Mixing the "Mad with the Bad"
The purpose of these series of Serpents at your front door writings are to educate laymen like myself of the imminent dangers that are lurking inside our prison filled with the mentally ill that are being ignored and mistreated as they are misidentified, ignored or worse, mistreated as criminals [rather than patients]when in fact they could benefit from a clinical and hospital setting to improve their coping skills, their functionality and their psychosis that appear way to often with no recourse but to handle it themselves as help is often overlooked. I, a retired deputy warden with no less than 25 years inside our prisons in New Mexico and Arizona, have witnessed the ignorance, the deliberate failures to treat and medicate and the daily abuses these mentally ill prisoners forgo when incarcerated and mixed with those societal rejects that are there for deliberate criminal intent and premeditated crimes including murder. Skilled in the art of criminal justice and those related fields, it is with great curiosity and intense desire to learn more about this phenomenon that roams the corridors of our prisons rather than being inside state certified hospitals.
Forensic psychiatry uses the legal aspect of psychiatry to aid in court cases. Expert psychiatric testimony influences legal verdicts and judgments. A forensic psychiatrist evaluates individuals involved in court cases, plays an important part in custody suits, and provides treatment to incarcerated patients. He or she can determine competency in criminal cases, in legal business procedures (such as contracts or investments), and give assistance in harassment and discrimination cases. One such psychiatrist is Doctor Stephen Rachlin, MD who said back in 1974 "The paramount civil right of the patient should be that of adequate treatment."
Many years ago in a letter Emily Cannon, a concerned parent reaching out with pleas of help for her mentally ill son took the time to write a letter to her local public health officials and the county commissioner, asking in writing 'Please remember that one of the most important things that can be done now and in the future is to make sure that those hired to work with the mentally ill are sensitive and caring human beings. Sensitive to the needs of patients and families, this country, this state and mankind." Ms. Cannon was a high school history teacher in Charlotte, North Carolina who had a son who was diagnosed with schizophrenia. She was killed by her son four days after writing this letter as he beat her to death brutally with a vacuum cleaner; He then slashed her body with a butcher knife and dumped her in the woods north of Charlotte, NC.
Arizona must not follow in California's footsteps in the treatment of the mentally ill. Today, their prisons are overcrowded and filled with the mentally ill who require regular treatment and medication to function safely inside these prisons. It is estimated that more than 16 % of these prisoners are mentally ill and need help. These mental health professionals, hired by the state, must take the time to conduct accurate assessments of their patients and write them off as they have in the past as being "manipulative and gamey" referring to the mind games prisoners' play in order to get something for nothing inside prisons. In most cases, these seriously mentally ill prisoners are reaching out for help and often receive none in return as they are classified into this group of manipulative and gamey inmates so often ignored because of the culture's view of their needs.
Taking the time to read Dr. E. Fuller Torrey's book "The Insanity Offense", it has become clearer to me how the government and the criminal justice system has failed its own by ignoring the negative fallout of the deinstitutionalization that occurred several decades ago and since that time, created a melting pot of mentally ill persons who should have been hospitalized and treated roaming the streets as homeless or in jail or prisons for failing to be able to cope within the guidelines of the law and human tolerances for their kind of misunderstood behaviors and the stigmas that they carry along with the innocence or guilt of not comprehending their social status and their needs for medication or treatment for their illnesses.
America has a responsibility to treat those who require treatment to avoid further damage to their social status and their vulnerability to be falsely accused of a crime and unable to defend themselves adequately due to lack of comprehension of the charges, the consequences or the plea bargains so eagerly offered to expedite the court caseloads filled with today. Assigned ill prepared public defenders inexperienced and certainly not educated or equipped to handle the seriously mentally ill (SMI) offenders, these persons are processed through the criminal justice system in mass numbers filling the prisons with a high number of mentally ill that pose a danger to themselves, the staff and other prisoners.
This tragedy could very well be remedied if the court system would facilitate a legitimate process at the pre-trial stage that would allow public defenders and those who can afford their own attorneys representing their SMI clients the accessibility and treatment for a pre-trial assessment whether or not they are competent to stand trial or if they are in dire need of psychiatric intervention and stabilization before they stand the charges. Learning a new phrase that makes a lot of sense even to a retired prison deputy warden was the quote found in Dr. Torrey's book that said" "Civil libertarians say no -- that it is our right to commit crimes that land us in prison that it is our choice to be so ill that we prefer to forage through garbage and live on the streets; that it is our prerogative to let voices in our heads torment us into sleepless nights. But something tells me that the people locked up in San Quentin with a mental illness and the people roving the back alleys of skid row are not singing "God Bless America." (Jim Randall, 2006.
