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Desiree Fischer, a med tech at the Androscoggin County Jail in Auburn, wheels a medication cart down the hall on Wednesday. Between 30 and 61 percent of Maine?s 1,774 county jail inmates were prescribed at least one psychiatric medication, according to a survey conducted by the Bangor Daily News in August (Troy R. Bennett | BDN).

STATEWIDE (BDN) — A Maine judge makes the unprecedented decision to forcibly medicate a murder suspect with antipsychotic drugs. A violent, severely mentally ill patient is shipped to state prison after twice attacking staff members at Riverview Psychiatric Center.

Now Gov. Paul LePage, besieged with troubles at Riverview, has plans to send even more violent patients to prison, and proposes to spend millions to convert the prison facility in Windham to house mentally ill inmates.

These headlines point to a much deeper crisis in Maine. After a well-intentioned move decades ago to shift the care of the mentally ill away from psychiatric institutions, many Mainers can’t find adequate care in their communities. They still end up institutionalized but now it’s behind bars.

The ranks of inmates taking psychiatric medications in Maine’s jails and prisons today once would have filled the state’s largest hospitals for the mentally ill.

Between 30 and 61 percent of Maine’s 1,774 county jail inmates were prescribed at least one psychiatric medication, according to a survey conducted by the Bangor Daily News in August. About a third of the 2,223 inmates in state prisons were taking drugs to manage their mental illness. At the Intensive Mental Health Unit at the state prison in Warren, all inmates were medicated at the time of the survey.

The figures are even higher at Maine’s now consolidated youth corrections facility. More than half of all juvenile offenders, or 79 of the 127, took medications. Many of them are at high risk of returning to the prison system as adults, still in need of mental health treatment.

As high as those percentages are, they underrepresent the real population of inmates with mental illness, because the figure is nearly impossible to nail down.

County jail and corrections officials broadly agree that the rising volume of mentally ill patients is untenable. But counting prescriptions offers only a point-in-time snapshot of the problem. It also fails to account for offenders who are undiagnosed or have mental illnesses that don’t require medication, or varying, facility-to-facility policies for dispensing medications.

Inmate advocates also contend that budget cuts have spurred jails and prisons to crack down on taxpayer-funded prescription drugs, leaving some prisoners unmedicated.

Penobscot County Sheriff Troy Morton said many of the people walking through his jail’s doors are undoubtedly experiencing a mental health crisis, whether they have an official diagnosis or not. The need burdens everyone it touches from the sick individual to the law enforcement official apprehending them, from the jail taking custody to the taxpayer picking up the tab.

“There was a day when if a person was on the street yelling and screaming, [police] didn’t know what to do with them, so they were charged with disorderly conduct, end of problem,” Morton said. “But it wasn’t the end of the problem. It was a temporary delay.”

A moving target

After an arrest, inmates typically are asked about their mental health. Most correctional facilities follow National Commission on Correctional Health Care guidelines for initial screenings, which include a questionnaire that asks about current medications and thoughts of suicide.

Jail and prison staff do not make decisions about medical care, including for mental health problems, Morton said. All correctional facilities contract out for those services.

“We are not doctors,” he said.

Screeners review the questionnaire, “triage it, and get them to a provider” if the inmate is on prescription medications when they enter jail, said Geoffrey Archambeau, CEO of Correctional Health Partners, a Denver, Colorado-based company that contracts with the Penobscot County Jail, the Kennebec County Jail and other facilities throughout the country.

If an undiagnosed person is in crisis, they are directed to a medical provider who can prescribe medications, if warranted, according to jail officials from across the state.

“Usually they have committed a crime due to not taking their medication,” Knox County Sheriff Donna Dennison said in an email.

One reason the state has no current count of inmates with mental health diagnoses is because “it’s not a searchable thing” since each jail uses a different computer management system, Archambeau said.

“Here’s the problem: Nobody has real numbers,” Morton said.

While the state has one centralized administrative system for all its facilities, called CORIS, it does not allow prison or Department of Corrections officials to query inmates’ mental health records because of medical privacy laws, according to Deputy Commissioner Jody Breton.

Only the department’s contracted medical provider, Correct Care Solutions, can search those records. John Newby, Correct Care regional vice president, found that in 2015, around 48 percent of juveniles and 34 percent of adult inmates were prescribed psych medications.

“For the State of Maine, we are actually below the national averages on prescribing of psychotropic medication,” Newby said in an email to Breton that she forwarded to the Bangor Daily News.

