Medical Systems & Mental Health

Dan Marshall:

So, it’s bad. In fact, the depositions I was doing earlier today was in a case where a prisoner literally starved to death in the Florida Department of Corrections. One of the groups we are suing is Corizon, the private company that was providing medical services at the time. It’s inconceivable to me how medical staff can sit there and watch—obviously, starvation is not a quick thing; it happened over many months—and they just sat there and watched it happen. The fact that something like that can happen in the United States is just nuts to me. Again, it’s all about saving money because a lot of places have contracted out medical services to these private companies. These private companies make more money by providing less medical treatment, and the prisoners lose out.

Dan Marshall:

They’re bad. The private companies are of a relatively recent vintage. Before then, the jails themselves had their own doctors and nurses and were providing care, but it still wasn’t great. The whole underlying problem is that providing medical treatment costs money, and no one wants to provide the money. It doesn’t really matter if it’s a private company or if it’s the jail system itself. If you’re not really providing the money for it, the treatment is going to be bad.

Dan Marshall:

If I knew the answer to that! Ultimately, the answer is probably a combination of things. Number one is trying to convince the legislature to provide more money for it and convince them that it’s actually a priority. They do stupid things with it sometimes, like the saying, An ounce of prevention is worth a pound of cure. There’s so little prevention going on, that they could save a lot of money by doing prevention and not having to spend way more once the problem arises. If there was a way to convince the legislature to fork over a little bit more money, that’d be nice, but I’m not holding my breath on that. It is kind of useful to reduce sentences because obviously older prisoners have more medical problems, so if fewer people in their 60’s are incarcerated, then that helps. Unfortunately, that’s helpful, but that’s not going to solve the problem by itself. Ultimately, it takes a smaller jail system and more funding, and of course, no one wants to give more funding to medical treatment to prisoners.

Dan Marshall:

For the most part, it’s coming from the government. For people who are incarcerated, they do try to charge them. Even in jail, for the guys who are making around 10 cents an hour in their jail job, if they have money, they will charge them co-pays to see the doctor in jail. Very few prisoners have the money to really pay for medical treatment. So for the most part, it’s coming from the government’s budget.

Dan Marshall:

We get hundreds of prisoner letters all the time. A lot of them are about medical things, so I hear stories about that all the time. Unfortunately, we have very limited resources, so we’re not able to take anywhere near where we would like to to change that kind of thing. It varies a lot place to place, too. Some places are horror stories like that, and other places are bad, but not quite that bad. That’s another thing that comes along with jails being their own unit. You get the bad ones and the relatively not-so-bad ones, even though none of them are really great.

Dan Marshall:

A lot. We see a lot of cases where a prisoner will have something that is a serious medical thing. They go see the doctor, and they are given Tylenol. This happens over and over again, all over the place. It’s easy and cheap to give a prisoner Tylenol, as opposed to the actual medical treatment they need. So you’ll see guys who have cancer, and they don’t know they have cancer, but they’re exhibiting the symptoms of cancer, and they go see the doctor, and they get Tylenol or some other pain medication. There’s a lot of “put a Band-Aid” over some very serious problems like that.

Dan Marshall:

It’s complicated, but basically, they get sued a fair amount. However, the lawsuits don’t add up. To them, it’s a cost of doing business. The main thing is, even having to share out million dollar verdicts, in some of these cases, it’s still way less than the money they’re making on the contracts. So, it’s almost like overhead to them. That’s the biggest thing. Most of these cases usually end up settling; they don’t usually go to trial. Most of them settle for some amount of money or other. The big, big numbers usually come at trial. That’s a very small percentage of the cases. If Corizon mistreats somebody or doesn’t treat somebody and they die, and they only have to pay $20,000 or $50,000 dollars out of the multi-million dollar contracts, that’s not necessarily a huge disincentive to them. The big, big numbers make the headlines, but that’s not the routine outcome.

Dan Marshall:

This varies a lot place to place. As part of this Eighth Amendment right to medical treatment comes mental health treatment. Prisoners have the right to adequate mental health treatment. But just like everywhere else, like, some places are better than others with medical treatment, some places are better than others with mental health as well. It’s really unfortunate because the way the system is set up, many states have cut way, way back on resources for people who have mental health issues. So, jails and prisons are where these people end up by default because there's nowhere else. We don’t have the facilities to treat those people anymore. So, they end up in prison and jail. It’s back to the lack of resources there too. A jail is not the right place to treat someone with a mental illness, but that’s where they end up and the way we have the system set up.