Interesting enough is the fact that when the earthquake / tsunami and nuclear plant disaster hit Japan earlier this year and when the tornadoes ravaged through Joplin Missouri and Dixie Alley or Ringgold, Georgia not too long ago, the media reported the mass numbers of people killed in these disasters but hardly ever took the time to identify each and every victim found dead by name, by family or by the way they lived their lives. In those individual humanized stories actually shown on the TV set, people's emotions were activated and compassion drew them closer to the disaster that had occurred there that resulted in them to reach out and help others through the Red Cross or donations to organizations helping the victims. Equally interesting is the fact that for the past several years, hundreds of prisoners have died inside Arizona prisons. A combination of natural deaths, suicides and homicides. This may well be a result of poor medical and mental health treatment or worse, ignoring the warning signs that could have prevented numerous needless deaths if someone would have paid attention to their cries for help and took the appropriate action required to get them on track regarding being in compliance with their medication, their treatment needs and often lacking follow up assessments to provide continued after care so that if released from these prisons they don't become another number already high for the recidivism in this state. Incarceration must start with educating the criminal justice system of those alternatives available to doing time in prison as recidivism is preventable if the right criminal justice tools are in place to manage these behavioral and mental health problems as there are realistic and successful evidence based alternatives to mass incarceration working in many other places of this country.
Finding Alternatives to Shutdown State Hospitals
In 1992, assigned as a correctional captain at the newly formed Mental Health Treatment Center (MHTC) located at the Central New Mexico Correctional Facility 30 miles south of Albuquerque, was my introduction to the seriously mentally ill up close and personal. Although having worked as a correctional officer inside the Santa Fe prison in 1985 through 1989, it was a sporadic interaction and only with those locked up and classified as special needs inmates that required little care except their basic food, drinks, shower and medication. There was an occasional use of force or cell extraction of those unwilling to comply with direct orders to come out of their cells but within5 minutes, these individuals were restrained and put in a strait jacket or other soft restraints to keep harming themselves or others.
At the MHTC, under the guidance of Dr. Eloy Romero, this treatment unit was formed to handle the most seriously mentally ill (SMI) inmates housed in the New Mexico prison system. The transition for this unit was from a lock up with punitive elements in place to a more open minded therapeutic milieu that enhanced and encouraged treatment practices that would stabilize and allow these SMI inmates to be reintegrated back into the general population along with the proper medications provided by their case by case assessments. It was to be the genesis for my interest in the mentally ill as I had to transform my security mind to a more open mind that allowed more flexibility in inmate movement, inmate behaviors and inmate disciplinary. Gradually understanding the principles required to maintain a successful treatment center, it took 48 specially trained and volunteering officers and 4 recreational specialists to embrace the new concept and make it work. The reason for this unit's existence was the mass number of SMI's coming into the prison system and having difficulties coping with general population functions. My tour of duty there lasted for 3 years as I was rotated out to an assignment as a program director since learning the fine balance of security and programs as an essential part of sound correctional practices
The closing of many state hospitals and the results of deinstitutionalization was not just a problem that occurred in California. There were drastic changes in the laws by many state governments regarding the management and treatment of mentally ill persons. The political climate of California's governor and other public leaders led to a dramatic change in the treatment of the mentally ill everywhere. New Mexico was no exception to the problem. Dr. E. Fuller Torrey writes in his book "The Insanity Offense" the following quote on the Lanterman-Perris-Short Act (LPS) passed in California in 1967. The LPS act modeled "most state commitment statutes today" and is used today in various states. One should take the time to read this act and see how it changed the way the mentally ill were treated as it limited the treatment options for individuals. Dr. Torrey writes that the makers of the LPS Act actually believed that almost all persons with psychiatric needs and disorders could in fact be competent enough to make "informed decisions regarding their need for treatment." In due time, it was believe that this act in fact created more homicides by the mentally ill as the number of violent offenses rose to a staggering number and spiraling out of control. He also writes that it was the distrust of psychiatric help and treatment as well as the involuntary psychiatric hospital commitments that propelled Lanterman to go forward and lead up to the LPS act. Doctor Donald T. Lunde, a longtime Bay Area psychiatrist who became "widely known in the American court system for his frank and eloquent testimony on all manner of grisly crime and human behavior" wrote "Yes, the LPS. It was in effect certainly at this time. It was now impossible to commit somebody for a prolonged period in the state of California, even though you know, as was mentioned repeatedly here (Herb Mullin's trial, 1973) that the patient is dangerous to himself or others." The law provides very limited, very specific numbers of days that you can keep somebody. Beyond that, even though a person may continue to be obviously dangerous, he must be released." In that trial, the jury found Mullin to be guilty of ten counts of murder on August 19, 1973. He was sentenced to life in prison where the mental health officials could not release him. Thus the public became aware of the needs to change their approach to the mentally ill and sought relief through the courts and other avenues. It was becoming clear that California had failed in the psychiatric field as their laws did not protect their citizens from the acts of the mentally ill as there was an "increase in episodes of violence, including homicides committed by the mentally ill." Over the next 30 years the rates of violence, homicides and suicides increased as more and more mentally ill persons were being neglected and left to fend for themselves on the street and the prisons. Untreated and left to deal with their own problems, these people were trying to cope with life the best they could be with their disorders hampering their ability to be successful and productive citizens, they had become society's burden as well as their off springs. In 1999 the state of California reported a prison population of 20 % being mentally ill and in need of treatment. The consequences of the past became predictable for the future. Dr. Torrey reports that "in 2005, a federal judge looking at the California prison system and its problems ordered a "takeover of medical incompetence and at times outright depravity" in the manner it took care of its prisoners.
