UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK
DISABILITY ADVOCATES, INC., Plaintiff
-vs-
NEW YORK STATE OFFICE OF MENTAL HEALTH (“OMH”), JAMES L. STONE, COMMISSIONER OF MENTAL HEALTH, OMH SATELLITE MENTAL HEALTH UNIT CHIEFS JURGEN KARKER, SCOTT CLAIR, MICHELLE PETRINO, WAYNE CROSIER, KATHY CAVANAUGH, MICHAEL HILL, JOHN DUNN, PETER RUSSELL, AL SHIMKUNAS, THOMAS RYAN, DAVID BOYD, LORETTA KLEIN, ANTHONY DEVITO, NEW YORK STATE DEPARTMENT OF CORRECTIONAL SERVICES (“DOCS”), GLENN S. GOORD, COMMISSIONER OF DOCS, FACILITY SUPERINTENDENTS VICTOR HERBERT, JOHN BURGE, ELAINE LORD, DANIEL SENKOWSKI, GARY FILLION, FRANK TRACY, DAVID MILLER, FLOYD G. BENNETT, JR., THOMAS POOLE, GEORGE DUNCAN, CHARLES GRIENER, LEONARD PORTUONDO, BRIAN FISCHER, MICHAEL P. MCGINNIS, JAMES WALSH, THOMAS RICKS, EDWARD DONNELLY,
Defendants.

COMPLAINT

Plaintiff, Disability Advocates, Inc., a New York protection and advocacy agency, sues defendants on behalf of prisoners with mental illness in New York State and alleges:
Preliminary Statement 1. This action seeks declaratory and injunctive relief on behalf of prisoners with mental illness who are or who will be confined in the custody of the New York State Department of Correctional Services (“DOCS”). The New York State Office of Mental Health (“OMH”) and DOCS defendants have continually and persistently ignored the serious mental health needs of the prison population in New York.