Rachel Gross:

Now, related to healthcare, one of the things that has surprised me pleasantly is that I know of guys on death row who have actually had cancer treatment. They’ve had surgery if they needed to have one kind or another. I wouldn’t have been sure that the prison would bother with that, but they have. I don’t know that that happened in every place. What’s happening right now at San Quentin State Prison is just horrific, in terms of the pandemic. Over one-fourth of the prisoners there, they think, have COVID-19, and several of them have died. I’ve seen that they haven’t been giving them adequate healthcare nor taking proper precautions at all.

Rachel Gross:

Well, one of the things I know, like in Florida, one of the guys used to write that he was having some health problems. He had to pay $5 to see a doctor or a nurse, and I think it might have been $5 to just see a nurse, but a lot of times, when he would go see a nurse, he would just be given Tylenol or something. So, he didn’t really feel like he was being cared for properly. He didn’t have any money, so it’s the thought of having to give up $5 that he didn’t even have and know that he wouldn’t get very good treatment. I think this is a really typical story for a lot of places. So then, this is at the same facility where I’ve heard some of the guys talk about having some kind of surgery, so I don’t have an understanding of how all that happens. So that is part of what I’ve heard, and that would be a pretty common thing—I have to pay, and the healthcare’s not going to be that good anyway. They feel really helpless about it.

There’s a man on death row in Florida, who has been diagnosed with schizophrenia; I’m sure there are a lot, but I’m thinking of one who writes to me a lot. I know that sometimes he’s been placed in the prison mental hospital. I can tell from his letters when he’s being treated or on some sort of medication and when he’s not. Sometimes we’ll get letters from him that are really coherent, and they all make sense. Other times, they’re not at all. Again, I have no idea how those decisions get made and who makes them, or how they decide when he should have treatment. Or sometimes he’s refusing treatment? I really don’t know.

Several years ago, there was a mother of a man who was on death row in Tennessee who started an organization, advocating for better health care for people in prison because her son had been so poorly treated. I don’t remember the details now, and the organization doesn’t exist anymore—it kind of just died out. That’s another story that I’m aware of, though, that she just felt that her son wasn’t getting the treatment that he needed.

Rachel Gross:

Well, depression, I think is one, for sure. That’s something we’re aware of partly because, well—somebody is assigned a penpal, and they’re writing to someone who is in prison, and then we hear that their prisoner has stopped writing. Months later, that person will hear from the prisoner again or will hear from the prisoner that they were just really depressed for a while and didn’t feel like writing. And I think that sometimes depression will lead to suicide, but I can’t tell you for sure that I know that for a fact. It just wouldn’t surprise me at all. So, depression, clearly, is a common one.

There’s also a lot of drug abuse that happens, so I think addiction is a problem. My husband got started on visiting a fellow on death row here in Indiana. I started visiting also, and he actually was eventually released from prison, but there’s two things about him. One was that I still remember the first time I visited him. I’m a very naive person, but in retrospect, partly because I know more and partly because he admitted it, he was actually using drugs for the first several years that he was in prison. I think part of it might have been abusing drugs that he was able to obtain legally, but probably a lot of it was also drugs he was getting illegally. In retrospect, I’m like, “Oh yeah! He just seemed kind of spacey,” but it was the first time I had ever met him. So, at the time, I didn’t really realize it. So that’s one thing. I’m aware that there is a lot of drug abuse that happens. The other thing about him is that he had a lot of back problems. He got some treatment while he was in prison, but probably not adequate. Right now, he just turned 60, and he’s basically been bed-ridden ever since he got out of prison, which it’s been several years now, because of this debilitating back pain. I’m guessing if it had been treated properly when he was in prison, he wouldn’t be having that. He doesn't have any money now. I mean he’s gone to a chiropractor and different doctors of some sort, but he can’t afford to have—or maybe he just doesn't have the resources to get—good quality care that maybe could fix it. I’m not even sure it’s fixable at this point.

Rachel Gross:

Something I wanted to throw in here somewhere is that a lot of prisons in the last year have shifted from serving three meals a day to two meals a day. Then, they expect the prisoners to supplement their own meals with food that they buy from the Commissary, which is usually way overpriced. That’s something that certainly contributes to poor health. I’ve heard from some guys that they choose to be on a kosher diet or a halal diet because they feel like they get better food that way than if they’re on a general one. I have a friend who has been to federal prison a few times, and she would always say she’s vegetarian. I think she prefers being vegetarian; it wasn’t like she was making it up. So I was just shocked when I found out that some prisons were only delivering two meals a day, and then they were expected to buy the rest.