Moving away from California's trials and tribulations regarding the treatment of the mentally ill it must be mentioned that during this time, California psychiatry influenced most others throughout the country and many models were mimicked or adapted for their own applications nationwide. Arizona, always in the role of catching up is coming to the culmination of the California system as it was in 2005 and is now experiencing a heavy flow of mentally ill persons being incarcerated into their prisons leaving them with inadequate care and resources. A conservative state that is financial troubled with their budget; the legislature did allocate $ 1 billion dollars to run its prison system. Hardly enough to address their operational needs and the burdensome and expensive costs to treat the seriously mentally ill prisoners, their care is sparse and sporadic as case by case crisis intervention identifies these inmates and puts them in a higher custody level with the result being isolation and sparse treatments available. Sparse treatment includes limited staffing, physical space and access to more professional resources.
Being among those correctional officials that found it difficult to manage and deal with these SMI prisoners, it was clear that the "mixing of the mad with the bad" was a dangerous combination inside prisons. Adding the elements of overcrowding, idleness and understaffing, this condition fuels a disaster in the making and is at the cusp of exploding. Today, we are trying to piecemeal this problem today with sporadic and weak attempts to treat the SMI's in Arizona's prisons. The bizarre behaviors are puzzling to untrained staff and overwhelm the psychiatric staff assigned to these prisons. Officers react to their conduct with extreme caution or extreme force regardless of their mental conditions. In the five years employed by the Arizona prison system I saw few who were sensitive to their needs, and I saw only a handful take the time and effort to ensure their personal safety was ensured by taking the time to do a good evaluation and prescribe the right medication to allow them to function as good as possible under strict conditions. Arizona prison time is hard time; very much like the same mentality that exists inside the California prisons their rules are strictly enforced and the consequences are real. One important fact that many officers often forget is that SMI inmates "find it difficult to understand or follow" rules and regulation thus are punished for breaking rules they do not comprehend or have an awareness that they did something wrong. Chief Supreme Court Justice wrote in 1999 "It must be remembered that for the person with severe mental illness, who has no treatment, the most dreaded of confinements can be the imprisonment by his own mind, which shuts reality out and subjects him to the torment of voices and images beyond our powers to describe." Comparing New Mexico prison cultures with the Arizona prison cultures I can see similarities but certainly not with the same intensity or unpredictability that exists in these Arizona prisons. Arizona crisis management is daily compared to infrequent accounts in New Mexico. Their culture related to race, ethnicity and gangs are the same. Their culture in taking care of each other is indifferent to say the least and the comparison between training and cultural awareness and diversity is night and day with New Mexico shining in the sun. Arizona is 10 years behind the times in prison life and management. There are no accreditation processes in place to ensure continuity and compliance with any other standard but their own policies which are flawed to say the least. This lack of accreditation and audit performed activities [such as those done by the American Correctional Association] leads to chaos and disarray of rules and regulation enforcement causing more stress and confusing to the mentally ill as well as staff who suffer a high rate of disciplinary for their lack of knowledge of these policies and insufficient training in the handling of these special needs offenders, It is also the main reason why Arizona is suffering in the area of mental health treatment as change is slow and an uphill battle through traditional barriers put in place over the years by those authoritarians who refuse to admit that SMI prisoners have special needs and should be treated different than other non-mentally ill prisoners. Today the Arizona prisons are filled with SMI inmates at their Level V [the highest custody level] and who suffer with inadequate care and treatment as Arizona struggles to catch up with the times.
Criminalization of the Mentally Ill
Arizona prisons have undergone so many changes since 2003 and under three different directors; have gone into 3 different directions. For the employees it is a constant shift in direction that includes political, operational and philosophical values as well as an attitude of mass incarceration within the state itself. Lawmakers and politicians are ignoring the obvious failures and legal plights of the California prison systems and are about a few years ahead of their court battles and internal strife before this same prison crisis hits the governor's office and legislature. As many states around the country are downsizing their prisons citing a decline in violent crime and extreme hardships coming up with the money to pay for their prison systems, these leaders are taking the opposite direction that caused these prisons to swell up and overcrowded from the beginning.
This year, State Representative Cecil Ash promoted and received support for the creation of a sentencing reform commission bill [HB 2664] that would in fact look into the rate of incarceration, the methods used to convict criminals and review the sentences that are designated to apply to these felony charges as written as current law. Passing the House the bill maker had hopes that died in the chambers of the Senate where the bill was never heard. An overview of this bill revealed Establishes the Commission's tasks to entail the following: Collect recidivism data, record treatment methods, and monitor financial obligations and effectiveness of probation departments, pretrial diversion programs, drug and mental health courts, city and county jails and the DOC - Evaluate emerging practices and trends in criminal sentencing and alternative punishments in other jurisdictions throughout the United States - Review Arizona's sentencing structure and recommend changes to the laws and other aspects of sentencing that would improve the sentencing structure - Submit an annual report to the chairpersons of the Judiciary Committees in the House of Representatives and the Senate. Maintain public inspection records of action taken by the Commission.