2. Plaintiff brings this action under 42 U.S.C. § 1983, the Eighth and Fourteenth Amendments of the United States Constitution, 29 U.S.C. § 794 (the Rehabilitation Act), and 42 U.S.C. § 12132 (the Americans with Disabilities Act of 1990). Plaintiff alleges that the defendants act with deliberate indifference to the serious medical needs of prisoners with mental illness by failing to provide adequate mental health services, including necessary inpatient and residential mental health programs, and by imposing punishments which aggravate the mental illness of prisoners. Defendants’ conduct discriminates against prisoners with mental illness on the basis of their disability and constitutes cruel and unusual punishment in violation of law.
3. OMH and DOCS do not provide necessary treatment opportunities and access to programs for prisoners with mental illness. The failure to provide adequate treatment and programs causes mentally disabled prisoners to psychiatrically deteriorate and to engage in behavior symptomatic of their illnesses. Defendants’ deliberate indifference to the serious mental health needs of prisoners in the New York State prison system has resulted in a disproportionately high number of prisoners with serious mental illness being housed in the harsh and punitive conditions of disciplinary isolated confinement.
4. In twenty-three hour disciplinary isolated confinement, special housing units (“SHU”), double-celled SHUs, and keeplock, the suffering of prisoners with mental illness is intensified and the severity of their mental illness is worsened by the near total lack of human contact and even more limited or non-existent treatment opportunities.
5. These abuses are systemic throughout the New York State prison system. 6. The DOCS prison population has increased more than three-fold since 1981 to more than 67,000 today. During the same time period, DOCS and OMH have observed an increase in the
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incidence and severity of serious mental illness among the prison population. In 1987, OMH estimated that 8% of the prison population suffered from very substantial psychiatric disabilities warranting mental health services; another 16% were deemed to suffer from significant psychiatric disabilities. Based on these assertions, at least 16,000 prisoners suffer from significant to severe psychiatric illnesses.
7. Notwithstanding the increase in the incidence and severity of serious mental illness among the prison population, the number of inpatient beds at the Central New York Psychiatric Center, the only New York State psychiatric hospital to serve DOCS prisons, has not increased since 1981. The current number of beds is not sufficient to provide intensive psychiatric treatment to the scores of prisoners with serious mental illness who require it. There is also a lack of sufficient space in Intermediate Care Program units to accommodate the number of prisoners with mental illness in need of therapeutic housing. Staffing levels have not increased with the demand for services; defendants lack an adequate number of staff persons to handle the growing need for mental health evaluations, treatment, commitments, transfers, and discharge planning.
8. The failure to provide for the mental health needs of prisoners causes serious, and sometimes permanent, mental and physical deterioration. Prisoners with mental illness who have been neglected and deprived of adequate treatment while incarcerated are likely to be more severely mentally ill upon their release from prison than they would be otherwise; they are more likely to experience homelessness, less likely to trust mental health care providers, and less likely to seek necessary mental health care upon their release. Disregard for the treatment needs of prisoners with mental illness harms the prisoner and poses both a burden and a danger to the public at large.
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Jurisdiction and Venue 9. This court has jurisdiction over these claims pursuant to 28 U.S.C. §§ 1331 and 1343. Plaintiff is entitled to declaratory relief pursuant to 28 U.S.C. § 2201. Venue is proper in this district under 28 U.S.C. § 1391(b).
Parties 10. Plaintiff Disability Advocates, Inc. (“DAI”), is a not-for-profit corporation, authorized to practice law under New York State law. 11. DAI is an authorized protection and advocacy agency under the Protection and Advocacy for Individuals with Mental Illness Act (“PAIMI”), 42 U.S.C. § 10801 et seq. 12. DAI has statutory authority to pursue legal, administrative and other appropriate remedies to ensure the protection of individuals with mental illness who are or will be receiving care and treatment in New York State. 42 U.S.C. § 10805. 13. DAI is pursuing this action to protect and advocate for the rights and interests of prisoners who are “individuals with mental illness” as that term is defined in 42 U.S.C. § 10802. DAI’s constituents are prisoners with a significant mental illness or emotional impairment who reside in New York State prisons, which are “facilities” rendering care and treatment for mentally ill individuals as that term is defined in 42 U.S.C. § 10802. 14. Prisoners with mental illness on whose behalf this litigation is brought have each suffered injuries, or will suffer such injuries, that would allow them to bring suit against defendants in their own right. These prisoners with mental illness are housed in prisons throughout the State and are frequently transferred from one facility to another. Approximately 70% of the prison population is from the five boroughs of New York City.
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15. Defendant New York State Office of Mental Health (“OMH”) is the agency created by the State of New York for the purpose of controlling, providing and supervising the State’s mental health services for New York State residents with mental illness, including mental health services for prisoners.
16. Defendant James L. Stone is the Commissioner of OMH. He is responsible for the operation and administration of programs for the treatment of prisoners with mental illness confined in New York State correctional facilities. He is sued in his official capacity.
17. Defendants OMH Satellite Mental Health Unit Chiefs Jurgen Karker (Auburn Correctional Facility (“C.F.”)), Scott Clair (Attica C.F.), Michelle Petrino (Bedford Hills C.F.), Wayne Crosier (Clinton C.F.), Kathy Cavanaugh (Coxsackie C.F.), Michael Hill (Downstate C.F.), John Dunn (Eastern C.F.), Peter Russell (Elmira C.F.), Jurgen Karker (Five Points C.F.), Al Shimkunas (Great Meadow C.F.), Thomas Ryan (Green Haven, C.F.), David Boyd (Sing Sing C.F.), Loretta Klein (Shawangunk C.F. and Sullivan C.F.), and Anthony DeVito (Wende C.F.) are all Forensic Unit Chiefs of OMH Satellite Mental Health Units in New York State correctional facilities. These defendants are sued in their official capacities.
18. Defendant New York State Department of Correctional Services (“DOCS”) is the agency created by the State of New York for the purpose of operating prison facilities within New York State.
19. Defendant Glenn S. Goord is the Commissioner of DOCS. He is responsible for the operation and administration of all facilities within the department. He is sued in his official capacity.
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20. Defendants Superintendents Victor Herbert (Attica C.F.), John Burge (Auburn C.F.), Elaine Lord (Bedford Hills C.F.), Daniel Senkowski (Clinton C.F.), Gary Fillion (Coxsackie C.F.), Frank Tracy (Downstate C.F.), David Miller (Eastern C.F.), Floyd G. Bennett, Jr. (Elmira C.F.), Thomas Poole (Five Points C.F.), George Duncan (Great Meadow C.F.), Charles Greiner (Green Haven C.F.), Leonard Portuondo (Shawangunk C.F.), Brian Fischer (Sing Sing C.F.), Michael P. McGinnis (Southport C.F.), James Walsh (Sullivan C.F.), Thomas Ricks (Upstate C.F.), and Edward Donnelly (Wende C.F.) are all Superintendents of maximum security prisons in New York State. These defendants are sued in their official capacities.
Facts Inadequate Mental Health Care Programs and Resources Overview
21. In New York State, the delivery of mental health care and treatment to prisoners with mental illness is the joint responsibility of the Commissioner of DOCS and the Commissioner of OMH. The Commissioner of DOCS, in cooperation with the Commissioner of OMH, is responsible for establishing programs for the treatment of prisoners with mental illness confined in state correctional facilities who are in need of psychiatric services but who do not require hospitalization. N.Y. Corrections Law § 401.
22. The administration and operation of the treatment programs established pursuant to Corrections Law § 401 are the responsibility of the Commissioner of OMH, as is the operation of Central New York Psychiatric Center (“CNYPC”). N.Y. Corrections Law § 401; N.Y. Mental Hygiene Law § 7.17.
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23. The Superintendent of each facility is responsible for the supervision and management of the facility and the care, custody and safety of all prisoners under his or her immediate jurisdiction. N.Y. Corrections Law § 18. Structure of the Mental Health Care System
24. The CNYPC provides both inpatient and outpatient services to the prisoners in DOCS correctional facilities. Inpatient services are provided at the psychiatric hospital, CNYPC, in Marcy, New York. Outpatient services are provided at DOCS correctional facilities through a system of OMH Satellite Mental Health Units and OMH Mental Health Units, each with a corresponding catchment area of correctional facilities.
25. OMH Satellite Mental Health Units are located in twelve of the seventeen maximum security prisons. OMH Satellite Mental Health Units have full time staff and operate Residential Crisis Treatment Programs (“RCTP”) that serve all of the prisons within the Satellite Mental Health Units’ catchment area, including medium and minimum security prisons. The RCTP consists of mental observation cells and a dorm area where prisoners may be admitted and housed within the Satellite Mental Health Unit. Prisoners in the RCTP either are eventually returned to their respective housing areas or committed to the inpatient unit of CNYPC.
26. Five maximum security prisons, including Southport C.F. and Upstate C.F. which consist only of cells for twenty-three hour disciplinary confinement, do not have an OMH Satellite Mental Health Unit. Each of those five maximum security prisons and seven out of 37 medium security facilities have OMH Mental Health Units (“MHU”). The MHUs do not have any full time mental health or medical clinicians and require only a minimum of eight hours of psychiatric services per week.
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27. Fourteen medium and minimum security DOCS facilities in the catchment area of an OMH Satellite Mental Health Unit or MHU have limited on-site mental health services including a part-time psychiatrist. Twenty-three medium and minimum security DOCS facilities in the catchment area of an OMH Satellite Mental Health Unit or MHU have limited on-site mental health services but do not provide the services of a psychiatrist on site.
28. Intermediate Care Programs (“ICP”) are located at maximum security prisons which have OMH Satellite Mental Health Units. ICPs are DOCS programs that are jointly staffed by OMH and DOCS. Prisoners housed in the ICPs have been deemed unable to function in the general population due to the effects of a mental illness.
29. OMH utilizes a classification system which designates each mentally ill prisoner with an OMH “service level designation” of 1, 2, 3, 4, or 6. There is no level 5. A designation of level 6 indicates that the prisoner “does not require or is not appropriate for Mental Health services,” level 4 indicates “need for and/or interest in psychotherapy,” level 3 indicates “current or future need for short term chemotherapy for minor disorders such as anxiety, moderate depression, or adjustment problems,” level 2 indicates “psychiatric treatment for major psychiatric disorder” or “current prescription of medication for a major psychiatric disorder,” and prisoners in need of the highest level of care are designated a level 1. Level 1 indicates “medication monitoring by psychiatric nurse,” “admission to CNYPC,” “day treatment program (AVP or ICP),” or “placement in a Satellite Unit bed.” OMH Treatment Needs/Service Level Designation Form 167.
30. Prisoners with mental illness are frequently switched from one OMH needs level classification to another, from therapeutic housing in an ICP setting to more restrictive nontherapeutic housing, and from one correctional facility to another. Such changes often drastically and inappropriately alter the mental health treatment provided or available to the prisoner.
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31. Despite their legal obligation to do so, defendants have systematically failed and refused to consistently provide prisoners with mental illness with medically necessary mental health care, including but not limited to inpatient hospitalization when needed, and intermediate level mental health care within the prison. Even when prisoners with mental illness clearly improve and benefit from treatment in a therapeutic environment, they are regularly returned to non-therapeutic housing and even to isolated twenty-three hour confinement within the prisons. As a result, and as set forth more fully below, the serious mental health needs of New York State prisoners are not being met. Insufficient Mental Health Care in Twenty-Three Hour Confinement
32. New York State confines close to 6,000 of its 67,000 prisoners in twenty-three hour isolated confinement housing areas: SHUs, double-celled SHUs, and keeplock. These disciplinary confinement units are, in operation and effect, isolation units.
33. In SHU and keeplock, prisoners are confined in small cells for twenty-three hours each day. Single cells in DOCS are approximately six feet by ten feet (they range in size from between 48 and 62 square feet). The new double-celled SHU cells at Five Points C.F. and Upstate C.F. are eight feet by thirteen feet.
34. SHU prisoners are allowed out of their cells only one hour per day, during which they are locked alone in a small cage outside. The recreation cages vary somewhat in size. At Southport C.F., they are eight feet by sixteen feet, twelve feet high with a bare concrete floor and no equipment. At the new double-celled SHUs at Five Points C.F. and Upstate C.F., the yard cages are attached directly to each SHU cell. These recreation cages are only eight feet by seven feet.
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35. In order to minimize their contact with others, SHU and keeplock prisoners are made to eat alone in their cells, cannot see other prisoners from their cells, and are not permitted to work at prison jobs, attend programs or engage in other rehabilitative activities.
36. Despite their known mental illness, prisoners with mental illness subject to DOCS disciplinary sanctions are frequently placed into these psychologically punishing twenty-three hour isolated confinement housing areas. Confinement in twenty-three hour isolated confinement housing areas is known to exacerbate mental illness.
37. In SHU and in blocks where a majority of prisoners are under keeplock, the noise level inside is often deafening because prisoners with mental illness scream and bang on their cell walls.
38. In the double-celled SHU twenty-three hour confinement housing areas, the conditions are similar to SHU except for extremely close and unbroken contact with one other cellmate/prisoner. The double-celled SHU cells have a solid cell door with one small opening that prisoners must use to speak to staff, including mental health and other medical staff. For prisoners with mental illness, the close and confined shared quarters in double-celled SHUs frequently exacerbate their mental illness.
39. Prisoners in twenty-three hour isolated confinement housing areas have extremely limited opportunities to participate in any form of mental health therapy. Often the only contact with mental health staff occurs during rounds when OMH staff walk through the housing unit and may stop and speak to prisoners from through the bars at the front of their cell or though a slot in the solid door of their cell, all within earshot of neighboring cells and in the presence of a cellmate in the double-celled SHUs.
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40. Frequently the only treatment offered or available in twenty-three hour isolated confinement is medication, which is dispensed by a nurse who makes rounds in SHU. It is difficult for SHU prisoners to discuss side effects from and concerns about medication because of the lack of privacy and because mental health staff who make rounds in SHU devote little time to meeting with their patients. Prisoners who suffer from side effects, who feel depressed, or who may believe that they no longer need medications, often begin to refuse medications. Little is done to discuss or to encourage compliance with medication regimes. Prisoners who become non-compliant with ordered medication regimens frequently psychiatrically deteriorate without intervention by mental health staff, and indeed are dropped from the list of OMH patients despite their known serious mental health needs.
41. Many mentally ill individuals cannot tolerate prolonged, isolated confinement without significant, and often life-threatening, exacerbation of their mental illness. Twenty-three hour isolated confinement has a serious adverse impact on persons suffering from depression, schizophrenia and other psychiatric disorders and may cause drastic decompensation in such persons, including increased disorientation, delusional thinking, paranoid thoughts, suicidal thoughts and thoughts of self-harm, and self-injurious and suicidal acts.
42. The lack of adequate mental health treatment to those prisoners housed in twentythree hour isolated confinement intensifies their suffering and psychiatric deterioration.
43. OMH and DOCS have persistently resisted identifying and removing from twentythree hour isolated confinement prisoners with mental illness who psychiatrically deteriorate as a result of the stringent conditions of confinement in isolation.
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44. OMH and DOCS have persistently resisted acknowledging the deleterious effects of long-term isolation on the mental health of prisoners housed under these conditions.
45. As described in detail below, the serious consequences of the failure of defendants to restrict the placement of prisoners with mental illness into, and their failure to intervene and to remove prisoners with mental illness from, twenty-three hour isolated confinement has resulted in a disproportionate percentage of suicides within the population of prisoners housed in SHUs, doublecelled SHUs and keeplock. A Cycle of Torment: Lack of Adequate Mental Health Care Results in the Placement of Prisoners with Mental Illness in Isolated Confinement, Which in Turn Causes Greater Psychiatric Harm
46. As a consequence of the symptoms of their illnesses, many prisoners with mental illness are incapable of conforming to the prison regimen and rules. The lack of adequate mental health treatment makes this problem more severe and widespread.
47. Inadequate mental health treatment in the prisons results in prisoners with mental illness suffering serious psychiatric deterioration and engaging in symptomatic behaviors which may include violent or assaultive behavior; acts of self-mutilation and self-harm; attempts or acts of suicide; depression, isolation and withdrawal; failure to keep clean and other unhygienic behavior; smearing feces on themselves and their cells; setting fires; screaming; hoarding or refusing food; and flooding their cells with water from the toilet.
48. These behaviors, symptomatic of serious psychiatric deterioration, violate DOCS rules for prisoner conduct. Prisoners with mental illness are frequently sentenced to periods of isolated confinement for engaging in such symptomatic conduct.
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49. As a direct result of the defendants’ failure to provide adequate mental health care, the disciplinary housing areas of New York State prisons are disproportionately filled with the mentally ill.
50. Once punished with confinement in a twenty-three hour isolated confinement housing area, many prisoners with mental illness become even less able to conform to prison rules because their mental conditions worsen. As a result, many prisoners with mental illness, who are suffering from their illnesses and who are serving time in isolated confinement, become subject to additional disciplinary sanctions including additional consecutive periods of isolated confinement.
51. Many prisoners with mental illness enter a cycle of placement in isolated confinement; the consequent exacerbation of mental illness; extreme decompensation, often to the point of dangerousness to self or others; commitment to CNYPC; a return to prison and isolated confinement after only a brief inpatient stay at CNYPC; followed by a repeated mental deterioration in twenty-three hour confinement leading to subsequent re-commitment to CNYPC.
52. Other prisoners with mental illness in twenty-three hour isolated confinement decompensate and become increasingly ill, but do not receive necessary hospitalization or other treatment for their decompensation. These prisoners may spend lengthy periods of isolated confinement while floridly mentally ill without receiving necessary treatment or release from their torment.
53. Because DOCS regulations impose no upper limit on the duration for which prisoners may be confined in twenty-three hour isolated confinement, many prisoners with mental illness spend years housed under these harmful conditions, isolated and virtually untreated, with many more years of isolated confinement ahead of them.
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Insufficient Emergency Mental Health Care in Observation Cells 54. Many prisoners with mental illness who have been identified to be at risk of suicide
or to be a danger to themselves or others, are secluded in observation cells in the prison Satellite Mental Health Units for twenty-three or even twenty-four hours a day.
55. Prisoners held in observation cells often are deprived of all property and furnishings except for mats on the floor, and are held with limited bedding or clothing.
56. Often the only treatment available to prisoners in observations cells is medication. No rehabilitative activities, therapy, or programs are offered.
57. Acutely mentally ill prisoners remain alone, almost naked, under these conditions for periods of many days and sometimes weeks before they are transferred to CNYPC for mental health treatment or simply are transferred back to the cell where they previously psychiatrically deteriorated.
58. Prolonged seclusion of acutely psychotic persons under the conditions in the observation cells presents a substantial risk of serious harm and can cause increased disorientation, delusional thinking, paranoid thoughts, suicidal thoughts, thoughts of self-harm, and self-injurious and suicidal acts. Prisoner Suicides
59. The serious consequences of the failure of defendants to restrict the placement of prisoners with mental illness into, and their failure to intervene and to remove prisoners with mental illness from, twenty-three hour isolated confinement is evident from the disproportionate percentage of suicides within the population of prisoners housed in isolated confinement. For each year from 1998 through 2001, from 30% to 50% of the suicides for the entire prison population occurred within
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the 8% of the prison population confined in twenty-three hour isolated confinement housing (SHU, double-celled SHU and keeplock). According to State Commission of Correction (“SCOC”) investigations of suicides, deficient mental health treatment and the stresses of isolated twenty-three hour confinement have been significant factors leading to suicide.
60. All of the following factual information concerning the suicides of prisoners in DOCS custody is derived from the final report on each death which was prepared by the New York State Commission of Correction (“SCOC”) and obtained from them pursuant to the Freedom of Information Law (Public Officers Law § 87). The SCOC is the state oversight agency which investigates and oversees correctional facilities. Due to the confidential medical information described, random initials have been substituted for the proper names of the prisoners. Suicide of Prisoner A.B.
61. On June 5, 2000, prisoner A.B. died of suicidal hanging at Elmira C.F. A.B. had a known lengthy history of suffering from serious mental illness from the age of nineteen, including a history of suicidal tendencies.
62. A.B.. had been held at CNYPC from September 10, 1999 through January 6, 2000 and then held at the Oneida County C.F. on a mental health tier (a housing area designated for prisoners with mental illness).
63. On May 3, 2000, A.B. was transferred from Oneida County to DOCS and housed at Elmira C.F. Reception Center. Due to his extensive mental health history, he was admitted to the RCTP in the OMH Satellite Mental Health Unit for evaluation and monitoring.
64. On May 14, 2000, even though his neurodiagnostic work-up was not completed, A.B. was released from the Satellite Mental Health Unit to a reception tier in general population (where new prisoners are housed while their classification and housing assignments are determined).
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65. Within two days of his transfer to general population, A.B. expressed to OMH staff that he wanted to die and that voices were telling him to hurt himself. Despite his existing mental distress and his known history of suicidal tendencies, he was not immediately transferred back to the Satellite Mental Health Unit.
66. On May 20, 2000, A.B. was transferred to the Satellite Mental Health Unit after he was found with a sheet tied around his neck.
67. On May 23, 2000, his primary therapist described A.B. as having a positive death wish and being hopeless and helpless. A.B. was kept in an observation cell in the OMH Satellite Mental Health Unit until May 31, 2000, when he was inappropriately transferred back to the reception tier and not to a therapeutic mental health housing program.
68. On June 5, 2000, A.B. was found hanging from a bedsheet in his cell on the reception tier. He was pronounced dead approximately one hour later.
69. The SCOC recommended that OMH address with staff “effective treatment in a safe environment, including timely use of the Intermediate Care Program, regardless of reception/classification status, for seriously ill patients with high impulsivity, history of suicide attempt, or propensity for rapid decompensation under stress. These patients may no longer be appropriate for the RCTP, but need enhanced supervision, observation or precautions in a therapeutic setting.” Final Report in the Matter of the Death of A.B., March 2001, p. 5, (emphasis supplied).
70. SCOC recommended that OMH undertake a review of their policies and procedures “regarding the provision of effective treatment in a safe environment; specifically, those governing timely placement in safer settings of inmates who have experienced difficulty adjusting to, or possess the potential to have problems coping with, general population for psychiatric reasons.” Id.
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71. OMH responded defensively to the SCOC preliminary report , indicating that because A.B. was a prisoner at Elmira C.F. Reception Center not Elmira C.F., he was not eligible for placement in the ICP notwithstanding his clinical need for a therapeutic treatment housing placement. SCOC determined that no such distinction for admission to ICP existed, that DOCS does not have any policy which would prohibit placement of a reception classification prisoner in the ICP, and that such placements had, in fact, previously been made. Moreover, SCOC learned that A.B. had been fully classified by May 9, 2000, and therefore was no longer a reception/classification prisoner.
72. In review of this matter, the New York State Medical Review Board appropriately found that “reception status is irrelevant to the objective of providing effective treatment in a safe setting.” Nothing in the OMH response reflected a clinical basis for the limited mental health care provided to this seriously mentally disabled individual. Suicide of Prisoner C.D.
73. C.D. was committed to CNYPC from July 17, 1998 through January 27, 1999. His diagnosis was schizophrenic disorganized type. He was discharged from the CNYPC pre-release ward where he had been assisting in preparation of a discharge plan for his pending release on parole.
74. CNYPC indicated in a discharge plan that C.D. needed to be linked to psychiatric aftercare services which should include regular contact with a therapist, continual prescription of psychotropic medications, and regular visitations with a psychiatrist to monitor his medications and his overall mental status. He was discharged from CNYPC to Downstate C.F. on January 27 and sent to Sullivan C.F. on February 5, 1999, to await community placement.
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75. Although CNYPC specifically recommended that C.D. be housed in the ICP at Sullivan C.F. pending his release from custody. C.D. was denied ICP placement at Sullivan C.F. The basis of the denial was that he was not expected to remain at Sullivan C.F. for a lengthy period of time. This refusal of intermediate care placement was not based upon an exercise of clinical judgment and, in fact, was done without Sullivan C.F. OMH staff ever even interviewing C.D.
76. C.D. deteriorated rapidly in general population. On February 11, 1999, C.D. was admitted to the OMH Satellite Mental Health Unit after exhibiting bizarre behavior.
77. C.D. became non-compliant with medication and was involved in two violent incidents on March 29 and March 30. He was served with several disciplinary tickets for his misbehavior during the incidents and was taken from the Satellite Mental Health Unit and placed into disciplinary twenty-three hour isolated confinement housing in the Sullivan C.F. SHU.
78. On April 16, C.D. sent a note to the Commissioner of DOCS and the OMH staff at Sullivan C.F. threatening suicide if he was moved to another facility.
79. A part-time psychiatrist then recommended that C.D. be placed in an observation cell in the OMH Satellite Mental Health Unit. He was taken back to the Satellite Mental Health Unit on April 23. While in the observation cell, C.D. was evaluated for possible transfer to CNYPC. He was not admitted to CNYPC. Subsequently, OMH approved his return to twenty-three hour isolated confinement in the Sullivan C.F. SHU.
80. On April 28, C.D. refused to speak with the psychologist who conducted rounds in SHU. On April 30, he was informed by parole staff that his parole date had been suspended due to his recent misbehavior and disciplinary tickets.
81. On May 3, 1999, C.D. was found hanging in his cell.
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82. The SCOC recommended that a quality assurance review be conducted to determine why C.D. had not been housed in ICP upon transfer to Sullivan C.F. as specifically recommended in the CNYPC discharge plan. The SCOC found that “[t]o be denied admission to the ICP because he was not expected to remain at Sullivan C.F. long enough to benefit from the program is not sound clinical reasoning.” Final Report in the Matter of the Death of C.D., December 1999, p.4, (emphasis supplied).
83. The SCOC further recommended that Sullivan C.F. develop and implement procedures which require close observation and intensive care management for patients observed to be refusing medications, decompensating or acting out.
84. The SCOC indicated that the notification to C.D. by parole on April 30, that his parole date had been suspended, was sufficient to alert OMH staff that C.D. was potentially at risk for life-threatening behavior. SCOC recommended that whenever an OMH Level 1 or 2 prisoner is decompensating in the SHU, enhanced security and supervision should be ordered for such prisoners, and more frequent supervisory checks should be performed until such prisoners can be transferred to a secure area of the facility designated for OMH cases.
85. OMH does not track its patients and former patients in the manner recommended by SCOC. There are no procedures in place to guarantee that OMH has knowledge about triggering events in the lives of prisoners with a known history of mental illness. OMH is not routinely and systematically informed of misbehavior, disciplinary hearings and decisions, or notifications about parole decisions or immigration proceedings.
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Suicide of Prisoner E.F. 86. E.F. was incarcerated in 1982 to serve a term of fifty-three years to life. In 1984, he
was hospitalized at CNYPC and discharged with a diagnosis of hallucinogen hallucinosis and antisocial personality disorder. OMH determined that he was defiant and considered him to be potentially assaultive. For several years he refused medication but remained an OMH active case as a self-referral for insomnia and paranoid ideation. In 1994, E.F. was designated as an OMH level 3 (i.e., it was determined that he might need mental health services).
87. E.F.’s disciplinary misbehavior escalated over the years, and he spent significant periods of time under keeplock and in SHU detention.
88. In June 1995, E.F. was accused of two assaults on staff. As a result, he was transferred to Southport C.F. to serve four years of SHU time. OMH did not intervene at his disciplinary hearing either to indicate that his assaultive behavior may have been due to his mental illness or to recommend that he remain at a facility with full-time mental health staffing.
89. E.F. was transferred to Southport C.F., which is an all-SHU prison and does not have an OMH Satellite Mental Health Unit on the premises. Prisoners’ mental health services are limited at Southport C.F. OMH staff from Elmira C.F.’s Satellite Mental Health Unit provide a part-time presence at Southport C.F.
90. Three months after E.F.’s transfer to Southport C.F., an OMH evaluation conducted on September 17, 1995, determined that he did not need any mental health services.
91. While at Southport C.F., E.F. accumulated misbehavior reports resulting in cumulative SHU time up to the year 2010.
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92. In 1997, E.F. was referred to OMH by a medical nurse who reported that he was “extremely delusional.” However, after assessing E.F., OMH determined that there was no evidence of mental illness. OMH did not make any contact at all with E.F. after 1997.
93. On March 6, 2000, E.F. committed suicide by hanging. 94. The SCOC Final Report on the death of E.F. states that “[i]t is a well established fact that inmates serving long term sentences in SHUs are likely to decompensate due to extended periods of isolation and sensory deprivation. CNYPC Outpatient Policy and Procedure, in accordance with ACA [American Correctional Association] Standards, states that all SHU inmates are to be evaluated every 90 days for documentation according to standards. The NYS Office of Mental Health, Bureau of Forensic Services is in violation of CNYPC and ACA Standards regarding 90 day reviews. This is of significant concern to the Commission in recognition of the obvious longterm effects of segregation on inmates.” Final Report in the Matter of the Death of E.F., September 2000, p. 3 (emphasis supplied). 95. SCOC determined that OMH was not in compliance with minimum staffing levels at Southport C.F. and that it failed to conduct evaluations of SHU prisoners every 90 days as required by ACA standards. 96. The OMH response to the SCOC preliminary report asserted that it did not have enough staff to comply with the required 90 day reviews. OMH further asserted that, in any event, it actually was in compliance with ACA standards because the resources were outposted from Elmira C.F. 97. SCOC stated in its final report that OMH could not claim a failure of 90 day reviews due to lack of staff at the same time that it was asserting sufficient staffing levels through outposting from Elmira.
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Suicide of Prisoner G.H. 98. Prior to his admission to DOCS custody in 1997, G.H. had been hospitalized for
manic depression in 1993 and 1994. The evaluation conducted by OMH in 1997 did not reflect this prior psychiatric history of hospitalizations.
99. In 1999, G.H. was placed on work release, which was revoked when he went AWOL and then was arrested for assaulting a girlfriend. He was given a disciplinary sentence of six months SHU confinement and an additional six months incarceration was added to his sentence.
100. Upon admission to the SHU at Fishkill C.F., G.H. was evaluated by OMH. At that time, G.H. revealed his prior history of psychiatric hospitalizations. However, OMH determined that G.H. was not in need of psychiatric services. He was given the lowest OMH needs classification level, level 6 (i.e., not in need of services). OMH staff did not obtain or even seek to obtain any information concerning his prior hospitalizations.
101. G.H. was re-evaluated by OMH on December 22, 1999. At this evaluation he admitted to being anxious and depressed, and he described his previous suicide attempts. He reported that he took the drug Elavil in the past and wanted to give it another try. Thereafter, OMH prescribed Elavil for G.H.
102. On January 17, 2000, G.H. was evaluated by OMH again. G.H. reported that he was sleeping night and day and that he found the SHU too stressful. OMH did not provide any counseling by mental health staff about coping with stress in SHU.
103. On January 27, 2000, G.H. requested that his medication be changed to Sinequan. OMH then prescribed Sinequan for G.H.
104. On March 3, 2000 and on April 7, 2000, G.H. complained about difficulties with Sinequan. OMH increased his dosage of Sinequan on April 7, 2000.
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105. On April 28, 2000, a SHU officer submitted a mental health referral which indicated that G.H. kept repeating: “they are going to kill me and my family, they have my address, nobody is doing anything about it, I’ll handle it my way.”
106. DOCS security staff placed G.H. on a special watch until he could be evaluated during mental health office hours on Monday May 1, 2000.
107. On May 1, 2000, OMH staff found that G.H. was paranoid and complaining that he was hearing prisoners’ voices threatening to kill him. OMH did not recommend that G.H. be removed from SHU.
108. On May 31, 2000, G.H. complained for a third time about Sinequan saying that it made him too “jittery.” On June 2, 2000, the psychiatrist changed his medication to Trazadone.
109. On June 2, 2000, G.H. was anxious about transfer to another facility and he complained of “being frustrated with fears for his family safety and felt that someone should be doing more to address the issue.” He denied hearing voices or having thoughts of self-harm. The mental health worker reported that G.H. was anxious but not as much as he had been in April.
110. On June 3, 2000, G.H. refused recreation and refused the lunch meal. When another prisoner returned from recreation, he observed G.H. hanging in his cell. G.H. was pronounced dead shortly thereafter.
111. In the SCOC Final Report on the death of G.H., the recommendations included: an overall effort to improve care management of prisoners with mental illness in SHU; better documentation and evaluation of prisoner safety concerns versus possible hallucinations; and better documentation and follow-up on referrals to security and on the results of investigations as part of the prisoner’s treatment plan.
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112. The Medical Review Board indicated that it is unacceptable to have a prisoner on a one-to-one watch by security without mental health intervention until the next business day.
113. OMH responded defensively to the SCOC preliminary report. OMH claimed that although there were recording errors, there was no causality between them and the prisoner’s death. OMH did not address in its response its failure to contact previous mental health providers concerning the patient’s treatment history. OMH blamed the delay between the suicide watch initiated by security and mental health assessment of G.H. on the fact that Fishkill is an OMH needs Level 2 provider. However, OMH did not explain, based on this noted problem and deficiency, why it failed to have G.H. moved to a Level 1 facility after the suicide watch.
114. In summary and as set forth below, the inadequacy of the mental health care programs and resources to address the serious mental health needs of prisoners is deficient across the board. There is insufficient long-term inpatient care, intermediate care, and emergency care, and there is a failure to care for, or intervene to remove, prisoners with mental illness housed in harsh twentythree hour isolated confinement housing even when isolation is clearly exacerbating their illness or causing serious mental deterioration. This cumulative failure, at all levels of need, to provide adequate mental health treatment results in serious and in some cases fatal consequences for prisoners with mental illness whose psychiatric needs are not met. Insufficient Long Term Inpatient Mental Health Care
115. Prisoners with mental illness who, due to the severity of their illness, require longterm inpatient care at a psychiatric hospital are not provided with this essential care. DOCS and OMH do not have any program to provide extended inpatient psychiatric treatment to prisoners; the only inpatient psychiatric facility for prisoners, CNYPC, has only 187 beds for a population of more than 67,000 prisoners and is operated as a short-term placement only.
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116. The immediate consequence of the insufficient number of available inpatient beds is two-fold: prisoners with mental illness experiencing grave psychiatric need either suffer an undue delay in admission or are prematurely discharged from CNYPC.
117. While awaiting admission to CNYPC, many prisoners with mental illness are held for twenty-three or even twenty-four hours a day in secluded observation cells in the OMH Satellite Mental Health Units for evaluation due to their severe psychiatric deterioration or acts of self-harm. Frequently they are held alone in these small cells for many days or even weeks while they wait to be admitted to CNYPC.
118. Many prisoners with mental illness, who suffer severe psychiatric deterioration and are admitted to CNYPC, are returned to prison prematurely even though they have a continuing need for inpatient care to stabilize their illness and to ensure that they remain stabilized.
119. The problem of the lack of necessary inpatient beds has been so severe that at times CNYPC has operated at or above capacity on a “one-for-one” basis, wherein a facility must take a prisoner back from CNYPC in order to send one in.
120. Prison outpatient services available to prisoners with mental illness who are discharged from CNYPC fail to provide appropriate treatment and services to meet the prisoners’ known mental health care needs. Prison mental health staff frequently do not follow, or quickly modify, the treatment plan developed at CNYPC that directs the mental health treatment a prisoner should receive upon release back to the prison.
121. The consequences of premature release from CNYPC often include serious painful episodes of psychiatric deterioration. Some prisoners with mental illness quickly psychiatrically deteriorate upon their return to prison and then must be treated in a crisis mode, forcibly medicated
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in an emergency situation after an agonizing return to an extremely psychotic state. Other mentally disabled prisoners released prematurely from CNYPC attempt or commit suicide, mutilate themselves, or stop complying with the limited treatment provided by prison mental health staff.
122. Another consequence of the limited available inpatient hospital care is that acute care is rarely offered to prisoners with mental illness unless they are deemed to be an imminent danger to self or others. Severely disabled prisoners may be gravely ill and suffering, exhibiting extreme paranoia, experiencing depression or delusions, but until they actively engage in behavior to injure themselves or pose an imminent threat to others, they often are not even evaluated for admission to CNYPC or are denied admission despite their serious medical need.
123. When prisoners with mental illness refuse their medication, prison mental health staff frequently fail to inquire into the reasons for the refusal or to attempt to persuade the patient to accept the treatment, or to modify the treatment. Instead, the prisoner often is deemed to be uncooperative and is discharged from OMH services despite a diagnosis of a serious mental illness and recent hospitalization at CNYPC. In such a case the prisoner almost inevitably psychiatrically decompensates due to the lack of treatment.
124. This failure to provide appropriate treatment in prison and to provide long-term inpatient care causes many prisoners with serious mental illness to repeatedly cycle back and forth between prison and CNYPC. The repeated cycle of deprivation of adequate treatment leading to psychiatric crisis leading to hospitalization is extremely detrimental to individuals with serious mental illness. It often becomes increasingly difficult to restore these individuals from a mentally deteriorated or psychotic state to some semblance of normal functioning, and frequently these individuals become increasingly distrustful of OMH mental health staff who do nothing to interrupt the cycle of their torment.
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Insufficient Intermediate Level Residential Mental Health Care 125. Many prisoners with mental illness require mental health services provided in an
intermediate level therapeutic residential treatment program rather than an acute care hospital setting. 126. Defendants provide only 513 therapeutic residential treatment beds in Intermediate
Care Programs (“ICP”) for the entire population of prisoners with mental illness. These ICPs are located within DOCS prison facilities and are staffed jointly by DOCS and OMH staff. The ICPs are intended to provide more intensive therapies and programs than are available to prisoners housed in the general population.
127. The 513 ICP beds available are insufficient to provide for the numerous prisoners with mental illness who are known by DOCS and OMH to be in need of intermediate level residential mental health treatment.
128. Many prisoners with mental illness who have committed disciplinary infractions are barred from ICP placement even though they are in need of residential mental health treatment. No other therapeutic residential treatment program is available to treat them.
129. Prisoners with mental illness for whom a therapeutic residential treatment program is clinically appropriate are barred from participating in the ICPs due to the lack of bedspace, their current or prior disciplinary history, or other non-clinical reasons. This failure to provide necessary intermediate mental health care for these prisoners with mental illness often results in increased psychiatric deterioration, increased frustration trying to cope with the conditions of their confinement, increased incidents of misconduct borne of their inability to cope, and a decrease in programs and work opportunities.
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Representative Constituents 130. All of the plaintiff’s representative constituents are mentally ill adult residents of New
York State and prisoners of the New York State Department of Correctional Services. Many of them have been confined to SHU, keeplock, double-celled SHU or administrative segregation at some time during the period of their incarceration. Many of them have been repeatedly held in OMH Satellite Mental Health Unit observation cells, ICP housing areas and have been committed to CNYPC. Each has an extensive history of mental illness well known to DOCS and OMH.
131. Due to the confidential medical information described, random initials have been substituted for the proper names of the representative constituents. Prisoner I.J.
132. I.J., a diagnosed schizophrenic with borderline intellectual functioning, has been committed to CNYPC on twenty-nine separate occasions since his incarceration in 1981.
133. I.J. has a history of being suicidal when he is mentally decompensated. His admissions to CNYPC have been precipitated by depressed and sometimes self-abusive behaviors, as well as regressive behaviors such as defecating and urinating on the floor of his cell and becoming withdrawn and mute.
134. I.J. frequently suffers from hallucinations which are paranoid, persecutory and command self-harm. On numerous occasions from 1993 through 1996, he became severely decompensated, experienced paranoia and auditory hallucinations, and was admitted to CNYPC.
135. I.J. has spent a large portion of his incarceration housed in twenty-three hour isolated confinement in SHU. He has repeatedly suffered serious psychiatric deterioration in SHU.
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136. During the occasions that he has been hospitalized at CNYPC or housed in an OMH Satellite Mental Health Unit and has accepted medication, he has not presented behavioral problems and has functioned markedly better than in isolated confinement.
137. In May 2000, while housed in the ICP at Great Meadow C.F., I.J. was again suffering a period of serious psychiatric deterioration. During that period, I.J. was sentenced to 180 days SHU time for two incidents of use of abusive language with no testimony from mental health staff requested or proffered at the disciplinary hearings.
138. I.J. was transferred to SHU where his deterioration escalated. According to a misbehavior report issued on May 24, 2000, I.J. refused to obey orders to turn the light on in his cell or to remove his jumpsuit from the cell gate; he reportedly began yelling threats at the corrections officer, ripped the light bulb from his wall and smashed it against the sink and toilet in his cell.
139. The misbehavior report indicates that OMH staff were notified and came to speak to I.J. after which he was escorted without incident to the OMH Satellite Mental Health Unit for observation.
140. On the date of his hearing, June 8, 2000, I.J. again was transferred to an observation cell in the OMH Satellite Mental Health Unit due to agitated behavior and smearing feces. He was reportedly exhibiting delusional thinking, refusing to eat and refusing medication.
141. I.J. did not appear at the hearing regarding the May 24 incident. OMH was not consulted by the hearing officer and did not testify at the disciplinary hearing. I.J. received one year in SHU for destroying state property, refusing a direct order, and using threatening language.
142. Shortly after his June 8 admission to an OMH observation cell, I.J. was returned to SHU from the observation cell at his request. He was transferred back to twenty-three hour isolated
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SHU confinement without having accepted medication and without any indication that his condition had stabilized. No efforts to encourage compliance with medications or to consult with CNYPC are recorded in his mental health record.
143. I.J. continued to psychiatrically deteriorate in SHU. In August 2000, he was admitted again to the OMH Satellite Mental Health Unit for observation. His behavior was described as being loud and yelling, he reported that he was hearing voices, seeing ghosts, and that he was experiencing suicidal ideation.
144. Despite the OMH-observed and recorded paranoia and delusions for the two days following his admission to the OMH Satellite Mental Health Unit, I.J. was transferred back to his SHU cell on August 7, 2000. He was not seen again by OMH until September 21, 2000 when DOCS staff requested OMH intervention.
145. On September 21, 2000, DOCS staff referred I.J. to mental health staff due to his “strange behavior.” No description of his behavior was recorded, and I.J.’s OMH record does not document any intervention by OMH staff.
146. I.J. was subsequently seen by OMH staff approximately every two to three weeks during rounds in SHU.
147. In October 2000, OMH noted that I.J. was compliant with his medications and that he requested an increase in medication because he was seeing ghosts.
148. The following month, I.J. began to suffer severe psychiatric deterioration again. He became medication non-compliant and refused to leave his cell to meet in private with OMH staff.
149. On November 9, 2000, I.J.’s medication orders were discontinued because he had been refusing to take medication. No efforts to encourage compliance with his prescribed medication regime are recorded in his OMH record.
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150. In December 2000, a month after the medication orders were discontinued, I.J. began to smear feces in his cell and became very agitated.
151. On December 6, 2000, I.J. refused to leave his cell to be transferred to an observation cell in the OMH Satellite Mental Health Unit. He was forcibly extracted from his SHU cell by DOCS staff utilizing a form of tear gas and an extraction team. After the extraction he was placed in an observation cell in the OMH Satellite Mental Health Unit.
152. Just two days later, on December 8, 2000, I.J. was returned to isolated confinement in SHU. In SHU, he deteriorated to the point where he refused to shower, refused to turn his light on, was paranoid, delusional, fearful and suspicious, and believed others to be possessed.
153. On January 4, 2001, I.J. finally was removed from SHU due to his beliefs that his food was being poisoned and that others were possessed, and due to his refusal to bathe. He was again taken to an observation cell in the OMH Satellite Mental Health Unit.
154. On January 10, 2001, I.J. was committed to CNYPC after remaining in an observation cell for six days where he continued to express paranoid beliefs and suspicions.
155. There is no indication in I.J.’s OMH records from June 2000 through January 2001 that I.J. was ever evaluated for psychiatric hospitalization prior to January 8, 2001.
156. On March 23, 2001, I.J. was discharged from CNYPC to the SHU at Clinton C.F. His discharge plan included a combination of medications, and an indication that he “will need observation, counseling and encouragement to take medications.”
157. I.J. was not seen in SHU by OMH staff between April 10, 2001 and May 1, 2001. On May 1, he was observed to be paranoid, and he stated that he did not feel well and that he felt confused. He informed OMH staff that he had stopped taking his medications two weeks earlier.
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158. OMH did not take any action to remove I.J. from SHU; he was not transferred to an observation cell in the OMH Satellite Mental Health Unit. He was in fact not seen by OMH staff again for two weeks. At that time, it was noted that his paranoia had increased; he reported that he believed that corrections officers were tampering with his food. The response of OMH staff was to discontinue all of his medications because he had not taken them, and to permit DOCS to continue to house him in SHU. Despite his noted deteriorating mental condition, mental health visits were reduced to a monthly basis.
159. By June 2001, I.J.’s mental status had further deteriorated. He was loud and disruptive and had begun to throw feces around his cell. His behavior resulted in disciplinary charges.
160. OMH mental health staff reported their view that I.J. was “manipulative” and they arranged for his transfer to the Attica C.F. SHU. OMH staff did not arrange for more intensive mental health treatment, nor did they consult with CNYPC.
161. On June 20, 2001, I.J. was transferred to Attica C.F. in an agitated and paranoid state. He refused to comply with a strip search at Clinton C.F. during the transfer procedure and was given an additional disciplinary ticket for this behavior.
162. I.J. was sentenced to two years of SHU time and 18 months loss of good time for refusing the strip search and he received six months of SHU time for throwing feces and urine at an officer.
163. At the Attica C.F. SHU, I.J. has continued to receive tickets for hostile and agitated behavior, and now faces nearly six years of SHU with no appreciable mental health treatment for his schizophrenia.
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164. On September 19, 2001, plaintiff DAI notified defendants by letter of its concern that I.J. had not received necessary mental health treatment at Great Meadow, Clinton and now Attica Correctional Facilities, and that he received only harsh punishment for the agitated behavior that resulted from his untreated psychiatric illness.
165. On November 28, 2001, H.E. Smith, the Executive Director of CNYPC, responded that through psychiatric treatment, I.J.’s condition had improved since he had been housed at Attica C.F. However, Mr. Smith offered no response to plaintiff’s request for quality assurance and training at Great Meadow and Clinton Correctional Facilities, and to plaintiff’s knowledge, defendants have taken no corrective action to resolve the deficiencies identified at those facilities.
166. I.J. is scheduled to remain in SHU through July 2006 - a date more than a year beyond the maximum expiration date of his sentence.
167. On May 16, 2002, I.J. was transferred from the Attica SHU to CNYPC. Prisoner K.L.
168. K.L. has been a New York state prisoner since 1997. On January 8, 2001, K.L. was transferred to the double-bunk SHU at Upstate C.F. Upon admission to Upstate he was evaluated by an OMH staff psychologist. The screening evaluation noted that he was an active patient on the OMH caseload for the past two years, that he had a history of paranoia and assaultiveness, and that he had been admitted to CNYPC on one occasion after seriously injuring another prisoner in an episode of paranoia. K.L.’s diagnosis as stated in the evaluation is chronic paranoid schizophrenia.
169. The OMH staff psychologist further indicated in the evaluation that K.L. declined mental health services, that no evidence of schizophrenia was present, and that K.L. would not be admitted to the OMH caseload at Upstate C.F.
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170. On January 9, 2001, one day after his evaluation, K.L. was seen cell-side by a social worker in response to a letter from K.L. and a DOCS nursing referral. The social worker observed that K.L.’s speech was “mildly illogical” with a “loose pattern” and that K.L. firmly believed that he had a transmitter fixed in the back of his head which gave him special powers. The social worker noted that K.L. had previously been diagnosed with delusional disorder and psychosis. The social worker determined that K.L. was not a danger to himself and was not interested in mental health services. He was transferred to a single-cell SHU at Upstate C.F. to be monitored “as needed.” He was not transferred to a facility that has an OMH Satellite Mental Health Unit.
171. On February 1, 2001, K.L. was seen at his cell on routine rounds and was noted to have become increasingly agitated, suspicious and paranoid. K.L. continued to claim that he had a transmitter in the back of his neck, that his birthdate gave him special powers, and that the corrections officers were telling other prisoners that K.L. is in the CIA. The psychologist also noted that he had a history of becoming assaultive when he mentally decompensates, and that he had not eaten in three days.
172. On February 2, 2001, K.L. was transferred to the OMH Satellite Mental Health Unit at Clinton C.F. for observation and evaluation and possible admission to CNYPC. A social worker observed that K.L. was extremely delusional and grandiose. He was claiming to be full of top secret information which he could not disclose lest he be killed and that he had a computer chip installed in the back of his head, which he wanted removed.
173. Stripped to his undershorts and wearing only a paper gown, K.L. was confined to an observation cell for the following twelve days. K.L. endured uncomfortably cold temperatures in the observation cell.
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174. K.L. was not seen by a psychiatrist until February 5, three days after his admission to the OMH Satellite Mental Health Unit at Clinton C.F. The psychiatrist noted that K.L. was “acutely psychotic, paranoid and grandiose.” The psychiatrist indicated that the treatment plan would be to begin treating him with Haldol and Cogentin.
175. K.L. refused medication on February 6 and continued to speak irrationally. He was reported to be paranoid, suspicious and refusing to eat because he did not trust the food.
176. In the morning of February 7, K.L. continued to speak illogically and continued to deny his need for medication. K.L. stated, however, that he needed to go to Marcy Hospital [CNYPC] because it was unsafe for him to go into general population.
177. On February 8, 2001, the social worker noted that K.L. would be transferred to CNYPC on February 13, 2001. The social worker noted that K.L. continued to express delusions about working for the CIA, and that he was suspicious of staff who prevented him from “carrying out his assignment.”
178. K.L. remained in an observation cell for the following five days, becoming angry, demanding and threatening. His thoughts were noted to be incoherent, illogical, and delusional. On February 12, 2001, an OMH social worker noted that his thought process “continues to focus on delusion of persecution” and on K.L.’s need to get somewhere “safe.”
179. Finally, on February 13, 2001, after spending twelve days in an observation cell in an acutely psychotic state, K.L. was transferred to CNYPC for stabilization. Prisoner M.N.
180. M.N., currently age 25, was incarcerated in 1995 to serve a term of 3 1/3 to 10 years for two counts of criminal possession of a controlled substance.
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181. Upon arrival in DOCS custody, M.N. had a physical and mental history which included lead poisoning at age 4, mental retardation and childhood behavioral problems. Notations in the OMH records indicate that M.N. also had a history of head trauma requiring surgery in 1982 to put a metal plate in his head. OMH records are devoid of specifics or independent verification of the head trauma and surgery. In 1988, he was diagnosed with conduct disorder, undifferentiated type.
182. During M.N.’s incarceration, he was diagnosed with delusional disorder and antisocial personality disorder.
183. While in prison, M.N. has frequently received misbehavior reports and has been punished with keeplock and SHU time for behavior that is symptomatic of his mental illness.
184. M.N. was committed to CNYPC in July 1998 from Elmira C.F. On arrival at CNYPC, he was paranoid and delusional. He was disheveled, his speech was slurred, and his thought processes were at times illogical. He denied that he had ever been incarcerated and asserted that he was being illegally confined.
185. During his commitment at CNYPC he was periodically restrained due to attempted assaults on staff. He was retained at CNYPC for approximately two months and then discharged to DOCS with recommendations that he be monitored by mental health staff and receive medication.
186. Within approximately one month of M.N.’s return to prison from CNYPC, he began another cycle of keeplock confinement as a result of being found to have violated prison rules. M.N.’s behavior problems continued, and in October, 1999, resulted in a penalty of twenty-four months SHU time.
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187. While in the SHU at Sing Sing C.F., M.N. began to psychiatrically deteriorate. In November 2000, he was reported to be disheveled and unclean. His hygiene was poor, his food and fluid intake was decreased, he had altered thought processes and he was nonverbal. On November 28, 2000, due to his obvious psychiatric decompensation, M.N. was transferred from SHU to an observation cell in the RCTP in the OMH Satellite Mental Health Unit.
188. After being held in an observation cell for nine days, on December 7, 2000, OMH determined that M.N. had improved enough to be returned to twenty-three hour isolated confinement in SHU.
189. After transferring him back to SHU, OMH did not have any contact with M.N. for seven weeks. On January 30, 2001, M.N. was seen by OMH staff at cell-side in SHU. OMH reported that M.N. had a chronic thought disorder, was refusing to shower and was only minimally verbal. M.N. was next seen by OMH staff on February 9, 2001, at another cell-side visit in SHU. He was reported by OMH to be distracted and responding to internal stimuli.
190. On March 6, 2001, OMH staff saw M.N. again during SHU rounds. At this time, M.N. was observed with his head covered with a blanket and he would not give verbal responses. OMH noted that an admission to CNYPC to be medicated over his objection might be necessary if his functional status deteriorated to the point that he was dangerous to himself.
191. M.N. continued to psychiatrically deteriorate in SHU. OMH reported that he was internally preoccupied with decreased responsiveness and poor personal hygiene.
192. On May 1, 2001, M.N. was again transferred from SHU to an observation cell in the RCTP at the Sing Sing C.F. OMH Satellite Mental Health Unit. He was nonverbal, unresponsive, was not sleeping or eating, and had poor hygiene. He reportedly had lost contact with reality and had
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not taken his medication for months. While in the RCTP, M.N. started voluntarily taking medication, eating and showering.
193. On May 17, 2001, OMH discharged M.N. from the RCTP back to twenty-three hour solitary confinement in the Sing Sing C.F. SHU.
194. On June 12, 2001, M.N. was re-admitted to the RCTP for a forty eight hour observation period and to be medicated by injection. After forty-eight hours, M.N. was returned to SHU.
195. Staff from plaintiff’s counsel, Prisoners’ Legal Services of New York (“PLS”), conducted a legal visit with M.N. on June 21, 2001, in the Sing Sing C.F. SHU. PLS staff noted a significant deterioration in M.N.’s physical appearance since their previous visit of May 17, 2001. M.N. was dirty, had dried food all over his clothing and reeked of body odor and urine. In addition, M.N. had shaved the hair off of various parts of his body including his eyebrows, arms and legs. PLS staff reported M.N.’s condition to OMH Satellite Mental Health Unit Chief David Boyd by telephone on June 21, 2001. PLS then confirmed this information in a letter to David Boyd dated June 25, 2001.
196. On July 9, 2001, M.N. was again re-admitted to the RCTP for medication by injection. On July 11, 2001, M.N. was returned to SHU.
197. M.N. continues to follow a pattern of being housed in SHU, significantly decompensating, being transferred to the OMH Satellite Mental Health Unit for brief periods primarily for the administration of long term stabilizing medication, and then being returned to isolated confinement in SHU. No other psychiatric services have been made available to M.N. to prevent his continual psychiatric deterioration in SHU.
198. M.N. continues to be housed in the Sing Sing C.F. SHU at this time. 38

