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

1. Solitary Confinement of Prisoners with Mental Illness:Litigation and Lessons Learned Academic and Health Policy Conference on Correctional Health Chicago, Illinois March 22, 2013 James F. DeGroot, Ph.D. Katherine L. O’Neill, 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

2. Solitary Confinement of Prisonerswith Mental Illness • Background Litigation (15 minutes) • James F. DeGroot, Ph.D. • Lessons Learned • Katherine L. O’Neill, 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)

5. 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.”

8. 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.

9. 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.”

10. Lessons Learned:The Massachusetts Department of Correction’s 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. O’Neill, LICSW Director of Behavioral Health Massachusetts Department of Correction Katherine L. O’Neill, 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

12. 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

14. 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.

15. Massachusetts's SMI Definition

16. 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

17. 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

18. 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

19. 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

21. Applying the MH Classification System

22. Massachusett’s Numbers*January 2013

23. Massachusett’s Numbers

24. Massachusetts's Needs

25. Developing our Alternative Units

26. Why CQI should NOT be an afterthought

27. Monitoring Performance

28. Collecting Meaningful Data

29. In the Headlines

30. 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

38. ITU Outcomes*May-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

39. Truly a Team Effort! Special Thanks to the following: -The Commissioner’s 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.

40. 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 offenders—the “Hannibal Lecters” of MO

42. 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?

43. 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.

44. 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 Committee—Unit 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 restrained—but 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 initially—offenders 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 it—the ice was broken

50. Next Steps • 3 months into the program, staff began discussing incentives for offenders—needed 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”