Funneling the Mentally Ill Into the Criminal Justice System
Funneling the Mentally Ill Into the Criminal Justice System
Without appropriate care, the seriously mentally ill often end up in jails or prisons

POUGHKEEPSIE, N.Y.—Standing in the middle of his prison cell, Masai Giardino Stewart could touch the walls if he outstretched his arms. Throughout the sweltering summer, Stewart was confined in this space for at least 23 hours a day. With no windows, and vents clogged with dust and dirt, Stewart frequently had difficulty breathing. 

The banging and yelling that echoed in the corridors, the constant chaos, made Stewart anxious. He went for days without sleep with frightening flashbacks of trauma from early childhood.

When Stewart was still a toddler, his father used to bathe him and his two siblings roughly. If he squirmed, it angered his father, and his face got dunked under the water faucet. His mom would rush into the bathroom, urging the father to stop, but that inevitably ended up in more fighting, endless fighting.

“He would fight me because he would say I’m interrupting their discipline,” Tami Bell said. No matter how she tried, Bell couldn’t stop the chaos, the constant emotional and physical abuse.

Bell believes that what Stewart suffered, and witnessed, took a toll on his mental health. “The biggest injustices to Masai were what his dad—and I—committed, not getting away from him sooner,” she said.

Tama Bell, with her daughter Eleve Stewart, at their home in Poughkeepsie, New York, on March 31, 2015. (Samira Bouaou/Epoch Times)
Tama Bell, with her daughter, Eleve Stewart, at their home in Poughkeepsie, N.Y., on March 31, 2015. (Samira Bouaou/Epoch Times)

Finally, in 2002, when her son was 10 years old, Bell worked up the strength to drive away with her children to a local domestic violence shelter. But the price she had to pay was leaving her dream job as a microbiologist, both to care for her children, and for fear that her partner might find her at her workplace.

Stabilizing her mental illness by keeping faithful to her therapy sessions and trusting her therapist has allowed Bell to focus her energy on helping Stewart cope with his illness. She knew what it was like living with someone who struggled with a mental illness; her father had bipolar and developed PTSD (post-traumatic stress disorder) after fighting in World War II.

With his mom’s constant support to get treatment and therapy, Stewart has received at least six diagnoses, including PTSD, intermittent explosive disorder, bipolar disorder, and dissociative disorder. The one considered most serious by mental health professionals is bipolar, a condition marked by extreme shifts in mood and energy levels.

Bell especially began to fear for her son when he turned 18 and became a legal adult, meaning she could no longer compel him to get treatment. When he struggled to adhere to treatment on his own, Bell fought to enroll her son into the state’s Assisted Outpatient Treatment (AOT) program, the only way to compel treatment for an adult living in the community.

Masai Giardino-Stewart, shortly before his incarceration. (Courtesy of Tama Bell)
Masai Giardino Stewart, shortly before his incarceration. (Courtesy of Tama Bell)

Her efforts were ultimately unsuccessful though, and Bell was forced to look on as her son’s illness was left largely untreated over the course of the next several years. When he landed in prison, Bell struggled to secure him sufficient mental health care, fearful again that her son’s illness would worsen while in solitary confinement.

Stewart’s life offers a glimpse into how the inadequacies of our mental health system tend to funnel the mentally ill into our jails and prisons. His crime in the first place stemmed from his illness; he punched a delivery man and stole food while he was homeless and off treatment, for which he served six months in jail. When he violated probation terms of attending regular mental health appointments, he landed a longer term in prison.

Stewart’s life offers a glimpse into how the inadequacies of our mental health system tend to funnel the mentally ill into our jails and prisons.
Tama Bell gets emotional as she talks about her son at her home in Poughkeepsie, New York, on March 31, 2015. (Samira Bouaou/Epoch Times)
Tama Bell gets emotional as she talks about her son at her home in Poughkeepsie, N.Y., on March 31, 2015. (Samira Bouaou/Epoch Times)

Our country’s jails and prisons house 356,000 people with serious mental illnesses, such as schizophrenia, schizoaffective disorder, bipolar disorder, major depression, and psychotic disorder, according to a 2014 estimate by the nonprofit Treatment Advocacy Center.

Awareness of the mental health crisis in our criminal justice system has grown in recent years. In the past year alone, cities like Chicago and New York launched new programs to identify and treat people with serious mental illness who are at risk of arrest or jail time. Public attention heightened after The Associated Press and The New York Times exposed the deaths of several mentally ill inmates after they were left unsupervised or beaten by corrections guards.

