Why the system had to change:
Posted on Tue, Oct. 19, 2004
A failure to deliver treatment
For mentally ill inmates, few programs and little expertise
By Karen de Sá
Mercury News
STOCKTON - It's another morning med call in California's largest prison unit for mentally ill juvenile offenders, and groggy young men shuffle out of the unit's 50 bare brick cells to the nurse's cart. Before the anti-psychotic drugs, mood stabilizers and anti-depressants hit their bloodstreams, there's a chance to chat with the perky RN in the brightly patterned smock.
David, 20, is anxious. Sent to the California Youth Authority for molesting a child, he'll be leaving the Merced treatment unit next week and heading south on a Greyhound bus, and he's terrified he won't find his stop.
A few cell doors down, a ward hangs his head as he accepts a Dixie cup of pills. Sexually abused by relatives, he was sent to the Youth Authority for burglary. Yesterday, he was bubbly and talkative; today, he is distraught over a letter from his mother.
Lewis, 19, barks through the food slot in the door of his 6-by-8-foot isolation cell, complaining of being bored and hearing voices.
``I go through phases with these voices I hear, and sometimes they're real intense. That's when I go on suicide watch,'' Lewis says.
These young men are among the few wards, as they are called, who receive psychological treatment in the state's youth prison system. Experts on criminal behavior insist that it is in the public's interest to give youthful offenders the help they need; within a few years, most will return to their neighborhoods, whether or not they have been educated, counseled or rehabilitated while in the Youth Authority.
Yet the vast majority of the institution's 3,900 wards are housed in large living units where gang-related fights are common and individual help is cursory. They receive little or no therapy, even though 71 percent have diagnosable mental disorders, 85 percent arrive addicted to drugs or alcohol, and an overwhelming majority were sexually or physically abused at home.
This lack of treatment programs is just one of the failures of the system that wards will encounter from the day they arrive to their final hours on parole. Even the Merced unit -- one of the Youth Authority's larger and better-established programs, designed to cloister the most troubled offenders -- is more a special kind of warehouse than a special treatment center.
Daily life is controlled by guards, and by other security staff members who, despite minimal training in health, social work or adolescent development, are known as youth correctional counselors. Although the counselors clearly try to offset their lack of training with compassion, and even affection, medical staff members complain they are often overruled by those whose tools are shackles and Mace rather than therapy and education.
Regular group therapy sessions and school hours are scheduled, but daily routines are disrupted whenever fights break out in a neighboring unit. Wards spend much of their day alone in their cells -- including those on suicide watch, which defies national standards for health care of mentally ill prisoners and could make their condition worse.
Does it? No one can say, because the Youth Authority doesn't monitor, track or measure the effectiveness of the few treatment programs it does have. In fact, although its goal is to help wards move from special programs to lower-level treatment and eventually into mainstream units, in reality, most -- like David -- head straight from years in Merced to the street.
A Mercury News reporter and photographer were given unprecedented access to the Merced unit for a week in June, during which they witnessed the daily life of the 42 inmates and the mental health professionals, guards and teachers who work there.
Medical staff members, correctional counselors and guards spoke openly, most on the condition that their full names not be used because of safety concerns. Youth Authority officials insisted wards on the mental health unit not be fully identified to protect their privacy and that of their victims.
What follows is a composite day, drawn from that week on the unit. For although disruptions explode each day's schedule, overall, as Lewis wailed from his cell, the days were mind-numbingly the same.
6:45 a.m.
Just after sunrise, guards in green jumpsuits and mirrored sunglasses take several young men to and from caged-in shower cells one at a time. The inmates dress in state-issued Velcro sneakers, white T-shirts and blue jeans with elastic waists that they are repeatedly reminded to pull up.
A correctional counselor, helped by wards, rolls a cart of styrofoam trays along the walkway. He peers in the small window cut into each of the salmon-color steel doors, checking that the ward is lying face down on his bed with his hands behind his back before bringing in the scrambled eggs, salsa and tortillas.
Meals are served this way because the staff members consider it a security risk every time a cell door is opened. Wards might physically charge them, or spit and hurl feces in an attack called ``gassing.''
Staff members are especially careful when approaching six of the doors. The young men inside are either troublemakers from other units or wards on suicide watch, monitored by a camera 24 hours a day. The suicidal wards are visited every 15 minutes and wear thick blue smocks that can't be unraveled to make a noose for hanging or strangling.
