Is There a Doctor in the House?
Nice piece from the Journal about how the U.S. is dealing with the mentally ill by incarcerating them:
03 May 2006
NO WAY OUT
by Gary Fields, Wall Street Journal
Trapped by Rules, the Mentally Ill Languish in Prison For Such Felons, Parole Is Rare, Recidivism Is Probable; Lack of State Hospitals ‘It Scares the Hell Out of Me’ LEXINGTON, Okla. — Jesse James, a mentally ill prisoner, squinted into the gleaming sunlight toward the six-story guard station towering over Joseph Harp Correctional Center.
“Kojack is up there in that tower right now, listening,” said Mr. James, looking up. “He’s got a rifle too. He wants me dead.”
Kojack isn’t “Kojak” of the famous TV series. Mr. James, 59 years old, who is bipolar, paranoid and schizophrenic, believes that a medical aide called Kojack — spelled with a “c,” he insists — has been stalking him for decades and has implanted a listening device in his prostate.
Nearly 16 years after robbing a convenience store, Mr. James has been rejected for parole three times. Because his sentence tops 100 years, parole is his only path out of prison. At his next hearing in December 2007, he will likely be rejected again. He has a history of prison-rule violations, stemming largely from his illness, and even if his record were clean, there are few qualified institutions to take him in. That alone would be grounds to deny his application.
For years American prisons have been grappling with a surge in the ranks of mentally ill prisoners, caused in part by the shuttering of state-run mental-health facilities a generation ago. The Joseph Harp prison spotlights an often-overlooked aspect of that problem: how it has become self-perpetuating. Once imprisoned, mentally ill inmates are rarely paroled. Some “max out” their sentence, serving at least 85% of their term, and are released. With nowhere to go, and with a recidivism rate higher than that of the general prison population, they often end up back where they started.
Of the mentally ill prisoners housed at Joe Harp, as it is known, none are likely to be paroled, says James Keithley, the prison’s psychologist and clinical coordinator. And then, if a violent inmate completes his sentence and is discharged, “Where do I send him? Mama don’t want him,” Dr. Keithley says. “If they act up here, you know what will happen if they’re released. It scares the hell out of me.”
In recent years, Oklahoma has had a dramatic increase in mentally ill prisoners, in part because it only recently shuttered state-run, mental-health facilities. According to the state, the number of inmates on psychiatric medications more than tripled between 1998 and 2005 to 4,017. The system’s budget for such medication climbed even faster, growing from $154,000 a year to more than $2 million, in part because of the growing number of medications available. By comparison, the overall prison population rose 14% to 23,205.
The National Alliance on Mental Illness estimates there are 300,000 people suffering from mental illness in state and federal prisons, compared with 70,000 in state psychiatric facilities. “Our jails and prisons are our largest mental-health facilities now,” says U.S. Sen. Mike DeWine, a Republican from Ohio who has co-authored bills to create federal programs to improve services for mentally ill inmates. Dr. Keithley, 50, has worked in the prison world since 1983, leaving once for several years to get his Ph.D. His voice is low and soothing, an asset when trying to coax information out of reticent patients. When he receives an emergency call to assess an inmate threatening nurses and doctors at a county hospital an hour away, he rearranges his schedule so he can drive there. “There’s no such thing as a normal day here,” he says.
For male prisoners in the state, Joe Harp is the primary facility providing mental-health care. About 440 of the prison’s 1,100 inmates are on psychiatric medication. Officials here estimate that medication in total costs $30,000 a month. The guard tower, the tallest structure for miles around excepting the water tower of a nearby prison, looks down on scores of inmates standing in line for their evening medication. It takes more than two hours for the last inmate in the line to make his way to the infirmary.
Among those are about 100 inmates from the intermediate unit, one of two mental-health sections at Joe Harp. Prisoners there have been stabilized to some degree and are temporarily allowed out of their unit.
Even these inmates can be unpredictable. Last year, one tried to commit suicide by tying an electrical cord around his neck and jumping from the second tier. Misjudging the distance and length of cord required, he hit the deck of the first floor. As the lone officer on duty ran to the area, the inmate limped back upstairs and jumped again. He misjudged the distance once more and broke his foot. Another time an inmate set a fire in his cell and took the responding officer hostage, periodically slashing him with a blade from a disposable razor.
Prison Within a Prison The most unstable inmates are housed in “Fantasy Island,” the nickname for the acute-care unit. Surrounded by a 12-foot fence, it’s a prison within a prison for 108. The walls, made of unbreakable glass, allow staff to see most of the unit at a glance. There is a four-point restraint table where uncontrollable inmates can be tied down until they’re calm.