Prisoner O.P. 199. O.P., currently age 23, was incarcerated in November 1999 to serve a term of two to
six years for criminal sale of a controlled substance. O.P. has an extensive mental health history that began prior to his incarceration.
200. In January 1996, at the age of 16, O.P. had a series of psychiatric inpatient admissions with diagnoses of psychotic disorder, bipolar disorder and organic psychosis. In addition, O.P. received outpatient mental health treatment from October 1996 through August 1999.
201. While in prison, O.P. has carried a variety of diagnoses including schizophrenia, antisocial personality disorder, mild mental retardation (with a verbal I.Q. of 61) and a learning disorder.
202. O.P. has continually received misbehavior reports in prison due to his inability to conform to prison rules and regulations. As a result of these misbehavior reports, O.P. has spent large amounts of time in keeplock and SHU confinement.
203. O.P.’s first misbehavior report was the result of an incident that occurred on November 14, 1999, just 13 days after his arrival in DOCS custody at Downstate C.F. He was charged with creating a disturbance, the failure to follow a direct order and disorderly conduct.
204. In November 1999, within weeks of O.P.’s arrival at Downstate C.F., he was referred by DOCS to OMH for evaluation. His behavior was noted by DOCS staff to include poor impulse control and an inability to sit still.
205. Approximately one month later, in December 1999, Downstate C.F. again referred O.P. to OMH. This time DOCS staff reported that he was refusing to shower or clean his cell and that he reeked of urine. He was in keeplock at the time.
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206. In February 2000, DOCS staff referred O.P. to OMH a third time. DOCS reported that O.P. was pacing in his keeplock cell, yelling and screaming, standing on top of his sink singing loudly and that he did not bathe.
207. On or about March 1, 2000, O.P. was transferred from Downstate C.F. to Sullivan C.F. On or about March 11, 2000, an OMH referral was made by DOCS noting O.P.’s loudness and “darting around his cell.” O.P. was still being held in keeplock.
208. On or about March 12, 2000, O.P. was transferred to an observation cell in the OMH Satellite Mental Health Unit. His behavior was reportedly bizarre and he exhibited poor insight.
209. On April 6, 2000, O.P. was committed to CNYPC. He reportedly was agitated, unable to sleep, had poor insight and judgment and was having periods of confusion. His diagnosis at the time of referral included psychotic disorder and he was receiving a number of psychiatric medications.
210. During his commitment to CNYPC, O.P. was placed in physical restraints on several occasions.
211. On May 31, 2000, he was discharged from CNYPC back to Sullivan C.F. By the time of his discharge, CNYPC had altered his diagnosis. The psychotic disorder was deleted and the disorder of antisocial personality disorder was added. However, O.P.’s discharge plan from CNYPC called for periodic mental health contact and continued supportive mental health interaction.
212. O.P. was admitted to the OMH Satellite Mental Health Unit RCTP upon his return to Sullivan C.F. On June 7, 2000, while he was still housed in the RCTP, a disciplinary hearing was held for an incident that took place on April 1, 2000, five days before O.P. was psychiatrically committed to CNYPC. O.P. received a penalty of keeplock time as a result of the disciplinary hearing.
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213. O.P. remained in the RCTP until June 19, 2000 when he was released to a cell on keeplock status. During his time in the RCTP he was reported to be easily agitated, his mood was unpredictable and he had periods of screaming and yelling.
214. On June 22, 2000, another disciplinary hearing was held for O.P. This hearing was based on an incident which had occurred on March 29, 2000, seven days before O.P. was psychiatrically committed to CNYPC. O.P. received an additional penalty of keeplock time as a result of this hearing.
215. On July 1, 2000, and July 2, 2000, O.P. was referred by DOCS staff at Sullivan C.F. to OMH staff for evaluation. He was described as standing at his cell gate and screaming throughout the night. He was also described as slamming his head into walls and his fist into his locker for no reason. He was reported not to comprehend his keeplock status or much of anything else.
216. OMH staff did not see O.P. in response to these two referrals until July 10, 2000. 217. On July 17, 2000, O.P. again was admitted to the RCTP for observation as a result of his psychiatric decompensation in keeplock. OMH noted that he was unable to control his behavior and that there was a potential for violence towards others. On or about August 2, 2000, O.P. was returned to his cell in the block and keeplock was resumed. 218. On August 4, 2000, O.P. again was re-admitted to the RCTP at Sullivan C.F. due to his “manic behavior.” OMH and DOCS reported that he was yelling, being disruptive and that his thought content was delusional, obsessed and preoccupied. 219. As a result of additional disciplinary proceedings, when O.P. was discharged from the RCTP on August 14, 2000, he was transferred to SHU.
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220. On September 12, 2000, O.P. again was admitted to the RCTP for observation as a result of his acting-out behavior. He was loud, his hygiene was poor with foul body odor, and he was fearful and suspicious. OMH staff noted that he had poor impulse control due to limited intellect and that as a result there was potential for violence directed at others. Recommendations by OMH staff included that he be placed in a safe environment, and that coping skills and medication compliance be encouraged. However, OMH permitted his transfer back to twenty-three hour isolated confinement in SHU.
221. On October 17, 2000, O.P. was again admitted to the RCTP because he was psychiatrically decompensating and refusing medication. His hygiene was poor and he was unable to control his behavior. O.P. reported to OMH that he could no longer tolerate SHU confinement. He was admitted to RCTP to help him cope with SHU time.
222. On October 26, 2000, OMH recommended that O.P. be placed in a highly structured environment. Later that month he again was returned to SHU.
223. In November 2000, O.P. was again admitted to the RCTP. OMH staff noted that he was not medication compliant and that as a result his medication had been discontinued.
224. Throughout the period following his release from CNYPC in May, 2000, O.P. continued to receive misbehavior reports and accrue SHU and keeplock time.
225. On or about January 26, 2001, Sullivan C.F.’s Deputy Superintendent Decker scheduled a case conference regarding O.P. Deputy Superintendent Decker stated, “I am seeking to establish a plan of action to eventually remove this inmate from the Special Housing Unit and place him in a proper locking location that will more suitably address his mental health needs.”
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226. On February 2, 2001, the case conference was held at Sullivan C.F. Present at the conference were DOCS and OMH staff. It was determined that further disciplinary action would be of no benefit to O.P. and that he needed to receive more programming in a heavily structured setting due to his impulsive behavior. It was decided that DOCS would submit a request that O.P. be transferred in the future to a setting where additional mental health services are available.
227. Despite the decision made at the case conference, O.P. remained housed in the Sullivan C.F. SHU, continued to receive misbehavior reports, was found guilty at disciplinary hearings and continued to accrue significant SHU time.
228. On May 19, 2001, O.P. attempted suicide by making a noose and attaching it to a ceiling grate in his cell. O.P. was admitted to the RCTP on that date and it was noted that he had decompensated and had a foul body odor. He was placed on a one-to-one suicide watch. OMH determined that O.P. needed a respite from SHU.
229. On or about May 30, 2001, OMH discharged O.P. from the RCTP and returned him to SHU.
230. On information and belief, on or about June 28, 2001, O.P. was transferred to Great Meadow C.F. where he remains in SHU confinement.
231. Despite defendants’ recognition of O.P.’s mental health needs, and despite their decision that his condition necessitated his removal from SHU, O.P. has not been removed from the harsh conditions of isolated SHU confinement and he has not been transferred to a structured therapeutic mental health program.
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Prisoner R.S. 232. In August 1998, R.S., currently age 24, was incarcerated to serve a term of four to
eight years for two counts of attempted assault and attempted criminal sale of a controlled substance. 233. When R.S. was transferred to DOCS custody he had a lengthy history of psychosis
and a prior suicide attempt by hanging. R.S.’s history and his suicide attempt were known to OMH. 234. OMH records note that R.S. was first committed to psychiatric hospitalization while
awaiting trial at Rikers Island. He was held incompetent to stand trial and was sent to Mid-Hudson Psychiatric Center where he remained from June, 1997 to April, 1998.
235. During his commitment to Mid-Hudson Psychiatric facility, R.S. was given a diagnosis of antisocial personality disorder and was determined to have a history of attention deficit hyperactivity disorder.
236. In April 1998, R.S. was deemed competent to stand trial, and was subsequently convicted.
237. Within the first month after his transfer to DOCS custody, while at Downstate C.F., R.S. began receiving disciplinary tickets for his behavior. R.S. has now accrued SHU and keeplock time which extends well past the September 2004 maximum expiration date of his sentence.
238. As a result of the inability to assign additional SHU time, other disciplinary penalties were imposed on R.S., including a “restricted diet.” The DOCS restricted diet consists primarily of a fortified loaf of bread and raw cabbage. R.S. was on the restricted diet for many months beginning in March 2000.
239. In December 1998, at Downstate C.F., R.S. was put on a suicide watch in an observation cell in the OMH Satellite Mental Health Unit after stating that he was going to hang
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himself. Two days later, R.S. was transferred back to SHU to continue serving isolated disciplinary confinement time.
240. In January 1999, R.S. was prescribed the antipsychotic Risperdal. 241. In February 1999, R.S. was transferred to Attica C.F. 242. On February 23, 1999, the prescription for Risperdal was discontinued by OMH staff who reported that R.S. had no major depression. 243. On March 12, 1999, OMH staff determined that R.S. suffered from only antisocial personality disorder. On the basis of this diagnosis they removed him from the OMH active patient list altogether. 244. On or about March 12, 1999, R.S. was transferred to Clinton C.F. 245. On April 19, 1999, R.S. advised Clinton C.F. OMH staff that he was fearful due to a gang-related matter. OMH staff concluded that there was no mental health issue based on this statement although, at the same time, they listed R.S.’s diagnosis as psychosis. OMH staff told R.S. to talk to DOCS staff about his gang-related concerns. 246. On May 30, 1999, while at Clinton C.F., R.S. received disciplinary charges for unhygienic acts, self-harm, assault on an inmate and possession of a weapon. He received eighteen months of SHU time for these disciplinary infractions. 247. In July, 1999, R.S. was transferred to Southport C.F. to continue serving his SHU sentence. Despite his well known and lengthy history of serious mental illness and repeated deterioration in SHU, R.S. was sent to Southport C.F., one of the two maximum security DOCS prisons which does not have an OMH Satellite Mental Health Unit.
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248. On July 29, 1999, OMH staff screened R.S. at Southport C.F. and concluded that he had no mental health diagnosis and no treatment needs. On or about March 13, 2000, and May 31, 2000, OMH staff again screened R.S. and concluded that R.S. had no mental health diagnosis.
249. On July 24, 2000, R.S. reported taking an overdose of the antihistamine Sudafed. As Southport C.F. does not have an OMH Satellite Mental Health Unit, R.S. was transferred to an observation cell in the Elmira C.F. OMH Satellite Mental Health Unit. While in the observation cell he smeared himself and the cell with his feces and continued to threaten self-harm. OMH staff diagnosed R.S. with antisocial personality disorder.
250. While in the Elmira C.F. OMH Satellite Mental Health Unit, R.S. was put on antipsychotic medication due to his threats of self-harm, threats of harm to others and behavior of banging and yelling. On July 29, 2000, his diagnosis was changed to add adjustment disorder with mixed disturbance of emotions. OMH staff recommended that R.S. be followed as an active OMH patient expecting R.S. to “act out manipulatively through his behavior.”
251. In early August 2000, R.S. was transferred back to the Southport C.F. SHU with a behavior management plan devised by OMH to be used at Southport C.F. if R.S. threatened suicide. Pursuant to the plan, DOCS security staff were to remove items with which self-harm could be attempted. If the incident occurred during normal working hours, R.S. would be evaluated by OMH staff. If the incident occurred after normal working hours, R.S. would be evaluated by OMH staff when they were next on-site at Southport C.F. The plan lacked any provisions for R.S. to be psychiatrically evaluated or counseled, if he became suicidal outside of “normal working hours.”
252. In November 2000, during cell-side rounds in the Southport C.F. SHU, OMH staff observed R.S. making vague threats of self-harm. OMH reported their belief that the threats were made in hopes of being transferred out of Southport C.F. and that R.S.’s behavior was manipulative.
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253. OMH’s response to R.S.’s threats of self-harm was to arrange for a psychiatric evaluation for the stated purpose of terminating him from mental health services. On November 25, 2000, R.S. refused to come out of his cell to be evaluated by the OMH psychiatrist who came to conduct the evaluation. OMH then terminated R.S. from OMH services on November 29, 2000, giving the reason that R.S. was “manipulative.”
254. R.S.’s condition immediately declined after OMH services were terminated. R.S. received additional misbehavior reports for incidents that occurred on or about December 1, December 4, and December 5, 2000. He was found guilty of various charges which included unhygienic acts, obstructing visibility into the cell, false alarm, and verbal threats. R.S. received restricted diet penalties for these incidents.
255. On December 6, 2000, R.S. was found unclean in his SHU cell, with feces smeared all over his cell window. R.S. refused to leave his cell and upon the order of Superintendent McGinnis was extracted from his cell by a team of corrections officers for the purposes of showering him and cleaning his cell. After the cell was cleaned and R.S. was showered, he was returned to the same SHU cell and stripped of all possessions, bedding, and clothing other than his underwear and two suicide prevention mats. R.S. received additional disciplinary charges for his behavior including the charge of committing an “unhygienic act.”
256. A disciplinary hearing held on or about December 12, 2000, resulted in a finding of guilt with an additional penalty of restricted diet.
257. R.S. has continued to accrue disciplinary charges and restricted diet penalties since the December 6, 2000 incident. DOCS continued to house R.S. in SHU confinement at Southport C.F.
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258. On or about July 23, 2001, PLS staff conducted a legal visit with R.S. at Southport C.F. R.S. presented as extremely paranoid and fearful. He reported visual and auditory hallucinations, stating that he saw bugs crawling on his walls and on his body, and that he was hearing voices. He reported feeling hopeless and suicidal. His physical appearance was disheveled and unclean.
259. On or about July 24, 2001, PLS staff wrote a letter to Superintendent McGinnis at Southport C.F. and Peter Russell, OMH Satellite Mental Health Unit Chief for the Elmira C.F., requesting that R.S. be transferred to another facility where his mental health needs could be addressed.
260. On or about August 10, 2001, Peter Russell, OMH Satellite Mental Health Unit Chief for the Elmira C.F. responded to the PLS letter by reporting that R.S. was evaluated after receipt of the July 24, 2001 letter and did not need enhanced mental health services at that time. The response further stated that since that evaluation, however, R.S.’s condition had changed and that he was transferred to a prison with an OMH Satellite Mental Health Unit so additional services could be provided.
261. On or about August 29, 2001, DOCS Deputy Commissioner and Counsel, Anthony Annucci, responded to the PLS letter stating that OMH clinical staff at Southport C.F. evaluated R.S.’s mental health condition after receiving the PLS letter. It was the opinion of the OMH staff that R.S. was “feigning mental illness symptoms in order to elicit sympathy and assistance in obtaining a transfer out of Southport C.F.” The letter further stated that subsequent to that evaluation, however, R.S. had made another attempt at self-harm and for that reason, DOCS transferred him to Clinton C.F. which has an OMH Satellite Mental Health Unit.
262. On information and belief, at present, R.S. is housed at Wende C.F. in SHU.
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Failure of DOCS and OMH to Establish Adequate Mental Health Programs 263. Despite their legal obligation to do so, defendants have systematically failed and
refused to provide medically necessary mental health care to prisoners with mental illness, including but not limited to, necessary and adequate inpatient hospitalization when needed, and necessary and adequate intermediate level mental health care within the prison.
264. As a result of defendants’ practices, policies and procedures, prisoners with mental illness, based on the symptoms of their disabilities, have been, and continue to be, excluded from participation in, or denied the benefits of medically necessary mental health services.
265. Despite knowledge from ongoing litigation that they have provided inadequate mental health care for prisoners with mental illness housed in twenty-three hour isolated confinement, DOCS and OMH have failed to enhance such services. In fact, defendants have increased the number and variety of restrictive twenty-three hour isolated confinement housing facilities.
266. There has been no comparable expansion of mental health staffing levels even though twenty-three hour isolated confinement is known to exacerbate mental illnesses and to make the prisoners’ need for care more urgent.
267. Prisoners with mental illness are housed and suffering from their illnesses in twentythree hour isolated confinement housing areas where they are either serving disciplinary sentences or are held as administrative segregation status prisoners.
268. Defendants have long been aware of the gross deficiencies in their delivery of mental health treatment to prisoners but have failed to remedy these known deficiencies. The SCOC has repeatedly notified OMH and DOCS of their findings of inadequate mental health policies and procedures in New York State prisons, and has cited inadequate resources to manage long-term
49

treatment for prisoners with chronic and persistent mental illnesses as a factor in suicides in past years. Despite such notice provided by SCOC, ongoing litigation, which has resulted in consent decrees and damage awards for prisoners pertaining to mental health treatment at various prisons, and other evidence of deficiencies in caring for prisoners with mental illness, defendants have failed to provide adequate mental health care to treat prisoners' serious mental health needs on a systemwide basis.
FIRST CAUSE OF ACTION Cruel and Unusual Punishment in Violation of the Eighth and Fourteenth Amendments to the United States Constitution 269. By their policies, practices and acts, defendants violate the rights of prisoners with mental illness to be free from cruel and unusual punishment as guaranteed by the Eighth and Fourteenth Amendments to the United States Constitution. 270. As a matter of policy and practice, defendants, with deliberate indifference, fail to provide prisoners with mental illness with adequate mental health treatment and therapeutic housing options necessary to treat and to prevent worsening of their mental illness. 271. As a matter of policy and practice, and with deliberate indifference to their mental health needs, defendants impose periods of prolonged isolated confinement upon prisoners with mental illness which lead to the deterioration of their mental health. 272. By imposing periods of prolonged isolated confinement without regard to the deleterious effect that it will have on prisoners’ mental health, defendants act with deliberate indifference to the substantial risk of serious harm to prisoners with mental illness.
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SECOND CAUSE OF ACTION Violations of the Americans with Disabilities Act (ADA) and
of Section 504 of the Rehabilitation Act (Section 504) 273. Plaintiff’s constituents are qualified individuals with disabilities as defined in the ADA and in Section 504. They have mental impairments that substantially limit one or more major life activity, including but not limited to thinking, concentrating, and interacting with others; they have records of having such an impairment; or they are regarded as having such an impairment. As state prisoners, all plaintiff’s constituents meet the essential eligibility requirements for the receipt of services or the participation in programs or activities provided by defendants DOCS and OMH. 42 U.S.C. §12102(2); 42 U.S.C. § 12131 (2); 29 U.S.C. § 794. 274. Defendants DOCS and OMH are public entities as defined under 42 U.S.C. § 12131(1)(B). 275. DOCS and OMH receive federal financial assistance. 276. Defendants discriminate against mentally disabled prisoners by failing to provide alternative punishments as a reasonable accommodation so that punishments which exacerbate mental illness are not imposed. 277. Defendants discriminate against mentally disabled prisoners solely on the basis of their disabilities in violation of Section 504 and on the basis of their disabilities in violation of the ADA. 29 U.S.C. §794; 42 U.S.C. §12132.
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Prayer for Relief
278. Prisoners have suffered and will continue to suffer irreparable injury as a result of the
unlawful acts, omissions, policies, and practices of the Defendants as alleged herein, unless they are
granted the system-wide relief they request. This complaint seeks systemic system-wide relief and
does not seek to duplicate or supplant relief, either court ordered or by settlement, sought in any prior
case litigated on an institutional basis.
279. Wherefore, plaintiffs request that this Court grant them the following relief:
a. adjudge and declare that the acts, omissions, policies, and practices of the Defendants with regard to Prisoners violate the Eighth and Fourteenth Amendments to the United States Constitution; the Rehabilitation Act, 29 U.S.C. § 794; and the Americans with Disabilities Act of 1990, 42 U.S.C. § 12132;
b. enjoin Defendants, their agents, officials, employees, and all persons acting in concert with them, under color of State law or otherwise, from continuing the unconstitutional and illegal acts, conditions, and practices described in this Complaint;
c. appoint an independent mental health professional to assess the treatment and housing needs of prisoners with mental illness and who is authorized to preclude placement of prisoners with mental illness into isolated confinement housing areas;
d. order Defendants, their agents, officials, employees, and all persons acting in concert with them, under color of State law or otherwise, to take all necessary actions to:
i. create sufficient hospital bedspace to provide short-term and longterm inpatient treatment for prisoners with mental illness in need of inpatient care;
ii. provide sufficient mental health treatment programs and services to prisoners with mental illness in state correctional facilities including expanded intermediate residential mental health services housing and other alternative housing so that prisoners with mental illness are not housed in 23 hour confinement housing areas or other countertherapeutic settings;
iii. provide increased and sufficient staffing to provide adequate mental health screening, monitoring and treatment within DOCS facilities and at CNYPC;
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iv. create patient tracking mechanisms so that OMH is notified of, or knows of, predictable stressful events when they occur to prisoners with mental illness (i.e. assaults, sentencings, losses of job, illnesses, arrests, disciplinary tickets, disciplinary sentences, psychiatric discharges);
v. teach DOCS staff during pre-service and in-service training programs to recognize the signs and symptoms of mental illness and to prevent suicides;
vi. provide advanced training to DOCS staff assigned to medical, mental health and high risk settings, including disciplinary detention and administrative segregation facilities, in suicide prevention and in the management of prisoners with mental illness;
280. award plaintiffs costs and disbursements of this action including reasonable attorney’s fees; and
281. grant such other and further relief as this Court deems just and proper.
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Dated:

New York, New York May 28, 2002

Respectfully submitted,

___________________________________ SARAH KERR (4174) DANIEL L. GREENBERG JOHN BOSTON BETSY GINSBERG The Legal Aid Society Prisoners’ Rights Project 111 Livingston St. Brooklyn, NY 11205 Phone: (718) 260-4757 Fax: (718) 260-4744

NINA LOEWENSTEIN (8540)

CLIFF ZUCKER (2254)

Disability Advocates, Inc.