Stewart’s experience in the penal system is emblematic of how prison staff struggle with diagnoses and care for the mentally ill—where those with mental illness can end up in solitary confinement, despite extensive scientific research on the detrimental mental health effects.

Our country’s jails and prisons house 356,000 people with serious mental illnesses.

His bipolar diagnosis prior to going to prison would have protected him under law from serving time in solitary, but prison mental health authorities did not concur with the prior diagnosis, and he served 3 months locked in a small cell alone.

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All three of Tama Bell’s children: Masai Giardino Stewart (R) at around age 5, Tafari Stewart (C) at around age 7, and Eleve Stewart as an infant. (Courtesy of Tama Bell)

Stewart is now 24. He was released on parole in September 2015 after serving one year and eight months.

When her son was five years old, Bell noticed that he frequently switched from periods of hyperactivity to moments of silence, and he was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). Later, Bell observed that Stewart would get angry easily, and it was difficult to calm him down afterwards. Stewart received early diagnoses for mood disorder, PTSD, and intermittent explosive disorder, according to Bell.

Stewart had his first long-term hospitalization after an incident on the school bus when he was 13. A classmate was making fun of Stewart’s older brother, who has cerebral palsy. So when the bus stopped in front of his home, feeling indignant, Stewart ran in and grabbed a kitchen knife. He then attempted to stab the girl, but she was wearing a heavy winter jacket that protected her from the punctures and she wasn’t hurt.

After this happened, Bell took Stewart to the Four Winds psychiatric hospital in Katonah, New York, where he stayed for a month. Stewart would have twelve more short and long-term hospital admittances later in his teenage years, according to Bell. At Four Winds, Stewart was diagnosed with mood disorder and conduct disorder, according to OMH records, which the Epoch Times obtained with permission.

About a month after the Four Winds stay, Stewart was still being disruptive at home, so Bell took Stewart to Astor Counseling Services, an outpatient clinic where he had received regular treatment, according to doctor’s notes. There, Stewart received his diagnosis for bipolar disorder.

In high school, Stewart’s doctors prescribed him different medications, but there were side effects. Lithium, a medication for treating bipolar, gave him skin rashes. Thorazine, prescribed for controlling aggression, caused weight gain and abnormally elevated liver enzyme levels. Stewart had to discontinue taking them, despite their effectiveness. Stewart also said the medications made him feel sluggish and lethargic.

Despite therapy and some use of medication, Stewart’s condition was difficult to stabilize. He was in and out of hospitals during his final years of high school, admitted for making threats to his family members or violent behavior in school and at home. He spent so much time in the hospital that he had homework and lessons sent to the facility, Bell said.

Turning 18

As Stewart approached his 18th birthday, the age when he would become a legal adult and make all treatment decisions on his own, Bell grew concerned that Stewart would go off treatment and pose a danger to himself and the people around him.

Bell had heard of the AOT program, which allows patients to continue living in the community. Created in 1999 by law, an AOT is a court-ordered treatment plan for qualifying individuals with a violent history or multiple hospitalizations stemming from treatment noncompliance. Depending on the patient’s needs, treatment plans can include medication, therapy, enrollment in counseling programs, and case management. Outside of inpatient hospital commitment, AOT is the only way adults with mental illness can be compelled into treatment.

AOT is the only way adults with mental illness can be compelled into treatment.

Months before Stewart became of age, Bell reached out to AOT coordinators in her local Dutchess County to enroll him. But her application was repeatedly rejected. “They said he ‘wasn’t ill enough.’ Or they said, ‘Yes, yes, he does qualify. But he has an apartment. You have to be homeless.’ When he was homeless, they said, ‘We have to be able to find them.’ They always had an excuse for why they wouldn’t file an AOT,” Bell said.

Meanwhile, Stewart turned to a life on the streets, selling drugs and “hanging out with the wrong crowd,” as he put it. He became homeless, couch-surfing at his friends’ apartments. While adrift, he often witnessed violence in the tough neighborhoods of Poughkeepsie. His good friends were shot and killed. “I was immature and didn’t know what life was,” Stewart said, reflecting back.

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Masai Giardino Stewart (R) celebrates his brother Tafari’s high school graduation, together with their sister, Eleve. (Courtesy of Tama Bell)

Stewart visited his assigned therapist (provided by the county mental health system) to try discussing his trauma, but he said she brushed off his problems. “She didn’t record my stress. She wrote that I was a gang member,” he said.