The unit echoes with the shouts of young men hollering for attention from any staff member who passes by.
7:15 a.m.
Guards keep the unit on a tight schedule, and nurse Virginia Simidian must dispense medications quickly. But this is her chance to connect with the young men and she tries, praising one for turning down his radio when asked and urging others to drink plenty of water. The two-tier unit is stifling this summer day, and the medications dry their mouths. Simidian promises to bring Lewis a copy of ``The Elephant Man'' and assures David he'll find his bus stop.
8 a.m.
Those not on suicide watch straggle out to attend a ``large group'' session led by parole agents assigned to the wards for as long as they are in Merced. More than two dozen young men and boys meet in a circle of plastic chairs on the central floor to discuss problems from the previous day, meet newcomers and hold mock parole board hearings.
Inevitably, some of the wards can't control themselves during the large group treatment session, so counselors hold a separate session with them -- known as the ``Pit Stop Group.''
Ten wards meet with a correctional counselor, in this case one of two at Merced who have a state ``psych-tech'' license for handling mentally ill patients. The group begins with Robert, a 20-year-old ward who is set to be released within a week, disrupting the disrupters. He talks out of turn. Then, he nibbles on forbidden pretzels. But he quiets down when the counselor chides the group for poor personal habits, such as not brushing their teeth or shoving on the basketball court.
The correctional counselor warns Luis, a former heroin addict and kidnapper whose arms are scarred from years of biting off chunks of his flesh, not to ``do any of that hospital stuff'' while at Merced. The counselor thinks that Luis, who also is developmentally disabled, will try to manipulate a transfer out of the Youth Authority and into a state hospital. She doubts that the 19-year-old is mentally ill, despite his ravaged limbs.
Soon, it's Robert's turn, and he admits that he acts up as a ploy to stay at Merced. Charged with crimes including burglary, assault, battery, grand theft and vandalism, he is afraid of running into his old buddies and falling back into the drugs that continue to haunt him, a toxic mix of ``crack, crank, acid and weed.''
The counselor urges him to talk about his fears and to develop some healthy interests on the outside. The other wards chime in, each in turn tossing off reassurances -- ``nothing's going to go wrong; life is what you make it; it's all going to work out.''
The quick encouragement seems well-intentioned, but inadequate, given the depth of Robert's problems.
Robert entered a string of foster homes at age 11, after years of being sexually abused by his father. In five years at the Youth Authority, he estimates he has received 300 or more ``write-ups'' for misbehavior and landed on suicide watch 30 or 40 times. He cuts his arms with whatever he can -- staples, paper clips, even a razor once. The resident psychiatrist explained that he does it to relieve emotional anguish.
When he came to Merced more than two years ago, Robert was ``hella scared,'' he said, having been raped by three other wards at the now-closed Karl Holton Youth Correctional Facility near Stockton.
After the morning sessions, some wards return to their cells and others are supposed to leave for classes in a neighboring building. But morning classes have been canceled because a fight has broken out in another unit of the N.A. Chaderjian Youth Correctional Facility, known as ``Chad,'' which contains the Merced unit, as well as buildings housing 600 other inmates. Classes can be canceled for Merced wards when fights break out elsewhere or when teachers are absent, a common occurrence.
So the Merced wards return to their cells, where they kill time alone, creating miniature furniture pieces out of folded paper, reading, sleeping or talking through air vents to their neighbors. The cells are mostly bare -- just a metal platform for a thin mattress, and a combination sink and stainless steel toilet with no seat.
The few who are tapped for kitchen duty consider themselves lucky.
11:30 a.m.
Lunch is served, with the same procedure and precautions as breakfast. Medications are handed out. Most are heavy anti-psychotic drugs like Respirdal and Seroquel, which can leave the wards listless. While many wards indisputably require medication, an Inspector General's report in 2002 and a state-commissioned report by outside consultants in 2003 found that there was little justification or monitoring of medications in Youth Authority programs. The 2003 report called the uses of psychotropic drugs ``inconsistent'' and ``substandard,'' and the 2002 report noted that 22 percent of the wards it reviewed were on anti-psychotic medications without a stated reason on file.