Rachel Gross:

Yeah, so I’ll have to see what’s in my memory. There definitely has been. I think that there are rarely any fresh fruits and vegetables. I think there's a lot of white bread, bologna, peanut butter, beans, sardines—is sticking in my head for some reason, and I don’t know if that’s something on the kosher diet that they get. A lot of places, I think, serve breakfast at around 4 o’clock in the morning. Then, I forget—if it is 3 meals a day, then it’s like supper is at 4 o’clock in the afternoon. They’re trying to do it so that they can minimize the shifts that they are delivering it on. So that’s another thing, that the timing of the meals seems a little bit off, although I suppose that people can adapt if everything’s earlier in the day. It just seems odd to have it be that way.

Then, you can go online and find prison cookbooks. Most of those talk about food that usually the guys buy at Commissary. Ramen noodles are a really big thing—that’s a huge thing. They can get ramen noodles, and they can usually buy coffee. There are a lot of different things that they can buy, but they’re really creative with what they can do with it and with what they can purchase through the Commissary. When we would go visit people up here in Indiana, a huge, huge deal was that in the visitor rooms, there were vending machines. That was a big highlight of the visit, just being able to get food from the vending machine, which is just junk food. They could pick what they wanted, though, out of the choices that were available. So, that was always a big excitement.

Jonathan Simon:

Well I think that we don’t have enough mental health capacity period. To a large degree, the reason that I think the current mental health system doesn’t currently accord with human dignity is that it ignores people because it doesn’t have the capacity to address them. So it cycles them back out very rapidly in a way that doesn’t respect their actual treatment needs. The very few public mental hospitals that we have are very stressed and overcrowded and generally driven by legal system needs and not medical needs. Most of the people in many of our public mental health systems are there on forensic psychiatric statuses basically because they’ve been arrested for a crime but determined to be mentally incapable of assisting in their own defense. In that case, they can be committed to a mental hospital, but they get very limited kinds of treatment and it’s often very dehumanizing. Again, the bigger problem is that we don’t have enough resources overall. We have a mental health crisis in society. If we addressed it, would we have as much crime? Would the things that caused people to eventually act in ways that get defined as crimes be as prevalent? I don’t think so.

Jonathan Simon:

Well, I wrote my book in 2011 about the famous Brown v. Plata case, which for those of you in your health professions, is a key case. It said that California prisons were unconstitutional because they couldn’t provide adequate medical and mental health care to prisoners. They were so overcrowded that even the best efforts of the court couldn’t change that without actually dramatically reducing the population. We are now in the system that they dramatically reduced, but we’re still way too overcrowded. We still have way too many people who are suffering untreated medical and mental health problems. Now, COVID is closing in on many of them and killing many of them.

When I wrote my book, I thought… Well, once we understand the nature of chronic illness—that it is the major health care threat of wealthier, older societies like ours, and that the only way to care for chronic illness is to have long-term, individualized care for people because you can’t just inject them with something or operate on them to make the disease go away. Chronic illness is something that, by definition, you have to struggle with, you need to live with. You need systems—and once we understand the nature of prisons being inherently overcrowded—because of our deep insecurities and our mythical fears of crime, we have overcrowded them since we invented them in the early 19th century—we can understand that prison is essentially a death trap for chronic illness. If you don’t actually die there because you’re released before you die, your chronic illness is going to get irreversibly and demonstrably worse in ways that will cause you to suffer, cause your community to suffer—in terms of the health care cost that will ultimately have to go into what may be the futile last months of your care at the end of a chronic illness. Remember, our crazy healthcare system means that even if you don’t have healthcare, you can go into the emergency room at the end of your life and get hundreds of thousands, if not millions, of dollars spent just to save you from a chronic illness that we ignored for a long time.

I thought that was enough! That we would look at prisons after Plata and go, “We can’t keep taking some of the most marginalized people in our population who we know have the greatest health vulnerabilities, and put them in a place where those vulnerabilities get worse, and in a place where it’s the most expensive to treat them.” It’s impossible sometimes to treat them. Unfortunately, it wasn’t enough. A decade went by in which our politicians, I think, dithered with modest reforms.