Studies have shown that poor relationships with mental health providers can lead to people dropping off their treatment, according to the Treatment Advocacy Center. Conversely, a 2013 study published in the “Journal of Clinical Psychopharmacology,” found that a bipolar patient’s positive perception of the relationship, including showing empathy, accessibility, and willingness to collaborate on treatment decisions, was positively associated with medication adherence. 

Feeling like therapy did not help address his mental health issues, he dropped off treatment. He also did not consistently take his medications because they made him feel dull, Stewart said.

Bell appealed to staff, counselors, and therapists in the OMH and her county mental health system to put her son back on track. But Bell said their response was that Stewart did not want the treatment himself, and was thus “hard to serve.” At least six mental health providers and officials at both the state and local county levels told Bell that her son had a better chance of getting help if he committed a crime and went to prison.   

Health authorities suggested to Bell that her son had a better chance of getting help if he committed a crime and went to prison.

She then started drafting letters to every state official she could think of, pleading with Gov. Andrew Cuomo’s office, the OMH, and the state attorney general’s office to allow her son into the AOT program.

Masai Giardino-Stewart, in kindergarten. (Courtesy of Tama Bell)
Masai Giardino Stewart in kindergarten. (Courtesy of Tama Bell)

In an e-mail dated Aug. 2, 2011, Bell wrote to New York Attorney General Eric Schneiderman: “Since becoming an adult he refuses meds, refuses help, does not believe he is sick, and has refused my assistance in getting him the help he needs. Unfortunately, since he has turned legally responsible for his own affairs, New York state and the county have now sat back with the attitude that since he doesn’t want the help there is nothing they can do to make him accept it.”

She requested a chance to meet with him and discuss Stewart’s situation, “so that my son does not fall any longer through the cracks and put himself and all of us at risk.”

Nowhere to Turn for Help

The 1999 law that created the AOT program, known as Kendra’s Law, was drafted after a mentally ill man pushed a woman onto the subway tracks, killing her. The program would secure treatment for people with serious mental illness who could deteriorate if left untreated, while protecting public safety.

According to the latest estimates by the National Institute of Mental Health, about 10 million of the 43.6 million American adults diagnosed with a mental illness have a “serious mental illness,” which the Institute defines as a mental, behavioral, or emotional disorder that leads to impairment of daily functional activities.

The program not only requires the individual to take treatment; it also requires the mental health system to give treatment, and if the patient violates the court-ordered conditions, the person will be brought to a hospital for an evaluation to determine if commitment is necessary.

Prior to the 1960s, the mentally ill were regularly institutionalized at state hospitals. But with the introduction of antipsychotic medication, as well as President John F. Kennedy’s push for creating community mental health programs under the Community Mental Health Act of 1963, the mentally ill were moved out of hospitals. The intention was for people with mental illness to be integrated back into society.

A corrections officer walks in a cell block at Coxsackie Correctional Facility in Coxsackie, N.Y., on Feb. 1, 2012. (AP Photo/Mike Groll)
A corrections officer in a cell block at Coxsackie Correctional Facility in Coxsackie, N.Y., on Feb. 1, 2012. (AP Photo/Mike Groll)

But in reality, funding for mental health services was on the decline. Most recently in New York, for example, the state mental health budget dropped 5.4 percent between fiscal year 2009 to fiscal year 2012, from $3.77 billion to $3.57 billion, according to the National Alliance on Mental Illness. In Poughkeepsie, New York, Hudson River Psychiatric Center, where Stewart was once treated, closed down in 2011 and transferred its patients to other local facilities.

Furthermore, landmark Supreme Court cases like O’Connor v. Donaldson in 1975 ruled that a state cannot confine a patient against his will if he is not an imminent danger to himself or others. Many states today, including New York, have laws that only permit involuntary commitment if the patient will seriously harm himself or others.

In the absence of resources and legal responsibility for assisting the seriously ill, many are left untreated: in any given year, there are about 3.9 million adults with an untreated serious mental illness, according to the Treatment Advocacy Center.

In any given year, there are about 3.9 million adults with an untreated serious mental illness.

Short of inpatient hospitalization (which itself is difficult to obtain), and a nationwide shortage of 100,000 hospital beds, the AOT is often the only safety net available—though there are civil liberties advocates who criticize AOT programs for restricting a patient’s right to refuse treatment.

