Solitary Confinement of Prisoners with Mental Illness: Litigation and Lessons Learned

1
Solitary Confinement of Prisoners with Mental
IllnessLitigation and Lessons Learned

• Academic and Health Policy Conference on
  Correctional Health
• Chicago, Illinois
• March 22, 2013
• James F. DeGroot, Ph.D. Katherine L. ONeill,
  LICSW Greg Markway, Ph.D.
• Director of Mental Health Director of Behavioral
  Health Director of Mental Health
• GA Dept. of Corrections MA Dept. of Corrections
  MO Dept. of Corrections

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Solitary Confinement of Prisonerswith Mental
Illness

• Background Litigation (15 minutes)
• James F. DeGroot, Ph.D.
• Lessons Learned
• Katherine L. ONeill, LICSW, MA Dept. of
  Corrections (25 minutes)
• Greg Markway, Ph.D., MO Dept. of Corrections
• (25 minutes)
• James F. DeGroot, Ph.D., GA Dept. of Corrections
• (15 minutes)
• Questions and Answers

3
Solitary Confinement of Prisonerswith Mental
Illness

• Background Litigation
• Basis of Litigation
• Human Rights Framework
• Scientific Research
• Position Statements

4
Solitary Confinement of Prisonerswith Mental
Illness

• Basis of Litigation
• Eighth Amendment
• Conditions of confinement (Deliberate
  Indifference)
• Evolving Standards of Decency
• Madrid v. Gomez (1995)
• Class Action Litigation in 14 states (AL, AZ, CA,
  CN, FL, IN, MI, MS, NJ, NM, NY, OH, WI, TX)

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Solitary Confinement of Prisonerswith Mental
Illness

• Human Rights Framework
• Principles
• Respect the humanity and inherent dignity of all
  inmates
• Prohibit torture or other cruel, inhumane or
  degrading punishment or treatment
• International Covenant on Civil and Political
  Rights
• Inter-American Commission on Human Rights

6
Solitary Confinement of Prisonerswith Mental
Illness

• Scientific Research (What happens to people
  deprived of social contact for months or years?)
• Challenges
• Definitions
• Samples
• Cress-sectional studies
• IRBs
• Colorado State Penitentiary SuperMax Study
• Longitudinal
• Hypotheses
• Results
• Controversy

7
Solitary Confinement of Prisonerswith Mental
Illness

• American Psychiatric Association (Approved by the
  Board of Trustees, 12/2012) (Approved by the
  Assembly, 11/2012)
• Prolonged segregation of adult inmates with
  serious mental illness, with rare exceptions,
  should be avoided due to the potential for harm
  to such inmates. If an inmate with serious
  mental illness is placed in segregation,
  out-of-cell structured therapeutic activities
  (i.e., mental health/psychiatric treatment) in
  appropriate programming space and adequate
  unstructured out-of-cell time should be
  permitted. Correctional mental health authorities
  should work closely with administrative custody
  staff to maximize access to clinically indicated
  programming and recreation for these
  individuals.

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Solitary Confinement of Prisonerswith Mental
Illness

• National Alliance on Mental Illness (11/2012)
• Solitary confinement is the placement of
  individuals in locked, highly restrictive and
  isolated cells or similar areas of confinement
  for substantial periods of time with limited or
  no human contact and few, if any, rehabilitative
  services. Placement in solitary confinement
  frequently lasts for weeks, months, or even years
  at a time. It is extensively documented that
  solitary confinement is used disproportionately
  in correctional settings for juveniles and adults
  with severe psychiatric symptoms. In some states,
  it is reported that more than half of all inmates
  in facilities utilizing the most extreme forms of
  solitary confinement and social isolation are
  diagnosed with serious mental illnesses NAMI
  opposes the use of solitary confinement and
  equivalent forms of administrative segregation
  for persons with mental illnesses.

