monitor mental health care behind prison walls, providing badly needed, and permanent, oversight.

Settlements in federal lawsuits undoubtedly have improved prison conditions. But the path to change has been tortuous and long. After a settlement involving the Green Haven Correctional Facility in Dutchess County, a frustrated court monitor wrote 13 reports from 1992 to 2000 in which he described care as "wretched," "callous" and "dangerous." Five inmates died needlessly, including one from a staph infection that wasn't treated for six months; others were transferred under the monitor's nose to prisons not covered by the settlement.

In 1999, after the suicide of another Attica inmate under conditions almost identical to those involving Inmate A, a court expert reported that "no substantively meaningful improvement" had occurred. This was about 19 years after the filing of the suit pertaining to inmate care at Attica. By 2002, when advocates decided to take their case against corrections officials systemwide, half of prison suicides were occurring in isolated confinement - and Attica's count was among the highest.

Given a cooperative state bureaucracy with an enlightened view of mental health care, advocates believe that the outcome in the most recent case - Disability Advocates Inc. v. Office of Mental Health - will be different from the outcome in other cases. Maybe. Maybe not. The track record isn't good.

Without legislation, I fear that someone else may be writing this very article in a decade or two. Or - denied progress reports under a confidentiality clause that keeps them under wraps - maybe she won't.

***

Mary Beth Pfeiffer is author of "Crazy in America: The Hidden Tragedy of Our Criminalized Mentally Ill," which includes a chapter on the New York State prison system.




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