In addition it would allow the Commission to - Request information, data, and reports from any state agency, political subdivision, or judicial officers of the state - Hold hearings, conduct fact finding tours, and take testimony from witnesses, including participants in the criminal justice system - Perform or delegate any additional function that may be necessary to carry out the Commission's purpose - Apply for and receive grants, donations, or other monies from public or private sources. The bill would have also authorized the Commission to enlist the assistance of any state agency's services, equipment, personnel, or facilities to the extent possible without costing the Commission. Certainly a move into the right direction, this effort was put off for another year with possible consideration during the next legislative session. Arizona must be "waiting for the world to stop" so they can catch up with more modern penology methods and come out of the dark ages. Spending $ 1 billion dollars and wasting resources to keep filling beds and not address alternative outpatient treatment programs and enhance their weak efforts in their existing community corrections programs, the time for decisions has come. Privatizing medical and mental health services and programs to save money it is likely that the current set up will be diminished and result in reduced treatments for those that are seriously mentally ill (SMI). Psychotropic medicine is expensive and although there are some generic drugs out there that will reduce the costs, there is less likeliness that any expansion of the present staffing and resources will actually occur during this director's term as his approach to these SMI prisoners has been calculated and limited in addition to placing many of them in the Level V maximum custody units in Florence Arizona. Their current program is called the Behavioral Management Unit and has a total capacity of 10 prisoners selected to follow the program's outline to become better cognizant on how to follow rules and regulations without disrupting the operation of the unit assigned. There is another program down in the Tucson prison but like the past, their progress has been interrupted frequently as prisoners are moved back and forth from Tucson to Florence because of management issues related to their behaviors or individual needs. Thus the stability of this treatment program at the Rincon Unit is not yet rated favorable but rather more ongoing.
Today it is commonly known that criminals are being locked up regardless whether they are SMI or not. Prosecutors and judges, oblivious to community placed outpatient alternatives incarcerate these individuals and are crowding the prison with more and more complexity in how to handle and treat these offenders. Judges, rather than finding them incapable of accepting personal responsibility of their wrongdoings are finding them of legal and substantial capacity to stand trial and sentencing. They are neglecting to take into consideration their disorders or illnesses and sentencing them to prisons. Failing to make sound judicial decisions and fearing the "soft on crime" label by the public, they refuse to take mental illness into consideration when sentencing these as regular criminals [although it was likely there was no criminal intent in their actions] who will serve long terms and be released in a more difficult situation due to not receiving their medication or treatment as required by their individual treatment plans or diagnosis. Arizona citizens and society in general has shown no signs for outpouring sympathy or compassion for these offenders or their families. This is reflective of the fact that when the state hospital was defunded and reduced capacity through budget cuts occurred; more inmates were sent to prison than ever before.
Ironically this is the same pattern that occurred in California as their criminal justice system took similar actions on these SMI offenders as the number of homeless that were mentally ill were arrested and incarcerated as well as those who were untreated and experiencing extreme psychosis while out there in the communities creating another class of people considered to be the "new lepers" of our society. Unfortunately, this stigma follows them into the prison environment and creates extreme hardships for others to live with as their behaviors are not always understood and more often misunderstood. Arizona must realize that this magnitude of SMI walking the streets and committing crimes will soon become epic in proportion and create the same ratio of mentally ill [about 20 %] inside their prisons needing expensive care and housing. Thus this philosophy of "mixing the mad with the bad "will come to a head sooner than expected. Today, to use the words of Dr. E. Fuller Torrey in his book "The Insanity Offense" he writes that once the SMI enter prisons they become 'Human Beings Rotting Away" inside dark and isolated concrete cells with no hope of ever receiving the proper care and attention by those individuals who took an oath to be sensitive and caring towards their individual needs for treatment and proper care. Just like the mass deaths that were inflicted in the recent earthquakes and tornado disasters, their names, their faces and their needs are only remembered by their loved ones and those committed to treat them most ethically while under their care. Unfortunately, the latter class is sparse and few in between in reality and in numbers. Thus it is true today that Arizona has jumped on the bandwagon of criminalizing mental ill people and their disorders ignoring the facts that these people need treatment more than they need a prison cell. In the present day there are hundreds of SMI prisoners that sit and rot daily wasting their lives away as they suffer through every moment of their tormented lives to exist but not be functional enough to exist in less restrictive housing with others around them rather than the dark and cold concrete boxes they are living in. "Lack of insight is so frequently present in schizophrenia (and some other psychosis as well) that it is unreasonable to expect patients to always recognize or accept their need for treatment on a voluntary basis. If we can agree with the premise that the liberty to be psychotic is no freedom at all, then we can begin to examine some of the current plights of the mentally ill patients. (Stephen Rachlin, 1974) this is a major problem with SMI inmates housed inside the Arizona prisons. Many of them are in disagreement that they need help or medication or thirdly, the medication prescribed has side effects that are unpleasant and hard to cope with on a daily