Studies have shown AOT programs are effective at preventing the seriously ill from having their conditions worsen. A 2010 evaluation of New York’s AOT program, published in the “Psychiatric Services” journal, found that patients with serious mental illness who received services under AOT had arrest rates that were two-thirds lower than those who did not use AOT.

A 2010 study by Columbia University’s Mailman School of Public Health also found that New Yorkers enrolled in AOT were four times less likely to “perpetrate serious violence,” compared to a control group.

DJ Jaffe, a local mental health advocate and executive director of the nonprofit think tank Mental Illness Policy Org., estimates that in New York state there are 8,012 adults with severe mental illness who can benefit from AOT. But, he says the program is underutilized. At the time of writing, there are 2,723 people under court order to be on AOT. 

According to Jaffe, who was part of the coalition of advocates who helped craft the AOT law in New York, federal and state policies prioritize treating high-functioning patients over the most seriously ill because the latter are often more difficult to stabilize. “Getting into AOT is very difficult. The mental health system doesn’t want responsibility for the most seriously ill,” he said.

The New York OMH did not respond to requests for comment on its AOT program or treatment services for the seriously mental ill.

Jaffe’s organization points out how the federal agency charged with improving the country’s mental health services, the Substance Abuse and Mental Health Services Administration (SAMHSA), reviews and certifies intervention programs like couples therapy, anti-adolescent smoking, and therapy for anxiety, while leaving out many programs for the seriously mentally ill, such as crisis intervention training for police officers who encounter the seriously mentally ill, or mental health courts that divert mentally ill people facing incarceration to treatment programs (AOT was reviewed in February this year). States rely on the certifications to receive funding.

Out of the 300-plus programs in SAMHSA’s list of certified programs (called the National Registry of Evidence-based Programs and Practices), less than ten serve people with serious mental illness, according to Mental Illness Policy Org.

Jaffe said the effect of such practices is that most local mental health systems are not proactive in assisting the seriously ill, since they are more difficult to treat than those with less debilitating illnesses. In his years of advocacy, he has observed that parents often find it difficult to secure AOT for their children. “Parents can go to court themselves and put in an AOT petition. But they’ll have to hire a lawyer, and navigate the system—it’s not easy,” he said.

As a result, many of the seriously ill end up in the criminal justice system. “When someone goes to jail, that’s a success for the mental health system, because it’s one less person to treat,” Jaffe said.

When someone goes to jail, that’s a success for the mental health system, because it’s one less person to treat.
— DJ Jaffe, executive director, Mental Illness Policy Org

In Stewart’s case, his mom’s persistence with local authorities had finally won them a verbal agreement from OMH that she could file for an AOT petition, which she promptly did. Unfortunately, the opportunity came too late. Stewart was picked up just two weeks later on a parole violation that resulted in a long-term prison sentence. When Bell later checked on the application, she was told it had not been processed.

Stewart believes the AOT program could have kept him from leading a life on the streets. “I think it would’ve kept me out of prison,” he said.

Inmates walk in a cell block at Coxsackie Correctional Facility in Coxsackie, N.Y., on Feb. 1, 2012.   (AP Photo/Mike Groll)
Inmates in a cell block at Coxsackie Correctional Facility in Coxsackie, N.Y., on Feb. 1, 2012. (AP Photo/Mike Groll)

 

PART II: The Plight of the Mentally Ill Incarcerated

On June 28, 2014, it was dinner time, and Masai Giardino-Stewart was on duty cleaning the mess hall tables in prison. After completing the task, he informed the correction officer. But she wasn’t satisfied and told him to clean the tables again. Stewart refused. That’s when the officer told him to stay behind after everyone else returned to their cells, Stewart said.

The officer gathered a group of about eight to ten other guards, then they proceeded to beat him, according to Stewart. He was injured all over his body, with abrasions on his neck, a nosebleed, and swelling on his head, he said.

But the officer had a different story. She wrote up an “inmate misbehavior report,” where she wrote that Stewart “came from behind and grabbed my left shoulder while attempting to grab my left brest [sic] area ripping my shirt pocket.” Stewart then “pushed me back and I fell to the floor and he landed on me facing me,” the officer wrote. Stewart was charged with violent conduct, assault on staff, interference with an employee, refusing a direct order, and forcible touching. He was sentenced to 18 months in solitary confinement.