5 Clinton Square, 3d floor

Albany, NY 12207

Phone:

(518) 432-7861

Fax: (518) 427-6561

BETSY STERLING

TOM TERRIZZI

Prisoners’ Legal Services of New York

118 Prospect Street, Suite 307

Ithaca, NY 14850

Phone:

(607) 273-2283

Fax: (607) 272-9122

JAMES W.B. BENKARD

JENNIFER H. REARDEN

BRIAN N. LASKY

Davis Polk & Wardwell

450 Lexington Ave.

New York, NY 10017

Phone:

(212) 450-4000

Fax: (212) 450-5649

 </s> UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK
------------------------------------------------------)(
DISABILITY ADVOCATES, INC.,
Plaintiff,
- against -
NEW YORK STATE OFFICE OF MENTAL HEALTH, et aI.,
Defendants.
------------------------------------------------------)(

02 Civ. 4002 (GEL)

PRIVATE SETTLEMENT AGREEMENT

TABLE OF CONTENTS
I. Commitment by DOCS and OMH to Heightened Level of Care; Definition of Serious Mental Illness. . ............................................................... 2 Diagnostic Criteria ....................................................... 3
I .J. Exceptional Circumstances. . ................................................. 5 a. Clinical Exceptions .................................................... 5 b. Safety and Security Exceptions ........................................... 5
2. Additional Keep10ck Mental Health Services ..................................... 6
3. Reception Screening ......................................................... 6
4. Increases in Bed Capacity .................................................... 7 a. ICP Expansion ........................................................ 7 b. Transitional ICPs ...................................................... 7 c. STP Expansion ....................................................... 8 d. New Residential Mental Health Unit ...................................... 8 (i) Housing ....................................................... 8 (ii) Program Building ............................................... 8 (iii) RMHU Not SHU ............................................... 9 (iv) Televised Programming Pilot .................................... 10 e. New Ward at Central New York Psychiatric Center ("CNYPC") ............... 10 f. Needs Reassessments ................................................. 10 g. Use When Available .................................................. II
5. Treatment and Housing Settings Consistent With Safety and Security ................. I I
6. Disciplinary Process ......................................................... 12 a. OMH Input .......................................................... 12 b. Self-Harm ........................................................... 13 c. Informational Reports ................................................. 13 d. Refusals of Treatment and Medication .................................... 13 e. Automatic Review of Certain SHU Sentences ............................... 14 f. Restricted diet ........................................................ 14 g. SHU Mental Health Assessment ......................................... 14 h. Review of Existing SHU Sentences ....................................... 14 i. Time Cuts ........................................................... 15 j. Expansion of CMCs ................................................... 15 k. Central Office Review ................................................. 15
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7. Crisis Observation Program ................................................... 16 a. Length of Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 b. Suicide Watch ....................................................... 16 c. Amenities ........................................................... 16 d. Clinical Contact and Treatment .......................................... 16
8. Conditions of Confinement - Cell Doors ......................................... 17
9. Maintenance of Level of Mental Health Services .................................. 17
10. Role of Parties' Experts in Administration and Enforcement ........................ 17 a. Designation and Role .................................................. 17 b. Periodic Tours and Assessments ......................................... 18 c. Access to Documents .................................................. 18 (i) In conjunction with tours ......................................... 18 (ii) Quarterly .................................................... 19 (iii) Semi-Annually ............................................... 20 (iv) Annually .................................................... 21 (v) On a one-time basis ............................................ 23 d. Confidentiality ....................................................... 23 e. Consideration of Experts' Recommendations ............................... 23
11. Enforcement Powers ....................................................... 24
12. Attorneys' Fees; Post-settlement Activities ...................................... 25
13. Private Settlement Agreement ................................................ 26
14. Term .................................................................... 27
IS. Binding Effect ... , ........................................................ 27
16. No Third-Party Beneficiaries ................................................. 27
17. Stipulation of Dismissal .................................................... 27
18. Funding ................................................................. 28
19. No Admissions or Precedential Effect .......................................... 28
20. Entire Agreement .......................................................... 28
21. Notices .................................................................. 28
22. Effective Date ............................................................ 29
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UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK ------------------------------------------------------x DISABILITY ADVOCATES, INC.,
Plaintiff,
- against -
NEW YORK STATE OFFICE OF MENTAL HEALTH, et a!.,
Defendants. -----------------------------------.------------------x

02 Civ. 4002 (GEL)

PRIVATE SETTLEMENT AGREEMENT

The parties hereto, by their attorneys, hereby stipulate and agree as follows: WHEREAS, plaintiff filed the instant lawsuit seeking declaratory and injunctive relief on behalf of prisoners with mental illness in the custody of the New York State Department of Correctional Services ("DOCS"), alleging that DOCS and the New York State Office of Mental Health ("OMH") have provided inadequate mental health services within the prison system in violation of 42 U.S.c. §1983, the Eighth and Fourteenth Amendments of the United States Constitution, 29 U.S.c. § 794 (the Rehabilitation Act), and 42 U.S.C. § 12132 (the Americans with Disabilities Act of 1990); WHEREAS, the defendants have denied that they have violated any such constitutional or statutory rights; WHEREAS, the parties have conducted extensive fact and expert discovery, and have commenced, but not completed, the non-jury trial of this Action before the Honorable Gerard E. Lynch in the Southern District of New York;

WHEREAS, the parties, without conceding any infirmity in their claims or defenses, have subsequently engaged in extensive settlement negotiations to resolve the claims raised by this Action;
WHEREAS, the parties represent and agree that this Agreement is fair, reasonable and adequate to protect the interests of all parties, and that entering into this Agreement will benefit inmates with mental illness, who may develop mental illness, or who are at risk ofdeveloping mental illness, who are confined in the correctional facilities of the State of New York; and
WHEREAS, this Agreement and New York State Senate Bill No. 333 and Assembly Bill No. 4870 ("S.333/A4870") both seek to ameliorate the conditions for inmates with serious mental illness who are housed in disciplinary confinement, and the Agreement establishes a commitment by the State to a heightened level of care for all inmates with serious mental illness in disciplinary confinement, and provides for additional treatment modalities and benefits for persons with mental illness in the State's correctional system, and both sides have entered into this Agreement with the expectation that the Legislature will not pursue S.333/A.4870, or other legislation covering issues addressed by this Agreement;
NOW, THEREFORE, IT IS HEREBY STIPULATED AND AGREED by and between the parties, as follows: I. Commitment by DOCS and OMH to Heightened Level· of Care; Definition of Serious Mental Illness.
Defendants agree that, upon completion of the construction period for the programs and facilities provided under this Private Settlement Agreement, a heightened level of care (i.e. at lea.t 2 hours of structured out-of-cell therapeutic programming and/or mental health treatment per day,
2

five days a week', in addition to exercise) will be offered to all inmates subject to a confinement sanction in a Special Housing Unit ("SHU") who meet the diagnostic criteria listed in (a) through (e) below ("inmate-patients with SMI" or "inmate-patients with serious mental illness"), except upon a determination ofexceptional circumstances as provided below. The terms "SHU confinement" and "Still confinement sanction" shall include Keeplock, if the Keeplock sanction is being served in a SHU. This Section shall not apply to inmate-patients subject to an aggregate SHU confinement sanction of 30 days or less and shall apply to inmate-patients witb an aggregate SHU confinement sanction of more than 30 days. The treatment and programming required by this Section shall be offered within 30 days of the imposition of such SHU confinement sanction in excess of30 days or which increases an aggregation of SHU confinement sanctions to a period in excess of 30 days. If an inmate who does not meet the diagnostic criteria set forth in (a) through (e) below at the time a SIill confinement sanction in excess of 30 days is imposed is later designated as meeting said diagnostic criteria and has 30 days or more remaining in a SHU confinement sanction, the treatment and programming required by this Section shall be offered within 30 days of such later designation.
Diagnostic Criteria a. Inmates determined by OMH to have a current diagnosis or a recent significant history' of any of the following types of Diagnostic and Statistical Manual IV (DSM-fV) Axis I diagnoses:
'References in this Agreement to periods of time, such as five days a week, shall exclude state or federal holidays.
'''Recent significant history" is defined as a diagnosis specified in Section l(a)(I)1(a)(9) within the past year and a recent history (within the past year) of commitment to Central Ncw York Psychiatric Center ("CNYPC") and such a confirmed diagnosis at CNYPC after such commitment. All determinations and diagnoses under subsections (a) through (e) shall be made byOMH.
3

(1) Schizophrenia (all sub-types) (2) Delusional Disorder (3) Schizophreniform Disorder (4) Schizoaffective Disorder (5) Brief Psychotic Disorder (6) Substance-Induced Psychotic Disorder (excluding intoxication and withdrawal) (7) Psychotic Disorder Not Otherwise Specified (8) Major Depressive Disorders (9) Bipolar Disorder I and II b. Inmates who are actively suicidal orwho have engaged in a recent, serious suicide attempt. c. Inmate-patients diagnosed with a serious mental illness that is frequently characterized by breaks with reality, or perceptions of reality, that lead the individual to experience significant functional impairment involving acts ofself-harm or other behaviors that have a seriously adverse effect on life or on mental or physical health. d. Inmate-patients diagnosed with an organic brain syndrome that results in a significant functional impairment involving acts ofself-harm or other bchaviors that have a seriously adverse effect on life or on mental or physical health. e. Inmate-patients diagnosed with a severe personality disorder that is manifested by frequent episodes of psychosis or depression, and results in significant functional impairment involving acts of self-harm or other behaviors that have a seriously adverse effect on life or on mental or physical health.
4

1.1. Exceptional Circumstances. a. Clinical Exceptions. In rare instances an inmate-patient meeting the diagnostic criteria set
forth in Section l(a)(1) - (9) may not, based upon the reasonable judgment of the treating OMH clinicians, need the heightened level of care provided in Section 1. For example, some inmatepatients with a diagnosed bipolar disorder, due to a successful regimen of medication, may not need a heightened level of care involving structured programming. Any such determination by the OMH treatment team that an inmate-patient does not need such heightened level of care shall be documented with a written statement of the reasons for such determination and be reviewed by the CNYPC Clinical Director or hislher designee. In addition, any such determination is subject to change, should the clinical status of the inmate-patient change, and any such determination shall in any event be reviewed and documented by the treatment team every thirty days, and in consultation with the CNYPC Clinical Director or hislher designee not less than every ninety days.
b. Safety and Security Exceptions. Exceptional circumstances may also occur creating an unacceptable risk to safety and security of inmates or staff. When providing the level of care otherwise required by Section 1 for a particular inmate-patient would create such exceptional circumstances, based on a determination by the Superintendent in the facility where the inmatepatient is housed in consultation with the OMH treatment team, such determination shall be documented by a written statement of the reasons therefor. Defendants shall attempt to resolve any such exceptional circumstances, so that the specified level of care may be provided as soon as practicable after the exceptional circumstances cease to exist. A determination of exceptional circumstances due to safety and security shall be reviewed by the Superintendent, in consultation with the OMH treatment team, not less than every seven days. When there is a determination ofsuch exceptional circumstances that remains unresolved for a period of30 days, the case shall be referred
5

to the Central Office Review Committee created under Section 6(k), for review and possible resolution at the next scheduled Committee meeting. 2. Additional Keeplock Mental Health Services
Inmate-patients subject to a Keeplock confinement sanction of more than 60 days, who (a) are serving that sanction in a separate Keeplock housing unit, rather than in a SHU or a general population unit predominantly housing non-Keeplocked inmates, and (b) have any ofthe diagnoses in Section lea) through (e) shall:
(iJ receive a minimum of two individual out-of-cell clinical sessions per month in a private setting with their primary therapist and one such session with an OMH psychiatrist or nurse practitioner, and at the first of such sessions, receive a mental health and suicide prevention assessment; (ii) be subject to regular Case Management Committee (HCMC")3 reviews to take place at least once every two weeks;
(iii) receive preference for admission to the Intensive rcp at Wende;
(iv) be eligible for admission to the RMHU, when it becomes operational. 3. Reception Screening.
The defendants will increase OMH staffin the system's reception facilities to provide mental health screening following intake ofall new inmates. The purpose ofthis staffincrease is to establish reception evaluation procedures which follow the model described in Guideline P-E-05 of the National Commission on Correctional Health Care.
3As used herein, the term HCMC" refers to the joint DOCS and OMH Case Management Committees established under 7 NYCRR §31 0. 1.
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4. Increases in Bed Capacity a. rcp Expansion. Defendants will add ninety (90) new beds in the Intennediate Care
Program ("rCp"), in addition to the 572 current rcp beds and the 118 additionallCP beds covered by the previously approved 2004 and 2005 initiatives.
b. TransitionallCPs. Defendants will create a new program which will provide heightened mental health services and program hours for inmate-patients who would benefit from a level of mental health programming and services in between the level ofprogramming and services available in general population and the intensive treatment and programming in the existing ICPs. Two Hundred and Fifteen (215) Transitional rcp beds will be created under the new program as part of this Agreement. Inmate-patients admitted to a TransitionallCP will be housed together in existing general confinement areas.
Admissions criteria will be defined. Transitional lCPs will have multiple feeder sources, including, without limitation, for example, (1) ICP inmate-patients no longer in need of an rcp level of care, but who would benefit from a transitional program before returning to other general population locations, (2) certain fonner BHU, STP or RMHU inmate-patients, (3) inmate-patients discharged from SHU or Keeplock on a case by case basis, (4) general population inmate-patients diagnosed with a serious mental illness who would benefit from Transitional rcp program and (5) inmates with mental illness entering the correctional system identified through intake screening as appropriate for the Transitional rcp program. The Transitional ICPs may also be appropriate for inmate-patients who would benefit from a long-tenn residential program. A goal and potential benefit of the Transitional ICPs will be a reduction of disciplinary involvement by inmate-patients with mental illness participating in the program.
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c. STP Expansion. Defendants will add ninety (90) new Special Treatment Program ("STP") beds, as previously approved in the 2004 and 2005 initiatives, in addition to the 43 current STP beds, for a total of 133 STP beds.
d. New Residential Mental Health Unit. Defendants will create a new Residential Mental Health Unit ("&\1HU") for disciplinary inmate-patients, using the existing "S-block" at Marcy Correctional Facility, which contains 100 douhle cells with a present capacity of 200 inmates.
(i) Housing. The designated S-block will be reconfigured as follows for use as the RMHU: Double celling will be eliminated, with the limited exception noted in this sub-section. Solid cell doors will be modified, so as to increase visihility and communication between inmate-patients and staff and among inmate-patients by including a barred or mesh opening on at least part of the cell doors. The initial capacity ofthe RMHU will be approximately 100 beds, each ofwhich will be located in a former double cell. In a limited number of instances, if the treating OMH clinicians determine that for particular inmate-patients, double ceiling would aid in the treatment of both inmate-patients, double ceiling may be utilized in those
instances, if it is not inconsistent with DOCS' regulations and policies on double
ceiling. The reasons for determinations that double celling would aid in the treatment ofthe inmate-patients will be documented in the mental health treatment records. (ii) Program Building. A new program building will be constructed, adjoining and connected to the RMHU's residential building. The program building will contain program areas, as well as clinical staff offices. The RMHU will offer out-of-cell therapeutic programming and/or mental health treatment to eaeh inmate-patient four hours per day, five days a week. This programming is in addition to exercise.
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Because of the characteristics of the cells, it will be possible to provide increased showers and exercise time. The RMHU will offer a range of security modalities for prograrruning, in order to assure the safety of inmate-patients and staff and enable appropriate inmate-patients to progress to less restrictive therapy milieus. Therapeutic cubicles will be available for group and individual therapy, as well as small classroom study where needed, utilizing a modified cubicle design to enhance communication and visibility. The configuration ofthe therapy and classroom space will also permit therapy and class room study without the use of cubicles. In lieu of cubicles, other appropriate restraints may be used depending upon an inmatepatient's behavioral progress and safety considerations. Options for congregate therapeutic recreational activities will also be made available inside the program building, should inmate-patient's behavioral progress and safety considerations permit. At the time of the first needs reassessment under sub-section (f) below, DOCS will consider the feasibility ofmaking outdoor congregate exercise available to inmate-patients in the RMHU. DOCS will retain absolute discretion as to whether and to whom such an option will be provided. Outdoor congregate exercise, if any, to be provided in the RMHU will be counted as out-of-cell therapeutic prograrruning for purposes of determining whether the required number of hours of such prograrruning has been provided. (iii) RMHU Not SHU. Once admitted to the RMHU, inmate-patients are not considered to be in SHU or Keeplock; however, their SHU and Keeplock time will continue to run. Notwithstanding the foregoing, in light of the security concerns associated with the behaviors that gave rise to their SHU confinement sanctions,
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inmates in the RJviHU can be limited to the amenities provided under parts 302 through 304 of Title 7 NYCRR (although additional amenities may be provided), Furthermore, DOCS may make determinations, in its sole judgment, that for safety and security reasons, selected provisions of Part 305 of Title 7 NYCRR, not inconsistent with other provisions of this Agreement, should be applied to inmatepatients housed in the RJv1HU, provided that the due process provisions of Part 305 are followed, (iv) Televised Programming Pilot. DOCS will launch a pilot program of providing televised in-cell programming, initially for 25 cells in an S-Block. This pilot may be part of or in addition to the RJv1HU, but shall not be in lieu of any level of care otherwise required by inmate-patients, i,e, will not be a substitute for the 2 hours of out-of-cell programming per day otherwise required by Section I or the 4 hours of out-of-cell programming to be provided in the RlviHU, e, New Ward at Central New York Psychiatric Center ("CNYPC"), OMH will create an additional 20-bed hospital ward at CNYPC, which shall be available for referrals from defendants' outpatient network in 2008, f Needs Reassessments, Needs rcassessments will be appropriate in the future to assure that all inmate-patients with SMI identified in Section I receive a heightened level of care. Reassessments will be conducted in December 2007 and December 2008. In addition to the foregoing, (i) in or about September 2008, defendants will conduct an assessment of the need in medium security facilities for additional lCP and Transitional lCP beds, and (ii) within a year after the RMHU is completed and becomes operational, defendants will conduct an assessment to determine whether there is a need for expansion of the RMHU to add capacity for an additional 50
10

beds. In connection with all such reassessments, defendants will solicit the opinions and advice of the parties' experts, although all final determinations about needs reassessments and the general operation of prison mental health programs shall be made by defendants in keeping with their statutory responsibilities and the provisions of this Agreement.
g. Use When Available. As the additional bed capacity referred to in this Agreement will necessarily take time to construct, full compliance with the heightened level of care requirement must be assessed upon completion of said construction. Defendants will use new capacity to meet the needs of inmate-patients as the additional capacity becomes available. No determination by defendants to increase capacity following any needs reassessment provided for herein shall be deemed evidence of non-compliance with any term or provision of this Agreement, nor shall such a determination delay an assessment of compliance with other terms and provisions of this Agreement. 5. Treatment and Housing Settings Consistent With Safety and Security
Consistent with existing practices, defendants agree that the housing setting of inmatepatients with SMI subject to a SHU confinement penalty will be reviewed, at least every 90 days, to determine if it is consistent with both their mental health treatment needs and safety and security requirements. At OMH Level I and 2 facilities, the review shall be conducted by the CMC with input from the OMH treatment team. At other facilities, the review shall be conducted by the Superintendent with input from OMH. In reviewing such inmate-patients' status, defendants' goals are the movement of inmate-patients from more restrictive to less restrictive settings, as well as the significant reduction of time inmate-patients with SM! spend in restrictive environments, if and when safety and security permit. Defendants recognize that inmate-patients should receive all necessary mental health services in a clinically appropriate environment and, subject to the need to
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ensure safety and security, should be removed from a more restrictive environment when this is clinically appropriate. While every inmate-patient with SMI in need of a heightened level of care, as provided in Section I, should receive it, housing designation and length of participation in particular programs must be determined by the responsible clinical and security staff and shall not be based on fixed or presumptive time limits. Actions taken, and reviews conducted pursuant to this Section shall be subject to oversight review by the Central Office Review Committee. 6. Disciplinary Process
a. OMH Input. OMH will continue to provide input and recommendations in disciplinary proceedings, including input and recommendations based upon opinions, if any, fonnulated by the reporting OMH clinicians on issues offitness to proceed, culpability, mitigation and duration ofand suitability for disciplinary housing. The written statement of the disposition of the charges, if any, shall reflect how the inmate's mental condition or intellectual capacity was considered in accordance with current procedures. Subject to the confidentiality provisions of this sub-section and Section lO(d) of this Agreement and solely for purposes of compliance with this Agreement, plaintiff may request up to 10 Superintendent's ('Tier III") Hearing tapes per month, including any tape-recorded testimony ofOMH personnel taken outside the presence ofthe inmate in connection with applicable regulations in instances where an inmate's mental condition or intellectual capacity was considered.' Such tape-recorded testimony ofOMH personnel and any information obtained during a review of that testimony must be kept confidentiaL Plaintiffs counsel is prohibited from revealing the content
'Where in the same Superintendent's Hearing, in addition to the tape-recorded testimony of OMH personnel, tape-recorded testimony of a teacher or correction counselor is also taken outside the presence or the inmate in connection with applicable regulations in instances where both an inmate's mental condition and intellectual capacity are considered, DOCS will also include the tape-recorded testimony of the teacher or correction counselor. Where this additional testimony is produced, it shall be subject to all of the same confidentiality and use provisions herein which govern the tape-recorded testimony of OMH personneL
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of the tape to the inmate or anyone outside OMH or DOCS, except plaintiffs experts, plaintiffs counsel, and employees of such counsel, and a court pursuant to Section 11 hereof. Plaintiffs counsel may use confidential hearing tapes produced under this Agreement to advocate privately with DOCS and/or OMH on behalf of individual imnates; provided that tapes used for such individual advocacy shall not be used in, or to bring, lawsuits or other proceedings without express written consent of DOCS. Nothing in this Agreement shall require the release to plaintiff or plaintiffs counsel of any other confidential testimony.
b. Self-Harm. There will be a presumption against pursuing charges for self-harming behavior and threats ofself-harming behavior, including related charges for the same behaviors, such as destruction of State property. In addition, pursuant to directions by DOCS' Central Office to all facilities, any such misbehavior report must be immediately referred to the facility's Deputy Superintendent for Security for review and a referral made to OMH. Only rarely or in exceptional circumstances mayan inmate receive a SHU or Keeplock confinement sanction based upon selfharming behavior or verbally reporting to DOCS or OMH staff feelings or intentions regarding selfharm or suicide, as referenced in the first sentence of this sub-section.
c. Informational Reports. In order to aid in diversion of inmate-patients from SHU and Keeplock, informational reports, following the Great Meadow-Sullivan BHU template, will also be used in all ICPs, Transitional ICPs, STPs and the RMHU in lieu of some misbehavior reports.
d. Refusals ofTreatment and Medication. Misbehaviorreports will not be issued forrefusing treatment or medication. An inmate-patient may, however, be subject to the disciplinary process or issuance of an informational report, where applicable, for refusing to go to the location where treatment is provided or medication is dispensed, in order to facilitate therapeutic involvement relating to an inmate-patien!'s decision to refuse treatment or medication.
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e. Automatic Review of Certain SHU Sentences. There will be an automatic review by the facility Superintendent in consultation with OMH ofall disciplinary hearing dispositions, where the inmate's mental health was an issue under applicable regulations, which impose aSHU confinement sanction ofover 60 days, or in the event the inmate has accumulated SHU confinement sanctions or Keeplock confincment of 120 days or longer. Such review shall occur within 7 days of the conclusion of the disciplinary hearing. The Superintendent shall consider the appropriateness of such confinement sanctions standing alone and in light of any accumulation of such sanctions that may have previously been imposed. This review is intended to be in furtherance ofthe goals set forth in Section 5 above.
f. Restricted diet. When mental health is at issue in a disciplinary hearing, the restricted diet will not be used as a sanction, except for safety and security reasons enumerated under Section 304.2(b)(1) - (b)(3) of7 NYCRR. Section 304.2(b)(4) will not be used as a basis for a restricted diet for such inmates. Absent exceptional circumstances (as such term is used in the first sentence of Section 1.1 (b) above), where mental health is an issue in the disciplinary hearing, no restricted diet sanction in excess of 7 days shall be imposed.
g. SHU Mental Health Assessment. There will he a mental health assessment within one working day of the imposition of a SHU confinement sanction, as defined in Section 1, for all inmates in OMH Levelland 2 facilities. A suicide prevention screening instrument will also be administered within 24 hours of all such admissions to SHU.
h. Review of Existing SHU Sentences. As part of defendants' efforts to implement the goals described in Section 5 above, existing SHU confinement sanctions of all inmate-patients with SMI will be reviewed on a one time basis by ajoint DOCS-OMH committee. The committee will include Central Office personnel from each agency to be designated by the Commissioners. The committee
14

