Toersbijns: Criticisms of Mental Health Treatment of Inmates at the ADC.

SOS DOJ: CRIPA AZ State Prisons
(Dodge Theater, Phoenix. Halloween, 2010.)

As some of you may have noticed, I've had a number of posts lately by former Arizona Department of Corrections' Deputy Warden Carl Toersbijns (ASPC-Eyman), most of which are pointedly critical of the ADC's high suicide rate under Director Chuck Ryan and its mental health programs, or lack thereof. Follow the link below and you can view and download the department's official response to Carl's advocacy (sorry, it took me awhile to figure out how best to get people access to a PDF from here, which is the only form I have this in).

I've also embedded a link to the document in the side column.


"Response to Criticisms of Mental Health Treatment
of inmates in the ADC."
(March 18, 2011)

Carl's response is as follows.
I'll let both his and the preceding documents speak for themselves, for now.

-------------------

Open Letter to the Arizona SMI Commission – Arizona Prisons

Carl Toersbijns

Response to document written by Deputy Director Charles Flanagan and Dr. Ben Shaw on March 18, 2011, related to maximum custody inmates and their mental health treatment needs. The following is submitted for your own information so you can be informed of the rationale behind the position paper written to enhance mental health treatment in the ADOC. It appears my criticism has created a need to defend current practices when in fact, my criticism was merely a vocalization of matters observed and experienced inside the Arizona prison system from 2005 through 2010.

Issue:

It is logical to agree that “there is overwhelming research” in the “scientific literature that mentally ill persons are no more likely to be violent or to commit crimes than are non-mentally ill persons.

Response -

	Population	Violent offenders	Non-Violent Offenders
February 2011	40,930	27,950	12,980
Per cent of population GAC 1/2011		68 %	32 %
Persons in Maximum Custody Count sheet 2/2011	3744	2546 (68%)	1199 (32%)

The rationale used to illustrate the violent properties within such a prison setting is based on the fact that in the Arizona Department of Corrections reports and statistics they report in their February 2011 Glance at Corrections report the system housed 27,950 violent offenders compared to 12,980 non-violent offenders. This relates to the prison population being 68 % violent and 32 % non-violent. This can best be compared to 7 out of 10 inmates in Arizona prisons are violent offenders regardless whether they are mentally ill or not. This is a fundamental dynamic in Arizona prisons.

Under the present conditions inside prisons, it has been documented that almost 7 out of 10 are already violent and with the influx of many more such individuals coming in with a ratio of 9.3 to 1 person that is housed inside a state hospital for treatment. It is highly likely that some level of mental illness is associated with the individual in question as they arrive into the system. Therefore, this is not just a perception but facts supported by the agency’s own statistics of violent and non-violent offenders housed in their prison system. This was established by the Treatment Advocacy Center report March 2010. [1]

However, as a new commit the stress levels to cope and function within such a predatory world is extreme and pushes many to high levels of anxiety creating a coping problem for many. 99 % new commitments and many of the repeat offenders are required to show their paperwork to live on a general population yard whether sex offender or not, this practice is established by those who have a gang mentality and operate their own race’s desired placement practice not addressed by the administration.

This may result in a 70 % chance of this inmate to receive a ticket for misconduct or other “manipulated efforts” to be removed from the general population and temporarily placed in detention where they must heighten their coping skills as they are mixed with many behavioral inmates awaiting disciplinary sanctions or a transfer to a higher custody. One must be aware that as the custody level rises, so does the propensity for violence for the individuals housed there. This is a fundamental dynamic of prison. Whether the threat is perceived to be real or not, these inmates are scared and want to leave the yards thus they refuse to house. This results in a disciplinary action [in fact repeated misconduct] and ordered to house every other day to go onto the yard making them subject to further disciplinary action elevating their classification scores once minor tickets are elevated to a major ticket due to repetitions of infractions.

This has resulted in three things.

1. Staff assaults,

2. Inmate on inmate assaults

3. Requests for protective segregation.

So you see by using these “manipulation tools” mentally ill inmates as well as non-mentally ill inmates created a route that may take them to maximum custody. Herein are two problems the administration is not able to cope with effectively.