Now, COVID is here. Now, it’s clear that we can’t operate prisons that don’t allow for social distancing. We don’t know if this will ever go away or if something will come like it. It will simply be irresponsible for any state to operate a prison system at anything above about 60% of designed capacity, in my view. I’d love to hear a more medically informed analysis of that. You’d have to go to a country like Japan to find a prison population density that low, or Norway perhaps, where I imagine it’s possible.

Jonathan Simon:

Brown v. Plata was a 2011 decision of the US Supreme Court, which ordered California to find some way to reduce its prison population by about 40,000 people, which, at that time, was about 20-25% of its total prison population. This was in order to achieve a level of overcrowding that would supposedly allow some progress toward the underlying mental health and medical care failures, which had already been the subject of federal court decisions that the prison was unconstitutional for over a decade. So, this was actually a very dramatic moment, which is why I wrote a book about it.

The court described California’s prison system as having “no place in a civilized society.” For lawyers, this is a rude thing to say about other state officials—that they're barbarians, which is kind of a racist term from the Roman era, but you get the point. So, it was a very important decision. The state chose to deal with it primarily by diverting people convicted of lower-level felonies from prison; this is what we call California’s correctional realignment. It succeeded along with some voter-led initiatives that further reduced some felonies to misdemeanors, Prop 47, six years ago or more. As a result, we actually are more now under the court’s limit, which was 137% of designed capacity.

Jonathan Simon:

So, Brown v. Plata was a mega-case that was actually a case that formed out of Coleman v. Wilson, which is a case about mental health in prisons. Plata v. Davis is about physical health, medical care, other than mental health care. In both cases, the claim was that California prisons were so inadequately designed and staffed in terms of mental health or medical care, that they left imprisoned people at a real risk of suffering tortuous-like conditions, if they were to befall a medical condition or mental health condition that went untreated.

In a nutshell, a lot of people find it confusing that people in prison are the only people in our society that actually have a constitutional right to medical and mental health care, but the basic idea is that if we isolate you from your own ability to protect yourself or from your family’s ability to care for you, and then we allow you to suffer untreated, that’s no different than allowing someone to just torture you as a punishment. There’s one thing that most judges agree on about the Eighth Amendment, which forbids cruel and unusual punishment, that torture—any direct imposition of physical or mental suffering—would constitute a violation of the Eighth Amendment. And so, when we know we’re going to fail to deliver adequate medical and mental health care, that has been treated as the equivalent of deliberately causing the suffering.

Jonathan Simon:

Terrible. This is documentable, and historians will ultimately write about California’s mass imprisonment in the same extremely condemnatory terms as they write about mental hospitals in the 1950’s when they were considered a scandal or the sterilization of tens of thousands of women who were considered unfit from a eugenic point of view, and California was the leader in that. Also, interning the Japanese; I don’t want to leave that out. We’ve got this long history as a state in mass human rights failures or crimes, and I do think that mass imprisonment in California will be reckoned with as among the most serious, and it’s not over. Despite the fact that we have the most progressive legislature and governor in California history, we are still practicing mass imprisonment in every meaningful definition. That includes failing to deliver mental health care and medical care on a grand scale.

There are still people dying. I can’t give you the numbers, but there is a medical receiver, who documents the supposed progress of the system toward complying with these underlying court orders. They do document deaths and failures. There is a process by which every prison in the system is supposed to be approved by this receiver as medically sound to go forward on its own without federal court oversight. To my knowledge, there’s not more than a handful of prisons in the state, if any, that have qualified for that.

Jonathan Simon:

It’s kind of a point that criminologists have been very influenced by medicine. We’ve always known that. Criminology in the modern scientific sense essentially was born out of medicine. It’s not something that medicine should be particularly proud of because it was a particularly defective branch of medicine that tried to identify crime with biological abnormalities in human beings. That has proved to be deeply discredited but [it] influenced things. So, part of that piece was just to point out that there is this persistent relationship between disease and crime as ideas. Even though we can point out the limits of that, it has a historical persistence that is worth being more precise about.