Stewart refuted the charges, and filed an appeal with the help of his mother and a lawyer from Prisoners’ Legal Services of New York, an organization that provides free counsel to inmates in prison. On Sept. 23, 2014, a memo from the Auburn Correctional Facility superintendent (where Stewart was placed in solitary), which Bell provided to the Epoch Times, noted that all charges except refusing a direct order “could not be substantiated per conversation with Inspector General’s Office.”

Stewart was released from solitary after spending three months isolated for at least 23 hours a day without human contact.  

Although the Office of Mental Health (OMH), which also provides mental health care to all inmates in the state prison system, kept a long psychiatric record of Stewart’s mental illness and psychiatric treatments, the agency did not diagnose him with a “serious mental illness” (SMI). This designation protects an inmate from receiving a solitary confinement sentence, under the rationale that people with a severe condition can experience their illness worsening under the duress of solitary.

Every day, about 3,800 people spend their days in solitary confinement in New York—including about 650 to 700 of whom are OMH patients, according to the nonprofit organization mandated by law to monitor and inspect New York prisons, the Correctional Association. 

Every day, about 3,800 people spend their days in solitary confinement in New York.

Solitary confinement is a common tool that corrections officers use to punish those who break prison rules or defy officers’ orders, especially in New York State. There are 5,000 solitary confinement units in the New York prison system—including two facilities that are solely dedicated to housing people in solitary confinement, according to a 2012 report by the New York Civil Liberties Union.

The detrimental effects of solitary confinement on one’s psychological state are well-studied and documented. The Correctional Association found that inmates held in solitary confinement were admitted into mental health crisis treatment units—meant for people who are suicidal or suffering a serious mental health crisis—at rates almost four times the general inmate population.

Inmates held in solitary confinement were admitted into prison mental health crisis treatment units at rates almost four times the general inmate population.

In 2002, mental health advocates filed a lawsuit charging that New York state prisons failed to give proper mental health care to inmates, especially those who languished inside solitary confinement. The two sides reached a settlement five years later, with the state promising to establish basic mental health treatment units inside prisons. The state also adopted a new law, the SHU Exclusion Law, classifying certain mental disorders as “serious mental illnesses” that would automatically qualify an inmate to be exempt from solitary. Those include: bipolar disorder, schizophrenia, delusional disorder, and major depressive disorder.

A Very Different Diagnosis

Upon Stewart’s arrival in prison in January 2014, the OMH diagnosed him with mood disorder and intermittent explosive disorder, but ruled out bipolar, a diagnosis he had received several times before. They also determined that he did not meet the criteria for PTSD, despite a history of childhood abuse.

OMH staff determined that Stewart’s treatment plan was to receive once-a-month verbal therapy. Each session usually lasted about 15 minutes, according to Stewart. When he was receiving regular treatment in the community, Stewart saw a therapist two to three times a week, for hour-long sessions. He also had an intensive case manager whom he met with once or twice a week, according to Bell.

Similar to the therapy Stewart received in the period prior to incarceration, he found it difficult to connect with the clinicians during such brief sessions.

In June 2014, a clinician from Central New York Psychiatric Center, an inpatient care facility for incarcerated patients, reviewed Stewart’s records and expressed that he should be considered for SMI designation. “Patient should be considered for S designation given history of violence, poor insight, and behavioral impulsivity,” the clinician wrote.

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Masai Giardino Stewart’s older brother, Tafari Stewart, visits him at the Rockland Children’s Psychiatric Center in upstate New York, sometime in the early 2000s. (Courtesy of Tama Bell)

But Stewart did not get that designation. Inside solitary, Stewart grew increasingly anxious. He told OMH clinicians that he was feeling more irritable, sleeping in the daytime and keeping awake at night. He reported feeling hyper-vigilant and easily startled when officers slammed the gates, triggering flashbacks to his childhood abuse.

On Aug. 25, 2014, he requested weekly therapy sessions with OMH staff to help him cope. On Sept. 2, Stewart asked to be transferred to an ICP (Intermediate Care Program) or RMHTU (Residential Mental Health Treatment Unit), both intensive treatment programs. The OMH clinician told Stewart he didn’t qualify.

In his notes, the clinician treating Stewart expressed suspicion that he was “malingering,” or faking his reported symptoms. Bipolar is ruled out, he said, because “he has displayed no symptoms.”

The clinician treating Stewart expressed suspicion that he was “malingering,” or faking his reported symptoms.