* The first stigma is a refuse to house inmate or RTH is considered to be manipulative by all staff including treatment staff. These groups of inmates are stereotyped into one group to show their reluctance to house on a particular yard and asking for a transfer. These inmates are subject to harsh treatment by the deputy warden of the unit who has been instructed to get these RTH numbers reduced and find a way to house them regardless of what the reasons are other than DO 805 issues that require immediate segregation into a detention unit pending the process. This is a fundamental dynamic in prison.

* The second stigma is the fact that mental health providers feed into this “manipulation” scheme by security and administration thus fail to follow up specific individual needs that may impact their personal safety and why they took the course to manipulate this removal off the yards writing it off as a manipulated effort to move.

The comment that “mentally illness can be present in individuals who exhibit criminal behavior – as diabetes or hypertension can – but generally unrelated to the motivations for this behavior. One must qualify that statement with the ambience this research was conducted as inside a prison such as the ADOC, it has already been established statistically, the nature of the correctional setting is both violent as well as associated predatory behaviors not likely to be found in such great numbers out on the street or community. It is reasonable this predatory environment requires a discriminating level of awareness to remain safe among those who are not mentally ill. This is a fundamental in prison.

Therefore, although I may agree that mentally ill persons are not particularly violent or antisocial when placed or housed within an uncontrolled environment that presents perils and dangers of personal harm and extortion, the mere fact that the majority of persons locked up with these mentally ill inmates are violent creates a domination factor that can’t be ignored.

Issue:

“Recent writings and presentations have suggested that inmates who are mentally ill are likely to be placed in maximum custody because they are ill and exhibiting symptoms of a psychotic disorder” is misleading or misinterpreted by the reader of the position paper. One must realize the history behind the recent high influx [beginning in October 2009] of maximum custody inmates who were formerly held at complex detention units based on bed space available at the SMU’s and Florence. Although the number of inmates has been reduced significantly by the current administration, the movement is still high and with it results the placement of mentally ill inmates inside maximum custody units needing treatment and alternatives to program under the ADA act.

Maximum custody population October – 2009 – 4,091 inmates in Level V and detention

Maximum custody population January - 2010 – 4,052 inmates in Level V and detention

Maximum custody population January - 2011– 3,744 inmates in Level V and detention

	Population	Inmates receiving Mental Health Treatment	Seriously Mentally Ill
Arizona Dept. of Corrections	39393	9733 (25%)	1350 (3.4 %)
Inmates in Max Custody[2] (including detention and Intake)	3744 (10.52%)	1123 (30%)	337 (3.7%)
Maximum Custody totals for SMU I and Browning	1891	581 30%	70 (3.7%)
Number of inmates in Max Custody not receiving the status of being SMI		(267)	(23.7 %)

The impression behind this conclusion was the various chasms or gaps that exist throughout the agency that demonstrates staff are ill prepared to handle or manage the mentally ill or others with learning disorders. The message in training of line staff to understand a mentally ill inmate and not misinterpret his or her actions as a disciplinary matter has not yet been endorsed by a culture that “treats every inmate the same” regardless of their status especially inside a detention unit or maximum custody facility. Records will reveal that inmates who are mentally ill are often written up for misconduct related to destruction of property or even to the extent of harming themselves without understanding the recourse available and due process unless offered an advocate of liaison that can mediate the actions observed and resolve it in a most therapeutic manner. This is a fundamental dynamic.

This mechanism of not treating the mentally ill with deliberate indifference does not yet exist universally within the agency and must be created to reduce the number of inmates housed in more restrictive housing because of repetitive misconduct that was misunderstood or “manipulated” to create an action that would keep an inmate safe. Wherever mental health is involved in such treatment of disciplinary cases, the inmate is cleared of misconduct that could result in a higher classification based on institutional disciplinary history and recommendations for supervisory changes. Therefore, mental health providers must explore this avenue of “manipulation” to find the truth and exact reason for the inmate’s refusal to cooperate that often results in three dynamics that are common. Suicide threats associated with the discontinuance of their prescribed medication and grievances that will not be finalized before they are either moved to an alternative housing e.g. detention or another yard. This is a fundamental dynamic in prison.

