I’m writing a new story and part of the new piece involves prison — specifically mental health treatment in prison. It’s a strange thing to witness a prison mental health crisis first hand and after working around correctional mental health units and activating one in a maximum security prison, it occurred to me that most readers don’t know what happens in prison mental health units. Watching One Flew Over the Cuckoo’s Nest, or some fictional portrayal on a CSI episode doesn’t quite capture the essence of being mentally ill in prison.

A decline in community mental health care resulted in thousands of mentally ill offenders going to prison rather than state hospital settings. A few decades ago, treatment for the most severely mentally ill could be summed up and “isolate and medicate.” Back then, two California prisons specialized in mental health disorders, the California Medical Facility and the California Men’s Colony. If you went out on one of those prison yards, you’d find dozens of inmates doing the “Thorazine shuffle,” drugged to the point of  barely being able to walk in a straight line. This was at a time when there were less than 30,000 inmates in the prison system.

By the late 2000’s, the California prison population exploded to over 170,000 and with that came an increase in the mental health treatment needs of thousands of inmates. Over 20,000 inmates came into the system needing some form of mental health treatment or medication management. The federal courts took over the management of mental and health care systems. Prisons became treatment centers with entire cellblocks set aside for the severely mentally ill. Crisis beds were established for acute care needs of inmates who swallow broken glass, try to drown themselves in their cell toilet or take a bite out of their own arm.

image via associated press and examiner.com

Over 8,000 inmates are segregated into special units, Enhanced Out Patient (EOP) units for housing and treatment. These inmates cannot function in general population settings without creating a danger to themselves or others. They require additional mental health treatment, medication and supportive services. Group treatment often occurs in a room furnished with metal cages arranged in a circle where the inmate-patients listen to a psychologist. Imagine a half dozen, or more, men listening to a discussion on empathy, while one is yelling at the video screen, another is having a conversation with one of the voices in his head and another tries to grab the psychologist through the bars.

image via la times

If you stab your cellmate and pour a bottle of hot sauce into the open wounds (true story) you’re likely to end up in the Psychiatric Services Unit (PSU). These units at Pelican Bay and the California State Prison at Sacramento treat the most violent mentally ill inmates in the system. Prisoners who fight internal demons as much as they fight with staff are unable to live in general populations and are housed in the PSU instead of the SHU, the Security Housing Unit. All movement is highly controlled and yard exercise takes place in individual metal “walk alone yards” which resemble dog kennel runs.

Inhumane? After working in and around these units, not having the segregated units would be inhumane. If left in general population, the mentally ill are targeted by gang factions because they are deemed weak. The EOP level of care inmates often lack the impulse control to resolve a dispute without stabbing someone. The staff working with this unpredictable population have urine and feces thrown at them when they bring food to the cell door. Housing these hard to manage offenders together allows the rest of the prison population to function safer and provide mental health treatment to those who need it most. Important to remember is the therapists here need to wear stab resistant vests.

The effectiveness of prison mental health treatment is another issue. It has created it’s own self sustaining economy. Prison has become the waste bin for all the public’s problems. Drug use, failings of the foster care system, and the mentally ill. If treatment were provided before these men and women committed their crimes to come to prison, who’s to say if victims could have been saved?