will assess the feasibility of diverting inmate-patients from SHU, including the feasibility of time cuts, when in the committee's judgment this can be done without unacceptable risks to safety and security. This one time review will be completed within one year after this Agreement is signed by the parties.
i. Time Cuts. Primary responsibility for time cuts will be delegated to the CMCs with the Superintendent's approval. A specific proposal in that regard is being formulated as part of defendants' efforts to meet the goal described in Section 5 above. The proposal will include CMC time cut reviews of OMH caseload inmate-patients at least once every three months and, for such caseload inmate-patients, the waiver of the existing Departmental requirement that SHU inmatepatients serve at least one-half of their confinement time before being eligible for time cut consideration. The proposal is consistent with existing regulations which permit CMCs to consider time cuts at any time, and is not intended to dilute the CMCs' powers with respect to time cuts.
j. Expansion ofCMCs. Case Management Committees will be created at all Level 2 facilities in order to perform CMC review functions with respect to SHU inmate-patients on the OMH caseload,
k. Central Office Review. In order to promote the review of the aggregation of SHU sentences of inmate-patients with SMI, and to provide oversight for other provisions of this Agreement, a Central Office Review Committee will be created. The Committee will include Central Office personnel from each agency designated by the Commissioners. The Committee will meet twice monthly and will conduct a specific review ofthe accumulation ofSHU confinement sanctions by caseload inmate-patients for at least two facilities per month on a rotating basis, as well as provide oversight and review of other matters referred to the Committee pursuant to the terms of this Agreement.
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7. Crisis Observation Program a. Length ofStay. The use ofobservation cells should be no longer in duration than necessary
to deal with the mental health crisis which caused the inmate-patient to be placed in observation. Defendants' goal shall be to keep inmates in observation cells for no more than four (4) days and there shall be a presumption in favor of releasing inmates from observation cells within four (4) days. However, any decision on when to release an inmate [rom an observation cell after more or less than any particular number of days is a clinical judgment. All cases in which an inmate is held over seven days in observation shall be referred to the CNYPC Clinical Director or designee for consultation.
b. Suicide Watch. Constant 24-hour observation will bc provided for inmates on suicide watch.
c. Amenities. No inmate should be left in an observation cell without clothing, smock or paper gown, and a paper gown should only be used where there is a specific safety and security need. The specific amenities provided to an inmate in an observation cell must be determined on the basis of clinical need and safety and security considerations relating to the particular crisis involved in each case.
d. Clinical Contact and Treatment. All inmates in observation cells will be seen by clinical staff every day, five days a week, and by nursing staff on two shifts every day, seven days a week. In addition, every inmate in an observation cell will be offered a minimum daily out-of-cell individual session with a therapist andlor psychiatrist, five (5) days a week, Monday through Friday, when this can be done without unacceptable risk to safety and security. Determinations of such unacceptable risk shall be documented in the mental health treatment record.
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8. Conditions of Confinement - Cell Doors. Solid front cell doors in (i) STPs, (ii) SHU cclls where inmate-patients with SMI are housed
and (iii) in Keeplock cells in separate Keeplock housing units referenced in Section lO(c)(i) where inmate-patients with SMI are housed, will be modified, so as to increase visibility and communication between inmate-patients and staffand among inmate-patients by including a barred or mesh opening on at least part of the cell doors. Nothing herein shall preclude the issuance of a cell shield order in accordance with 7 NYCRR § 305.6. 9. Maintenance of Level of Mental Health Services.
Defendants have no intention of reducing the level ofmental health services made available to inmate-patients following or based upon completion ofthe additional mental health programs and services provided under this Agreement. Additionally, the parties' experts may make recommendations as to possible changes to assist inmate-patients in SHU, BHU, RMHU, STP or any other elements of, or mental health programs in the prison system. Defendants will give full consideration to any such recommendations, provided that all final determinations with respect thereto shall be made by defendants. 10. Role of Parties' Experts in Administration and Enforcement.
a. Designation and Role. Plaintiff and defendants shall each designate a psychiatric expert. Plaintiffmay also designate a security expert, provided that any such designated security expert shall participate in no more than one four-day tour per calendar year under Section 1O(b) of this Agreement, and such expert shall not participate in interviews of inmates during any such tours. No designated psychiatric or security expert shall be a monitor, but shall advise, consult with and assist the parties as provided in this Agreement. Nothing shall limit defendants' ability to retain additional experts.
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b. Periodic Tours and Assessments. Based on an agreed schcdule of specified tours and assessments, each side's experts shall report to the retaining party concerning defendants' compliance with the terms ofthis Agreement. In or about September 2007, the experts, accompanied by counsel, shall conduct an initial consecutive four-day tour and assessment of mutually agreed selected correctional facilities. Tours will include SHU, Keeplock Units, all mental health program areas, Satellitc Mental Health Units and any other areas of concern to the experts in evaluating mental health treatment and compliance with the terms ofthis Agreement. Further consecutive fourday tours and assessments at mutually agreed selected correctional facilities shall be conducted by the parties' experts, accompanied by counsel, according to the following schedule:
March 2008 September 2008 March 2009 September 2009 March 2010 September 2010 c. Access to Documents. (i) In conjunction with tours: Approximately thirty (30) days in advance of the tours, the parties' counsel shall be provided with the following documents prepared by OMH relating to the facilities to be visited: a list of imnate-patients referred to the CNYPC Clinical Director or designee under Section 7(a) above; a list of inmate-patients who, while in SHU, were diagnosed within the past 6 months as meeting the diagnostic criteria set forth in Section 1 and who currently have an SM! diagnosis; a list of inmate-patients currently in mental health programs and/or beds, including AVP, ICP, Intensive ICP, Transitional ICP, BHU, STP, RMHU and
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RCTP as of the last day of the prior month; a list of inmate-patients in SHU with designated OMH level; a list of inmate-patients in the separate Keeplock housing areas at Albion, Attica, Clinton, Coxsackie, Elmira and Great Meadow with designated OMH level'; and an Excel file of the data generated by the OMH SHU Mental Health Data Application as of a date approximately 30 days prior to each tour. During the tours the parties' experts shall be given reasonable access to current mental health records, to current DOCS disciplinary history printouts, facilities and access to, not private sessions with, personnel whose duties pertain to the provision of mental health services and/or who deal with inmate-patients within the correctional system, and the parties' experts shall have a reasonable opportunity to conduct confidential interviews of inmates in a location to be determined by the defendants. Plaintiffs counsel may be present during any such interviews conducted by their expert. After the tours, the parties' experts may request and shall be provided with copies of a reasonable number of current OMH mental health records and a reasonable number of additional DOCS disciplinary history printouts and disciplinary hearing packets and any reasonably available data as to informational reports.
(ii) Ouarterly: Parties' counsel shall be provided with the following documents: all systemic quality improvement/quality assurance reports applicable to mental health prepared by OMH and DOCS, respectively; new or updated CNYPC operations and policy and procedure manuals and any accompanying transmittal letters; new or updated directives and training materials related to mental health programs prepared by OMH and DOCS, respectively; summary memoranda, notes or other documentation, including any custodial and clinical recommendations or determinations generated by the Central Office Review Committee meetings or CMCs; OMH
, Defendants shall notify plaintiff if any additional separate Keeplock housing areas are created and will not house inmate-patients with SMI in such newly created Keeplock housing
areas.
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Incident Review Committee sununary memoranda, summary notes, memoranda, and/or reports; the OMH Risk Management Report, for the quarter; and tables generated during the quarter by the OMH SHU Mental Health Data Application, including a table providing medication information similar to that provided as part of the Management Indicators Reports, namely as to the number of inmate-patients in SHU and STP on psychiatric medication, on anti-psychotic medication, on 2nd generation (atypical) medication, on c10zapine and data relating to medication refusals during the quarter; DOCS' list of inmates who have received a SHU or Keeplock confinement sanction during the quarter based upon an act of self-harm (Rule 123.10); and documentation of any determination during the quarter of "exceptional circumstances" for clinical or safety and security reasons made in accordance with Section 1.1 of this Agreement, such documentation to be provided by OMH as to Section Uta) and by DOCS as to Section LI(b); DOCS' list of inmates who have been placed on a restricted diet during the quarter as a result of a disciplinary hearing where mental health was at issue; a list of inmate-patients who have been subject to the automatic review under Section 6(e) above of certain SHU sentences and the outcome of such
reVIews.
(iii) Semi-Annually: Parties' counsel shall be provided with the following documents: expert reports, at the option of the retaining party; lists of inmates who in the previous six months: had an RCTP Observation Cell stay oflonger than 7 days and the prison location(s); had three or more admissions to RCTP Observation Cell and the prison location(s); had two or more admissions to CNYPC and the prison location(s) transferred from and discharged to,
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(iv) Annually: OMH shall provide parties' counsel with the following reports: Outpatient Statistical Report; STP Report; BHU Report; RMHU Report"; Intensive Iep Report; and Transitional Iep Report. The STP, BHU, RMHU, ncp, and Transitional ICP Reports shall include, inter alia: the total number of inmates admitted to the program; length of stay in the program; housing locations where admissions are from; number of inmate-patients discharged or transferred from the programs; housing locations where they are discharged to (but not for transfers to Observation Cells or Dorm Beds since these are temporary moves and do not constitute program discharge); the number and percentage of inmate-patients in each OMH level in the program; number and percentage of seriously mentally ill inmate-patients in the program; number and percentage of inmate-patients on each medication at intake; number and percentage of medication compliant inmate-patients at intake; number and percentage of seriously mentally ill inmate-patients who are offered 2 hours out-of-cell programming on a program day; number and percentage of inmate-patients with SMI who are participating in the 2 hours of out-of-cell programming; number and percentage of inmate-patients with SMI who are refusing out-of-cell programming; average number of inmate-patients with SM! receiving Tier III misbehavior reports during the program; number of inmate-patients with SMI on Keeplock status; number and percentage of inmate-patients with SMI with a SHU or Keeplock time cut, and average amount cut.
Regarding Iep, once a year as of the last day of a specific month, OMH shall provide parties' counsel with a report on the number of admissions in that month; census by mental health level by unit for that day; the percentage of SM! for that day; the percentage of inmate
6The first RMHU report is not expected to be issued by OMH until approximately 12 months after the RMHU is opened. The first report shall be somewhat limited due to program start-up and shall be based on available data.
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patients receiving 20 hours of treatment each week that month by unit; the number in Keeplock as of the last day of the month.
Regarding RCTP, OMH shall provide parties' counsel an annual report on the number of admissions; median length of stay in Observation Cell and in Dorm; prison and housing type admitted from and housing type discharged to, to the extent available; number discharged from RCTP; number and percentage admitted by mental health level; number and percentage admitted with serious mental illness; number and percentage of observation cell inmates who were offered out of cell treatment; number and percentage of inmates who utilized out of cell treatment. The RCTP report will include information on transfers to CNYPC, disclosing the prison and housing type where the transfers to RCTP and then to CNYPC originated from.
Regarding long term Keeplock units at Albion, Attica, Clinton, Coxsackie, Elmira and Great Meadow, once a year as of the last day of a specific month, OMH shall provide parties' counsel with a report regarding the number of inmate-patients on the caseload; census by OMH level; and percentage of SM!.
Regarding SHU, OMH shall provide parties' counsel with an annual report that includes information as of the last day of a selected month regarding: the number of inmates on the OMH caseload; percentage by mental health level; percentage of SMI; average time in SHU to date; average time remaining in SHU; a summary of current medications; percentage of inmatepatients offered 2 private contacts the month of the report; percentage of inmate-patients receiving 2 private contacts the month of the report; average refusal rate of private contacts the month of the report.
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Regarding CNYPC, OMH shall provide parties' counsel with an annual demographic and diagnostic report that shall include: the number of admissions that year; the census as of a specific date; a diagnostic and demographic profile of the admissions during that year.
OMH shall also provide parties' counsel once a year, with a report on the OMH input into the disciplinary process, which shall summarize the annual quality assurance review, conducted by CNYPC staff of the OMH testimony tapes.
(v) On a one-time basis: Parties' counsel shall be provided with the following documents: a summary report regarding the results of the joint DOCS-OMH committee's one-time review of existing SHU sentences of all inmate-patients with SMI; the proposed modified cell door configuration referenced in Section 8; a summary report of the results of each assessment and reassessment discussed in Section 4(f); draft and final reception mental health evaluation tools and suicide prevention screening instruments.
d. Confidentiality. Materials provided to plaintiffs experts shall be deemed confidential and for use in conjunction with tasks described in Sections 10 and 11 of this Agreement only. Materials provided to plaintiff and its counsel shall be deemed confidential and shall be used solely for purposes of compliance with this Agreement, including advocating with DOCS and/or OMH on behalf of individual inmates pursuant to Section 6(a) above.
e. Consideration of Experts' Recommendations. The experts' reports may include not only an assessment of defendants' compliance with the tenns of this Agreement, but may also include additional advice, suggestions or proposals of a quality assurance or quality improvement nature as the experts deem appropriate. Although the defendants will give full consideration to advice, suggestions and proposals offered by the experts, all decisions concerning the provision
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of mental health services within the State's correctional system will be made by defendants, in accordance with the goals of this Agreement and their statutory responsibilities. II. Enforcement Powers.
In the event of any reported non-compliance by defendants with a material provision of this Agreement, counsel to the parties shall meet and confer in an effort to resolve the reported noncompliance within 30 days of receipt of written notice by DOCS and OMH of any such claimed non-compliance. In the event of a claimed pattern of pervasive non-compliance with a material provision of this Agreement and a failure to achieve a resolution of the issue within 60 days of the meet and confer, either side may seek mediation by Judge Lynch. If such mediation fails to achieve a resolution, plaintiff may move the Court for reinstatement of the lawsuit or ask the Court to recommend a one-year extension of the duration of this Agreement. Should the Court recommend that this Agreement be extended for one additional year, the parties agree to be bound by that recommendation; provided, that there may be no more than a single one-year extension during the term of this Agreement, as so extended. In the event that the lawsuit is reinstated pursuant to this Section, defendants shall have no further obligation under this Agreement, which shall thereupon be null and void. Plaintiff may also elect to proceed in State court and seek specific performance of the terms of this Agreement; provided, that plaintiff shall have first sought to resolve any compliance issue through the meet and confer and mediation procedures set forth in this Section, and such meet and confer procedures and mediation by Judge Lynch shall have failed to achieve a resolution. To prevail in either State or federal court plaintiff must make a clear showing that defendants have failed to comply with a material tem1 of this Agreement, and that such failures were not minimal or isolated, but were sufficiently frequent and widespread so as to be pervasive. Experts designated by the parties hereunder shall have no
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authority to initiate proceedings in any court, or to report to, or otherwise communicate with any court in any manner in connection with this Agreement. The parties agrce not to submit any of the experts' reports to any court, except in connection with an application to a court pursuant to this Section for specific performance, mediation, or reinstatement of the lawsuit. 12. Attorneys' Fees: Post-settlement Activities.
a. Defendants shall pay to plaintiff the sum of $2,000,000, in full satisfaction of any and all claims in this lawsuit for attorneys' fees and up to $1,450,000 in full satisfaction of any and all costs and disbursements with respect to this lawsuit up to and including the date of cxecution of this Agreement, which costs and disbursements shall he substantiated by back-up documentation satisfactory to defendants' counseL In the event that payment of the amounts referred to in this Section 12(a) is not made within one hundred and twenty (120) days after the receipt by defendants' counsel of a copy of this fully executed Agreement, approved by the Court as provided on page 31 below, interest shall accrue on the outstanding balance at the rate set forth in 28 U.S.c. § 1961, beginning on the one hundred and twenty-first day after receipt by defendants' counsel of a copy of this fully executed and so approved Agreement.
b. During the term of this Agreement, as provided in Section 14 hereof; it is anticipated that plaintiff will incur certain legal fees, expert and other costs and disbursements with respect to Sections 10 and 11 hereof. Plaintiff and plaintiffs counsel agree to limit all such attorneys' and experts' fees, costs and disbursements to what is directly and reasonably necessary in connection with such Sections up to a combined total, which shall not exceed $87,500 per year, calculated on the basis of a 365 day year, beginning on the effective date of this Agreement under Section 22 hereof and ending on thc date this Agreement terminates pursuant to thc provisions of Section 14 hereof. During the term of this Agreement, as the same may be extended pursuant to
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Section II, plaintiff's counsel agree to submit vouchers to defendants' counsel on a semi-annual basis for any such attorneys' fees, costs and disbursements and defendants agree to reimburse plaintiff's counsel within ninety (90) days of receipt of such vouchers. If payment is delayed bcyond ninety (90) days, defendants will also pay interest at the rate set forth in 28 U.S.c. § 1961, which shall accrue beginning on the ninety-first day.
c. Payment of each of the amounts referred to in this Section 12 is subject to the approval of all appropriate New York State officials in accordance with the provisions of Section 17 of the New York Public Officers Law. 13. Private Settlement Agreement.
This Agreement is a private settlement agrcement within the meaning of 18 U.S.c. § 3626, and shall not be deemed to grant "prospective relief' within the meaning of said Section 3626. Nor shall this Agreement be deemed to constitute a consent decree or an adjudication on the merits. Neither this Agreement, nor any policies or procedures established thereunder, shall define any state or federal constitutional rights, be deemed an admission, or a waiver of sovereign immunity or Eleventh Amendment protection. Moreover, none of the parties will contend that any of the provisions, policies, procedures, and goals stated herein define clearly established constitutional rights of inmates or create any private right of action against the State of New York, its agents, employees or representatives. This Agreement in no way waives or otherwise affects, limits or modifies the obligations of inmates to comply with the exhaustion requirements of the Prison Litigation Reform Act, DOCS' directives and regulations, or any current or future state or federal law governing the rights and obligations of incarcerated persons. Nothing in this Agreement shall be deemed to limit any existing authority of DOCS to transfer inmates to other state or federal jurisdictions. Moreover, nothing in this Agreement shall be
26

deemed to require or permit the defendants to violate the laws of the State of New York or the. United States, or to violate any terms or conditions of any collective bargaining agreement to which DOCS or the State of New York is a party. The defendants are not aware of any conflict between any of the provisions of this Agreement and any such law or collective bargaining agreement referred to in this Section. 14. Term.
Without further action by the parties or the Court, and subject to Section 11 hereof, this Agreement shall expire either two years from the commencement of operation of the RMHU to
be created under Section 4(d) above, or one year from the date on which all additional rcp and
TransitionallCP beds to be created under Sections 4(a) and (b) of this Agreement shall become available for use, whichever is later. 15. Binding Effect.
This Agreement is binding upon the plaintiff, plaintiffs successors, employees and agents, the defendants named in this lawsuit, and on the defendants' successors in office, employees and agents. 16. No Third-Party Beneficiaries.
Only the plaintiff named in this Agreement shall have standing to seek enforcement of any of the terms and conditions of this Agreement, which does not confer, and is not intended to confer rights on any other party. 17. Stipulation of Dismissal
The parties shall simultaneously herewith execute and deliver a Stipulation of Dismissal with respect to the captioned Action in the form annexed as Exhibit 1 hereto. The parties agree that after the Court orders said StipUlation of Dismissal, the Court shall have only the jurisdiction
27

and authority specified in Section II of this Agreement, subject to the termination provisions of Section 14 hereof. 18. Funding.
Capital improvements and material on budgeted staffing increases associated with this Agreement will necessarily be subject to approvals and budgetary processes and contingent upon legislative appropriations therefor. The parties will use their best efforts to seek approval of the additional funding necessary to implement this Agreement. 19. No Admissions or Precedential Effect.
Nothing in this Agreement shall be construed as an admission or acknowledgment of liability whatsoever by any of the defendants or the New York State Department of Correctional Services regarding any of the allegations made by the plaintiff in his complaint. It is the parties' intention that this Agreement and any Order entered thereon shall have no precedential value or effect whatsoever and shall not be admissible in any other action or proceeding as evidence or for any other purpose, except in an action or proceeding to enforce this Agreement. 20. Entire Agreement
This Agreement embodies the entire agreement of the parties in this matter and no oral agreement entered into at any time nor any written agreement entered into prior to the execution of this Agreement regarding the subject matter of the instant proceedings, shall be deemed to exist, or to bind the parties hereto, or to vary the terms and conditions contained herein. Captions are included herein solely for convenience of reference, are not part of this Agreement, and shall not be used to limit or otherwise interpret the terms hereof. 21. Notices
All notices under this Agreement shall be in writing and shall be mailed Certified Mail,
28

Return Receipt, to the recipient or recipients at the address or addresses specified in the signature pages of this Agreement. Copies of any notice to a party shall also be mailed in the manner provided above to the below-listed counsel to the parties at the addresses specified for such counsel. 22. Effective Date
This Agreement shall be effective upon the later of (i) its execution and delivery by the parties and (ii) execution by the Court on page 31 below.