My position paper on mental health issues is based on inmates placed in maximum custody that includes detention units at all units statewide. One can calculate the number of beds used for such interim level V placement as many fall under four categories. They are:

1. Disciplinary – assaultive behaviors, theft, RTH, etc
2. Protective Segregation – nature of crime, witness, debriefing STG etc.
3. Pending criminal investigation – various criminal charges
4. Transient waiting for a bed or movement out of the unit (detention units are used for this purpose and at times, there are up to three inmates inside a cell designed for two creating an even more stressful living environment while waiting for adjudication of the report, movement to an alternative housing or awaiting a criminal procedure.)


One must include these beds when you configure the number of inmates in maximum custody as well as the maximum custodies in Florence Central unit and the female maximum units. Secondary, a number of suicides have occurred within these detention units and to not include them will alter the perception that maximum custody is not used as an alternative housing for those reasons mentioned above. Otherwise the total numbers of inmates housed in maximum custody are not accurate and only reflect the partial housing of maximum inmates at two locations when in fact maximum custody exists at almost all statewide units through the mere existence of detention units holding inmates for the various reasons already outlined. This creates a tremendous burden on mental health staff assigned to the smaller or more remote units as they are ill prepared to deal with such offenders at such high numbers and deal with general population inmates. This is a fundamental dynamic in prison.


Thus when the agency re-configures their total number of inmates held in maximum custody [including detention where there are high risks for suicides], these figures will reflect a higher percentage of inmates who are receiving mental health treatment inside these level V units versus those required ongoing treatment while incarcerated that is approximately 9,862 inmates during the month of February 2011.

Issue:

One’s inference that “inmates placed in maximum custody may decide to show improved rule compliance and generally improved behavior in order to be moved to lower custody settings and avoid returning to maximum custody” is false and flawed by both perception and reality.


Response –

It would be reasonable to conclude that would be the rationale for any inmate in maximum custody, however, classification dynamics govern custody settings and the override tool used for mental health and behavioral misconduct is used to keep them at a higher level. Second, unless the dynamics that caused them to go to maximum custody changed, they will “manipulate” a way to stay in maximum custody and be released from a level V unit. Some inmates just refuse to house in dormitory or double bunk settings thus prefer the single cell at maximum custody levels. Detention units are the exception as they are double bunked and triple bunked most of the time pre-April 2010. One should check the actual risk assessment scores to reveal this practice of overriding inmates regardless whether mental health or behavioral. Normally, these inmates’ score lower than actual placement. Thus that logic will not work at maximum custody for the large part as the administration deems what inmate goes down on a custody level based on their own risk assessments rather than the evidence based management tool provided by the agency and make a decision based on “knowing the inmate.”

An inmate, regardless whether he or she is mentally ill or behavioral, will not be allowed to be reduced in custody levels as long as they have severe disciplinary records that shows they are poor risks regardless how long ago such an event might have occurred. This is a fundamental dynamic in prison.

As for the comments related to doing better or worse within a program setting or therapeutic environment, it is beyond my qualifications to comment on clinical matters but rather, my approach has always been from the operational aspect of inmate treatment, supervision, classification and behavioral control. This position paper was written from this same position as voicing my concerns for these operational and environmental impacts on security and safety of all.

Issue –

The denial of recreation and showers, basic living conditions important to the inmates is based on two things daily. The first element of a regular day in maximum custody is the occurrence of an Incident Command System (ICS) event that will draw first responders from the entire unit. This interrupts or completely halts these basic services as staffs are unable to conduct their normal duties as they are handling an emergency. Second, these ICS events are frequent enough to interrupt at a minimum two of the five days of the week creating “make up” showers and rec during the weekends. This is a viable option if staff is available and no further ICS event occurs. A contributory fact is since the double bunking at Browning and SMU I, the lack of physical space to follow the required schedule on time thus staff encourages Inmates to “skip” their showers every now and then to get the majority showered. Mathematically, one can’t meet the mandate to shower and rec each inmate per policy and unless there are cancellations, some go without either. I have documentation to show such a shortcoming and welcome the findings submitted to the warden at the time of the study. I also have documentation showing how the unit deputy warden proposes to provide showers and recreation with certain staffing levels that are staged into different levels. This is a fundamental prison dynamic. In a perfect world, this would not be an issue.

