Prisoner or Patient
Prisoner or Patient
Dr. Darryl Winer
The battle has long raged over how mentally ill persons are handled and treated when they come in contact with the criminal legal system. Unfortunately such contact is not particularly uncommon. Back in 1975 I had the privilege of doing a year-long internship at the Denver County Jail under the direction of Glenn E. Swank M.D., a truly first-rate psychiatrist who was as fine a friend as he was a physician. Based on our first-hand experiences, we published a couple of papers shining a light on the issues surrounding the management and care of incarcerated mentally ill people. (Swank, G.E. and Winer, D., “Occurrence of Psychiatric Disorder in a County Jail Population”. American Journal of Psychiatry, November, 1976. Swank G.E. and Winer D., “A Psychiatric Team Provides Services in a County Jail”. Hospital and Community Psychiatry. January 1978.)
It is not my intent at this time to rehash all of the issues surrounding incarcerated mental patients, but I would like to share a story of Eric G. as perhaps a definitive example of this issue. Following is a vignette of Eric’s journey through Denver’s legal and mental health systems.
The City and County of Denver (a geographically unitary city and county), at that time, and not all that changed today, operates a city jail for very short term holding and a county jail for somewhat longer holding. Long term imprisonment is handled by the State of Colorado in its facilities. Back in the 1970’s Denver also had an extensive federally funded mental health program incorporating emergency services, inpatient alcohol detox, inpatient (locked) psychiatric facility, outpatient services, rehabilitation, child and adolescent programs and halfway house facilities. (Following my internship I worked for Denver for six years in the research and evaluation department of the mental health program.)
Though there was little overlap in staff between the jails and the mental health program (pretty much just Dr. Swank and myself), their respective tracking systems were independent. The Sheriff’s Department who operates the jails certainly knew when inmates were in their facilities, and the mental health program closely followed patients using their services. In the case of Eric G. we followed him from patient to prisoner and back again over a several month period of time. What we found actually came as little surprise, but does exemplify the issue at hand.
Eric G. the inmate:
The inmate is a 220 pound 34 year old white male, previously diagnosed as psychotic, who was brought in to the County Jail last night. It seems that Eric G. was insistent about meeting with the Mayor at the City and County Building at about 2:15 a.m. The Denver Police intervened, arresting him, removed him from the building and transported him to the County jail.
As he is known to the jail personnel from several prior terms at the jail, he is placed in a special individual cell in the infirmary where there is 24 hour direct observation. The cell is a floor-flush, and as such, has only a mat on the floor and in one corner an opening in the floor with a wide grate on top, and some toilet paper. When the facilities are used the inmate knocks on the door and a Deputy Sheriff steps on a flush mechanism on the floor just outside the door. The door on the infirmary cell is solid on the lower half and a tight mesh screen at top to facilitate uninhibited observation. While this cell may sound Spartan, it is so for good reason. Any bed frame or porcelain fixture easily becomes a tool to harm the inmate or other persons and unchecked running water is a problem.
At morning rounds, starting with Eric G., we find him actively hallucinating and seemingly oblivious to all around him. He is finger painting in the only materials available to him. We call to him several times and he finally responds by taking a handful of his finger painting material and presses it vigorously through the screen. He becomes greatly agitated. The trustee, using tempered water from a connection in the shower, hoses the cell and Eric G. down from outside the cell. Eric G. is somewhat less agitated and actually seems to be calmed by the water.
Our records show that Eric G. tends to be very aggressive and uncooperative with men; male doctors, deputies, other prisoners - it doesn’t really matter. With women (the female doctors and nurses), however, he is compliant and docile. (Of course there are no female prisoners or deputies in the men’s side of the jail.) The prisoner’s chart shows that even extreme doses of oral anti-psychotic medications have an imperceptible effect. Injected anti-psychotic medications are also similarly ineffective. Nonetheless, prescribed medications can be successfully and uneventfully administered by a female care provider.
Eric G. has periods of lucidity where he is aware of where he is, and vaguely cognizant of what transpired that brought him to jail. He is usually remorseful, thankful for the “three hots and a cot” but fervently wants to be released. On those particularly rare and short lived occasions where Eric G. manifests some semblance of sanity he remains relatively unable to participate in his defense, or, for that matter, his life. Eric G. is always represented by a Public Defender.
Eric G’s typical path through the jail system can take him to short term or long term involuntary psychiatric commitment, court ordered outpatient care, halfway house, private care giver (though uncommon as Eric G. does not have funds for such), or simply be released (with or without bail) awaiting a court date. Serving an actual jail sentence has previously been, and would likely continue to be, markedly unsuccessful and fraught with peril for all involved.
The jail was simply not equipped or staffed, nor a suitable venue, to provide intensive psychiatric care to inmates. A jail’s first priority is, quite understandably, security.
Eric G. the mental health patient:
Within hours after release from jail, with injected anti-psychotic on board and a counseling booster, a prescription for oral medications and a court-ordered appointment at the mental health outpatient facility, Eric G. apparently decompensates, comes to the attention of the police as either incapacitated or an apparent danger (though no actual crime) and is brought to the psychiatric emergency room for evaluation.
Being well known to the mental health center, if he presents as he usually does (agitated and hallucinating) he typically earns a 72 hour stay in the inpatient ward. With improvement, he can be released to the outpatient center. With no improvement, he can be held longer, but that then triggers another path through the court system. Ultimately the court can rule on a long term involuntary commitment at a State facility.
On infrequent occasions when Eric G. actually enters outpatient or half way house treatment, he is usually seen multiple times a week in an effort to maintain his fragile hold on reality. When the inevitable decompensation occurs, it’s back to the psychiatric emergency room, the inpatient ward, and all too often , the courts.
When we reviewed all of Eric G’s contacts with the mental health program and the jail for a six month period we found that there was hardly a single day that he was not in jail, a mental inpatient, a medical inpatient (from injury), and alcohol detox inpatient (though he rarely used alcohol - but when found incapacitated outside a bar...), in the psychiatric emergency room (most commonly, but not exclusively, on weekends), or receiving outpatient contacts.
It has been 35 years since Dr. Swank and I were drawn into Eric G’s sad orbit one can only wonder where he is now.
As a society that does its best to discharge its obligations to its citizenry, our treatment of the chronically mentally ill still falls, all too often, to the legal community rather than the psychiatric community.
I felt compelled to write this article now, at the 20th anniversary of Glenn’s passing. Still, today I recall his humor, intelligence, and compassion. These traits helped his sons grow to be fine men and helped me teach my beautiful now grown children the same.