Dated: New York, New York April 2007

DISABILITY ADVOCATES, INC. Plaintiff 5 Clinton Square, Third Floor Albany, New York 12207-2201 Tel. No. (518) 432-7861

Nina Loewenstein Staff Attorney Cliff Zucker Executive Director
PRISONERS' RIGHTS PROJECT Legal Aid Society Attorneys for Plaintiff 199 Water Street New York, New York 10038 Tel. No. (212) 577-7977
BY~~ Sarah Kerr Staff Attorney John Boston Project Director

29

PRISONERS' LEGAL SERVICES OF NEW YORK
Attorneys for Plaintiff 114 Prospect Street Ithaca, New York 14850 Tel. No: (607) 273-2283

D By

~·C,~L-
BetSYd. Sterling

Director of Special Litigation

and Projects

Alba Susan Johnson

Executive Director

DAVIS POLK & WARDWELL

Attorneys for Plaintiff

450 Lexington Avenue

New York, New York 10017

Tel

12) 450-4000

'C-_ _ _

~~~hla~.~~.~~~~

James W.B. Benkard

NEW YORK STATE OFFICE OF MENTAL HEALTH 44 Holland Avenue
Albany, New York 12229
B~
Commissioner

NEW YORK STATE DEPARTMENT OF CORRECTIONAL
SERVICES 1220 Washington Avenue State Office Campus Building 2
Albany, New ~ (i226
By~ -VI eX'\\..A...
Brian Fischer Commissioner
30

ANDREW M. CUOMO Attorney General of the
State of New York Attorney for Defendants 120 Broadway New York, New York 10271-0332 Tel. No.( 416-8650
i ard W. Brewster Leonard A. Cohen Lee A. Adlerstein John Knudsen Assistant Attorneys General

The Court approves this Private Settlement Agreement as to form only. Section 12 is so ordered by the Court. To the extent that this Agreement permits or requires disclosures to plaintiff of any confidential medical or mental health information, the Court hereby authorizes such disclosures, subject to the confidentiality provisions set forth in the above Private Settlement Agreement.

Dated: New York, New York
April/" 2007 ~7

ENTER:

~-=---=--{~ .~
HONORABLE GE.v,-,"u United States District Judge

31

EXHIBIT 1

UNTTED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK
------------------------------------------------------x
DISABILITY ADVOCATES, INC.,

- against -

Plaintiff,

02 Civ. 4002 (GEL)

NEW YORK STATE OFFICE OF MENTAL HEALTH, et aI.,

Defendants.
------------------------------------------------------x
IT IS HEREBY STIPULATED AND AGREED by and between the parties, by their respective counsel, that this Action be and hereby is dismissed and discontinued with prejudice.

New York, New York April ,2007

DISABILITY ADVOCATES, INC. Plaintiff 5 Clinton Square, Third Floor Albany, New York 12207-2201 Tel. No. (518) 432-7861

By____~~----~-----Nina Loewenstein
Staff Attorney
Cliff Zucker
Executive Director

PRISONERS' RIGHTS PROJECT Legal Aid Society Attorneys for Plaintiff 199 Water Street New York, New York 10038 Tel. No. (212) 577-7977

By__~~~__________ Sarah Kerr Staff Attorney John Boston Project Director

32

PRISONERS' LEGAL SERVICES OF NEW YORK
Attorneys for Plaintiff 114 Prospect Street Ithaca, New York 14850 Tel. No: (607) 273-2283
By_ _ _ _ _ _ _ _ _ Betsy C Sterling Director of Special Litigation and Projects Alba Susan Johnson Executive Director

DAVIS POLK & WARDWELL Attorneys for Plaintiff 450 Lexington Avenue New York, New York 10017 TeL No. (212) 450-4000
By__~__~~~~~_ James W.B. Benkard

ANDREW M. CUOMO Attorney General of the
State of New York Attorney for Defendants 120 Broadway New York, New York 10271-0332 Tel. No.(212) 416-8650

By

- - ~:-:--:-::cc:-=--

Richard W. Brewster

Leonard A. Cohen

Lee A. Adlerstein

John Knudsen

Assistant Attorneys General

33

 </s> CLOSED
U.S. District Court United States District Court for the Southern District of New York (Foley
Square) CIVIL DOCKET FOR CASE #: 1:02−cv−04002−GEL

Disability Advocates v. NYS Office of Mental, et al Assigned to: Judge Gerard E. Lynch Demand: $0 Related Case: 1:02−cv−05418−WHP Cause: 42:1983 Civil Rights Act
Plaintiff

Date Filed: 05/28/2002 Date Terminated: 04/30/2007 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: Federal Question

Disability Advocates, Inc.

represented by Betsy Ginsberg The Legal Aid Society 111 Livingston Street Brooklyn, NY 11205 (718) 260−4757 LEAD ATTORNEY

Betsy Sterling Prisoners' Legal Services of New York 118 Prospect Street Suite 307 Ithaca, NY 14850 (607) 273−2283 LEAD ATTORNEY

Brian N. Lasky Davis Polk &Wardwell 450 Lexington Avenue New York, NY 10017 (212) 450−4000 LEAD ATTORNEY

Cliff Zucker Disability Advocates, Inc. 5 Clinton Square 3rd Floor Albany, NY 12207 (518) 432−7861 LEAD ATTORNEY

Daniel L. Greenberg The Legal Aid Society 111 Livingston Street Brooklyn, NY 11205 (718) 260−4757 LEAD ATTORNEY

James W.B. Benkard Davis Polk &Wardwell 450 Lexington Avenue New York, NY 10017 (212) 540−4000 LEAD ATTORNEY

Jennifer H. Rearden Gibson, Dunn &Crutcher LLP (NYC) 200 Park Avenue New York, NY 10166 (212)−351−4057 Fax: (212)−351−5284

V. Defendant New York State Office of Mental Health ("OMH")
Defendant James L. Stone Commissioner of Mental Health
Defendant Jurgen Karker OMH Satellite Mental Health Unit Chief
Defendant Scott Clair OMH Satellite Mental Health Unit Chief
Defendant

Email: jrearden@gibsondunn.com LEAD ATTORNEY
John Boston The Legal Aid Society 111 Livingston Street Brooklyn, NY 11205 (718) 260−4757 LEAD ATTORNEY
Nina Lowenstein Disability Advocates, Inc. 5 Clinton Square 3rd Floor Albany, NY 12207 (518) 432−7861 LEAD ATTORNEY
Sarah Kerr Prisoners' Rights Project Legal Aid Society One Battery Park Plaza New York, NY 10004 (212) 577−3530 LEAD ATTORNEY
Tom Terrizzi Prisoners' Legal Services of New York 118 Prospect Street Suite 307 Ithaca, NY 14850 (607) 273−2283 LEAD ATTORNEY
represented by John Eric Knudsen Attorney General of the State of New York 120 Broadway New York, NY 10271 (212) 416−8625 LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by

Michelle Petrino OMH Satellite Mental Health Unit Chief
Defendant Wayne Crosier OMH Satellite Mental Health Unit Chief
Defendant Kathy Cavanaugh OMH Satellite Mental Health Unit Chief
Defendant Michael Hill OMH Satellite Mental Health Unit Chief
Defendant John Dunn OMH Satellite Mental Health Unit Chief
Defendant Peter Russell OMH Satellite Mental Health Unit Chief
Defendant Al Shimkunas OMH Satellite Mental Health Unit Chief
Defendant Thomas Ryan OMH Satellite Mental Health Unit Chief
Defendant David Boyd OMH Satellite Mental Health Unit Chief
Defendant Loretta Klein OMH Satellite Mental Health Unit Chief
Defendant Anthony Devito OMH Satellite Mental Health Unit Chief
Defendant New York State Department of Correctional Services ("DOCS")

John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY

Defendant Glenn S. Goord Commissioner of DOCS
Defendant Victor Herbert Facility Superintendent
Defendant John Burge Facility Superintendent
Defendant Elaine Lord Facility Superintendent
Defendant Daniel Senkowski Facility Superintendent
Defendant Gary Fillion Facility Superintendent
Defendant Frank Tracy Facility Superintendent
Defendant David Miller Facility Superintendent
Defendant Floyd G. Bennett, Jr. Facility Superintendent
Defendant Thomas Poole Facility Superintendent
Defendant George Duncan Facility Superintendent
Defendant

represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by

Charles Griener Facility Superintendent
Defendant Leonard Portuondo Facility Superintendent
Defendant Brian Fischer Facility Superintendent
Defendant Michael P. McGinnis Facility Superintendent
Defendant James Walsh Facility Superintendent
Defendant Thomas Ricks Facility Superintendent
Defendant Edward Donnelly Facility Superintendent

John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY
represented by John Eric Knudsen (See above for address) LEAD ATTORNEY

Date Filed 05/28/2002 05/28/2002 06/19/2002
06/24/2002

#

Docket Text

1 COMPLAINT filed. Summons issued and Notice pursuant to 28 U.S.C. 636(c). FILING FEE $ 150.00 RECEIPT # 0440407. (dle) (Entered: 05/31/2002)

Magistrate Judge Henry B. Pitman is so designated. (dle) (Entered: 05/31/2002)

2 Memo−Endorsement on letter addressed to Judge Lynbch from Richard W.Brewster, dated 06/14/02; reset answer to complaint due for 7/1/02 for Edward Donnelly, for Thomas Ricks, for James Walsh, for Michael P. McGinnis, for Brian Fischer, for Leonard Portuondo, for Charles Griener, for George Duncan, for Thomas Poole, for Floyd G. Bennett Jr., for David Miller, for Frank Tracy, for Gary Fillion, for Daniel Senkowski, for Elaine Lord, for John Burge, for Victor Herbert, for Glenn S. Goord, for NYS Dept. of Corr., for Anthony Devito, for Loretta Klein, for David Boyd, for Thomas Ryan, for Al Shimkunas, for Peter Russell, for John Dunn, for Michael Hill, for Kathy Cavanaugh, for Wayne Crosier, for Michelle Petrino, for Scott Clair, for Jurgen Karker, for James L. Stone, for NYS Office of Mental ; The application is denied to the extent it requests additional delay ; ( signed by Judge Gerard E. Lynch ); Copies mailed. (djc) (Entered: 06/21/2002)

3 NOTICE OF MOTION by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier,

06/24/2002 06/24/2002 06/24/2002 07/02/2002 07/09/2002

Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly to transfer case . Return Date 7/31/02 . (sb) (Entered: 06/27/2002)
4 MEMORANDUM OF LAW by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in support of [3−1] motion to transfer case . (sb) (Entered: 06/27/2002)
5 AFFIDAVIT of Steven Stark−Riemer by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in support of [3−1] motion to transfer case . (sb) (Entered: 06/27/2002)
6 AFFIDAVIT of Anthony J. Annucci by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in support of [3−1] motion to transfer case . (sb) (Entered: 06/27/2002)
7 ANSWER to Complaint by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly (Attorney John E. Knudsen) . (sb) (Entered: 07/10/2002)
8 Memo−Endorsement on letter addressed to Judge Lynch from James W.B. Benkard, dated 6/27/02. Plaintiff's Response to motion reset to 7/16/02 for [3−1] motion to transfer case ; defendants' Reply to Response to Motion reset to 7/25/02 for [3−1] motion to transfer case . ( signed by Judge Gerard E. Lynch ); Copies mailed. (kw) (Entered: 07/15/2002)

07/15/2002 07/18/2002 07/29/2002 07/31/2002 07/31/2002 07/31/2002 07/31/2002 07/31/2002 08/01/2002
08/01/2002
08/01/2002

9 AFFIRMATION of Steven Stark−Riemer by NYS Office of Mental and all other defendant's Re: correcting statement made in previous affirmation (of Steven Stark−Riemer). (db) (Entered: 07/17/2002)
10 DECLARATION of Jennifer H. Rearden by Disability Advocates in support Re: opposition to defendants' motion to transfer . Received in night deposit box on 7/18/02 at 5:31 p.m. (yv) (Entered: 07/22/2002)
11 REPLY MEMORANDUM by Disability Advocates in support re: plaintiff's motion for protective order. Proposed Protective Order attached. (yv) (Entered: 07/31/2002)
12 MEMORANDUM OF LAW by Disability Advocates in opposition to [3−1] motion to transfer case . (yv) (Entered: 08/02/2002)
13 DECLARATION of Cliff Zucker by Disability Advocates in opposition Re: [3−1] motion to transfer case . (yv) (Entered: 08/02/2002)
14 DECLARATION of Betsy C. Sterling by Disability Advocates in support Re: [12−1] opposition memorandum . (yv) (Entered: 08/02/2002)
15 DECLARATION of Sarah Kerr by Disability Advocates in opposition Re: [3−1] motion to transfer case . (yv) (Entered: 08/02/2002)
16 DECLARATION of Jennifer H. Rearden by Disability Advocates in support Re: [12−1] opposition memorandum . (yv) (Entered: 08/02/2002)
17 MEMORANDUM OF LAW by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in opposition to plaintiff's motion for a protective order. (yv) (Entered: 08/07/2002)
18 AFFIDAVIT of Lawrence Farago by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in opposition to plaintiff's motion for a protective order. (yv) (Entered: 08/07/2002)
19 AFFIDAVIT of Leonard A. Cohen by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in opposition to plaintiff's motion for protective

08/01/2002
08/05/2002 08/05/2002 08/05/2002 08/08/2002 08/14/2002 08/16/2002 08/16/2002 10/02/2002
10/02/2002

order. (yv) (Entered: 08/07/2002)
20 AFFIDAVIT of John Culkin by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in opposition to plaintiff's motion for protective order. (yv) (Entered: 08/07/2002)
21 NOTICE OF MOTION by Disability Advocates for an order, purs. to FRCP 26(c), for a protective order, to preseve the privacy and confidentiality of the prisoners with mental illness described in the Complaint ; Return Date not indicated. (sac) (Entered: 08/09/2002)
22 MEMORANDUM OF LAW by Disability Advocates in support of [21−1] motion for an order, purs. to FRCP 26(c), for a protective order, to preseve the privacy and confidentiality of the prisoners with mental illness described in the Complaint. (sac) (Entered: 08/09/2002)
23 DECLARATION of Sarah Kerr by Disability Advocates in support Re: [21−1] motion for an order, purs. to FRCP 26(c), for a protective order, to preseve the privacy and confidentiality of the prisoners with mental illness described in the Complaint. (sac) (Entered: 08/09/2002)
24 ORDER granting plaintiff's [21−1] protective order motion to the extent reflected in the Court's Protective Order dated 8/15/02. ( signed by Judge Gerard E. Lynch ); Copies mailed. (dle) (Entered: 08/19/2002)
26 CERTIFICATE OF IDENTIFICATION filed by Disability Advocates (sac) (Entered: 08/19/2002)
25 ORDER, regarding the procedures to be followed that shall govern the handling of the identity of inmates . ( signed by Judge Gerard E. Lynch ); Copies mailed. (dle) (Entered: 08/19/2002)
27 ORDER that the plaintiff's [21−1] motion for a protective order is granted to the extent reflected in the Court's Protective Order dated August 15, 2002 . ( signed by Judge Gerard E. Lynch ); Copies mailed. (dle) (Entered: 08/20/2002)
28 Case Management Plan: after consultation with counsel for all parties, the following case management plan is adopted: all discovery is to be completed by 10/15/03; first request for production of documents, if any, to be served by 10/15/02; interrogatories pursuant to local rule 33.3(a) of the Civil Rules of the S.D.N.Y. to be served by 3/3/03; depositions to be completed by 9/30/03; experts, if any, are to be designated by 5/30/03; experts' reports exchanged no later than 7/30/03; requests to admit, if any, are to be served no later than 10/30/03; dispositive motions are to be served and filed by 11/15/03; answering papers are to be served and filed by 12/15/03; reply papers are to be served and filed by 1/10/04; next case management conference 5/2/03 at 10:30a.m. ( signed by Judge Gerard E. Lynch ); (dle) (Entered: 10/07/2002)
Deadline(s) updated: scheduling order deadlines: Response to motion deadline 12/15/03 ; Reply to response to motion deadline 1/10/04 ; . (kkc) (Entered: 10/08/2002)

10/31/2002 11/18/2002 02/26/2003 02/26/2003 02/26/2003 03/04/2003 03/07/2003
03/07/2003
03/10/2003 03/10/2003 03/10/2003

29 ORDER denying [3−1] motion to transfer case. The Clerk of Court is respectfully directed to record this motion as closed for the purposes of all internal court reports. ( signed by Judge Gerard E. Lynch ); (kg) (Entered: 11/01/2002)
30 NOTICE of Address Change by Disability Advocates . (sac) (Entered: 11/20/2002)
31 NOTICE OF MOTION by Disability Advocates for a protective order under FRCP 26(c) governing the production and use of confidential information in this litigation . Return Date 3/6/03. (laq) (Entered: 02/27/2003)
32 MEMORANDUM OF LAW by Disability Advocates in support of [31−1] motion for a protective order under FRCP 26(c) governing the production and use of confidential information in this litigation . (laq) (Entered: 02/27/2003)
33 DECLARATION of Matthew S. Warren by Disability Advocates in support Re: [31−1] motion for a protective order under FRCP 26(c) governing the production and use of confidential information in this litigation . (laq) (Entered: 02/27/2003)
34 Transcript of record of proceedings before Judge Gerard E. Lynch for the date(s) of January 31, 2003. (dt) (Entered: 03/04/2003)
35 NOTICE OF CROSS−MOTION by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly for protective order pursuant to Rule 26(c), governing the production and use of confidential information in this litigation . Declaration of Leonard Cohen in support of motion attached. Return Date 3/11/03. (db) Modified on 03/10/2003 (Entered: 03/10/2003)
36 MEMORANDUM OF LAW by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in support of [35−1] cross motion for protective order pursuant to Rule 26(c), governing the production and use of confidential information in this litigation . (db) (Entered: 03/10/2003)
37 REPLY MEMORANDUM by Disability Advocates in support re: [31−1] motion for a protective order under FRCP 26(c) governing the production and use of confidential information in this litigation . (laq) (Entered: 03/11/2003)
38 DECLARATION of Nina Loewenstein by Disability Advocates in support Re: [31−1] motion for a protective order under FRCP 26(c) governing the production and use of confidential information in this litigation . (laq) (Entered: 03/11/2003)
39 REPLY DECLARATION OF SARAK KERR by Disability Advocates Re: [31−1] motion for a protective order under FRCP 26(c) governing the production and use of confidential information

03/11/2003 03/11/2003 03/12/2003 03/14/2003
03/14/2003
04/01/2003 04/01/2003 04/14/2003 04/14/2003

in this litigation. (laq) (Entered: 03/11/2003)
40 Memo−Endorsement on letter addressed to Judge Lynch from Leonard A. Cohen, dated 3/3/03, defts will serve their response and a cross−motion seeking entry of their own version of the protective order on 3/6. Plntf will then have until 3/10 to serve reply papers in support of its motion ( signed by Judge Gerard E. Lynch ); (cd) (Entered: 03/12/2003)
41 ORDER, the order authorizes the disclosure for plntf's inspection of inmate mental health records, as may be agred between the parties and solely for the purposes of the above−referenced tours ; to the extent that any such mental health records include "Confidential HIV related information", this Order authorizes the disclosure of such documetns for the same limited purpose of the scheduled tours, as further set forth in this document ( signed by Judge Gerard E. Lynch ); (cd) (Entered: 03/13/2003)
42 MEMORANDUM OF LAW by Disability Advocates in opposition to [35−1] cross motion for protective order pursuant to Rule 26(c), governing the production and use of confidential information in this litigation . (laq) (Entered: 03/13/2003)
43 REPLY MEMORANDUM by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in support of [35−1] cross motion for protective order pursuant to Rule 26(c), governing the production and use of confidential information in this litigation. (sb) (Entered: 03/17/2003)
44 REPLY DECLARATION of Leonard A. Cohen by NYS Office of Mental, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill, John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, NYS Dept. of Corr., Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett Jr., Thomas Poole, George Duncan, Charles Griener, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly in support of [35−1] cross motion for protective order pursuant to Rule 26(c), governing the production and use of confidential information in this litigation. (sb) (Entered: 03/17/2003)
45 NOTICE of Supplemental Authority by Disability Advocates. (sb) (Entered: 04/02/2003)
46 SECOND DECLARATION of Matthew S. Warren by Disability Advocates in support of [45−1] notice of supplemental authority. (sb) (Entered: 04/02/2003)
47 PROTECTIVE ORDER, regarding procedures to be followed that shall govern the handling of the confidential materials as set forth in this order . ( signed by Judge Gerard E. Lynch ); (dle) Modified on 04/15/2003 (Entered: 04/15/2003)
48 ORDER, granting [35−1] cross motion for protective order pursuant to Rule 26(c), governing the production and use of confidential information in this litigation; granting [31−1] motion for a protective order under FRCP 26(c) governing the production

01/30/2004
02/17/2004
02/17/2004 06/30/2004 10/14/2004 10/22/2004 10/22/2004 10/22/2004 10/22/2004 10/29/2004

and use of confidential information in this litigation; the Clerk of the Court is respectfully directed to docket the attached protective order . ( signed by Judge Gerard E. Lynch ); (ae) (Entered: 04/15/2003)
50 ORDER, that DAI's reques tfor disclosure of the documents designated by numbers two through seven on defts' privilege log is denied, and the claim of privilege as to those documents, and as to the 9/1/99 letter from Comm. Goord to Comm. Stone, is sustained...Copies of the documents reviewed in camera, designated as numbers one through eight of defts' privilege log, shall be maintained under seal to facilitate any appellate review that may become necessary. (Signed by Judge Gerard E. Lynch on 1/27/03) (cd, ) (Entered: 02/05/2004)
51 SCHEDULING ORDER: First request for production of documents served by 10/15/2004; discovery to be completed by 11/1/2004; Interrogatires to be served bt 3/3/2003;experts to be desgnated by 8/16/2004 and experts reports no later than 9/15/2004.Deposition due by 11/1/2004. Request to admit to be served by 8/31/2004. Next case management conference 7/23/2004 at 11:00am. (Signed by Judge Gerard E. Lynch on 2/7/2004) (jsa, ) (Entered: 02/20/2004)
Set Deadlines/Hearings: Case Management Conference set for 7/23/2004 11:00 AM before Judge Gerard E. Lynch. (jsa, ) (Entered: 02/20/2004)
52 CASE MANAGEMENT PLAN: Discovery due by 3/4/2005. Case Management Conference set for 7/23/2004 11:00 AM before Judge Gerard E. Lynch. See Document for further Scheduling Deadline. (Signed by Judge Gerard E. Lynch on 6/23/04) (sac, ) (Entered: 07/01/2004)
53 CASE MANAGEMENT PLAN: The case is to be tried by a jury. All Discovery due by 7/1/2005, further discovery extensions will be strongly disfavored. Case Management Conference set for 11/19/2004 03:30 PM before Judge Gerard E. Lynch. Deposition of fact witnesses due 2/28/04. (Signed by Judge Gerard E. Lynch on 10/13/04) (db, ) (Entered: 10/20/2004)
54 MOTION for Protective Order under Fed.R.Civ.P. 26(c). Document filed by Disability Advocates, Inc. (rw, ) (Entered: 10/25/2004)
55 MEMORANDUM OF LAW in Support re: 54 MOTION for Protective Order under to Fed. R. Civ. P. 26(c). Document filed by Disability Advocates, Inc. (rw, ) Modified on 10/25/2004 (rw, ). (Entered: 10/25/2004)
56 DECLARATION of CLIFF ZUCKER in Support re: 54 MOTION for Protective Order under F. R. Civ. P. 26(c). Document filed by Disability Advocates, Inc. (rw, ) (Entered: 10/25/2004)
57 DECLARATION of NINA LOEWENSTEIN in Support re: 54 MOTION for Protective Order under F. R. Civ. P. 26(c). Document filed by Disability Advocates, Inc. (rw, ) (Entered: 10/25/2004)
58 MEMORANDUM OF LAW in Opposition re: 54 MOTION for Protective Order.. Document filed by Floyd G. Bennett Jr., David Boyd, John Burge, Kathy Cavanaugh, Scott Clair, Wayne Crosier, Anthony Devito, Edward Donnelly, George Duncan, John Dunn, Gary Fillion, Brian Fischer, Glenn S. Goord, Charles Griener, Victor Herbert, Michael Hill, Jurgen Karker, Loretta Klein, Elaine Lord, Michael P. McGinnis, David Miller, New York State Department of Correctional Services, New York State Office of

11/08/2004 12/14/2004 12/21/2004 01/06/2005 02/24/2005
02/24/2005
02/24/2005
02/24/2005
02/24/2005
02/24/2005

Mental Health, Michelle Petrino, Thomas Poole, Leonard Portuondo, Thomas Ricks, Peter Russell, Thomas Ryan, Daniel Senkowski, Al Shimkunas, James L. Stone, Frank Tracy, James Walsh. (djc, ) (Entered: 11/03/2004)
59 REPLY MEMORANDUM OF LAW in Support re: 54 MOTION for Protective Order.. Document filed by Disability Advocates, Inc.. (pa, ) (Entered: 11/09/2004)
60 ORDER granting 54 Motion for Protective Order . (Signed by Judge Gerard E. Lynch on 12/13/04) (cd, ) (Entered: 12/16/2004)
61 ORDER, the Clerk is directed to file the correspondence, submitted by plaintiff for ex parte review in connection with plaintiff's motion for protective order, under seal. (Signed by Judge Gerard E. Lynch on 12/13/04) (djc, ) Modified on 12/28/2004 (kg, ). (Entered: 12/27/2004)
63 TRANSCRIPT of proceedings held on 11/19/04 before Judge Gerard E. Lynch. (es, ) (Entered: 01/06/2005)
64 ORDER; that an Assistant Attorney General may take the deposition of Ram Lall before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
65 ORDER ; that an Assistant Attorney General may take the deposition of Rene Lewis before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
66 ORDER ; that an Assistant Attorney General may take the deposition of Easton Beckford before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
67 ORDER ; that an Assistant Attorney General may take the deposition of John Brown before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
68 ORDER; that an Assistant Attorney General may take the deposition of Jerry Exhume before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
69 ORDER ; that an Assistant Attorney General may take the deposition of Hamilcar Barca before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge

02/24/2005 02/24/2005 02/24/2005 02/24/2005 02/24/2005 02/24/2005 02/24/2005 02/24/2005

Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
70 ORDER ; that an Assistant Attorney General may take the deposition of Adrian Trice before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
71 ORDER ; that an Assistant Attorney General may take the deposition of Takarla Carroll before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
72 ORDER ; that an Assistant Attorney General may take the deposition of Alan Cata before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
73 ORDER ; that an Assistant Attorney General may take the deposition of Jimmy Gonzalez before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
74 ORDER ; that an Assistant Attorney General may take the deposition of Maria Rosado before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
75 ORDER ; that an Assistant Attorney General may take the deposition of Guillaume Nijman before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
76 ORDER ; that an Assistant Attorney General may take the deposition of Robert Hodges before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)
77 ORDER ; that an Assistant Attorney General may take the deposition of Nathaniel Pearson before a notary public, or some other officer authorized to administer oaths by the laws of the United States or the State of New York, at any New Yrok StateCorrectional Facility, upon notice to the pltff and Superintendent of the correctional facility. (Signed by Judge Gerard E. Lynch on 2/4/2005) (jp, ) (Entered: 02/25/2005)

05/17/2005 05/17/2005 08/08/2005 10/24/2005 10/24/2005 12/16/2005
02/24/2006 03/08/2006
03/08/2006

78 ENDORSED LETTER addressed to Judge Lynch from Nancy B. Ludmerer dated 5/5/2005 re: the expert reports to be due in hand by 6/1/2005 and the close of expert discovery is extended to 7/14/2005. The time for the defendants to respond to plaintiff's requests for admissions is extended to 6/1/2005. The conference with the Court scheduled for 7/8/2005 is adjourned to 7/29/2005 at 11:00am. So ordered (Signed by Judge Gerard E. Lynch on 5/10/2005) (jsa, ) (Entered: 05/18/2005)
Set/Reset Hearings: Pretrial Conference set for 7/29/2005 11:00 AM before Judge Gerard E. Lynch. (jsa, ) (Entered: 05/18/2005)
79 ENDORSED LETTER addressed to Judge Gerard E. Lynch from Kimberly Ann Dasse dated 7/12/05 re: granting the parties request for permission to take Mr Lewis's deposition on 8/2/05. (Signed by Judge Gerard E. Lynch on 7/25/05) (pl, ) (Entered: 08/10/2005)
80 ORDER;pretrial breifs are to be submitted to the Court by 12/16/05, they may attach exhibits to the brief, the brief is not exceed 30 pages in length. The parties are to appear for a pretrial conference on 1/6/2006 at 3:00 PM. (Signed by Judge Gerard E. Lynch on 10/18/05) (kco, ) (Entered: 10/25/2005)
Set Deadlines/Hearings: Brief due by 12/16/2005. Pretrial Conference set for 1/6/2006 03:00 PM before Judge Gerard E. Lynch. (kco, ) (Entered: 10/25/2005)
81 PRETRIAL MEMORANDUM. Document filed by John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, New York State Department of Correctional Services, Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett, Jr, Thomas Poole, George Duncan, Charles Griener, New York State Office of Mental Health, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill.(dle, ) (Entered: 12/19/2005)
82 ENDORSED LETTER addressed to Judge Gerard E. Lynch from John E. Kundsen dated 2/17/2006 re: to request that any inmate witnesses offered by plaintiff testify on dircet examination in person rather than by affidavit, pursuant to section 3(C)(I) of the Court's individual parctices.ENDORSEMENT: Denied. The issues raised can adquately be addressed by live cross−examination. (Signed by Judge Gerard E. Lynch on 2/21/2006) (jmi, ) (Entered: 02/27/2006)
83 MOTION in Limine. Document filed by John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, New York State Department of Correctional Services, Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett, Jr, Thomas Poole, George Duncan, Charles Griener, New York State Office of Mental Health, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill. Return Date set for 4/3/2006 10:00 AM. (jmi, ) (Entered: 03/08/2006)
84 MEMORANDUM OF LAW in Support re: 83 MOTION in Limine.. Document filed by John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, New York State Department of Correctional Services, Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G.

03/20/2006
03/20/2006 03/20/2006 04/20/2006 04/28/2006 04/28/2006 06/05/2006 09/18/2006 09/18/2006 11/16/2006
04/30/2007
05/17/2007 08/15/2007

Bennett, Jr, Thomas Poole, George Duncan, Charles Griener, New York State Office of Mental Health, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill. (jmi, ) (Entered: 03/08/2006)