Issue:

“Mr. ToersBijns’ writing reflects a misunderstanding of the process used for the few cases in which involuntary medication is being considered. The mental health staff who are involved in the ongoing treatment of such inmates have tried all of the reasonable alternatives before the PMRB is asked to consider involuntary medication.”

Response –

One can pretend that “chemical restraints” are not used. Technically and fortunately, the procedure is very rare and required the approval of a psychiatrist via a telephone call or presence once the inmate has been cleared by the PMRB committee to be sedated or medicated. There have been occasions where an inmate refused to participate with the committee and the majority present, seeing the inmate is no longer able to make good decisions concerning his own health, agrees to medicate and this has resulted in the inmate being strapped onto a gurney and taken to medical to get his prescribed medication or shot. Never qualified to determine such medical condition or psychiatric decision, we followed protocol established and cooperated with mental health and medical staff. It is the question of “tried all of the reasonable alternatives before the PMRB” action is taken since I have observed behaviors by mental health providers that appeared to be futile in efforts and reluctance to deal with. This is fortunately also rare but has occurred thus a reality it exists.

Issue:

“In his most recent writings, Mr. ToersBijns posts two new concerns; increased suicides and increased homicides, as well as the repeated and unsupported allegation that administrative disciplinary charges lead to higher custody levels for inmates with mental health issues already addressed above. These writings attempt to fit some pieces of factual data into what seems to be opinion –based thinking, which draws conclusions to suit a particular position.”

Response –

One needs to glean the individual inmate disciplinary files to show how his conduct, although related to mental health fitness has created a long string of disciplinary actions that do two things; elevate his or her custody levels and takes away time credits resulting in longer serving of the sentences. The commission can go to the website and identify the inmate’s needs at www.azcorrections.gov inmate database, pick out a mentally ill inmate and glean their history of disciplinary, classification actions and time taken to confirm this opinion.

Issue:

“Director Ryan increased the number of security staff in key inmate contact and supervision areas by restoring posts and positions. The data seems to indicate that these initial steps are resulting in positive outcomes.”

The key words are “increased the number of security staff in key inmate contact and supervision area by restoring posts and positions. The data seems to indicate that these initial steps are resulting in positive outcomes.” As you can see by the memorandums attached, there is no “increase of the number of staff but rather, a reallocation of resources to handle one area of the prison and neglecting another area of the prison. This rob Peter to pay Paul is a common strategy to “increase” staffing as well as cross leveling staff whenever they are short on shift creating deep cuts in the shifts of units having to “share” their staff with other units.

Prior staffing practices –

ARIZONA DEPARTMENT OF CORRECTIONS MEMORANDUM

TO: DW C. Lang, ASPC-Tucson, xxxxxxxxxxxx

FROM: xxxxxxxxxxxx ASPC-Tucson,

SUBJECT: Replacement of Zone/Rover Posts at xxxxxxxxxxxx

DATE: 02/01/11

Approximately six months ago, before all the new changes to Winchester Unit, we had 2 yard officers, 4 zone/rover posts and control room officers conducted their own health and welfare security checks.

Now the control room officers can not leave the control rooms and the 4 zone/rover posts have been replaced by floor officer posts that can not be pulled for any reason except for an ICS response. At the same time the yard responsibilities have not changed.

That leaves the 2 yard officers trying to conduct the work of six officers with the assistance of the supervisor(s). Where at times there is only one supervisor on site to run shift which does not allow us to post ourselves without leaving the shift without a supervisor.