With an hour of free time before school reconvenes, most nap. But small groups who have earned extra privileges are allowed out to watch television or play cards. They could go out to play basketball, but it's too hot.
The unit reeks of soggy carpets. The night before, one ward flooded his toilet with bed sheets to protest a 20-minute cut in free time. The wards had been confined to their cells because Merced staff members were called away as back-up when a disturbance broke out in another unit at Chad.
It had been a day like many at Chad. A three-on-two fight broke out among members of rival gangs. Later, there was a one-on-one fight in the exercise yard used by the general population. Three wards were sprayed with Mace because they refused to leave the individual cages in which they spent their hour of physical recreation.
Now, outside the door of Robert's cell, a shredded homework assignment is floating on a growing pool of water. Robert has covered his window with a towel so that no one can see whether he flooded the toilet, and he is laughing hysterically.
The guards, correctional counselors and mental health workers all know that Robert is uneasy about leaving Merced. But they play different roles in handling it -- and later evaluate problems like these differently -- revealing the gap between the correctional and treatment staffs in Merced.
``C'mon man, take this down,'' says one correctional counselor of the window covering, ``I need to know what's going on.''
The second staffer to respond, a former guard trained in counseling skills, rushes over to make sure Robert isn't wielding any pencils. ``In about five minutes, I'll be back,'' he warns. ``If I don't get the pencils, I'm calling security.''
Now Merced's senior youth correctional counselor, Michelle Lewis, weighs in. She leans close to the window in Robert's cell door. ``How is this going to help you in the long run?'' she asks.
``A lot!''
``Aren't you supposed to be getting out?''
``They ain't going to parole me!''
``Remember, when you get out in the world, are you going to be flooding your bathroom? Make your decision, recover from what you did or go to suicide watch,'' she threatens.
Robert thunders back: ``I didn't say anything about suicidal!''
1:30 p.m.
A fragile peace returns when Robert winds down. A fellow inmate brings a mop and lets out a big sigh -- another flood to clean up. Robert rushes to the cell door and threatens to ``gas'' him, but quickly falls silent.
The psychologist, security guard and three correctional counselors on duty see incidents like these in very different ways.
``A lot of these guys don't belong here,'' says a burly correctional counselor, who came to Merced with no prior experience working with juveniles, after 10 years at San Quentin Prison guarding adult inmates on death row. He sees this kind of incident as manipulative acting out that shows the wards mainly need ``good parenting.'' They need someone consistently telling them, ``Pull your pants up, brush your teeth, take a shower,'' he says.
Another guard-turned-counselor shares the day shift with the former San Quentin guard. He has worked in the Youth Authority for 13 years and came to Merced after he got tired of the fights and violence in the mainstream living units. He received no special training to earn the title of ``counselor'' in this psychiatric program, and when asked whether he views a ward primarily as a prisoner or a patient, he doesn't hesitate: ``I see a prisoner,'' he says.
In contrast, the staff psychiatrist describes the young men as ``seriously and persistently mentally ill.'' But the unit is under the control of the guards and guards-turned-counselors and, ``Their mission is correction, and they see things differently than we do,'' he said. ``The mental health staff is commonly overruled. They think what I do is all nonsense.''
The problem with giving a person a title without training, adds James Hamilton, a Merced psychologist, is that ``you tell them they're counselors, they think they're counselors, but the reality is, they don't have the skills.''
Hamilton is one of two psychologists at Merced; the psychiatrist is one of only four in the Youth Authority. Ten psychologist and four psychiatrist positions are vacant.
Youth Authority managers have control over assigning just 30 percent of the jobs -- even in a special unit like Merced -- while the guards union assigns the other 70 percent, under a contract negotiated in the mid-1990s. Guards with more seniority often bid for jobs at units like Merced because of the relatively good hours and better resources, whether or not they have the skills to handle especially needy wards.
``We've negotiated ourselves out of our mission,'' says Joan Lucraft, who administers mental health programs throughout the Youth Authority.
2 p.m.
Of the 42 wards in the Merced unit this week, 18 are sex offenders. They attend their own specialized group counseling sessions twice a week with Hamilton, who wears a Buddha earring and Hawaiian shirts with suspenders. Hamilton has worked at the Youth Authority for 11 years and drinks one Diet Coke after another to get through the day.