Another clinician noted that Stewart’s community health records “paint an inconsistent picture of symptoms,” and since he is currently stable despite not taking medications, he likely does not have bipolar.

“He presents as disingenuous in his reporting,” the clinician wrote on Sept. 4, 2014. “Taken as a whole, this case is most consistent with ASPD [anti-social personality disorder], and likely goal-directed reporting of symptoms to escape current SHU sanctions or for other secondary gain.”

Bell appealed to OMH to conduct another, more thorough evaluation, given his long history of mental illness. In December 2014, another OMH clinician ruled out bipolar once again, reasoning that Stewart did not show signs of “manic or major depressive episodes,” or “significant mood symptoms,” while not taking any medications.

We know what’s wrong with our loved ones. We don’t have a diagnosis, but we live with these people and we understand their illness.
— Tama Bell

Bell says this contradicts the explosive behavior she witnessed at home before Stewart was incarcerated, or the shopping splurges Stewart sometimes indulged in, which were consistent with bipolar.

“We know what’s wrong with our loved ones. We don’t have a diagnosis, but we live with these people and we understand their illness,” Bell said.

A Pattern Emerges

After the SHU Exclusion Law went into full effect in 2011, the Correctional Association noticed that people diagnosed with a “serious mental illness” by the OMH were on the decline, while diagnoses of personality, anxiety, and adjustment disorders—which are not listed as “serious” illnesses protected under the law—increased.

In testimony provided to a New York State Assembly hearing in November 2014, Jack Beck, director of the Correctional Association’s Prison Visiting Project, said that between 2007 and 2014, diagnoses for schizophrenia and other psychotic disorders protected under the Exclusion Law dropped from 21.4 percent to 14 percent, while personality, anxiety, and adjustment disorders went up from 23.5 percent to 40.6 percent.

It is unreasonable to assume that the patient population has changed so dramatically during this period to justify such a significant shift in diagnoses.
— Jack Beck, director, Correctional Association Prison Visiting Project

“It is unreasonable to assume that the patient population has changed so dramatically during this period to justify such a significant shift in diagnoses,” said Beck in his testimony. He and a few of the assembly members expressed concern that the “serious mental illness” designation seemed so difficult for mentally ill patients to obtain.

In 2014, despite an increase in the proportion of inmates on OMH’s caseload (712 out of 53,197 total inmates, compared to 657 out of 54,142) from the year prior, the number of S-designations actually dropped by one (32 to 31), according to records from the state prison system, Department of Corrections and Community Supervision (DOCCS).

Eleve Stewart comforts her mother, Tama Bell,  at their home in Poughkeepsie, New York, on March 31, 2015. (Samira Bouaou/Epoch Times)
Eleve Stewart comforts her mother, Tama Bell, at their home in Poughkeepsie, N.Y., on March 31, 2015. (Samira Bouaou/Epoch Times)

Beck estimated that of a total of 288 units meant for mental health treatment alternatives to solitary confinement, there were more than 100 that were empty. The authorities should make use of these spaces, Beck said, instead of creating an artificial barrier that prevents people deemed not ill enough from getting treatment.

Anthony Annucci, acting commissioner of DOCCS, explained in his testimony that their reason for not placing more inmates in treatment programs is because they want to give inmates mental health care in the least restrictive setting possible.

Donna Hall, an official from the OMH who supervises treatment for the mentally ill in prisons, added that if inmates can function well in the general population, the agency encourages them to stay there. “We try to get them to the point where they just living like everybody else, because we want integration of our population. [But] if they need the residential ICP [Intermediate Care Program, a therapy program for inmates with serious mental illnesses] services, they’re there,” she said at the hearing.

We try to get them to the point where they just living like everybody else, because we want integration of our population. —
— Donna Hall, Associate commissioner, Division of Forensic Services, Office of Mental Health

Sarah Kerr, a lawyer with the Prisoners Rights Project at the Legal Aid Society, regularly receives letters from prison inmates seeking help to amend their diagnoses. Some inmates were initially classified as “seriously mentally ill,” but later got their diagnosis changed and were no longer considered “serious.”

Kerr regularly writes appeals for inmates who were recognized as “serious and persistent mentally ill” by the Social Security Administration to qualify for disability benefits (prior to incarceration), but in prison did not receive the “seriously mentally ill” designation. Stewart had received disability benefits due to his mental illness.