The yard officer responsibilities include:

3 exterior perimeters - takes approximately 15 minutes each

3 interior perimeters - takes approximately 30 minutes each

2 interior lock/fence checks - takes approximately 15 minutes each

Hot dinner - takes approximately 2.5 hours

Conducting evening chow (a hot dinner):

There are 4 officers required to conduct chow -

One at the scanner

One at the ticket register

One at the serving window

One conducting random pat searches

Run Sally port gate -

For inmates returning from dialyses 3 times per week that normally come back to the yard during chow, Canteen, and Complex moves etc.

Coordinate all movements on the yard

Conduct security checks of Programs

Cover Medical after hours and from 1500 to 1700 on Mondays

Make up bedding packs for new arrivals

Supply security for the commissary

Conduct Ice call, trash run and Uranalysis

Watch the recreation shack

Transports to West Medical, UPH, and other Units

Pick up and drop off paperwork etc. to the buildings

Observations, Suicide, 805, and Disciplinary cases must be watched continually or temporarily until able to be transported

Strip searching all the kitchen workers prior to them going back to their living area, that requires 2 officers per policy

Per. Department Order 708, Searches:

All inmates entering the programs building are to pat searched

All inmates turning out to or exiting from the recreation field need to be randomly pat searched

All inmates exiting the chow hall need to be randomly pat searched

Per. Policy/Post Orders:

There are to be a minimum of 2 staff monitoring the Recreation field at all times

as well as security checks are to be conducted on the Recreation field.

In comparison, Manzanita Unit has 3 yard officers and their yard is physically half the size ofxxxxxxxxxxx. xxxxxxxxxxx also holds 376 more inmates and feeds a hot dinner where Manzanita feeds sacks for dinner.

Due to the overwhelming amount of stress of trying to get everything done with limited resources, staff moral on all shifts is going down and may have a direct effect on the yard and inmate population.

Inclosing,

For the security and safety of xxxxxxxxxxxx we need to replace the 4 zone/rover posts that we lost.

Looking at the statistics for 2009 there were an average of 29 staff assaults per month and 52 inmates on inmate assaults reported. Gleaning the same statistics for 2010 the data reveals there the average of 28.5 staff assaults per month and 62 inmates on inmate assaults reported. There is no significant drop in suicides or assaults. However, time will tell if 2011 is a better year as it will be monitored for progress.

Per ADOC statistics this averages:


2009 – High = 74 inmate on inmate assaults

- High = 45 inmate on staff assaults


2010 - High = 88 inmate on inmate assaults

High = 35 inmate on staff assaults

ADC ratio of assaults on inmate to inmate = 17.36 Projected for FY 11 – 17.44

ADC ratio of assaults on staff by inmate = 8.83 Projected for FY 11 – 9.50



Issue:


“Picture of maximum custody housing which is quiet disturbing”

Response –

Regarding my “picture of maximum custody housing which is quiet disturbing”, I can only refer to first hand experience inside the special management units that have revealed numerous incidents detailed within this document. As the deputy warden of SMU II aka Browning, I could in fact, go back to my records and request affidavits from both staff and inmates on specific incidents that may have been concluded as abuse if the informal actions taken had not been effective to avoid a repeat incident. One should glean the misconduct tickets written and the number of grievances written to determine if there are incidents such as these actually occurred and do this under oath could reveal more severe abuse such as hazing, water torture, sleep deprivation, deliberate use of chemical agents that are dispersed as staff walk passed the cells, and many other forms of corporal punishment that were corrected but not ignored.

A public records review will glean such behaviors and documented results. One must remember that these actions are of a few and not the majority but if you take the time to look at the disciplinary issued to staff for excessive use of force, unlawful discharge of chemical agents etc you will find a pattern that will support my statement that this does occur as detailed although shocking and disturbing to many. The others, because of a flawed culture turn a blind eye to these occurrences. One must work the place to realize what staff do and don’t do in order to remain safe and in control. You must be there on every shift and every day of the week and weekends to be able to glean such poor correctional practices but as mentioned several times before, a review of all inmate grievances related to their treatment and living conditions can be gleaned from their inmate grievances related for the time period of June 2007 until April 2010.

[1] www.treatmentadvocacycenter. org



[2] One must consider that no matter where the inmate is housed in a maximum custody unit, if they require mental health treatment and observation, they must be given access to these services per ADA.