Many inmates diagnosed with mental illness also have developed drug dependency from “self-medicating,” according to Morton.

That often leaves jails serving as their region’s largest detox and mental illness crisis centers, he said.

“My question is: Is that what corrections is supposed to be about?” said Morton, who started as a corrections officer in 1988. “Is that really how we should be treating people with mental illness and substance abuse? To me, this is really an expensive way to do it.”

Cost pressures

Jails and prisons often fail to identify inmates with mental illness, according to an April 2014 report by two Texas doctors. Published in the American Journal of Public Health, the study examined a nationally representative sample of U.S. prisoners, finding that more than half who were taking medications for mental health conditions upon arrival failed to receive the drugs after incarceration.

“This lack of treatment continuity is partially attributable to screening procedures that do not result in treatment by a medical professional in prison,” the report states. “This treatment discontinuity has the potential to affect both recidivism and health care costs on release from prison.”

Joseph Jackson, who formed the Maine Prisoner Advocacy Coalition upon his release from prison two years ago, says many inmates go without drugs they need or receive “cheaper” substitutes.

When he was arrested for shooting another man in 1995 and locked up in county jail, Jackson was taking medication for depression.

“I was on one treatment going in and they got rid of that,” said Jackson, who was the triggerman in a drug-related slaying in Lewiston on Easter morning 20 years ago that left one man dead. “It doesn’t matter if you’ve been on one [prescription] for 20 years and it’s been working well. They say it’s because doctors on the outside are manipulated.”

When he was eventually convicted of manslaughter later that year, Jackson entered the state prison system. Again, his prescription for depression changed.

“They gave me amitriptyline,” Jackson said. “That is how, mostly, they dealt with us. They gave it away back then.”

But today, the cost of medications has changed how correctional facilities dispense them.

“It depends on what those pills cost,” said Jackson, who started a chapter of the NAACP and earned a college degree while behind bars. “They’re going to give you the cheapest pills.”

Providing substitute medications may help county and state pocketbooks, but Jackson describes that approach as an injustice against inmates.

At the Cumberland County Jail in Portland, inmates formerly received psychiatric medications upon request. But in 2011, the jail changed its policy “to only giving the medications when the inmate comes into the jail taking the medications and after being verified,” Cumberland County Sheriff Kevin Joyce said in a recent email. “Or, when the doctors and/or psychologist believes that the medication is necessary.”

That change saved the jail thousands of dollars per year on medication costs, he said. Other jails have instituted the same policy.

For his part, Archambeau, the medical contractor for the Penobscot County Jail, disputes the contention that cost drives decisions on which drugs are dispensed. PCJ spends about $40,000 a year close to 8 percent of its $525,000 annual medical budget on psychotropic medications.

Yet costs can vary by facility. What jail and prison leaders say they have in common is that they’re doing all they can to accommodate inmates with mental illness.

Capt. Jeff Chute, Androscoggin County Jail administrator, said he has witnessed the transformation of county jails over the years. He started in law enforcement in 1984, joining the jail in 1995.

“We are de facto mental health facilities,” Chute said. “Sometimes we’re there to stabilize them. In order to prevent recidivism, we try to get them back on their meds.”

The costs go beyond prescription drugs, according to Dennison, the Knox County sheriff. When hospitals are full, jail officials pull double duty.

“We have to have a guard sit one-on-one with this person,” Dennison said. “Sad situation all around, not only for mental health folks but also for jails and officers.”

Fewer beds

The housing of Maine’s mentally ill in correctional facilities may be making headlines today, but the problem dates back decades, according to Sharon Sprague, superintendent of Dorothea Dix Psychiatric Center in Bangor.

Many of the country’s psychiatric institutions downsized or closed starting in the 1950s, under a process known as deinstitutionalization. States intended to care for psychiatric patients in their local communities, but often failed to set up adequate services.

“When you consider we had 1,200 patients in 1970 and are down to 40 patients today, it says a lot,” Sprague said of Dorothea Dix, which opened in 1901 as the Eastern Maine Insane Hospital. “Our capacity, if we were to fill all the units, is 51. That has been a huge change.”

Riverview opened in 2004, replacing the Augusta Mental Health Institute, which began in 1840 as the Maine Insane Hospital. Riverview has dual roles: to treat violent offenders and to assess those charged with crimes to determine whether they understand the charges and are competent to stand trial.