85 Objections and Cross−Designations as to Plaintiff's Deposition Designations. Document filed by John Dunn, Peter Russell, Al Shimkunas, Thomas Ryan, David Boyd, Loretta Klein, Anthony Devito, New York State Department of Correctional Services, Glenn S. Goord, Victor Herbert, John Burge, Elaine Lord, Daniel Senkowski, Gary Fillion, Frank Tracy, David Miller, Floyd G. Bennett, Jr, Thomas Poole, George Duncan, Charles Griener, New York State Office of Mental Health, Leonard Portuondo, Brian Fischer, Michael P. McGinnis, James Walsh, Thomas Ricks, Edward Donnelly, James L. Stone, Jurgen Karker, Scott Clair, Michelle Petrino, Wayne Crosier, Kathy Cavanaugh, Michael Hill. (djc, ) (Entered: 03/21/2006)
86 Defendants' Marked Copy of Plaintiff's Exhibit List. (document filed by Defendants) (djc, ) (Entered: 03/21/2006)
87 DEFENDANTS' PROPOSED FINDINGS OF FACT AND CONCLUSIONS OF LAW. (djc, ) (Entered: 03/21/2006)
88 TRANSCRIPT of proceedings held on 3/29/2006 before Judge Gerard E. Lynch. (jar, ) (Entered: 04/20/2006)
89 TRANSCRIPT of proceedings held on 4/12/06 before Judge Gerard E. Lynch. (mo, ) (Entered: 04/28/2006)
90 TRANSCRIPT of proceedings held on 4/3/06,4/4/06,4/5/06,4/6/06 before Judge Gerard E. Lynch. (mo, ) (Entered: 04/28/2006)
91 TRANSCRIPT of proceedings held on 5/19/06 before Judge Gerard E. Lynch. (mo, ) (Entered: 06/05/2006)
92 ORDER: The parties shall appear before the Court for a status conference on 11/17/2006 at 10:30 a.m. Unless the action has been settled, the parties shall appear for trial on 1/29/2007. (Signed by Judge Gerard E. Lynch on 9/11/2006) (lb, ) (Entered: 09/19/2006)
Set/Reset Hearings: Status Conference set for 11/17/2006 at 10:30 AM before Judge Gerard E. Lynch. (lb, ) (Entered: 09/19/2006)
93 ORDER: It has come to the Court's attention that the defendants' motion in limine (docket entry #83) is listed by the Clerk as an open motion for statistical purposes. That motion having been denied in part and granted in part in open Court, at a pretrial conference on March 29, 2006, the Clerk is respectfully directed to close the motion. (Signed by Judge Gerard E. Lynch on 11/13/06) (js, ) (Entered: 11/17/2006)
94 PRIVATE SETTLEMENT AGREEMENT, regarding Commitment by DOCS and OMH to Heightened Level of Care; Definition of Serious Mental Illness, and as further set forth in this document. (Signed by Judge Gerard E. Lynch on 4/27/07) (cd). (Entered: 05/01/2007)
95 TRANSCRIPT of proceedings held on April 27, 2007 before Judge Gerard E. Lynch. (jpo) (Entered: 05/17/2007)
96 ORDER: On August 2, 2007, the Court received a communication from Annette Vogelsang, a prisoner in a New York State corrections facility, styled a "motion for order of contempt of court," and an accompanying affidavit, alleging certain mistreatment and contending that the New York State Office of

10/05/2007

Mental Health and Department of Correctional Services are in violation of the Court's order settling the above−captioned litigation. The motion will be denied. (Signed by Judge Gerard E. Lynch on 8/3/07) (tro) (Entered: 08/16/2007)
97 AFFIDAVIT of Annette Vogelberg in Support motion for an order finding Bedford Hills officials in contempt of court order. (cd) (Entered: 10/11/2007)

 </s> UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF NEW YORK

PlaintifPs Trial Exhibit

DISABILITY ADVOCATES MC.,
- PlainW,
v.
NEW YORK STATE OFFICE OF
MENTAL HEALTH, et a].,
Defendants. :

02 Civ. 4002 (GEL)
REPORT OF PLAINTIFF'S EXPERT
STEVE J. MARTIN-CONFIDENTIAL
June 1,2005

I. INTRODUCTION I have been retained by plaintiffs'

counsel as an expert viitnessto provide testimony on

behalf of prisoners with mental illness who are or who will be confined in the custody of the

New York State Department of Correctional Services ("DOCS"). Specifdly, I have been asked

to render opinions on the policy and practice by DOCS and the New York State Office of Mental

Health ("OMH)of confining prisoners with mental illness to twenty-three hour disciplinary

isolated confinement,special housing units ("SHU"), double-celled SHUs, administrative

segregation, protective custody, and keeplock, and whether such punitive management of

prisoners with mental illness causes unnecessary harm to both the prisoners and the staff

responsible for the safe and secure custody of such prisoners. In addition, I have been asked to

provide testimony on whether the legitimate penological objectives of the DOCS can be achieved

in a secure custody environment without the serious and harmful consequences engendered when

prisoners with mental illness are placed in isolated cells for punitive purposes twenty-three and

twenty-four hours a day for months and years at a time.

11. QUALIFICATIONS OF THE EXPERT WlTNESS My general qualifications as an expert in the field of corrections are set forth in my
Curriculum Vitae, attached hereto as Exhibit 1. I began my career as a correctional officer in 1972 at a maximum security prison operated by the Texas Department of Corrections ("TDC").
While employed with TDC as a correctional officer, I also worked at a prison for female felony offenders. I subsequently served as casework intern in mental health programs with the Federal
Bureau of Prisons at the Federal Correctional Institution, Fort Worth, Texas. In 1981 1rejoined the TDC as an administrator of technical programs, and subsequently served as Legal Counsel, General Counsel, and Chief of Staff to the Director of the TDC. In my service with the TDC, I was involved in-thedevelopment of policies and procedures in the m a s of classification, ,, administrative and punitive segregation, inmate disciplinary procedures, use of fotce, special needs prisoners (protective custody, mentally/physically impaired, etc.), and numerous other operational issues. Much of this work related to compliance with court orders in Ruiz v Estelle, a statewide prison conditions lawsuit brought by prisoners and the U. S. Department of Justice against the TDC. Pursuant to the court's orders to develop remedial plans for such issues as classification, administrative and punitive segregation, and the treatment of special needs prisoners, I was a member of the state's negotiating team that, in concert with the Special Master and plaintiffs' attorneys, developed these plans. My directorate, the General Counsel's Office,
was responsible for assisting TDC personnel in the implementation of the remedial plans. The
General Counsel's Office was directly charged with supervising the monitoring of compliance
with those plans adopted pursuant to the orders in &&. In my capacity as General Counsel, I
was directly responsible for formulating and coordinating ?"DCYsresponse to all compliance

monitoring reports filed with the corn by the Special Master. Among the plans adopted were comprehensive orders for the delivery of psychiatric services and the management of special needs prisoners incarcerated in TDC facilities. During the course of this work, I routinely conducted site inspections and conferred with facility managers regarding implementation of the remedial plans.
As an independent corrections consultant, I have been retained as a corrections expert by
the U.S. Department of Justice, Civil Rights Division, on many occasions related to a wide . variety of correctional management issues; by both defendants' and plaintiffs' counsel in
numerous cases; by federal courts; and, by a variety of state and local governmental entities relating to corrections issues. 1have made well over 500 site visits/inspections to prisons and jails in more than 30 states, Puerto Rico, Guam, Saipan, Jamaica, and Northern Ireland. I am currently serving as a court monitor and court appointed expert in conditions cases involving a state prison system and two large metropolitanjails. I have served as a federal court monitor in cases involving two other state prison systems and the New York City Department of Corrections.
I have been qualified as an expert in the field of corrections and have testified as such on more than forty occasions, mostly in federal courts. I am co-author of Texas Prisons: The Wails Came Tumbling Down (Texas Monthly Press, 1987), and contributed to Courts. Corrections and the Constitution(Oxford University Press, 1990), and Buildin2 Violence: How America's Rush to Incarcerate Creates More Violence (Sage Publications, 2000). I have published articles on correctionalsubjects in Law and Societv Review, Pace Law Review, Texas Tech Law Review, Texas Lawer; and journals for the Center for Research in Crime & Justice, New York

University School of Law, the National Conference on Crime & Delinquency, and the Texas Public Policy Foundation. I have also served on the adjunct or visiting faculties of six universities, including the University of Texas School of Law. I was also a Visiting Scholar at Queens University Belfast, Institute of Criminology and Criminal Justice in the fall of 2000.
In addition to these general qualifications, I have specific expertise with the correctional
management of special needs offenders, i.e., offenders whose mental andlor physicalconditions require special handling and treatment by both security staff and professional health care providers. My first experience with prisoners with mental impairments (mental illness, mental retardation and developmentally disabled) was as a correctional officer in supervising housing areas at both a maximum security prison and a prison for female offenders in which s p i a l needs , inmates were confined. During my work as a casework intern for the Director of Mental Health Programs at the Federal Correctional Institution, Ft. Worth, I was a working member of a case management team with an offender caseload that included prisoners with mental impairments. As a Federal Probation and Parole Officer (1975-1980), I assisted in the pre-release planning, placement and supervision (community, sheltered and assisted living placement) of offenders with mental impairments.
From 1981-1985, as a member of the TDC negotiating team to deveiop remedial plans in the Rujz litigation, I routinely worked with professional medical and mental health care experts on development of court approved plans on the management of special needs prisoners, including those who required segregated housing from the general population inmates. 1was continuously involved in monitoring and implementation issues of these plans until my departure in July 1985. I also coordinated with the department training division on development of training programs

specificallydesigned for correctional oficers assigned to work with special needs offenders. In 1988 I was appointed by the Texas governor to the lnteragency Council on Mentally
Retarded, Developmentally Disabled and Mentally I11 Offenders. The Council, created by an act of the Texas Legislature in 1987, was charged with determining the status of these special needs offenders in the state criminaljustice system, identifying and coordinating services for these populations, evaluating existing programs, and developing new programs. The activities of the council were governed by the Chair and a seven-member Executive Committee, of which I was a member. I also chaired the Sub-committee on Legislative Issues and was a member of the Committee on Mentally Retarded Offenders. While on the council, I exercised direct oversight of a major study on special needs offenders most at risk to be victims and aggressors, and the situational factors that put these offenders most at risk in institutional settings,
During the course of my consulting work the past eighteen years, I have on many occasions been involved in working on remedial issues such as administrativefpunitive segregation and inmate discipline procedures related to special management populations. I have served as a consultant, court expert and court monitor for numerous correctional facilities housing offenders with mental impairments in which security and treatment issues had to be coordinated/integrated for delivery of program services. I am presently serving as a Rule 706 Court Expert in Carruthers v. Jenne, a conditions case in Broward County, Florida, involving the management and treatment of offenderswith mental impairments. I am also serving as an expert
for the U. S. Department of Justice involving the Augusta State Medical Prison which houses a
substantial population of offenders with mental impairments. I recently served as a consultant to the Georgia Attorney General's Office in Fluellen v. Wetherinpton, litigation involvingthe

Phillips State Prison, a facility which provides psychiatric services to a large number of inmates. I also recently served as an expert in Har~etvt . Adams, litigation involving the Joliet Treatment and Detention Facility, a secure treatment facility for sexually violent offenders. I have been involved in two class action lawsuits involving the treatment of offenders with mental impairments in the California Department of Corrections ("CDOC"). Gates v. Deukmeiian concerned the treatment of prisoners confined to the California Medical Facility at Vacaville, and Clark v. California, involved the treatment of prisoners with mental retardation and developmental disabilities housed throughout facilities operated by the CDOC. I served as one of two Joint Expert Consultants for four years (1998-2002) in S h e ~ ~ avr.dPhoenix, in which
oma an A. Carlson (former Director of the Federal Bureau of Prisons) and I monitored the
Central Punitive Segregation Unit ("CPSU") of the New York City Department of Corrections at Rikers Island. The CPSU housed offenders who had committed serious institutional disciplinary infractions. Our oversight responsibilities included the monitoring of the provision of mental health services to CPSU inmates, which included protocols for identifying CPSU inmates who required removal from the CPSU for appropriate mental health evaluations in order to determine their suitability for continued housing in the CPSU. Finally, I have been involved in numerous cases related to the management and treatment of inmates in high maximum or super-maximum ("supermax"), prisons or housing units within prisons wherein prisoners are isolated from the general population and from each other, typically in excess of twenty-two hours a day. I testifid for the plaintiffs in Madrid v. Gomez, which involved prisoners confined at the Pelican Bay State Prison, a supemax facility with a Special Housing Unit ("SHU") that housed mentally impaired offenders for up to twenty-three hours a day. I have served as an expert in class action lawsuits

involving supennax prisons in Virginia, Missouri, Oklahoma, Arizona, and Maryland. I have been involved in litigation at maximum security prisons in no less than fourteen states. 111. PUBLICATIONS AUTHORED BY THE EXPERT WITNESS
A listing of publications I have authored/coauthored may be found at pages 9-10 of my Curriculum Vitae, attached hereto as Exhibit 1. IV. TESTIMONY AS AN EXPERT WITNESS AT TRIAL OR D E P O S ~ ~ O N
A listing of cases in which I have testified at trial or deposition within the preceding four years is attached hereto as Exhibit 2. V. COMPENSATION
I am being compensated at a rate of $150 per hour for in-oflice work and $I200 per day for work performed on-site. VI.DATA AND OTHER INFORMATION CONSIDEREDIN FORMING OPINIONS
- In formulatingmy opinions in this case, between August 26,2003 and October 31,2003, 1conducted site inspections of Special Housing Units ("SHU") at six correctional facilities of the New York State Department of Correctional Services ("DOCS"): 1) Albion, 2) Attica, 3) ~ u b u r n4,) Five Points, 5) Great ~ e a d o wa,nd 6) Wende. In addition to inspecting the SHUs at each of these facilities, 1 was given access to other areas of each facility such as mental health observation rooms, mental health satellite units, keeplock housing units, Intermediate Care
Program units ("ICP"), Specialized Treatment Program units CSTP"), and general population housing units. The SHU inspections included access to outdoor recreation areas, as well as program and administrativesupport space.
During the course of the site inspections at the six facilities, I conducted structured
7

interviews with over eighty inmates as set forth in Exhibit 3. The large majority of these interviews were conducted with inmates confined to SHU. However, additional interviews were conducted with inmates confined to keeplock, administrative segregation, protective custody, ICP units and mental health observation rooms. In addition to these structured interviews, I had brief interchanges with a significant number of other inmates at cell fronts and other areas of the facilities, although these discussions were strictly limited by defendants' counsel. I was also allowed to make, through defendants' counsel, very limited inquiries of staff at the six facilities related to certain security and custody procedures such as showers, recreation, escorting, handcuffing and food service practices.
A complete listing of the materials I have received from plaintiffs counsel in preparation of this report is attached as Exhibit 4. Among the materials I have received, reviewed and considered in the preparation of this report are: 1) inmate disciplinary history printouts for close to 500 inmates; 2) OMH records for approximately 100 inmates confined to SHU; 3) approximately 30 deposition transcripts of DOCS and OMH officials as well as inmates and third parties; 4) OMH and DOCS inmate suicide data; 5) information related to the proposed operaaion of the Behavioral Health Unit ("BHU"); 6) OMH studies on Special Housing Units; 7) training materials for conducting inmate disciplinary hearings for inmates with mental impairments; 8) DOCS directives related to the operation of SHUs; 9) DOCS and OMH training materials related to the management of mentally impaired inmates; 10) SHU inspection reports prepared by DOCS
employees at various facilities; 1 1) log book entries from various facilities for SHU, ICP, and mental health observations units; 12) DOCS institutional files for twenty-five SHU inmates,
including restraint orders, cell shield orders, restricted diet documents, deprivation orders,

referrals, disciplinary hearing packet$ and cell locator cards; as well as case management committee meeting minutes referencing those inmates; and 13) six video tapes and one audio tape of incidents involving particular inmates.
I have also reviewed the following professional standards and guidelines as they relate to special needs prisoners and punitive segregation: 1) Standardsfor Adult Correctional lmtitutiom, 31dEdition, American Correctional Association, 1990; 2) Standardsfor Health Services in Prisons, 2* Printing, National Commission on Correctional Health Care, 1997; and ' 3) Prison Health Care: Guidelinesfor the Management of an Adequate Delivery system,' National Institute of Corrections, U. S. Department of Justice, 1991.
I have reviewed the following publications: 1) The Mentally Disordered Inmate and the
Lau,Fred Cohen, Civic Research Institute, Inc., 1998;2) The Mentally Disordered Inmate and
the Law, 2003 Cumulative Supplement, Civic Research Institute, Inc., 2003; 3) Ill-Equipped:
US.Prisons and Oflenders with Mental Illness, Human Rights Watch, 2003; 4) Lockdown New
York: Disciplinary Confinement in New York State Prisons, Correctional Association of New York, 2003; 5) Mental Health in the House of Corrections: A Study of Mental Health Care in New York State Prisons, Correctional Association of New York, 2004; 6) A Death in the Box, New York Times Magazine, October 31,2004; 7) Correctional Mental Health Report, J&eb 2002, pages 65,79 & May/June 2005, pages 3-6, 16; and 8) Prison and Jail Administration: Practice and Theory, Peter M . Carlson & Judith Simon Garrett, Jones & Bartlett, 1999, Chapters 4,6, 11, 14-15,26,30,35,48, and 58.
1 reviewed declarations I submitted in the following lawsuits: I) b e v. Cou~hlin, 93 Civ.8417, SDNY; 2) Clark v. State of California, C-96-1486 FMS, NDCA. I also reviewed

the Sertlement Agreement in State of Connecticut O a c e of Protection and Advocacy for Persons with Disabilities v. Choinski, 3:03CV1352, as well as the Report Regarding Conditions and Menial Healfh Services at Supermax Correctional Institution and Mental Health Correctional Institution by Terry Kupers, M.D., M.S.P. in that case. I reviewed the following materials from the Texas Department of Criminal Justice, Institutional Division; the Ohio Department of Rehabilitation and Correction; and the New Jersey Department of Corrections, respectively: 1)Administrative Segregation Maintenance Psychiatric Program, University of Texas Medical Branch, Managed Health Care, June 21,2001; 2) Exclusion Criteriafor Inmates Recommended for Ohio State Penitentiary, Bureau of Mental Health Services, Standard Operating Procedures No: 2, and Program Overview, Southern Ohio Correctional Facility, Intensive Mental Health Treatment Unit, August 2,2001 ;and 3) New Jersey court's acceptance of proposed settlement in D.M.. et al. v. Terhune, July 30, 1999, providing for increased mental health services to inmates. VII. OPINIONS
A. Punitive segregatiodisolation is a major disciplinarysanction employed to regulate and control inmate behavior that adversely effects institutional order, safety and security. Because of the severity of the conditions that accompany this sanction, conditions long recognized by correctional administrators to have a potentially damaging effect upon the well being of some inmates, it is typically employed when other forms of action prove inadequate or where the safety of others or the serious nature of the offense makes it necessary. Such a sanction when misapplied can cause, rather than prevent, the development of seriously recalcitrant behavior.
B. In correctional management terms, inmates with mental illness are classified as

special needs inmates whose mental condition requires special handling and treatment by staff. Such inmates require close medical treatment and multi-disciplinary management (custody and treatment). It is the responsibility of correctional administratorsto custodially manage prisoners with mental illness in a concerted manner with the treatment prerogatives of the mental health
care delivery system. The imposition of disciplinary segregationas administered by DOCS for
inmates with mental illness creates an environment that is so overwhelmingly punitive that the delivery of required mental health care is seriously and needlessly compromised; thus, increasing rather than diminishing the difficulty in managing prisoners with mental illness.
, C. The indiscriminate mixing of inmates with mental illness with inmates who do not have mental illness, all of whom have committed disciplinary infractions, in a punitive 8'1segregationunit for long term confinement, results in unsafe, unsecure and inhumane conditions of confinement.
D. The placement of inmates with mental illness in SHU and other forms of isolated confinement for an extended duration under such conditions that undermine the delivery of mental health care services, needlessly heightens the risks of harm to prisoners with mental illness, the staff charged with managing them, and the other inmates with whom they are confined. VIII. BASIS FOR OPINIONS
A. Punitive Segregation As Applied to Special Needs Inmates Inmates confined to SHU are separated from the general population and may be housed in single or double occupancy cells. With the exception of those inmatesconfined to the doublecell SHUs at Five Points, Upstate, and in the SHU 200's, the vast majority of all SHU inmates in

maximum-security DOCS facilities are housed in single cells. SHU inmates are permitted one hour of out-of-cell daily exercise in individual recreation compartments and two five minute showers per week. They are otherwise confined to their individual cells. SHU inmates confined to double-cell housing units remain locked in their cells twenty-four hours a day as they exercise and shower in their assigned cells, which includes a small adjoining recreation pen. SHU inmates have limitations on, among other things, personal hygiene articles, clothing, personal property, commissary, visiting, telephone privileges and access to library services (both general and law). They have limited, if any, in-cell programming and are not allowed to participate in any out-of-cell programs. Keeplock as used by DOCS includes most, and sometimes all, of the same restrictions of SHU. In addition, DOCS can house inmates with disciplinary dispositions of keeplock in either regular cells in general population or another housing location, or may have the inmate actually serve his keeplock time in a SHU cell.
In addition to the standard limitations set forth above, additional restrictions may be imposed on SHU inmates, including the following: 1) restraint orders requiring leg and waist chains any time the inmate is moved from the cell; 2) cell shield orders requiring that a thick plexiglass covering be placed over the cell front to further block an inmate's open access to the spacejust outside the cell; and 3) deprivation orders removing an inmate's basic necessities, including showers, basic property and hygiene articles, cell cleaning supplies, and even the basic food service r~ormallyprovided to inmates. The food restriction, referred to as the "restricted disciplinary diet," consists of feeding an inmate, perhaps for weeks at a time, a compacted food loaf which by design is nutritious but unpalatable. The ACA standards do provide for restricted diets as an administrative measure when an inmate in punitive segregation "uses food or food

.I
service equipment that is hazardous to self, staff, or other inmates....I tJhefood substitutionperiod
shall not exceed seven days." (ACA Standard 3-4252) However, fiom the records I have
reviewed, it is clear that DOCS routinely imposes restricted diets as a punitive sanction unrelated
to incidents involving food service and in excess of seven days.
The practice of isolating inmates fiom the general population as an institutional penal
sanction may be described by terms such as punitive segregation, disciplinary detention,
disciplinary segregation or solitary confinement. Punitive segregation is believed by most correctional professionals, including myself when properly applied, to constitute an effective
mechanism to control serious inmate misbehavior. Its effectivenessis grounded in two sound
principles of penology. First, it is a means to maintain the orderly operation of a prison by
physically isolating those inmates who engage in seriously disruptive behaviors. Second, it can
serve as a deterrent (both specific and general) because it results in a nearly complete cessation
and deprivation of the commonplace incidents and routines of prison life afforded to the general
population inmate. Current ACA standards define punitive segregation or disciplinarydetention
as follows: A form of separation from the general population in which inmates committing serious violations of conduct regulations are confined by the disciplinary committee or other authorized group for short periods of time [emphasis added] to individual cells separated from the general population (ACA Standards for Adult Correctional Institutions. 1998 Standards Su~~lemenat,181).
Because of the substantial deprivations that accrue to those placed in punitive
segregation, its use is normally subject to limitations, both in terms of the length of stay and the
severity of the conditions, that can, in certain circumstances, compromise the health of the

subject inmate. The American Correctional Association ("ACA") has recognized, at kast since
the mid-1 960ts, the potentially harmful effects of punitive segregation as a disciplinary sanction:
It is a major disciplinary measure, which can have a damaging effect upon some inmates, and should be used judiciously when other forms of action prove inadequate or where the safety of others or the serious nature of the offense makes it necessary. Perhaps we have been too dependent on isolation or solitary confinement as the principle method of handling the violators of institutional rules. Isolation may bring short-term conformity for some, but brings increased disturbances and deeper ingrained hostility to more (ACA Manual of Correctional Standards, Yd Edition, 1966, at 413).
Under the heading of "Authority and Responsibility for Disciplinary Matters," the 1966
ACA Manual also contains the following warning and prohibition regarding length of stay in
punitive segregation:
Segregation for punishment should be for the shortest period that will accomplish the desired result of a favorable adjustment, and in any event not over thirty days. With most inmates and for most infractions, a period of a few days proves sufficient. In other cases, a few days in punitive segregation followed by thirty to ninety days in administrative segregation, or in some other status that involves continued control or loss of privileges, is sufficient. Excessively long periods of punishment defeat treatment goals by embittering and demoralizing the inmate (at 418).
The current ACA Standard that specifically addresses the potentially hannful egects of
segregation on inmates (Standard 3-4244) contains the following "Comment":
Inmates whose movements are restricted in segregation units may develop symptoms of acute anxiety or other mental health problems; regular psychological assessment is necessary to ensure the mental health of any inmate confined in such a unit beyond 30 days (ACA Standards for Adult Corre.ctiona1Institutions, Yd Edition, at 81).
