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An inmate at Los Angeles County Men's Central Jail in 2011.
Commentary

Handling, Not Manhandling, the Mentally Ill

A close look at the L.A. County Jail settlement

Los Angeles County’s ballyhooed settlement of a long-running lawsuit over the abuse and neglect of inmates in its jail isn’t just a big deal for California. The case, the compromise, and the remedial plan now in place to help ensure inmate safety could serve as a model for other jurisdictions around the state, and around the nation, whose prisoners (and officials and staff) face similarly grim conditions in their jails and prisons.

Florida, for example, a state wracked with violence in prisons and jails, soon will have to confront these issues head-on with a new corrections chief. There is a pending jail abuse lawsuit in Indiana. The massive Cook County jail now faces a broad lawsuit alleging systemic abuse of inmates. In Colorado, officials at the chaotic Denver County jail just settled an abuse lawsuit charging an epidemic of excessive force. And those are just the cases involving some of the nation’s jails, not its prisons, where the abuse and neglect of inmates, especially mentally ill prisoners, also is pervasive.

In Los Angeles County now there will be monitors overseeing conditions of confinement at the crowded jail. Those monitors will in turn be overseen by a federal judge. Jail officials will be required not just to implement significant reforms but also to chronicle the pace and efficacy of the changes to allow for meaningful review of the data by the outside overseers. Some of the provisions of the settlement seem obvious to the layperson—requiring guards not to attack mentally ill inmates, for example -- but some of the other measures in the agreement are novel.

One of the key themes of Tuesday’s settlement, for example, focuses upon the care and treatment of mentally ill prisoners within the county’s jail. Those inmates, often the most vulnerable in any jail environment, were for years particularly brutalized by corrections officers at the jail. And one of the key sub-themes involves the extraction of mentally ill inmates from their cells, a scenario that can and does cause a great deal of trauma to the inmate and a great deal of drama to the corrections officers charged with ensuring the extraction takes place, by brute force if necessary.

To get a sense of what the agreement requires, and what it portends, we spoke Wednesday with Dr. Raymond Patterson, a psychiatrist with a long history of work in and out of prisons and jails, an expert with specific experience as a court monitor in cases like this. We asked about the specific provisions in the LA County agreement that will shape the way mentally ill inmates are treated, or should be treated. Below are some of the key provisions in the agreement, specifically focused upon the extraction of mentally ill inmates from County jail cells, followed by Dr. Patterson’s analysis of them:

I wholly agree with this. It should be standard in every system but it usually is not. Usually it is not happening because of staffing, or because of institutional practice, where they simply haven’t required participation by mental health professionals in planned use of force. Sometimes it’s the “we’ve always done it this way” explanation. There is usually some initial resistance by prison staff who are reluctant to have medical staff involved in extractions, but when they get used to it, and realize it actually helps get the inmate out more quickly and safely, it can work well.

This one may be difficult to enforce. Some systems have this kind of provision and many others do not. The taping of the interview gets into issues of trust within the facility itself between staff members and medical professionals. There may also be issues of confidentiality relating to the inmate. The idea of having the mental health professional comment about what was done, how it was done, or about the performance of the other members of the extraction team may be more difficult to enforce, unless there are very specific parameters that the comments are restricted to the actual interaction between the mental health professionals, the other prison staff, and the inmate. The question is consent of both the mental health professional and the prisoner.

This would be novel. I don’t know of any system that has this sort of provision based upon mental illness. Here’s the rub—enforceability. This does not mean I am a proponent of chemical sprays. But in the context of extraction, where an inmate is threatening to harm himself and others, the alternatives become very limited to the use of chemical sprays or physical force. Every effort should be made to de-escalate the situation and give it time when it is safe and practical.

This one I think varies across systems. This is perfectly acceptable and reasonable but it would require, during the cooling off period, for that inmate to have direct observation—for someone to have eyes on him or her. Essentially that means a staff member, correctional staff or nursing staff, has to have direct eye contact with that individual during that cooling off period to ensure there is no self harm or what is called “decompensation.”

This one I think would be novel as well because the kinds of things that happen, the examples I am familiar with, usually have to do with an inmate receiving medication that they don’t give in a cell or for a full or more comprehensive examination, where an inmate has become a “cave dweller,” someone who isolates himself in his cell and doesn’t come out for activities. There are concerns about those people being quietly psychotic or mentally ill. They are not banging on walls or reaching out. They have withdrawn. And, at some point, if they are not coming out of their cell, we may need to bring them out to find out what is going on in their head, if they are at increased risk.

The issue, again, is going to be enforceability. If you don’t have the prescriber available, for whatever reasons, is the general medical officer, a non-psychiatrist for example, going to be able to make the call? There are ways around this, though, like having an “on-call” person.

All of these are minimally acceptable—minimal requirements for the training of staff. But here is the thing. I have done training in many different scenarios. The whole issue about the training is that you want the training to work. There should be both clinical and custodial trainers participating in these training activities that apply to these officers. You want to get people to understand what this mental illness issue is across the board. Giving them the textbook definitions might be helpful. But it would be a lot more effective if the custodial officers can relate to the instructors. I have great respect for the people who do this work but they need a great deal of support as well.

How do you do that? They are going to have to design something based upon the training. They are going to have to go to the trainees to evaluate whether they have been involved in crises, how they reacted to them, do they still know what to do in the event of a crisis as well as the other aspects of the training. As part of this evaluation, should also include the trainees’ opinion about the training. Was it helpful? Was it a bunch of crap? Did I fall asleep?