In the piece, I tried to look at crime and how we try to deal with crime and relate it to this sort of changing ways that medicine has been a metaphor or direct influence on our crime policy. So, in order of their development:

The prison itself, what we think of as the penitentiary prison—this bunch of cellular rooms, secured by some kind of wall but also attempting to put people individually into their cells to create the possibility at least of well-ventilated, well-cleaned spaces, which is kind of a modern penitentiary—had developed in about 1780 or so. It began to be built at the beginning of the 19th century. That whole idea was actually anchored in, what was then, the defining idea of disease associated with miasms, which was a term to describe gases created by organic decomposition. Many physicians and others believed that diseases were caused by absorbing decomposing organic matter. And they lived in a world full of it—slaughterhouses, feted conditions around them—so you can’t really blame them. Probably some of those same places are places now where, we would understand, microbes were being transferred and whatnot. They believed it was the gases, so they also thought crime was possibly that kind of disorder. So, they went into the slums, where they believed they saw the most crime—of course they were ignoring most of the rich, as they usually do—and there they saw feted conditions. They put two and two together and said that feted conditions were causing crime, so let’s pull people out of these bad places, put them in austere clean places, make them go through medical-like rituals of self-cleansing and purification, and that will cure crime. So that was the first medical model.

The second medical model I identify is the eugenic one, which I think was the most powerful by far. This is one of our great myths of crime, that we still have in America, that most crime is the product of a degenerate, dangerous minority that has some underlying trait that makes them particularly dangerous. Even if it’s not biological, we now tend to believe it could be socialization, trauma, the neighborhood effect, or sociological forces. We still believe somehow that there are some people who are just much more prone to crime than others and that we can pick them out and treat them, in effect, by excluding them. Or maybe we can treat them in more rehabilitative ways. But if we can identify them, we can exclude them. So that’s the eugenic model, which I think was a huge one.

The third model was really what happened after the eugenics was discredited and no one wanted to admit that they were picking out criminals, so it became a focus on psychological abnormality and how to treat people who were persistent deviants, in the sense of committing crimes, like drug use or auto-theft. That’s sometimes what we call the rehabilitative era in American Corrections, the 1940’s and 50’s and 60’s. This was when we believed very much that we could use prison as a time to subject people to group therapy and other ways of psychologically adjusting them.

The fourth one is really the negative state of the medical model, what I call zombie medicine. This is the idea that people who commit crimes are like zombies, where you can’t change them, and therefore, it’s an extreme version of the eugenic system that just reverts back to total exclusion. I thought that very much fit with California in the late 20th century, when we imprisoned people forever for all types of crimes and also put people in solitary confinement, on the theory that they were Hannibal Lecter-type monsters that would attack other people unless they were locked up all the time.

Finally, maybe we’re in a new era of a new medical model. Or maybe there’s a new medical model possible, which is associated with chronic illness, as the metaphor. That is based on care. You know more about pre-med than I do, but my impression of medicine as it addresses chronic illness is that its greatest tool is care, self-care, and sustainable persistent care. If you have diabetes, HIV, cancer, or other chronic illnesses, you need to take care of yourself. You need people around you to help care for you. You need a medical system that can keep getting you what you need and doesn't depend on just giving you a shot and hoping you disappear forever. I saw that when my mom, who passed away some years ago, needed blood thinners because of an arrhythmia, and Kaiser would email her every day to check on her self-care and would test her blood to find out if she needed to adjust her behavior. It was a kind of caretaking method, I would say. I think a lot of what we call crime today—the kinds of crime that we care about, especially violent and persistent crime—might actually—and here, I’m way out of my league because I don’t usually study the causes and solutions of crime; what I study is mistaken views of punishment—be reduced by an aggressive effort in caring for people. We can call this a chronic medical illness model.

Paul Wright:

Basically, across the board, I’d say that medical care is characterized by inadequacy, neglect, combined with statism and maliciousness. I can’t think of a single prison system in the country that has anything I would approximate as adequate or decent medical care. It all tends to be from bad to worse. A lot of states and jails have privatized their medical care system, which I think adds just another element of problems to an already bad system, which is namely a profit-motive. Cost considerations are bad, but a profit motive is even worse. That’s used as the basis to deny prisoners a lot of basic medical care and such.

Paul Wright:

Yes, I did. I had the good fortune of not getting seriously ill with anything in the 17 years I was in prison. When I first went to prison, like everyone else, I was afraid of the ideas of being assaulted or stabbed or things like that. After being in prison for a while, I realized that realistically, my biggest concern and worry was the possibility of getting sick; that’s the number one killer in prisons. Medical neglect is the number one killer in prisons and jails in America today.