His job is to help young people change their thinking, but he finds the setting too harsh. It takes time and professional interaction to uncover the roots of destructive behavior, he says, and the wards spend too many hours alone in their cells. The bleak two-story cell blocks, with the guard tower, and the shackles and chaotic disruptions, create an environment that is not rehabilitative, let alone therapeutic.
``This is a youth correctional center, but if you drive around the state of California, you're not going to find an ounce of difference with this place and any of the adult prisons,'' Hamilton says. ``The reality is, they all live in cells.''
On this day, Ryan, a freckled 20-year-old, is shyly presenting a report on his crime that he has been writing for three years. This approach to treatment is based on a ward sharing his ``assault cycle'' with the group, a first step in Youth Authority institutions.
Hamilton uses the method but says there is no evidence that it deters criminal behavior. So he augments it with another form of therapy, called Rational Emotive Behavior Therapy.
The technique was developed in 1955 by Albert Ellis and has become the foundation of behavioral modification therapies. It aims to help people replace self-defeating thoughts, feelings and actions. It holds individuals responsible for their emotions and tries to teach them to think rationally. Hamilton reminds wards repeatedly each day to ``apply REBT to your situation.''
Ryan reads a statement detailing his ``original trauma'': Sexually assaulted by his grandfather at 3 months old, and at 5 years old beaten and further abused in a foster home before being adopted. His new family, he says, beat him, tried to drown him, sodomized him and forced him to perform oral copulation. Ryan says he often was abandoned and left alone with no food.
``When I was molested, I thought it was OK to do it to another person,'' he tells the group. ``So when I was 13, I molested my 12-year-old brother.''
``Challenge that irrational thought,'' Hamilton urges.
``I hate everyone because of what they did to me, but I could use REBT,'' Ryan responds tentatively. ``I take responsibility for my crime, what I did, but not for what they did to me.''
Ryan is described by psychiatric staff as a chronic mental patient with an unspecified psychotic disorder who is ``floridly delusional.'' In addition to practicing the assault-cycle and behavior techniques, Ryan is medicated. Every day he takes two anti-psychotic drugs and two more to suppress the side effects. They help quiet his hallucinations and the voice of Satan, which he says he has heard since age 12, when he was ``baptized in blood.''
Earlier this year, ``the Devil'' told Ryan to reach across the table during Bible study and choke the unit chaplain, who turned blue and struggled for breath before he reached the alarm button.
Ryan is due to be released soon.
3 p.m.
While Hamilton's sex offender group wraps up, Lewis shuffles back to his suicide cell from a day in court.
A bearded, stocky 19-year-old, Lewis landed in the Youth Authority after he hit and killed another driver with his car, fleeing the scene while high. The son of a drug addict and former prisoner, he is now being charged with assault while incarcerated for spitting on two counselors and a psychologist. He may end up in adult prison for the new offenses.
When he left for court, the former South Bay resident was dressed in a bright orange jumpsuit, shackles on his hands and feet, with a blue, fine mesh ``spit mask'' over his head.
Lewis takes Respirdal for his psychotic behavior and tells the staff he hears voices and feels suicidal. Because of those revelations, he's spent the past two of his 18 months in a suicide cell. Staff members veer around it whenever possible. Lewis often smears feces on the walls. He once banged his head feverishly against his pillow for 12 straight hours.
``Every time I go back to my room, the voices tell me to kill myself, so I don't want to go back to my room,'' Lewis says through the crack in his door.
But most custody staff members don't believe him. ``I think he's just a scared boy who doesn't want to take responsibility for what he does,'' says correctional counselor Chavez, who works the night shift.
The unit psychiatrist disagrees. He tried to have Lewis transferred to a state hospital but was overruled by Chad administrators who are waiting for the judge's ruling on the new assault charges.
What eventually becomes of Lewis will not be known by the Youth Authority. If he disappears into the prison system, he will not be tracked. If he is released, he won't be tracked. Whether his time in the Merced unit helped or made him worse will never be known, because the Youth Authority doesn't monitor, follow-up or assess the effectiveness of its programs.
``We don't have outcome numbers,'' says Rick Flynn, a supervising casework specialist who manages the Merced unit. ``If I get a guy to not kill himself, take meds and get on parole, that's a success.''
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Contact Karen de Sá at kdesa@mercurynews.com or (408) 920-5781. |