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Solitary Confinement of Prisonerswith Mental
Illness

• National Alliance on Mental Illness (11/2012)
  cont.
• NAMI calls upon states to establish mental
  health alternatives to solitary confinement that
  include enhanced mental health treatment,
  services and programs crisis intervention
  training for correctional officers, and mental
  health step-down units. States that have adopted
  such proactive efforts to eliminate solitary
  confinement have documented highly positive
  results that include reduced psychiatric
  symptoms, less violence, and significant cost
  savings.

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Lessons Learned The Massachusetts Department
of Corrections approach to treating and managing
mentally ill offenders with long-term segregation
sanctions

• Academic and Health Policy Conference on
  Correctional Health
• Chicago, Illinois
• March 22, 2013
• Katherine L. ONeill, LICSW
• Director of Behavioral Health
• Massachusetts Department of Correction

Katherine L. ONeill, LICSW Director of
Behavioral Health Massachusetts Department of
Correction
11
Time-line of litigation

• 1/2006 -Records requested in conjunction with
  inmate suicide in segregation
• 10/2006 Investigation launched by Disability Law
  Center (DLC) into our Segregation Units
• 1/2007 Pre-litigation meetings with both sides
  took place to try and address concerns
• 3/2007 DLC filed suit against MA-DOC alleging
  that confining prisoners with serious mental
  illness in segregation violates the 8th
  Amendment, ADA and Rehabilitation Act of 1973
• 4/2012 DLC and DOC achieve Settlement Agreement

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The Requests

• DLC asked Court to prohibit DOC from confining
  inmates with mental illness from segregation for
  more than 1 week
• DLC proposed a broad definition of SMI which
  would have required special treatment units for
  a large percentage of inmates
• DLC toured facilities with their counsel and
  experts interviewing several inmates
• DLC issued requests for extensive documentation
  from mental health records and administrative
  records.

13
MA-DOC Response

• Retained psychiatric expert (Jeffrey Metzner,
  M.D.,) for input
• Developed and implemented initiatives stemming
  from expertise and experience of MHM (MH
  provider) Dr. Metzner
• DOC created buy in and executive leadership
  showed strong support for mental health input and
  reform
• Worked with MHM to identify needs and to develop
  programs and protocols that made sense for our
  population

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MA-DOC initiatives

• DOC implemented legal definition of Serious
  Mental Illness (SMI)
• Trained all staff (custody, administration
  clinical in applying definition)
• Developed a system for identification and
  tracking inmates with SMI
• Committed to excluding inmates with SMI
  designation from long-term segregation to include
  DDU.

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Massachusetts's SMI Definition
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MA-DOC Initiatives

• DOC implemented MH Classification System
• Individually based needs assessment tool
• Identifies appropriate level of services
• Service levels range from case management to
  inpatient hospitalization
• Clearly identifies inmates with history of
  suicidal behavior, SMI designation, and inmates
  with high level of need for mental health services

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MA-DOC Initiatives

• Developed specialized mental health units as
  placement alternatives to long-term segregation
• Secure Treatment Program (February 2008)
• 19 Beds, Maximum Security Prison
• Behavior Management Unit (July 2010)
• 10 Beds, Maximum Security Prison

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MA-DOC Initiatives

• Complete revision of the 103 DOC 650 MH Policy
  and Procedures to memorialize all initiatives
• DOC opened the Intensive Treatment Unit (ITU) in
  May 2012
• 32 Beds, Female Offenders
• Designed to provide behavioral interventions and
  crisis stabilization
• Inmates with shorter term segregation sanctions
  are provided enhanced services
• Weekly out of cell clinical contact

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MA-DOC Initiatives

• Complete enhancement of Residential Treatment
  Unit Program (RTU)
• 4 RTUs across system, total of 208 beds
• Designated mental health staff
• Evidence based curriculums
• Meaningful activities socialization
  opportunities
• Support for therapeutic communities

20
MA-DOC Initiatives

• DOC formalized process for MH input into
  disciplinary process
• Developed specialized training for all staff
  working in specialized units
• DOC enhanced Inmate Management System (IMS)
• Improve communication across disciplines
• Easily track performance data
• Monitor trends and revise practices accordingly