With temperatures in the teens one day earlier this year, few inmates ventured outside. Many milled around a recreation area in the zombie-like gait of the heavily medicated. Others, visibly agitated, paced back and forth and stared through the glass.
Those considered too unpredictable and uncontrollable ever to be free are locked behind thick doors with small windows. Screams, moans and chanting are normal. The noise level rises as the sun goes down and before the medication kicks in. One inmate believes he is in a prisoner of war camp in Vietnam while another screams that communists are taking over the facility. He believes two of the officers on the unit are Nikita Khrushchev and Fidel Castro.
A couple of years ago, one resident of the acute-care unit sculpted figurines out of his feces. Another feigned a catatonic episode and nearly bit off the tip of an officer’s nose. Earlier this year, officers had to forcibly remove and shower an inmate who refused to clean himself.
The prisoners in “Fantasy Island,” almost never get paroled. Behind each decision is a hard question: Should the prison records of the mentally ill be treated like those of any other inmate?
“The [parole] board here in Oklahoma is conservative towards these types of issues and unfortunately they judge the mentally ill like they judge the rest of the inmates in the system,” says J.D. Daniels, deputy director of the Oklahoma Pardon and Parole Board. The board looks at the initial crime, the overall institutional record — which, in the case of the mentally ill, is often poor — and whether the inmate has anywhere to go if released.
Many states, responding to budget pressures and changing ideas about how to treat mental disorders, closed their residential mental institutions. Oklahoma was one of the last. It shuttered Western State Hospital in Fort Supply in 1997 and turned over the inpatient psychiatric hospital at Eastern State Hospital in Vinita to the Department of Corrections, a process completed in 2001.
The idea was that community agencies would take over treating and monitoring these patients but in almost all cases they haven’t picked up the slack. The number of long-term, non-criminal psychiatric patients housed in Oklahoma’s state facilities is about 200, a fraction of the 1,300 they held in the 1980s, according to the state’s department of mental health. Griffin Memorial, the remaining state hospital, houses about 162 of those but generally only for two weeks at a time until patients are judged stable enough to be released into the community.
There are private and community facilities where families can pay to have a patient placed, but most are not for the indigent. These organizations are also reluctant to take in people released from prison with mental problems, Dr. Keithley said.
Jesus House, which helps people who are homeless and mentally ill, is one of the few shelters in Oklahoma City that takes in ex-felons. The facility has 70 beds and usually has one or two ex-felons among the residents, says Executive Director Jan Mercer. “I could fill up another couple hundred beds if I had them,” she says.
Corrections and mental-health officials are trying to ease the situation by developing new programs, such as mental-health courts that would steer some mentally ill defendants away from prison.
In his prison photos, Mr. James, the Joe Harp inmate, looks like a 1920s gangster. In person, he is a small, thin man with weather-beaten features. A native of southern Oklahoma, just north of the Texas border, he committed a raft of burglaries in the 1970s and, not yet diagnosed, spent until 1990 in Texas prisons.
On Aug. 16, 1991, he went into a Colbert, Okla., convenience store shortly after 8 p.m. and pulled a knife on the clerk. He fled on foot through the back door with checks and cash from the register. A state trooper caught him a few minutes later less than a mile away trying to hide in some weeds. Drunk, he confessed immediately. He wanted to flee his nemesis — Kojack — he says now.
Since then, Mr. James has spent time at several facilities in the prison system where he often violated behavioral rules. Infractions range from smuggling contraband such as cigarettes to disruptive behavior and disobedience. He also has several attempted escapes on record. Once he tried to hop the 12-foot fence surrounding the acute-care unit. The guard tower has authority to shoot but the officer that day recognized Mr. James and stopped. “He wasn’t trying to escape,” Dr. Keithley explains. “He was trying to get away from Kojack.” Mr. James’s most recent infractions include refusing to provide a urine sample. Last June, he was caught smoking — tea. Smoking of any kind is banned.
All this weighs heavily against his chances of parole. His file reads: “There’s no place for him in the community. The defendant’s mental illness compounds the defendant’s unpredictably causing him to be a great threat to society.”
In conversation, Mr. James is lucid as he talks about living outside on his own. He gets agitated, however, when talking about Kojack. He says he has lost weight because he can’t sleep. Kojack has “been bugging the hell out of me. He’s taken my life from me.”
