Editor’s note: Reporters from the Topeka Capital-Journal and KHI News Service collaborated for a six-month exploration of how the state’s legal system deals with people with mental illness. This is one of the stories in a four-day series.
Kansas prisons weren’t intended to function like psychiatric hospitals, but they have had to adapt as more inmates showed signs of serious mental illnesses in recent years.
In January 2013, then-Kansas Department of Corrections Secretary Ray Roberts told lawmakers the number of adult inmates with mental illnesses had increased 126 percent since 2006. He estimated 38 percent of inmates were mentally ill, and 14 percent had a severe and persistent mental illness. The number of inmates needing mental health care hasn’t fallen in the three years since then.
“Our mental health beds are always full … it’s a pressing issue. The governor is very aware and supportive of that. It’s one of the critical issues in our system,” he said then.
Kansas closed many of its state hospital beds in the 1990s as part of a push to treat people in their communities, but policymakers didn’t follow through with funding for those community resources. Some people with mental illnesses thrived outside the hospital setting, while others became homeless or their mental states deteriorated — placing them at risk for being arrested, even if they didn’t intend to commit crimes.
Some cities in Kansas have begun training their police officers to calm agitated people and direct them toward mental health treatment, and a few have mental health courts to divert those who are arrested away from prison. Still, KDOC continues to house a large number of inmates who need mental health treatment.
Lori Ammons, KDOC mental health program director since 2008, said the increased need for care led the department to hire more mental health workers. KDOC hired psychiatrists, master’s level practitioners, activity therapists and psychiatric nurses, boosting total mental health staff by about 25 percent in 2013 and 2014, she said.
There has been some employee turnover, but the department has been able to maintain staffing levels since that increase, Ammons said. It also recently added six employees to work with about 60 inmates who were transferred from Larned State Hospital to KDOC, she said.
More inmates, greater need
The need for psychiatric treatment in prison isn’t going away. The percentage of adult inmates with mental health conditions has held roughly steady since 2013, around 37 percent, but their conditions have become more severe, said Viola Riggin, director of health care services for KDOC.
About 11 percent of offenders in the KDOC population have a “significant and persistent” mental illness, which is the most severe classification, Riggin said. Four years ago, only 7 percent had reached that threshold, she said.
“Those are the people you would see at Osawatomie State Hospital,” she said.
Inmates with the most severe needs are housed in the security wing of Larned State Hospital or in the Larned Correctional Mental Health Facility. Most other inmates can live with the general prison population, Riggin said.
“We try to keep them in the least restrictive environment possible,” she said. “We try to integrate them into the general population as much as possible.”
In the past year or so, the department increased the number of beds in a residential treatment unit from 120 to 280 and added a 30-bed transitional unit, Ammons said. Those units house inmates who need more intensive care than they would receive in the general population but who don’t need to be at the mental health facility in Larned.
“We always want a flow where patients have the ability to get out of a residential unit,” she said.
In the residential units, inmates are separated from the general prison population and have around-the-clock coverage from nurses trained to work with psychiatric patients, Riggin said. Inmates housed there receive six to eight hours of mental health treatment per day, she said.
“That is very comparable to the state hospitals,” she said.
In the transitional unit, inmates can go out to the yard with the general population but are separated during meals and when medication is distributed, Riggin said.
The residential and transitional mental health units differ from segregation because inmates get more time out of their cells for therapy and recreation and are allowed to talk with each other and eat their meals together, Riggin said. Inmates with mental illness are placed in segregation only if their behavior is too violent to be controlled in another setting, she said.
Inmates who are in segregation still receive treatment, including therapy, and can have some unstructured time out of the cell if they can do so safely, said James Heimgartner, warden of El Dorado Correctional Facility, which has 1,500 medium- and maximum-security inmates, and a segregation unit. Most of the time, an inmate with mental illness will be placed in segregation if he stops taking medications and his symptoms worsen dramatically, he said.
“It’s like people on the street. You take your meds and you feel better, and they think, ‘I’m managing (my illness), why do I need this?’” he said.
Getting buy-in for treatment
Encouraging those reluctant inmates to take their medications and go to therapy has become an area of emphasis in Kansas prisons, Ammons said. Some of the most seriously ill inmates don’t believe they have a problem, so employees try to “gently” guide them to think through their current condition and decide that treatment might help, she said.
“We spend a lot of time looking at those who are noncompliant with our recommendations,” she said. “If you can get buy-in from them, they’re more apt to engage in treatment in the community as well.”
Dawn Shepler, a community corrections supervisor based in Wichita, said she has noticed that some offenders who cycled through parole and back to prison recently were more willing to take medications and keep appointments when they got out.
“They’re coming out and they’re actually engaging in treatment,” she said.
Mental health employees also have developed ways to adjust the behavior of inmates at a higher risk for self-harm, Riggin said. For example, they found one man with a history of self-mutilation could be occupied by playing a simple game with a tennis ball, so they encouraged him to ask for the ball when he felt the urge to hurt himself, she said. Another apparently enjoys mopping the floors and asks to do it when he feels overwhelmed.
“It’s working with that patient to see what’s going to keep their mind occupied,” she said.
While suicide is the leading cause of death in jails, prison inmates are about as likely to die by suicide as the general population.
The Bureau of Justice Statistics reported 15 deaths by suicide for every 100,000 inmates in state or federal prisons in 2013. In the United States as a whole, there were 13 deaths by suicide for every 100,000 people that year.
In fiscal year 2016, there were no inmate suicides in the KDOC system, but there were three attempts, 44 threats of suicide and 29 incidents of “self-harm,” which varied in severity, Riggin said.
One inmate has committed suicide since the current fiscal year started in June, she said. If no one else dies by suicide during the current fiscal year, the rate would be about 10 per 100,000 people.
“We are dealing with severely mentally ill patients,” she said. “But our level of crisis (events) compared to seriously mentally ill prisoners is very low.”
Rick Cagan, executive director of the Kansas chapter of the National Alliance on Mental Illness, said the care inmates receive in prison still may not be exactly the same as what they would receive in the community, but it has improved noticeably in recent years.
“They have made progress,” he said. “They do have standards. They do provide care.”
KDOC has a continuous process to evaluate treatment and look for better ways to reduce recidivism, Ammons said.
“I see us always as a work in progress,” she said. “I see (correctional psychology) as a developing field.”
Heimgartner, the El Dorado warden, said KDOC’s approach to inmates with mental health issues has changed in the 25 years he has worked there. Now, the idea is to identify the inmate’s needs and improve his condition as much as possible, he said.
“Twenty-five years ago, mentally ill inmates were just inmates,” he said. “If it was the same (now) as it was 25 years ago, I probably wouldn’t be (working) here.”