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Applying the MH Classification System
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Massachusetts NumbersJanuary 2013
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Massachusetts Numbers
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Massachusetts's Needs
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Developing our Alternative Units
26
Why CQI should NOT be an afterthought
27
Monitoring Performance
28
Collecting Meaningful Data
29
In the Headlines
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The Outcomes As of January 2013
31
Sample
32
Use of Force Incidents
33
Staff Assaults
34
Inpatient Hospitalization Days
35
Inpatient Days (Averages)
36
Disciplinary Infractions
37
DDU Outcomes
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ITU OutcomesMay-December 2013

• 15 reduction in all self-injurious behaviors
• 20 reduction in transfers to inpatient
  psychiatric hospitalization
• 33 reduction in days on constant mental health
  watch
• 46 decrease in total crisis contacts

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Truly a Team Effort!

• Special Thanks to the following
• -The Commissioners Office
• -DOC Legal Division
• -DOC Health Services Division
• -Joel Andrade, Ph.D., LICSW Dana Neitlich,
  LICSW
• -MHM Services, Inc.
• -Site Superintendents and DOC Administrations
• -University of Massachusetts Correctional Health
• -The clinical teams and unit coordinators for the
  STP, BMU, RTUs and ITU.

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An Innovative Approach to Solitary Confinement

• The Potosi Reintegration Unit (PRU)
• Potosi Correctional Center
• Missouri Department of Corrections
• Presented by Greg Markway, Ph.D.

41
Background

• Potosi Correctional Center is the most secure
  facility in Missouri
• Very limited movement in the camp
• PCC houses offenders sentenced to death
• Historically, has housed most difficult
  offendersthe Hannibal Lecters of MO

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Background (2)

• PCC had a small Ad Seg unit that housed offenders
  with serious Protective Custody needs, as well as
  offenders who had seriously assaulted or killed
  other offenders or staff
• How do you decide when an offender is ready/able
  to return to general population?
• What makes this offender safer today than last
  week?

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Background (3)

• HU-1 was a small Ad Seg Unit, housing
  approximately 21 offenders
• The unit was no longer economically feasible
  unless it took on a new mission
• Through the creativity of our custody division,
  and the cooperation mental health, a new mission
  was developed.

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Mission of PRU

• Take some of the most difficult to manage
  offenders, those in long-term single cell ad seg,
  and provide programming with the goal of
  returning them to general population if possible
• Be able to answer why they can be returned to GP,
  or why they need to stay in Ad Seg
• Develop collaborative programming with mental
  health, custody, and classification

45
Initial Obstacles

• Resistance of custody staff How far down has
  corrections gone?
• Perception of coddling offenders who have been
  the worst of the worst

46
Seeds of Change

• Warden approached staff with new mission (Staff
  Buy-In)
• Developed Oversight CommitteeUnit Manager,
  Deputy Warden, Classification, Mental Health, and
  Medical Staff (Broad Input)
• Any committee member allowed to veto a
  recommendation (all staff on committee equal in
  input and responsibility)

47
Program Development

• Cleared an office to be used as small
  classroom/group room (camera, panic buttons)
• Special desks designed (allowed offenders to be
  in room together while still restrainedbut also
  allow movement)
• Offenders assessed fresh (WAIS, MMPI, etc.)
• Programming brought into unit (MH, volunteers,
  chaplain, classification staff)

48
Uneasy First Steps

• Offenders brought into class for programming
• Little progress initiallyoffenders struggling
  Would just sit there in a fetal ball
  emotionally
• No interaction

49
Signs of Progress

• Psychologist noted one offender liked to draw, so
  she took an art therapy approach
• Art supplies were allowed on the unit
• Offender drew a picture in group, and others
  began commenting on itthe ice was broken

50
Next Steps

• 3 months into the program, staff began discussing
  incentives for offendersneeded to be
  personalized and realistic
• Began with things the offenders had shown they
  liked to do
• Led to development of true individualized
  behavior plans
• Offenders did not trust this Had to throw them
  a bone

51
Incentive Program

• Once program began, officers stated Weve never
  seen these guys act like this before.