Warden Mike Addison says Mr. James would have to be paroled to a mental-health unit, and since there aren’t any government-run places like that available, “he’ll stay here with us. He’ll be with us the rest of his life.”
Michael Bruton is a mentally ill prisoner who has been paroled a few times before winding up back in jail again. His crimes have been minor — usually involving worthless or stolen checks totaling no more than $800 — and his behavior in prison often exemplary. In the past, he lived with relatives or in state mental institutions.
The fifth of seven children, Mr. Bruton left school without graduating in 1972 and enlisted in the Army. There, he had a nervous breakdown, according to Mr. Bruton and his prison records.
As he was being discharged, military doctors suggested he take Thorazine and Cogentin, two drugs that help control schizophrenia and the tremors that come on when he gets nervous. It was the first time any medication had been suggested for him. For years after, he resisted the idea. “I used to be ashamed to take medication because they teased you,” he says, referring to people in general. “They’d say you’re doing the Thorazine shuffle.”
Instead, Mr. Bruton turned to alcohol and drugs. His first crime came in April 1976. Then 20, he was living in El Reno, Okla., when he wrote a $20 check to a crafts store in town even though he didn’t have a bank account. He wrote another check for $40 to a grocery store and a third for $21.50 to another business.
Over the years he would go back to jail or prison for infractions from setting his cell on fire to stealing $15 worth of gas from an El Reno Wag-A-Bag grocery store. He stole a Wizard sewing machine from a family member.
With his spotless, wrinkle-free uniform, neatly trimmed goatee and amiable manner, Mr. Bruton is well liked here. He greets people as an old friend and shakes hands vigorously.
Mr. Bruton’s smile vanishes, though, when he talks about his imaginary gunfights. On many mornings, including that day, after Mr. Bruton makes his bed and heads to his job picking up trash in the yard, he imagines he is a gunfighter, say prison officials. With knees bent and hands hovering over a make-believe holster on his hips, Mr. Bruton stares at his adversary, usually one of the guards. Then, as prison officials describe it, he laughs hysterically before sobbing uncontrollably.
Asked about the incidents, the 6-foot-4 inmate, with braids dangling from his scalp, stares menacingly before blurting out: “What are you talking about? I don’t do that…I’m not Quick Draw McGraw.”
Mr. Bruton, 50, has been in jail since 2000 on a 10-year term for using a stolen credit card. He is scheduled for a parole hearing in May 2007 but he likely won’t get out because of his lengthy, albeit non-violent, record as well as his mental-health status. Even if he crosses those two hurdles, he doesn’t have any place to go. His mother, with whom he used to live, suffers from schizophrenia and is in a nursing home.
Dr. Keithley says he would rather Mr. Bruton be paroled and put on supervision than be allowed to finish his sentence and simply dissolve into the outside population. “The parole board doesn’t necessarily see it that way,” the doctor says. “He deserves to have a better life than being crazy.”
Maurice Smith is one of the prisoners who most worries Dr. Keithley. Mr. Smith, who is schizophrenic, has been at Joe Harp on a drug-possession charge since June 2004 and has been in and out of prison since 1989. At the age of 16, he was convicted in an adult court for dropping a rock on a passing car from a train trestle. His other crimes included car burglaries to fund a drug habit.
Mr. Smith has been eligible for parole but was passed over. In September, though, he will be released after completing his sentence.
His record doesn’t suggest he’s a violent man, but he talks about how he has threatened his mother with a knife when she hasn’t given him money. He also gouges himself with his fingernails, according to prison records. At 5 feet 9 inches and less than 130 pounds, he is a small man and looks older than his 33 years. He says his fear is to be moved into the general prison population where he couldn’t protect himself from stronger inmates. “I can’t fight,” he says.
“When the day comes for him to be released, we’ve got to let him out,” Dr. Keithley says, sighing and shaking his head. The doctor says he’ll refer Mr. Smith to whatever treatment is available in Tulsa and will warn the man’s mother that he may be violent. He also plans to introduce Mr. Smith to the Program for Assertive Community Treatment, a pilot program that tries to monitor ex-offenders.
The prison will discharge Mr. Smith with two weeks of medication that Mr. Smith says he won’t take, because a “genie in my rectum” told him he doesn’t need it. He says he has heard the genie for as long as he can remember. Throughout his life, he says, he has used drugs and alcohol to quiet the voice.
Having served his time, Mr. Smith won’t be under court supervision. “I won’t have to take any drug tests,” he says. Asked why that’s important, he answers bluntly: “Because I want to do drugs. I like crack and marijuana and drinking.”