basis. The need to conduct mandatory or forced medication inside a prison is rare and only done as a last resort in many cases. Being privy to at least 6 or 7 of these prescribed medication review board sessions, I must admit that by the time these prisoners are seen by this board, they are so far out of touch with reality they have no idea what the session is all about and leave their fate and their treatment at the hands of a few who can legally force injections and other medications to maintain their presence inside these prison walls. On other occasions, there have been situations where these SMI inmates cope so well through their adaptive skills and coaching from other inmates that their disorder is well hidden although documented in their files but not active enough to draw the attention of a provider. This unawareness is fatal for some and problematic to others as they are the silenced patients that cope but are suffering for either being untreated or not taking their medication offering these pills up for bartering purposes to gain access to other amenities such as tobacco, snacks or other store bought goods. After all, survival is the most important part of prison life
The danger for those in denial or refusing treatment is the eventuality that someday this disorder will peak and create a situation that will be translated or interpreted by providers as manipulative in nature just because they managed to function without coming to them for help for a certain amount of time. It has been experienced that this is a wrongful assumption that creates animosity between the patient and the provider as their relationship is based on suspicion rather than mutual agreement that a need for treatment is in order. The other extreme that has been experienced as a correctional administrator is the result of self-medicating and accidently overdose or become ill because of taking the wrong type of pills bought from another mentally ill person and taken in excess to make it better.
Overdoses are often viewed as "suicide attempts" that often result in isolation and placement in a suicide watch pod where they are separated and single bunked with an officer inside the pod watching up to 10 inmates at a time unless the watch is a constant watch and then there is an officer stationed in front of the cell for direct observation purposes and a log is activated to keep notes of all the activities that occur while on this "mental health" generated watch. It is likely the person did not want to commit suicide but based on this mental health order, he or she is to remain on a watch for a minimum of 24 hours before re-evaluated by a provider and contingent arrangements are made based on that interview. Here the decision to remain or to remove this individual is made and as policy requires that once released he returns back to his place of origin that often results in a relocation of the person's property and bed assignment as bed space is sparse and the moment one vacates a bed, another prisoner is assigned into that bed regardless whether the watch is 1 day or 1 month. This total disruption to an SMI is both harmful and counterproductive to the environment as it took weeks to acclimatize the behavior among the other prisoners. In a dormitory setting, this may result in losing contact with your previous friends in the unit you were assigned to and a reassignment to a new unit where others may not be so tolerant of their illness or disorder. The ostracizing of these SMI can trigger two negative responses that include making strange noises and the smearing of their own feces to be moved and to escape what they perceived to be a hostile environment often ending up in a level V single bunk cell for the duration of their sentence or time left to serve. Although somewhat learned behaviors to meet the needs, this manipulation often saves them from a severe beat down or worse.
Once an SMI prisoner has been moved to a temporary detention or holding area, they are reviewed and often recklessly assigned another housing area. Depending on the administrator, it could result an administrative move to a higher custody level thus having the SMI moved off the unit. The reason for such extreme action is based on the callous and insensitive manner staff perceived this act to be and misunderstanding the prisoner's motive. The administrator takes this act as a threat to the institution because it irritated or angered the other prisoners causing a point of no return to be drawn in the sand and leaving few option left as not every unit has the capabilities to address SMI needs and housing. Having already agreed that the failure to treat people caused an increase in homelessness and jail/prison populations, the next concern is the criminalization of the mentally ill has economic consequences in many states including Arizona. State officials are trying to justify the expenditures of state funds and are cutting back funding on medical and mental health care as a savings. This is extraordinarily difficult in Arizona as the state has in the past agreed to prescribed requirements under a lawsuit filed that created a bill of rights for the mentally ill in Maricopa County located in the center of the state Times are getting rough and more Arizona citizens are counting on their political leaders and the governor to make sound decisions in the matter of cutting back funding designed to protect citizens from harm and wellness.
Last May, Governor Brewer announced that because of the dire fiscal crisis inside the state, the state "may try to withdraw from the 28 year old Arnold vs. Sarn class-action lawsuit that was filed to provide care for people with serious mental illnesses (SMI) in Maricopa County. Ironically the state has never met the terms of the order but wants to withdraw from the treatment requirement all together by their desire to withdraw entirely saving the state more money. Under the budget proposal presented by Gov. Jan Brewer (R) last week, the state would effectively cut health care for roughly 280,000 low-income Arizonans currently under the state's Medicaid program, including an estimated 5,200 who are mentally disabled. Brewer is preserving $10.3 million for those affected to purchase generic prescription drugs, but they would lose all other care. In the looming debate over mental health, Brewer is a central figure. Throughout her career, she has advocated for behavioral health services; her adult son, Ron, has long suffered from a mental illness and has been living in a state institution. He was diagnosed with schizophrenia and was found not guilty by reason of insanity in a sexual assault and kidnapping case 20 years ago.