52
Incentive Examples

• Listen to books on CD with portable CD player in
  cell for set time
• Keep book or magazine in cell
• Work on jigsaw puzzle
• Rec time outside cell with another offender
• Purchase a CD player with own funds
• Have access to art materials
• Eat lunch outdoors with another offender

53
Other activities

• TV time/movie discussion groupGroundhog Day
  example
• GED classes
• Other programming with inmate facilitators
• Dogs

54
Behavior Change Examples

• Offender with poor reading skills requested book
  to go along with CDworking on his own reading
  skills
• Offender who frequently swallows objects now is
  able to wear his eyeglasses and keep Bible in
  cell
• Some offenders are helping others learn to read,
  complete homework, etc

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Staff Behavior Changes

• We became like parents looking at our kids
  pictures. People developed an interest in the
  offender as a person.
• Oversight Committee truly became
  interdisciplinary
• Interestingly, now mental health has to slow
  custody down in granting privileges
• Custody officers advocate for offenders

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Results

• Dramatic reduction in uses of force in the unit
• Officers now raise questions about
  medication/mental health/medical issues
• Officers see offenders as people
• Officers are proud of their accomplishments with
  the offenders
• Administration treated us like human beings

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Georgia Lessons Learned

• The Georgia Department of Corrections Approach
  to Reducing Mentally Ill Offenders in Solitary
  Confinement
• James F. DeGroot, Ph.D.
• Director of Mental Health
• Georgia Department of Corrections

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Georgia Lessons Learned

• Time-line of Litigation
• 1972 1998 Guthrie v. Evans
• 1984 1998 Cason v. Seckinger
• 2002 2004 Fluellen v. Wetherington

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Georgia Lessons Learned

• Eighth Amendment Complaints
• External Audit Results (2008) Mentally ill
  offenders were disproportionally represented in
  lock-down units.

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Georgia Lessons Learned
Data 2008
of offenders receiving MH services 32
of all DRs received by MH offenders 41
of MH and GP receiving sanctions MH88/GP47
of MH and GP placed in disciplinary segregation MH56/GP21
of all offenders in disciplinary segregation receiving MH services 63
of MH and GP serving more than 2 weeks in disciplinary segregation MH43/GP30
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Georgia Lessons Learned

• Procedures already in place
• DR Evaluations (mitigating circumstances)
• Alternative sanctions
• Weekly lockdown treatment sessions
• Weekly lockdown rounds
• Activity Therapy
• Individualized Behavior Therapeutic Unit
• Isolation/Segregation Health Screening
• Out-of-cell mental health services
• Out-of-cell structured/unstructured activities
• Mental Health input into disciplinary process

62
Georgia Lessons Learned

• New Procedures
• Publish monthly oversight results
• Upper level management support

63
Georgia Lessons Learned

• Six months after publishing oversight

Data Original 6 Months Later Males Females 6 Months Later Males Females
on Mental Health 32 32 51
of all DRs to Mental Health 41 43 65
of MH and GP Sanctions MH 88 GP 74 MH 78 GP 84 MH 50 GP 59
MH and GP in Disciplinary Seg MH 56 GP 21 MH 18 GP 14 MH 19 GP 16
of all offenders in Disciplinary Seg MH 63 GP 37 MH 33 GP 67 MH 67 GP 33
of MH and GP serving more than 2 weeks in disciplinary seg MH 43 GP 30 MH 14 GP 27 MH 4 GP 14
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Georgia Lessons Learned

• Data
• of males receiving MH services system-wide
• 14
• of MH in High-Maximum Security
• 46
• Corrective Action
• High-Maximum Security Supportive Living Unit
• Therapeutic Modules

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Georgia Lessons Learned
Therapeutic Mental Health Modules at Augusta
State Medical Prison
66
Georgia Lessons Learned

• Data
• of all self-injurious behavior in lockdown
• 60
• of all suicides in lockdown
• 63

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Georgia Lessons Learned

• What works in reducing mentally ill offenders in
  solitary confinement?
• Upper Level Management Support
• Mental Health Standards of Care
• Monthly Data Reports
• Publish the results

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Questions?