Among the patients housed there today is Leroy Smith, who made headlines earlier this month after Kennebec County Superior Court Justice Donald Marden issued an order authorizing the state to medicate him for six months against his will in an attempt to restore his competency to stand trial.

Smith was charged on May 6, 2014, with killing and dismembering his father, 56-year-old Leroy Smith II, and initially was found not competent to stand trial. He is now receiving psychotropic medication and will return to court in April.

Meanwhile, Riverview is fighting a 2013 decertification for poor patient care, which resulted in $20 million in forfeited federal Medicaid funding.

LePage has said his plan to modify the Windham prison for mental health patients will help get Riverview recertified.

At its peak, Riverview had a capacity of 1,500.

Today, Maine has just a fraction of that number, with about 270 psychiatric beds statewide. Riverview accounts for 92 and Dorothea Dix has 51. The other 127 beds are split between Acadia Hospital in Bangor, Spring Harbor Hospital in Westbrook, and eight community hospitals that all limit patient stays to 30 days.

That’s rarely enough to accommodate the need, experts say, even with Spring Harbor planning to reopen a dozen psychiatric beds after the recent award of $420,000 in state money. Such shortages are a problem in Maine and throughout the country, said Jenna Mehnert, executive director of National Alliance on Mental Illness in Maine, who came to Maine after working in Pennsylvania and New York.

“There aren’t enough psychiatric beds. And sometimes when officers need to divert a person to the hospital there is no room, and they end up back on the streets in jail or the emergency room,” she said.

Just compare the number of people in mental health institutions back in the 1970s to the populations in homeless shelters today, said Shawn Yardley, Bangor’s former director of health and community services.

“It’s an incredible correlation it’s the same number of people. What we’ve done is move the need for that comprehensive service from mental institutions to homeless shelters, not very successfully and not in the best interest of anybody,” he said.

Changing philosophies

In the past, the philosophy in prisons was to keep inmates with mental illness quiet until they completed their sentence, according to Dr. Dan Bannish, a psychologist at the state prison’s Intensive Mental Health Unit. Now prisons are treating the illness, he said at the unit’s opening in February 2014.

“It’s not a hospital. It’s an intensive mental health unit,” Corrections Commissioner Joe Fitzpatrick said in December. “We really did want this for treatment purposes, not for management purposes. It’s a critical piece and it’s probably the most challenging piece.”

A total of 70 inmates 39 from the Department of Corrections, 29 referred by county jails from across the state, and two from Riverview had been treated in the unit as of the end of January.

The number of suicidal behaviors has dropped considerably and self-abusive incidents among inmates in the program have fallen dramatically, he said.

Maine’s county jails also have made changes.

Aroostook County has a mental health nurse practitioner to screen every inmate’s case, said Sheriff Darrell Crandall.

Penobscot County Jail works with Acadia Hospital, which provides clinical services, including two hours of psychiatric services, each week.

Cumberland County Jail has two social workers and Androscoggin County Jail added a full-time social worker who helps inmates transition back into society in an effort to prevent recidivism, Chute said.

“We had to give up some positions for that,” he said. “It was extremely necessary.”

Chute, Crandall and Morton said law enforcement officers also have learned new ways to deal with people suffering from mental health problems.

The Portland Police Department has developed a specialized behavioral health response program, employing a special liaison who goes out on calls whenever mental illness is identified. The liaison also follows up with patients, conducts referrals and serves as a conduit between the department and behavioral health providers.

Mehnert said other departments should follow Portland’s lead.

“We expect [law enforcement] to be social workers, and it’s really not fair, and when they fail we demonize them,” Mehnert said.

The National Alliance on Mental Illness Maine has spent years offering crisis intervention training to law enforcement and emergency responders from all over the state. Every police academy cadet in Maine also goes through that training, along with mental health first aid.

“A lot of this is educating the officers on the street trying to make sure [they can] identify if somebody is in mental health crisis or needs to be incarcerated for a crime,” Mehnert said. “I think that is a crucial thing.”

A smooth transition back into society is key to preventing criminals from reoffending, experts said. But those who are prescribed medication often struggle to pay for their drugs without a job or insurance coverage.

Most jails have transition programs in place, but funding for them often falls short of addressing the multiple factors that affect inmates’ success on the outside, Morton said.

“It’s crucial because if we only set up the mental health part of it, yet they don’t have housing, or they don’t have food or transportation, we’re setting them up for failure,” the Penobscot sheriff said.

“This is not a county jail issue,” Morton said. “It’s a societal issue.”