Paul Wright:

For me, one of my observations is that people who are mentally ill when they go to prison, for the most part, only get worse. There’s really nothing about prison that I think is good for people who have mental health issues. They’re not likely to get any better, and a lot likely to get a lot worse. So, I think those are issues there.

I think that part of the problem is that prisons are uniquely poorly situated to provide mental health care to the prisoners that are caught up in it. Incarceration is one of those things that makes mental illness worse. I don't think anyone really seriously disagrees with that. I think a lot of the practices—from solitary confinement to… lots and lots of these practices—are all things that guarantee that the mentally ill get worse. Depending on the statistics and what you’re reading, I think anywhere from 40%-60% of the prison population have serious mental health issues. There’s not even a pretense that people with serious mental illness are undergoing any type of programs or treatment that’s designed to make them better or help them.

Paul Wright:

Well, basically the same stuff we’re hearing is the same stuff we’ve been hearing—medical neglect, lack of medical attention, lack of social distancing, basically the total callous disregard for the lives and safety of prisoners. They’re viewed as an expendable population, and we're just seeing rising death rates as a result. We’re getting [letters] from prisoners that are sick and those that are not getting medical treatment or care. Infected prisoners are being mixed in with other infected prisoners. In fact, just before this call, I was looking at a Harvard Report that said that jail and prison practices are leading the spread of COVID in the community. I’m thinking, well… that’s really stating the obvious, but when Harvard states the obvious, it’s presumed not to be that obvious.

Paul Wright:

Yeah, so basically, we have two staff attorneys and we partner with lawyers and law firms around the country to sue over everything from unconstitutional prison and jail conditions, to First Amendment issues, to communications issues, and we also do wrongful death cases. For example, one of the cases that we’re doing right now involves Vincent Gaines. He was a mentally ill Black prisoner who was starved to death by the Florida Department of Corrections and Corizon. Basically, [our goal is to] increase our capacity and let us increase our ability to do more cases like that.

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Their whole business model is the problem—to get as much taxpayer money as they can and to provide as little service as possible with that money. Basically, it’s an HMO model. The problem is that the prisoners that are impacted by it don’t have a choice in this matter.

David Stephens:

When somebody first comes into a jail, they’re assessed by a mental health professional within 24-48 hours. It’s called a mental health screening. You get information about prior mental health treatment, current mental health symptoms—are they on psychotropic medications? So, when someone comes into the jail, you get that information. I don’t know if you’re aware, but there are accrediting entities for mental health and medical treatment in jails and prisons. So, those standards require that you do an initial screening within the first 24-28 hours, and then you have 14 days to do a comprehensive mental health assessment. That includes things like IQ, brief psychological testing, more in-depth interviews. Then, if somebody goes from jail to prison, when they get to prison, they go to what’s called a reception and diagnostic center. They may spend three months there getting testing or all different kinds of things, which includes mental health testing, more IQ testing. By that point, either in a jail or prison, you have a pretty good sense of their mental health history and their mental health needs.

David Stephens:

Many systems, not all of them, have what’s called a mental health classification system. Most of the time, somebody’s assigned, what’s called, a P-Level, which means a psychiatric level. Usually, 1 is the least intense, so that [would be] somebody with very little mental health history. Those are getting more and more and more rare; when we factor in trauma, psychological trauma, physical abuse, sexual abuse, verbal abuse, and head trauma in the form of concussive injuries or traumatic brain injuries, hardly anybody comes into a jail or prison without a history of one or both of those things. So, very few meet that P1 level of care, which is basically none.

Then, it usually goes to a P5, which is somebody who’s actively and/or acutely psychotic, paranoid, so depressed that they’re on the verge of suicide, may be having an active manic episode and they need to go either to the jail or prison infirmary. Depending on the jail or the prison system, they may have actual mental health treatment units within the jail or prison. So, the 4’s and 5’s typically would go there. A P3 would be more of your traditional outpatient. Even in a jail or prison setting, we talk about outpatient treatment vs. inpatient treatment.