Kerr said OMH will occasionally amend its diagnosis as a result of her advocacy. But the agency rarely explains its rationale for its diagnoses. “We don’t always get what we ask for,” Kerr said. “They will say, the person has been evaluated and does not qualify. They won’t be explicit [with why],” she added.

Incarceration Complicates Care

Making accurate diagnoses in prison settings can be very challenging, according to Dr. Jeffrey Metzner, who has studied mental health systems in prisons across the country for the past 30 years.

Mental health staff must determine whether an inmate’s psychiatric history or request for help is credible.

Mental health professionals typically make diagnoses based on a person’s mental health history, similar to how doctors prefer examining a person’s medical history rather than performing a physical exam when making a diagnosis, Metzner explained.

But oftentimes, inmates may exaggerate symptoms, or fabricate a prior history, in order to get care and attention.

“For example, someone may want their housing changed, because they got into trouble with a fellow inmate. Or that inmate is forcing them to do something they don’t want to. The officers aren’t as responsive to that. But then when they say they’re suicidal, officers may accommodate them,” Metzner said. Mental health staff thus must determine whether an inmate’s psychiatric history or request for help is credible.

Joseph Galanek, a former researcher at Case Western Reserve University studying the mentally ill population in the criminal justice system, emphasized that mental health staff need to establish trust, while working with corrections officers, so patients feel safe sharing their therapeutic needs.

“Just seeing someone in an office once a week, that doesn’t work. Mental health staff have to interact with the inmate and officers. They have to be trusted by inmate and officers,” said Galanek, who now works for SciMetrika, LLC, a public health consultation firm.

Stewart said he found it difficult opening up to OMH staff. “I pleaded with mental health to help me but they said to me you’ll do fine here in the box and were very dismissive,” he said. He added that during his time in solitary confinement, mental health staff did daily rounds to check on inmates, but “they speed walk right by with no form of acknowledgment and act as though they don’t hear your calls for help.” 

I pleaded with mental health to help me but they said to me you’ll do fine here in the box and were very dismissive.
— Masai Giardino-Stewart

Officers also need mental health training to know how to properly identify symptoms. “For example, people are yelling and screaming. Criminals do that to get what they want. They’ll manipulate, scream and yell, threaten people violently. But someone with schizophrenia who needs treatment is also yelling and screaming, because of what they’re hallucinating,” Galanek said.

Adding to the confusion is that some psychological symptoms for Axis I disorders—considered serious mental illnesses with a biological basis—are also symptoms for Axis II disorders, typically personality disorders considered less severe by mental health professionals.

Prison staff have a tough job on their hands. But Galanek stressed that effective treatment begins with respecting patients. “Trying to work with them like human beings, explaining what treatment is, what symptoms are, and how treatment can help them,” he said. Galanek added that by listening to the person and addressing their concerns, they can get “appropriate treatment so that they’re ready when they’re out on the street,” he said.

A Chance to Start Again

In September 2015 Stewart was released on parole. Shortly after his release, Bell suggested that they go to the mall together. But Stewart felt overwhelmed when he entered the space, unaccustomed to the huge crowds.

Bell is determined to find the right diagnosis for her son. Through successfully raising money on an online crowd-funding campaign, she was able to pay for a new psychiatric evaluation from a psychiatrist at Columbia University, Dr. Jonathan Slater.

masainandrea
Masai Giardino Stewart with his favorite cousin. (Courtesy of Tama Bell)

Dr. Slater diagnosed Stewart with bipolar II disorder, PTSD, and ADHD. Bipolar II is listed as a “serious mental illness” under the SHU Exclusion Law.

With the evaluation, Bell and Stewart hope the county and OMH mental health providers will craft a treatment plan that will truly help Stewart. Bell still has yet to hear back about her latest AOT application.

But Stewart’s experience in prison made him realize the importance of managing his illness. He now attends all his mental health appointments, with Bell helping to drive him there. He sees his appointed doctor twice a month, for 20 to 30 minutes per session.

I want to take care of my family, and deal with my demons.
— Masai Giardino-Stewart

And despite his troubled childhood, Stewart has forgiven and reconciled with his father, who occasionally visits. Stewart now considers him a role model. “He taught me a sense of humility and humanity, what it is to be a man,” Stewart said.

Stewart has big plans for the future. His dream is to go back to school for a business degree and then start his own small business. “I want to take care of my family, and deal with my demons,” he said.

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