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AUGUSTA, Maine — Inmates in Maine’s state prisons are more likely to be sexually assaulted than those in most other correctional facilities around the U.S., a recent Department of Justice report suggests.

The Maine State Prison in Warren was one of eight facilities from among 463 visited by Department of Justice officials in which the rate of sexual assault was significantly higher than the national average. Those assaults, according to DOJ, are perpetrated by other inmates and prison staff.

State prison officials are working to change that poor record in response to the federal Prison Rape Elimination Act, or PREA, of 2003, and to a report prompted by the law earlier this year that featured survey data of 81,566 inmates nationwide. Also, in May, the Obama administration began pushing a zero-tolerance approach for sexual assault in prisons.

Inmates at the Maine State Prison and the Maine Correctional Center in Windham were surveyed between 2007 and 2009 for the report.

In the 2007 survey at the Maine Correctional Center, 173 of an estimated 650 inmates were asked about sexual assaults and unwanted sexual advances, responding using a computer touch screen that maintained confidentiality. The overall rate of sexual assault — including inmate-on-inmate, staff-on-inmate and inmate-on-staff — was found to be 5.6 percent, compared with a national rate of 4.5 percent, according to Allen Beck, senior statistical advisor at the federal Bureau of Justice Statistics.

“If the data are restricted to inmate-on-inmate sexual victimization,” Beck reported, “the Maine facility rate was 4.4 percent, compared with a national rate of 2.1 percent.”

The 2008-2009 survey of 143 of about 950 prisoners at the Maine State Prison found an overall rate of 9.9 percent sexual victimization rate. The corresponding national rate was 4.4 percent, Beck said. If limited to inmate-on-inmate assaults, the rate at the facility was 5.9 percent, compared to a national rate of 2.1 percent.

Beck said both surveys were found to have high rates of statistical accuracy. Comparing the sampling process to a presidential preference poll, Beck said, “This is actually better,” because larger numbers were sampled and because mathematical formulas and historical data confirmed the accuracy.

The survey included 10 questions each for men and women inmates about various sexual acts. Each question started with one of the following two phrases: “During the last 12 months, did another inmate use physical force to make you …?” or “Did another inmate, without using physical force, pressure you or make your feel that you had to …?”

The survey found that nationally, most sexual assaults occurred in the first 24 hours of a victim’s incarceration and occurred between 6 p.m. and midnight.

Corrections Commissioner Joseph Ponte, who has been overseeing state prisons in Maine since 2011, said he had not been able to review the raw data that came from the inmate surveys conducted in Maine.

“I don’t know if it’s accurate,” he said of the DOJ report. “You just have to take the data for what it is.”

In Maine, any sexual contact between inmates and between staff and inmates is prohibited, and officials assume any such contact is not consensual. Maine also does not tabulate complaints from inmates of sexual assault at the hands of other prisoners or by staff, Ponte said, nor does it keep easily retrievable lists of criminal charges that followed such complaints.

“We’re just not collecting data in a sophisticated way,” he said, “but we probably should.”

The commissioner also noted that there is a range of complaints. Some fall into the petty category, he said, such as when an inmate claims a guard groped him during a pat-down search.

Better data will come as part of a $545,000 PREA grant to the state, Ponte said.

The grant is paying for a PREA coordinator at the Corrections Department, new information technology infrastructure and software, an outside consultant to review the culture at Maine State Prison to bring it into compliance with PREA, and a screening process which Ponte hopes will identify likely perpetrators and victims when they enter the facility, thereby allowing administrators to house them accordingly.

All states have until August to comply with PREA.

“Ten years ago, it was an untalked about topic,” Ponte said of rape in prison. Many prison officials viewed it as an inevitability, and incidents often were not reported. In those days, he said, “An assault was an assault,” and so a punch was not differentiated from a sexual attack.

That attitude changed with PREA, he said.

“It’s clearly an area that we’ve put a lot of attention and focus on,” he said, and improvements will come.

Stan Moody, who served as prison chaplain at Maine State Prison from 2008 to 2009, paints a different picture.

Though he gives Ponte high marks for making changes in the culture by moving staff and prisoners to different parts of the facility, Moody described a system he likened to “a mini Mafia.” Inmates were beholden to some staff members as their “kids,” and lower in the hierarchy, inmates were beholden to other inmates as their “kids.” Sexual favors and drugs were the currency in this power structure, he said.

Moody said prisons are “a hormone factory,” and that sex, both consensual and nonconsensual, “may not be tolerated officially, but it’s going to be a regular feature of prison.”