David Stephens:

For the services, they are quite different in that they may have four or six hours a day of mental health groups. They may have educational either groups or training, so that they can get a GED if they don’t have that. They may have a recreational therapist that does leisurely activities with them altogether. But it really is, very often, a therapeutic treatment program that’s implemented on that housing unit. Many of them are run in a way that’s called a therapeutic community—I don’t know if you’re familiar with those. The therapeutic community originated with the Tavistock Clinic in London in the late 1950’s, early 1960’s. They say that community is therapy. They’re encouraged to make note when a fellow resident or fellow participant does well. They have a community meeting every morning, where they note positive behaviors and then problematic behaviors. If you had a problematic behavior, you might have to write an essay for the next day on what you did and how you can do something differently. You may have an exercise that you need to do, but those are called pull-ups and push-ups. They document those. You very often progress through a level system by having progressively more positive behaviors, more mental health stability. Many programs are run that way in jails and prisons.

David Stephens:

If there is a mental health unit, they will be in the mental health unit. They might be in that mental health unit or mental health facility their entire incarceration. They may never become mentally stable enough to function in a general population unit. So, they are almost without question, going to be on psychotropics. There’s a process in jails and prisons that allows somebody to be involuntary medicated. The statute, really it’s more of a Supreme Court case—Washington v. Harper—provides for a prison system to be able to involuntarily medicate somebody. That happens fairly regularly if they’re so psychotic they can’t function.

I don’t know how much you know about mental health programming, but there’s a mental health program called the social learning program that came out of UCLA. That is really a very basic token economy behavior management program for people that are acutely mentally ill. So, some facilities have some version of that social learning program for those P5 people. More commonly, the P5 person is there for a short period of time because they have an episode of acute mental illness and once that’s stabilized through medication or through treatment, then they can go back to a general population unit.

David Stephens:

So you have to have a committee that includes a treating psychiatrist, an independent psychiatrist, and a prison official of some sort. They review the case, they review the mental health needs of that person and it takes a two out of three vote for doing the involuntary medication in order for that to happen.

In my experience, it’s very seldom, if ever, abused. I don’t know if I can say that I’ve seen a case where it’s been abused. There’s a concept called chemical restraint. So, instead of keeping people shackled, it used to be that people would just be put on such significant anti-psychotic medication or any psychotropic medication, that they were essentially non-functional. Accrediting standards don’t allow that; that just doesn’t happen anymore, but if Washington v. Harper was misused, then it could go in that direction. But, it really just doesn’t happen.

David Stephens:

There’s a lot of variability, and this actually even goes back to the chemical restraint. Depending on the size of the system or the jail, depending on the location, depending on the administration, there probably are some cases of chemical restraint. There are certainly cases where people don’t get adequate psychotropic medication. Accrediting standards make that more difficult, and it’s perceived to be a significant benefit to be accredited by either the National Commission on Correctional Health Care or the American Correctional Association. When you have that accreditation, it protects you in the event of a lawsuit. That’s where a lot of systems see benefit, but there are standards for how often somebody sees a psychiatrist—do they get the medications they need? For the most part in most systems, when somebody needs medication, they get it.

My opinion is that sometimes people get medication when they don’t need it, and not in a chemical restraint kind of way. But, inmates often like to be sedated. In California, and this was maybe 20 years ago, but in the California DOC, there was a paper that circulated not only amongst the inmates in a given facility, but it circulated amongst inmates across facilities of what to say to get a medication—how you need to present your symptoms, this is what you need to talk about—so it will sound credible. And so, there’s motivation on the part of some inmates, for sure, to get medication when they don’t need it. Sometimes, that’s not screened adequately enough, so people are put on medications that they don’t truly need.

David Stephens:

I think that's relatively uncommon. Inmates are very happy to sue anybody affiliated or associated with the jail or prison, and so, most practitioners or clinicians are aware of that. So, in a certain way, that’s a good thing. This is because they’re going to be more motivated to make sure they’re providing appropriate care, so when the inevitable lawsuits come, they’re protected and there’s medical justification.

To say it never happens, that would certainly be incorrect. And, there are certain types and specific medications that have high “street value” in the prison or the jail. Narcotics, opiates, painkillers of any kind have pretty high street value. People can sell them really easily to other inmates. A whole class of medication called benzodiazepines, which are anti-anxiety medications, are chemically very similar to alcohol. Those have a very high street value and are seldom prescribed to any inmate in any jail or prison. Some antidepressants (Wellbutrin is one of them), stimulants like Adderall, or Strattera, or Ritalin—those are hardly ever prescribed because they’re stimulants and have a similar effect to cocaine or meth. So, part of the art of prescribing in a jail or a prison is to meet the person’s medical need but to do so in a way that doesn’t provide much opportunity for abuse, sale, or inappropriate use of that medication.