Arizona, the place where the "Perfect Storm" is now forming with the recent mass shooting of congresswoman Gabby Giffords and others by shooter Jared Loughner in Tucson last January 8th. The Washington Post wrote: "Charles Arnold, a longtime mental-health advocate here, said Arizona's laws are strong enough to identify people like Loughner before they descend into violence. “The vision of the statutes has been undermined by the philosophy of government," he said. "Our problems are not our statutes. It's this very conservative philosophy here that decides that the best government is no government." The National Alliance on Mental Illness lists Arizona as among the top 10 states most hurt by mental-health budget cuts. During previous state budget shortfalls, Brewer has made relatively smaller cuts to mental and behavioral health programs compared with other programs, said her spokesman, Paul Senseman. "She is known and well regarded as a proponent of these types of services and as a protector of this type of funding," Senseman said. Brewer said in a letter to lawmakers that Medicaid spending was "unsustainable," having increased by nearly 65 percent over the past four years. "If we are to regain control of state spending, we must reform Medicaid," she wrote. In a legislative informational post the lawsuit is discussed in detail as the mission was to protect Arizona persons who are seriously mentally ill and in need of care and treatment. Located at: http://www.azleg.gov/briefs/Senate/ARNOLD%20V.%20SARN.pdf the state goes on to fully explain the birth of this lawsuit in detail which states in part "In 1981, a class action suit was filed alleging that the state, through the Department of Health Services (DHS), and Maricopa County did not fund a comprehensive mental health system as required by state statute. The lawsuit, Arnold v. Sarn, sought to enforce the community mental health residential treatment system (A.R.S. 'Æ'''§'Æ'''§ 36-550 through 36-550.08) on behalf of persons with a serious mental illness in Maricopa County. In 1986, the trial court entered judgment holding that the state had violated its statutory duty, which the Supreme Court affirmed in 1989. A plan to implement the court's findings was developed in 1991 and, in 1996; the parties negotiated criteria to exit the lawsuit. The exit stipulation is a method for determining when the defendants have established a system sufficient to satisfy the requirements of the state statutes as interpreted by the Arizona courts. The exit stipulation defines class members and priority class members; sets restrictions and requirements at the Arizona State Hospital; and establishes restrictions on the use of supervisory care homes, quality management requirements, budget requests, service planning, case management, and vocational/rehabilitation and housing services requirements. In 1998, in order to avoid further litigation regarding DHS's compliance with the exit stipulation, the parties negotiated a supplemental agreement prioritizing the needed services. The supplemental agreement required DHS to evaluate the needs within the mental health system and develop strategic plans to increase provider capacity in vocational, housing and substance abuse services. The supplemental agreement also required the Office of the Monitor to conduct independent reviews to determine compliance with the lawsuit.
In July 1999, an independent report was released estimating the total annual cost of complying with the lawsuit in Maricopa County at $240 million, and a total of $528 million in federal, state and county monies to support a statewide system. However, the final cost of Arnold v. Sarn is unknown. The cost to provide services rises annually. Funding for services has increased since the lawsuit as the state continues to identify needs for serving adults with serious mental illness. For instance, both Title XIX (Medicaid) and state only non-Title XIX monies have been utilized to meet obligations." DHS developed a corrective action plan to address these findings, which included proactive and concurrent oversight of the treatment of seriously mentally ill individuals by Value Options. In addition, the parties negotiated a final exit stipulation for the lawsuit that included estimated completion dates for numerous requirements that range from 2004 to 2008. The stipulation also included requirements for DHS to request specified funding increases for services to individuals with serious mental illness in Maricopa County. A Maricopa County Superior Court judge agreed to the completion dates identified in the plan. The Office of the Monitor continues to track DHS's compliance with the stipulation and the parties may enter into additional stipulations as progress toward the exit criteria continues. Beginning in September 2007, Magellan Health Services (Magellan) assumed contractual responsibility for behavioral health services in Maricopa County and, accordingly, responsibility for meeting the exit criteria for Arnold v. Sarn. Thus the government, experiencing serious budgetary issues has lost insight of their past and their agreements to provide services and treatment to the SMI of Maricopa County, the largest incarcerating county in the state.
Dr. Torrey states in his book that 'a massive increase in the number of mentally ill persons in jails and prison is another consequence of emptying public psychiatric hospitals and then passing laws that prevent the treatment of individuals after their release. He further writes that "jails and prisons were not created to be psychiatric hospitals and their staff were not selected or trained to be psychiatric nurses some of the problems precipitated by the rise in seriously mentally ill inmates including the following: Suicides, Abuse and beatings, rape and murder".