“The DOC has a zero-tolerance policy regarding sex, but that defies reality and really amounts to a zero-tolerance policy of dealing with sexual assault — the three-monkey defense of hear no evil, see no evil, speak no evil,” Moody said.

When pressed for specifics, the former chaplain said that during the time he was at the prison, no inmate filed an official complaint about a sexual assault. Moody said that was because assaulted inmates feared retribution from other inmates or guards. He stressed that he would warn inmates for their own protection that if they reported a sexual assault to him, he was obligated to report the incident and the name of the complainant.

“Virtually all of the reporting that I received had to do with physical and emotional harassment and guard complicity with harassment,” he said. “Sex could very well have been part of that harassment, but if so it was not mentioned. … What that tells me is that sexual assault is an accepted part of prison life and buried.”

Ponte declined to comment specifically on Moody’s claims because he was not commissioner during the years Moody worked at the prison, he said. But he cast some doubt on those claims based on his contact with inmates and their families.

“I think the place was much different when [Moody] was there,” Ponte said. “I take 10-15 calls a day and I get 10-15 emails a day from families,” and in his nearly two-year tenure, no one has reported a sexual assault.

“I talk to family members, I talk to inmates,” he said.

Now, any complaint of sexual violence from an inmate is required to be passed up the chain of command. “That goes right to the warden,” Ponte said, and an investigator is assigned to the case. The perpetrator is removed from the general population.

With the federal PREA grant, a special telephone number on a phone in the prison’s day rooms can be accessed by inmates to make complaints of sexual assaults. The calls will be monitored by the PREA coordinator hired through the grant, the commissioner said.

“We established a security team at Maine State Prison,” Ponte said, which identifies sexual predators and drug dealers. “We have a very good handle on who’s in those categories.”

Two important keys to changing the culture, the commissioner said, are training and hiring practices. Ponte wants to raise the employee screening process to that used by the Maine State Police, which employs polygraph tests and psychological profiles to ensure good hires.

Last month, the Corrections Department published a request for proposals to develop an inmate screening process. A $75,000 grant, created with federal funds, will go to the winning bidder, expected to be announced next month. The work must be completed within six months and the state must be in compliance with the federal law by Aug. 20, 2013.

Once developed, the screenings will be conducted at the Maine State Prison, the Maine Correctional Center, the Mountain View Youth Detention Center in Charleston and the Long Creek Youth Development Center in South Portland.

In Maine, there are just over 2,000 adult prisoners in the state facilities and about 200 under 21 in state facilities.

The department is not limiting the bidders for the grant to any particular kind of organization, though psychiatric research centers and institutions of higher learning would be likely groups to respond, according to the Corrections Department’s Michelle Urbanek, who has been named the state’s PREA coordinator.

“Nobody has been able to form [an effective] screening tool yet. We’re hoping someone out there can help,” Urbanek said.

Judy Plummer, a Corrections Department spokeswoman, said two or three states had developed their own screening process, but when they were applied to Maine prisoners, nearly everyone was identified as either a potential perpetrator or victim, rendering it useless.

If potential perpetrators and victims can be identified, Urbanek said, “It’s going to help us know where to house them. It will help us fit them appropriately.”

Urbanek said information generated by a screening tool also would help medical and mental health staff in prisons.

Not everyone sees the screening as innocuous, though.

Judy Garvey of the Maine Prisoner Advocacy Coalition said her group wholeheartedly supports the goal of eliminating sexual assaults in prisons. But she worries that an incoming prisoner’s criminal history might unduly affect the screening, and that the process may be too subjective, resulting in curtailed civil liberties.

“Our concern is that the screening can cause problems that are not there,” Garvey said.

“It’s a problem in all prisons,” she said of sexual assault, the result of “putting together hundreds of people” without adequate outlets.

On TV and in movies, rape in prison is often a punchline to a joke, the DOJ report notes.

“But sexual abuse is never a laughing matter, nor is it punishment for a crime,” the report asserts. “Rather, it is a crime, and it is no more tolerable when its victims have committed crimes of their own.

“Prison rape can have severe consequences for victims, for the security of correctional facilities, and for the safety and well-being of the communities to which nearly all incarcerated persons will eventually return,” the department concluded.

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Political Prisoners

Welcome to the blog from inmates of Maine's jails and prisons.

In collaboration with the Holistic Recovery Project, the Political Prisoners Blog provides a prisoner's view into what's happening at Maine's correctional facilities.

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