When I was Head of Mental Health in the Colorado Department of Corrections, we discovered a group of four offenders who—all of them were on multiple psychotropic medications and other medications as well. They were pretty good at being able to cheek their medication, or not take it, and save it up. So, every Friday, one of them would get to take everybody’s weekly medication. And then the next Friday, the next guy would get to take everybody’s weekly—the whole amount of meds they got for the whole week, they would save them up. That one person would take the medications for all four of them. They just rotated, so every week, somebody got to take the whole pile. Those kinds of things are not uncommon, and so, managing appropriate medical needs and appropriate medication needs in a way that protects those people, like I said—that’s part of the art and part of the challenge.

David Stephens:

Yeah, I don’t think you can justify that. There’s no excuse for somebody not to get their medical needs taken care of; that’s actually illegal to not appropriately care for their medical needs. So, some systems... If a medication can be ground, they will grind them and put them in applesauce. The applesauce doesn’t have a negative effect on whatever the medication is, and there’s no way to save the medicine that way. Almost every jail or every prison has the nurse and an officer monitor and look inside their mouths after they’ve taken it, but some are good enough that they can still hide it. Some medications are done in injection form for that reason.

By in large, most jails, administrators and systems, prison administrators and systems, and clinicians, are committed to the health of the inmates and are wanting to provide good care. They are definitely exceptions, but I would say that that’s the majority of healthcare providers in jails and prisons.

David Stephens:

Another good question. There can be benefits to them, in that they can provide healthcare at lower cost. And one of the big reasons that jails and prisons started going to private healthcare providers is that it allows the state or the jail to get people off their retirement payrolls, so they would become an employee of the private contractor. Then, the state didn’t have to keep paying retirement benefits. Those people weren’t accruing retirement benefits. So, there was significant cost savings.

The other primary motivation has been that the perception is that that private healthcare provider would assume all the legal risk for the healthcare, but that’s not the reality. When there are lawsuits, both the provider and the jail or the prison get sued. So, everybody’s named in the lawsuit.

I would say there's really a lot of variability, even within a big company like Corizon, in terms of quality of care. I worked for one of the private companies that was part of the two-company merger that became Corizon, called Correctional Medical Services. We actually were able to get one of the states where I worked for them out of a Department of Justice Consent Decree because we demonstrated that the quality of care being provided exceeded that even of hospitals. I would say, the majority of it depends on the quality of two people: the regional manager and the—every jail or prison that has privatized healthcare has what’s called a—Health Services Administrator. Just like the name implies, they’re the ones that are responsible for and coordinate all of the care in that facility. If you have a good Health Services Administrator, then the quality of care, even if it’s from a private company, will be very high. If you don’t have a very good Health Services Administrator, privatized or not, the healthcare in that facility will not be of very good quality. So, it’s not so much whether it’s privatized or not, because I was a state employee when I was the Director of Mental Health with the Colorado Department of Corrections, and there were some Health Services Administrators that honestly were not very good. The health services in those facilities suffered until we replaced that administrator with a different one. So, it’s really, in my opinion, not so much private vs. public or state or county run, it’s the quality of the person at the site and the quality of their supervisor or administrator.

David Stephens:

It depends on their boss. Sometimes, their bosses hardly ever show up. Other times, they come and do audits, and come and talk to inmates, and review documentation. So I would say it’s very dependent on the quality of their supervisor. When I oversaw state departments of correction, I would go to every facility two or three times a year and do audits, talk to staff, talk to inmates, and I would make sure that the quality of care was there. When you do that, quality improves. It also depends on the quality of the clinician; sometimes if it’s not being monitored, there’s enough going on that some of that systemic quality suffers.

David Stephens:

Yes, there’s quality assurance processes, or something that's called continuous quality improvement. Almost every facility and system does or say they do quality assurance or continuous quality improvement. Many times, it’s just collecting and collating data. And that doesn’t really do anything. If you just have a stack of data and report that data, you could be providing horrible care and still be able to report data. So, I think it takes an understanding of what a healthcare system is and what a true continuous quality improvement process is, which is—the short-ish version—identifying the key quality metrics, doing chart reviews, talking to offenders, looking at outcomes, and then taking all of that data; then, when you find a problem in a system, or a problem in an element of care, [it’s] then providing a fix to that, and then checking and monitoring to see if your solution was successful. And if it’s not, then come up with another solution. But, by doing that, that’s the way to make sure quality healthcare is happening consistently.