Lowering Resistance to Change
America's jails and prisons are overcrowded with mentally ill persons in dire need of treatment and consistent supervision of their behaviors and medication. The recidivism rate for those convicted and released as being seriously mentally ill (SMI) have a greater chance of going back to prison for the lack of a better explanation, "with no provisions for post release treatment" plans and accessibility. Psychiatrist Richard Lamb noted "Simply to release these seriously mentally ill persons who have, in addition, high proved potential for antisocial and violent acts does a tremendous disservice to these patients as well as to society.... These mentally ill persons cry out for treatment and social controls and their cries should not go unheard."
Just recently, the Arizona community corrections have stepped up their efforts to manage SMI prisoners released into the community and assign them SMI trained probation-parole officers to better understand them and take into those considerations needed to allow them the rational adjustment that have to be made in order to meet parole or probation conditions as well as following their rules and medication requirements. Released with a blister pack for 30 days and their SSI card in hand, they are given a better opportunity to stay out of prison than ever before however, they are still falling short in their delivery of service as they are overwhelmed with caseloads and lacking sufficient staff to maintain good supervision ratios in the process. The problem is these SMI prisoners are the ones doing shorter sentences and able to avoid being caught into the trap of those at higher custody levels and who are left untreated until it is time for their release back into society. Regardless of how intense their supervision was, the final product at the end of the door consists of a blister pack and their SSI card at the least. Many are eligible or were drawing disability checks before being incarcerated and the agency maintains their contact with the SSI administration ensuring their checks are deposited into their inmate bank account every month. The system is far from perfect but in the majority of the time, it appears to be working.
Herein we take a direction that finds no popular support within a correctional setting as the protection of those afflicted with these illness and disorders is frowned upon by many in uniform although it is the right thing to do. We already know that the Corrections Dept. does not do an adequate job in training staff on how to deal with mental illness. We know that uneducated correctional staff (uneducated in what is mental illness), tend to taunt mentally ill inmates, deliberately provoke them, physically mistreat them, use force against them or turn a blind eye to abuses against them by others. Most correctional staff and the public think of mental illness as clinical disorders which require clinical attention, i.e. your typical Schizophrenic, Axis I. For this reason we are now working in faux mental institutions with no resources to make it better.
Hence, there is the stigma of the mentally ill and the consequences of being identified as such a person with a disorder or illness. Dr. Torrey wrote it so well when he said "imagine if we treated individuals with severe mental retardations or Alzheimer's disease the same way we treat individuals with severe psychiatric disorders". We already know that SMI prisoners suffer needlessly inside jails and prisons just because they have difficulties following or understanding the written and verbal rules and regulations of the facility or institutions. One must ask an honest question and wonder what kind of person or societal group would allow these SMI persons to be victimized and mistreated whether in prison, in the communities or homeless and wandering the neighborhoods. Speaking from a correctional point of view, it is the stigma of mental illness that harms the person the most. The reasons are as stated earlier related to training and communication skills but the main reason is the perception that all SMI persons are violent and dangerous. Correctional officers catch wind of the violent offenders as soon as they hit the gate and arrive at the units. There is an unwritten code among officers that cop killers are among that group that are mistreated upon arrival. Being an SMI prisoner makes no difference as you can see already from the start, this unusual aggressive conduct by staff is confusing to the SMI as he or she does not know why they are being mistreated upon arrival when they have in fact, not done anything wrong [yet]. This same principle or code applies to those who commit physical assaults upon correctional staff as this is usually an automatic trip to the maximum custody units where the word has gotten around that this inmate {whether alleged or proven] s violent and must be treated with extra precautions that include stricter rules to go by from day one. It is this kind of mythical thinking or associated stigmatic conduct by the untrained officers or unaware citizens results in giving these persons poor opportunities for gainful employment, housing and social relations whether inside a prison or out on the free world. Persons with a sufficient amount of training will recognize an important fact that avoids putting all SMI persons into one group and that one group being the violent group. Thus the actions of a few stigmatize all of them in the real world. Researchers in Dr. Torrey's book "The Insanity Offense" state that "perceptions that such people are dangerous increased nearly 2 '½ since 1950 to a point that in 1996, nearly 1/3 of respondents spontaneously volunteered the idea that psychotic persons may be violent." It has been speculated that the increase in mentally ill persons committing homicides spurred that type of rationale through highly publicized efforts feeding the stigmatizing effect.
Needless to say, people of America and Arizona need to pay more attention to this matter related to the mentally ill as it impact them at home, at work and as taxpayers. The challenge is the prevention of the problem from becoming worse and grows within the criminal justice system that is already overburdened with these SMI prisoners. Proliferating their victimization needs to stop and acceptance of their needs and right to treatment needs to take a turn for the better so that they are not stigmatized by society for accepting this help to be better citizens with better chances of coping while taking their medication and following their treatment plans whether at home with a family member or on their own. There is no doubt a lot of resistance to such a change as the first objection that comes to mind is the high cost of creating such opportunities for the SMI and paying with taxpayer's funds to keep these programs going. Of course, given a chance to do some comparative pricing the taxpayers would benefit much more if these SMI aren't incarcerated as a first option and change their way of thinking and opting to rather seek alternative outpatient resources in the communities. Dr. Torrey's estimates on these costs are broke down to reflect cost factors using studies of others to compute costs of the SMI including schizophrenia, panic disorders, obsessive-compulsive disorders, and depressions. Dr. Torrey's figures reflect a cost of $ 19,900 dollars per year to treat these illnesses. Those experiencing less than SMI disorders cost about $ 1,700 dollars per year to maintain.
On the other side of the coin, if these SMI persons were to be incarcerated the costs for maintaining their treatment per year while in prison would cost the taxpayers a hefty price compared to being on the outside. Using Broward County in Florida as a price factor, it costs the county jail $125.00 a day for the SMI compared to $ 78.00 a day for those without severe mental illnesses. These costs include the extra staffing needed and the cost of medication for those that are SMI identified. Thus the price taxpayers pay to get the SMI off the streets and into the prisons is a hefty sum compared to treating them at the outpatient clinics or other approved outlets. Looking at this comparison you can see why the Arizona Department of Corrections is lagging behind on treatment for the SMI as it carries along with it a hefty price tag that would severely cut into their other budget concerns as the legislature does not increase their corrections budget for additional expenditures for mental health services beyond those already in place. It would be logical that prison costs would be higher but reflective in parity as demonstrated by this county jail. Another element of this cost related to the treatment of the SMI prisoners is the hidden costs of the litigious nature of our society to file a lawsuit for anything and everything as there is a evitable consequence that these lawsuits are often associated with agencies to treat the SMI properly as some end up in wrongful death lawsuits based on suicides or preventable suicides that are happening as we speak. Last but not least is the resistive nature of the profession itself to allowing SMI persons in this outpatient status and would rather see these"dangerous" offenders incarcerated and protect society in a whole. In order to better understand this professional resistance to this matter, there appears to be a split in the professional ranks with the issue of violence and its connection to the mentally ill. Until that matter is satisfactorily resolved this split will be in place dividing the mental health community on its own points of view. Looking at society today, the temptation to be "politically correct" has been demonstrated to be the most current position on this matter. Thus as a neutral observer related to this matter it would appear that before the concept of alternative sentencing includes some reassurances that minimizes the association of violent behavior and the mentally ill, this is a stalemate impacted by local politics and views on this matter. Thereby, it is reasonable to conclude that in order to change professional practices and laws to minimize violence associated with these SMI we have to educate the professionals first.
Arizona has begun a process with their behavioral management unit to target a specific group that needs to be identified and managed first in order to maximize their resources. Secondary, they need to do the same with the SMI and identify those "frequent flyers" who are the highest risks and problematic with their treatment plans and medication compliance. As a correctional official I have cooperated with professional providers to target a group for SMI treatment and used the same criteria listed by Dr. Torrey in his book. Together as a treatment team member, we looked at SMI inmates with: past history of violence, substance abuse, medications noncompliance, antisocial personality disorders, paranoid symptoms, and neurological impairments. Those SMI patients would be put in a batch report and prioritized and listed according to severity, risk of suicides, time remaining to serve and other criteria that would put those in dire need first and those less psychotic as pending space availability with local treatment in a non-program area. It is likely because of lack of funding this project to gather these SMI persons inside our prisons will be delayed until proper funding can be located to conduct such treatment. It is feared that this may come too late as there are many SMI hidden in the general population of Arizona prisons numbering 40,000 and coming. Too many have already succumbed or submitted to the hopelessness of their legalized isolation and deprivation for being left alone and untreated for so many years already. It is highly doubtful that unless there is divine intervention by God to change the way these prisons are run or a class action lawsuit filed by families of these SMI inmates comes to an awareness forcing legally bound changes, these SMI prisoners will be lost in the abyss of our prisons and forgotten like all the others that have passed this way and rotten away or died trying to survive. Perhaps if it is not too late, there could be some hope if the conscious awareness of American freedoms and liberty principles related to our constitution are finally upheld, we will see a change in the incarceration of the SMI and the growth of outpatient clinics as alternatives to mass incarceration in America.
Sources:
Dr. E. Fuller Torrey "The Insanity Offense" - A must read to understand the SMI population
http://www.treatmentadvocacycenter.org/about-us/our-blog/83-arizona/1823-can-a-state-just-withdraw-from-a-lawsuit-
http://www.washingtonpost.com/wp-dyn/content/article/2011/01/20/AR2011012006266.html
http://www.azleg.gov/briefs/Senate/ARNOLD%20V.%20SARN.pdf
http://www.treatmentadvocacycenter.org/about-us/our-blog/83-arizona/1823-can-a-state-just-withdraw-from-a-lawsuit-
http://www.washingtonpost.com/wp-dyn/content/article/2011/01/20/AR2011012006266.html
http://www.azleg.gov/briefs/Senate/ARNOLD%20V.%20SARN.pdf
http://www.phoenixnewtimes.com/2011-09-01/news/why-did-the-arizona-department-of-corrections-put-a-mentally-ill-man-in-a-cell-with-a-convicted-killer/
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