The National Commission on Correctional Health Care ("NCCHC") also recognizes the
14

potentially harmful effects of punitivk segregation on inmates by requiring a qualified health care
professional to periodically assess whether "any known contra-indications to segregation exist"
(see, Standards for Health Services in Prisons, 1997,at 50, Standard P-39 Health Evaluation of
Inmates in Disciplinary Segregation, Essential Standard).
The foregoing standards represent generally applicable safeguards for the use of punitive
segregation without regard to particular special needs or vulnerabilities. Prisoners who require
special services, including services from mental health professionals, clearly fall within the
management category of special needs inmates. The failure to provide the requisite level of
special needs services (both custody and treatment) in the appropriate setting can render these
inmates more vulnerable to the potentially deleterious and harsh effects of a predominantly
punitive environment such as the SHU. Moreover, when a custody practice or regimen
compromises the effective delivery of required mental health services, two of the most essential
of the NCCHC standards are violated:
Standard P-01 Access to Care (essential) Written policy and defined procedures require, and actual practice evidences, that inmate have access to care to meet their serious medical, dental, and mental health needs. Discussion Unreasonable barriers to
inmates' access to health services must be avoided...(at 3).
Standard P-03 Medical Autonomv (essential) Written policy and defined procedures require, and actual practice evidences, that clinical decisions and actions regarding the health care services provided to inmates are the sole responsibility of qualijied health care professionals and are not compromised for security reasons. Discussion The delivery of health care is a joint effort of correctional administrators and health services staff and can be
achieved only through mutual trust and cooperation... (at 5).
DOCS inmates found guilty of disciplinary infractionsmay be confined in SHU with no

upper limitations as to length of time (DOCS Directive #4932, Section 254.7 {a) (1) 9%).

Inmates who have been diagnosed with a mental illness are not excluded from SHU confinement.

In fact, as of March 31,2003,62% of SHU inmates at the eleven OMH Level 1 facilities were on

the mental health caseload. (OMHCNY 0080338) SHU sentences imposed o n inmates with

mental illness in excess of one year are common. Cumulative disciplinary sanctions can ~esulitn

SHU lengths o f stay that exceed ten years. Defendants provided, and I reviewed, the DOCS

disciplinary history print outs and associated documentation for twenty-five inmates and was

astounded by the following data which is set out in detail in Exhibit 5:
92% had received sentences totaling over 6 months of SHU time 84% had received sentences totaling over 1 year of SWU time 72% had received sentences totaling over 3 years of SHU time
- 48% had received sentences totaling over 5 years of SHU time 24% had received sentences totaling over 10 years of SHU time

A few specific examples reflect how fai DOCS officials will go when there is no upper limit on

the amount of SHU time that can be imposed on a single inmate:

F -L,

,has received sentences

totaling over 20 years of SKU time and almost two years of

additional time in keeplock. (Inmate Disciplinary History,

DCSCOF 0022102-0022111 )

C

8 rL

has received sentences totaling

over 18 years of SHU time and over two years of additional time in

keeplock. (Inmate Disciplinary History, DCSCOF 0022083-

0022094)

c-c-u,

,nas received sentences totaling

over 17 years of SHU time and over seven years of additional

keeplock time. (Inmate Disciplinary History, DCSCOF 0022215-

0022228)

It is truly striking that the twenty-five inmates for whom I received complete institutional files

had been sentenced to a total of over 220 years of SWU and keeplock time. This is so obviously extreme in relation to standard correctional practices for punitive segregation and, indeed, so seriously undermines all accepted rationales for imposition of such a punishment that it borders on the absurd.
In addition to these strikingly long sentences in SHU, it should be borne in mind that
there are other very severe consequences that may accompany SHU placement. SHU placement
may adversely impact parole consideration. For inmates with mental illness housed in SHU, new criminal convictions (and, accordingly, perhaps a new prison sentence to be served) may also be sought against an inmate who, for example, engages in unhygienic acts against comections
personnel. (NYPenal Law 5240.32) Finally, a disciplinarysanction often imposed in
conjunctionwith extending an inmate's SHU time is the recommended loss of accrued good time that would accelerate the inmate's release from prison. For instance, the twenty-five inmates for whom 1 recejved complete institutional files had a total recommended loss of almost 40,000 days of good time.
The following incidents and episodes involving inmates with mental illness confined to SHU or other forms of isolated confinement in New York State prisons are illustrative of the
systemic failure of DOCS and OMH to manage these inmates in a manner that reduces rather
than heightens or magnifies the noxious effects of punitive segregation. Above all else, these
incidents reflect a cyclical pattern I observed with mind numbing regularity as I reviewed OMH
records for over 100inmates that were produced by defendants: self-destructiveandlor irrational behavior, followed by punishment, followed by continued self-destructive behavior, followed by more punisbent, in a continuing cycle with little or no evidence of intercession by professional

staff to interrupt or question the eficacy of this predominantly punitive method of managing

offenders with mental illness (e-g., during my record review, I observed not a single instance in

which OMH

provided input that altered the outcome of the disciplinary hearing

involving an inmate with mental illness ):

Y L5

: ' 5.

) is a 28 year old female offender who was

confined to Albion at the time I interviewed her on September 24,2003. A review of her OMH

file indicates a substantial history of mental illness including diagnoses for depression and post

traumatic stress disorder. She has a history of self-injurious behavior and is subject to seizures.

The following episodes represent only a portion of her disciplinary history:

3/6/03: she was charged with harassment for "yelling" at an unidentif~d inmate while on a walkway from the mess hall.

3/17/03: at 8 5 9 a.m., she was found guilty of the 3/06/03 harassment charge and assessed 30 days keeplock plus 30 days loss of recreation, commissary, phone and packages.

311 7/03: at 9:15 a.m., afier admission to keeplock, she stabbed
and slashed her wrist, slammed her head into a sink and then collapsed. She was then charged with self-hann and violent
conduct.
- 3/20/03: at 8:43 a.m., she was served notice of her charges from
the 3117/03 incident.
- 3/20/03: at 9:25 a.m., she attempted to hang herself. She was
again charged with self-harm.

4117/03: she was charged with self-hann for taking medication she had previously hoarded.

8/2/03: she was charged with five separate violations when she was observed "snuggling" and appearing "very affectionate" with another inmate in the mess hall. p o t e : during the course of my interview with her, she claimed she was being congratulated by

another inmate for having successfilly graduated from a recent program-]
8/7/03: after the hearing for the 8/2/03 charges for which she received additional punitive segregation time, she was subjected to a major application of staff use of force in order to strip-frisk her for placement in SHU.

i: ' C-C- is a 50 year old male offender confined to the
Upstate SHU. He has accumulated SHU time through 2015. He has an extensive history of

mental illness including a principal diagnosis of adjustment disorder with depressed mood. Mr.

Torres is also HIV positive. His OMH core history of 6117/03 included the following notes:

"Mental Health-Depression, anxiety, insomnia and irritability in relation to incarceration and

medical condition. Pt. willing to participate in services, accepting prescribed medication. .

Rehabilitation-Nonecurrently in SHU." (OMHPR0281281) An OMH progress note of 6117/03

noted that he "has not had structured tr. [treatment] in the last few years." (OMHPR0281307) He

has an extensive history of disciplinary infractionsdominated by such violations as flooding,

harassment, obstructing visibility into the cell, and unhygienic acts, behaviors typically

C,cc associated with inmates with mental illness.

Q a is also frequently subject to deprivation

orders for loss of exercise, showers, and haircuts. The following incidents are illustrative of the

aforementioned punishment cycle:
4/27/03: he was charged with interference, obstructing visibility and unhygienic act for covering his cell window and "pushing what appeared to be urine, feces and water out from under his door out on to the gallery." (DCSCOF0021734) He received 12 months SHU time, 12 months loss of commissary,phone, and packages.

6/21/03: he was charged with refusing a direct order and destruction of state property for refising to relinquish a food tray and then breaking it over his toilet. He received 6 months SHU

time, 6 months loss of commissary, phone, and packages. An OMH progress note on 7/9/03 (OMHPR028 1322) reflected a nurse's concern over the inmates "erratic" behavior. The physician was "concerned because his liver function test is very high, indicating high triglycerides and he was concerned this may be affecting his behavior."

~pproximatelyone year later this cycle continues:

6115/04: he was charged with refusing a direct order, delaying count, and visibility obstruction when he refused to uncover his cell window. He received 6 months SHU time, 6 months loss of commissary, phone, and packages.
As of April 5,2005, the date of the disciplinary history printout I reviewed C cattJ, ,he
was housed at Upstate Correctional Facility, an all-SHU facility with minimal mental health

services in comparison to most other maximum security facilities, and was sentenced to remain

'" in SHU until April 11,2015.
A a

t ' p.,

is a 31 year old male offender who was

confined to Five Points at the time I interviewed him on October 31,2003. He has a principal

diagnosis of schizophrenia paranoid type.
6/16/02: at 8:15 a.m., he was charged with interference, unhygienic act, and violent conduct for throwing his "spork" (plastic eating utensil) out of his food slot. He was immediately placed on a restricted diet until 6/23/02.

6/16/02: at 12:45 p.m., he was charged with flooding and refusing a direct order for flooding his cell with toilet water.

6/16/02: at 3 5 0 p.m., he was charged with refusing a direct order and interference for refusing to return paperwork.

6/20/02: a progress note indicated that "PT.'s neuroleptics were discontinued here shortly after his arrival [to Five Points] due to noncompliance. His deteriorationis compatible with his having cleared them from his system. I will try to get PT. to resume

Seroquel200 mg pm. I will reevaluate him next week." (OMHPR0557838).

7/2/02: he was found guilty of all of the above charges and received 9 months SHU time and 12 months loss of such things as recreation, commissary, packages, and phone.

c'l r

I:

is a 34 year old male offender currently

confinedto the Southport SHU. He has an extensivehistory of mental illness.and is borderline

mentally retarded. He has been diagnosed with impulse control disorder and psychotic with

delusions and auditory hallucinations. An OMH psychological evaluation done in August 1997

concluded that "the amount of time he faces in Special Housing should also be reduced as it will

throw him back onto himself psychologically, which he will not be able to tolerate for long.

Following these recommendations, his prognosis appears fair, avoiding them, his prognosis

appears guarded to poor." (OMHPR0248268) Notwithstanding this report, he has since been

confined almost continuously to SHU and has accumulated SHU time through 2012. A review

of his cell locator system printout indicates a continuous cycle between mental health observation

cells and SHU. (DCSCOF0022248-022252) In addition to a huge number of disciplinary

infractions, he also has been subjected to a seemingly limitless number of deprivation, restraint,

cell shield and diet restriction orders. The following represents only a portion of the total number

of bizarre episodes over the past ten years:
1/3/03 thru 2/4/03: he was charged with no less than 7 separate disciplinary infractions for unhygienic acts and obstructing visibility for which he received a variety of punishments ranging from additional SHU time to diet restrictions. A progress note on 1/22/03 indicated that a mental health worker "attempted to see pt. at SHU but was unable to evaluate due to the stench of feces smeared on the cell walls." (OMHPR0261762) A progress n d e on 2/8/03 indicated that "pt. appears to be decompensating."

11/20/03:he was charged with smugglingwhen three plastic bags of vitamin A and D ointment were found secreted in his rectal cavity.
2/9/04: he was charged with soliciting, harassment and sex offense when he handed a letter to a correctional officerthat contained a bizarre offer to a female employee, that while clearly inappropriate, did not threaten physical harm. The misbehavior
report noted that O 1, was prepared to give the employee
"his grocery food packages, commissary, soda, chips, donuts, candy bars, cookies, cakes and a e l 1 cooked meal." He was found guilty of all charges and received 12 months SHU time and I2 months loss of commissary, packages, and phone.
3/9/05: he was again charged with harassment, sex offense and facility correspondenceviolation, for writing a letter to an OMH employee that again contained a bizarre offer that, while clearly inappropriate, did not threaten physical harm. He was again found guilty and received 3 months SHU time. The day before this
charge, he had received 6 months SHU time for refusing a direct
order.
ASof April 5, 2005, the date of the disciplinaryhistory printout 1reviewed for 8,T , .,he
was housed at Southport Correctional Facility, an all-SHU facility with minimal mental health
services in comparison to most other maximum security facilities, and was sentenced to remain
in SHU until September 11,2012.
F.E,B " E , E , ~ , is a 33 year old maie offender cumently
housed as an inpatient at CNYPC. He has been diagnosed as having a schizoaffective disorder,
depressed type. A 2003 OMH discharge summary and service plan concluded that he "is at risk
for future hostile and paranoid behavior as the result of a stressful situation, that may lead to
medication non-compliance and hrther decompensation into active mental illness."
(OMHPR0563593) In early 2 0 2 . E,E, 3, incurred a series of disciplinary infractionsfor

which he accumulated over twenty-four months SHU time, two of which are summarized below.

Within a matter of days after this series of infractionshe was diagnosed as presenting

"persecutory delusions + depression." (OMHPR0563126) He claimed "he was in a 7 man dorm,

he was sleeping and another inmate, which he described as crippled and HIV+,sodomized him

while a CO took pictures."

1/26/02: he was charged with harassment, refusing direct order, and threats when he refbsed to step to the back of his cell to receive a food tray. He received 6 months SHU time and 6 months loss of commissary,phone calls and packages.

1/27/02: he was charged with harassment and rehsing direct order when he refbsed to return his food tray. Several hours later he was also charged with unhygienic act for throwing an unknown liquid from his cell. He received an additional 6 months SHU time and 6 months loss of commissary, phone calls and packages.

In the months following this series of events, Mr. Walker was subjected to a series of

deprivation orders, cell shield orders, restraint orders and diet restrictions.

B-.P 1:: 8-e is a 26 year old male offender who was
confined at Great Meadow at the time 1 interviewed him on August 26,2003. He has an

extensive history of mental illness, beginning during childhood. He has been diagnosed with

mood disorder, impulse control disorder, schizoaffective disorder and mental retardation. He

also has a history of suicide ideation.

has an extensive disciplinary history that

includes over 300 deprivation, cell shield, restraint and food restriction orders. The following

series of events from 10121/02through 12L2f02 graphically illustrate that acute well-documented

mental illness is not allowed to interfere with the imposition of punishment by DOCS:

10/21/02: he was placed in an observation cell after threatening self-harm by breaking his cell light for a cutting instrument. Just

prior to this move he was charged with refising to obey a direct order.
10/22/02: he was returned to SHU.
10/25/02: he was charged with harassment.
10/25/02: he was retumed to an observation cell again threatening self-harm.
10/28/02: he was returned to SHU.
10/28102: he was charged with unhygienic act and threats for throwing liquid on his cell front which was covered with a cell shield.
11/1/02: he was charged with harassment.
11/7/02: at I :25 p.m., he was charged with damaging property.
11/7/02: at 1:40 p.m., he was charged with unhygienic act for which he later received 365 days SHU time and 365 days loss of packages, commissary and phone.
I 1/7/02: at 3:00 p.m. he cut his face and wrist with a broken cell light (as he had threatened to do on 10/21/02) leaving wounds that required 14 sutures, after which he was returned to an observation cell.
12/2/02: he was released from the observation cell and retumed to SHU after which he received no less than nine additional charges in the following thirty days, accumulating 5 months of additional
SHU time.
e> - A, b"; ' d is a 38 year old male offender who was
confined at Wende at the time I interviewed him on September 22,2003. At the time of the
following disciplinary infraction, he was diagnosed with impulse control disorder. Also at the
time of the disciplinary infraction he already had spent approximately 7 years in SNU. The
fo]lowing is indicative of how dominant punitive sanctions are in DOCS facilities even when a

treatment program is deemed necessary:

9/11/02: he was charged with self-harm when he was observed banging his head into his cell bars. On 10/7/02 he received 30 days keeplock confinement. While serving his keeplock sentence he was accepted into the Intermediate Care P r o m ("ICP") but was not allowed to filly participate in programming until he completed his 30 day keeplock sentence.

EA, 1: EA,

is a 35 year old male offender who

was confined at Five Points at the time I interviewed him on October 31,2003. He has

accumulated SHU time to 2009 and keeplock time to 2010. He has a diagnosis of

schi~o~hreniafparanoaindd adjustment disorder with disturbance of emotion and conduct. He

, has an extensive disciplinary history that includes the frequent imposition of deprivation, food

restriction, restraint and cell shield orders.

L~ has sustained significant periods of

"I time locked in a SHU cell 24 hours a day with virtually no property or cell amenities. The

following DOCS incidents and accompanyingOMH notes demonstratethe often utter futility of
managing a mentally disturbed offender through the confines of a strictly punitive regimen. .

These incidents likewise demonstrate the benefits of integrating a treatment regimen wifh or in

place of a strictly punitive approach. The selected incidents represent only a small portion of the

total number of incidents spanning some fifteen years:
8/ I 8/94: a discharge summary contained the following note after he had been diagnosed with delusional disorder (grandiose). "We would like to strongly recommend that DOCS be asked if they would be willing to remit some of this patient's SHU time if the patient would be willing to take medication. The patient clearly does not believe that he really needs medicine, and yet, when taking medicine, he is calm and peaceful. This stands in stark contrast to this extremely dangerous behaviors when he is decompensated." (OMHPR0545962)

11/16/98: an update fromhis OMH core history contained the following note: "He has been transferred to various facilities, and he has been u n d e r p r o g m e d due to being in a long-term S W . He has continued to accumulate various disciplinary tickets due to violent behavior, and at the present time he is tentatively scheduled for release from SHU on 1 2 19/2003." (OMHPR0545469)
5/6/99: an update from his core history contained the following note: "Since being discharged from CNYPC, [he] has refised prescribed medication. He has expressed to mental health staff that he wishes to be out of the SW. Eventually, he gradually decompensated in mental condition and was observed talking to himself and expressing paranoid and grandiose ideas." (OMHPR054547 1)
4/17/02: he was charged with assault on staff and unhygienic act when he threw a food tray out of his feed-up slot hitting an officer in the chest. He was given 3 months SHU time and placed on diet restriction for 5 days. [Note: Due to his accumulated SHU time, he would not actually serve this sentence of SHU time for over two years after it occurred, as is often the case with offenders who have extended SHU sentences.]
7/24/02: he was charged with violent conduct, property dainage, assault on staff, unhygienic act, threats, and self-inflicted bodily harm when he threw liquid smelling of urine and feces from his cell hitting a correctional officer. He was given 48 months5HU time (which, given his other SHU time accrued, would not be served until 2008) and 48 months loss of recreation, commissary, packages, and phones. The disciplinary hearing record under reasons for disposition contained the following: "You have amassed 4,500 days of SHU confinement for assaulton staff. It is obvious that this penalty has yet to gain your attention or deter you for violent behavior. It is therefore necessary to impose a longer period of confinement to encourage you to refrain from acting in this manner and provide for the safety and security of all concerned." (DCSCOF009198)
8/7/02: on the day following the hearing for which he received 48 months SHU punishment for the 7/24/02 infraction, he attempted to flood his cell and received an additional 6 months SHU which, given his other SHU time accrued, would not be served until 2009. He also lost his recreation, commissary, phone and package

privifeges through 2008.

10118/02: he was charged with violent conduct, unhygienic act, visibility obstruction and refusing a direct order when he covered his cell window prompting an extraction team to enter the cell afier administering five applications of a chemical agent. Force was also used to conduct a strip fiisk. Along with the charges, he was immediately subject to a deprivation order in which "All personal property, a11 state property including clothing, and recreation" was taken from his cell. (DCSCOF-0017697) A 21 day disciplinary diet restriction was also imposed as punishment even though none of the violations related to food abuses.

11/12/03: after ten admissions to CNYPC fiom the Five Points
SHU,a Discharge Summary Services Plan contained the following
conclusion: "[He] is unable to improve his sense of self-efficacy in order to combat the self-perpetuation of his chaotic and violent cycle, and his housing in SHU. (OMHPR0547112)

KTd.i

::' Ta'T, is a 35 year old male offender who was

confined at Great Meadow at the time 1 interviewed him on August 27,2003. He has an

extensive disciplinary history with substantial accumulated time in both SHU and keeplock. At

the time of the following disciplinary infractions he had been diagnosed with a psychotic

disorder, delusional; chronic and fixed:

2118/03: he was charged with self-inflicted bodily harm, violent conduct, assault on staff and interference with employee when he grabbed a nurse's hand through the food slot during sick call. The nurse quickly extricated himself and then assisted oficers in forcibly closing the food slot. The inmate believed that there was "pepper spray" flowing through his cell air vent. Following the incident a medical exam documented injuries to his wrists which he claimed occurred when oficers forcibly closed the food slot. After medical personnel concluded the wrist injuries were "not consistent with the description of assault and may be selfinflicted," he was charged with self-harm. (DCSCOF 0023149)
- 3/5/03: he was found guilty of self-inflicted bodily harm along
with the other charges and given 24 months SHU time with 24

months loss of commissary, packages and phone. Prior to these charges he had a conditional release date of 3/3/06, but along with the SHU time and loss of privileges, he received a recommended loss of 24 months good time.

3/17/03: the Medical Department at Great Meadow requested an evaluation posing the following question: "is he psychotic 2O thyroid problems or just psychotic?" (OMHPR0257860). During the next four months he received no less than seven disciplinary infractions notwithstandingthe following OMH notes: 4/1/2003 progress note indicated that "he has a history of hyperthyroidism and his referral to mental health was precipitated by an apparently psychotic episode most probably secondary to that." (OMHPR 0261437) 4/21103OMH progress note documented his "well encapsulated belief' that 'his cell is being monitored and that his body is being damaged by low-grade radiation which has caused bums on his elbow, penis and anal area." (OMHPR0257869)

Rat

R,2, is a 25 year old offender who was

confined at Attica at the time I interviewed him on September 23,2003. On June 19,2003 he

was admitted to CNYPC from Attica after having been observed engaging in bizarre behavior as

foIlows: 611 1/03 Progress Note: "He was rolling back & forth on bunk, singing Bk talking loudly

to himself. When asked about taking meds pt. stated, 'I don't want them' in singlsong voice"

(OMHPR0379716); 6114/03 & 6/15/03 Progress Notes: "pt. is awake all night singing &

frequently, openly masturbating" and "Pt. presented as manic t (sic) flight of ideas-incoherent

speech. Cont's to masturbate frequently." (OMHPR 03797 18) His Discharge Surnmary/Service

plan of 7110103 concluded that: "[His] extremely poor coping skills, egocentrism, history of drug

abuse, and behavior for secondary gain, appear to make him a good candidate for behavioral

therapies and settings." (OMHPR0477699) A psychological evaluation also done during this

commitment to CNYPC contained the following note: "Referral to an ICP does not appear

appropriate at this time, as there is the likelihood that [he] would use ICP for exploitive and

antisocial objectives instead of legitimate therapeutic goals...If Ws] hture behavior were to
progress from malingering psychiatric symptomatology to self-abuse behavior, the development
of a structured outpatient behavioral plan should be considered for effective management."
(OMHPR0477443) R_ t,, was returned to the Attica SHU where he was, in a matter of
days, moved to an observation cell after correctional officers asked mental health staff to see
him. Officers had observed him "naked, rollinglrockingback & forth on cot-ceil in disarray-
feces on floor, light turned out." (OMHPR0730416) Nevertheless, he remained in SHU. This
same type of problem was noted by Richard Harcrow, a representative of the New York State
Correction Officers and Police Benevolent Association, when he testified before the New York
state legislature on'January 13,2004 that OMH may decide not to have a particular inmate
moved to a mental health treatment setting, and:
...if they say no, just keep him here, you know, and then usually
what they do is they just sit on him, monitor him until they really act out, and maybe starts a fire, or maybe breaks something, or maybe tries to self-harm himself, and then we end up taking him away. If we would have taken him at the beginning and gotten him to a professional, maybe this wouldn't have happened. (Transcript, page 25: 1-9).
During the ensuing three months R, 3 was charged with no less than fourteen
disciplinary infractions, a sample of which follow:
9/10/03: he was charged with two separate infractions for throwing his food all over his cell. He also attempted to throw coffee at an officer, but the cell was covered with a shield. He received 3 months SHU time, 3 months loss of package, commissary, phone, recommended loss of 6 months good time and was placed on 14 days diet restriction.
9/20/03, 09/25/03, and 10/07/03: he was charged with violations for refUsa1 to return his eating utensils. He received a total of 6

months SHU time, 6 months loss of packages, 3 months loss of commissary and phone, and 14 days restricted diet.
10116/03: he was charged with two separate violations for attempting to hit an officer with his food loaf. He received a twenty-one day diet restriction and recommended loss of 3 months good time.
11/12/03:he was charged with three separate violations for refbsal to return his food tray in which he had urinated and defecated. He received 4 months SHU time and 4 months loss of packages, commissary, phone and 7 days diet restriction.
1 1/26/03: he was charged with two separate violations for attempting to throw his food loaf at an officer. He received 6 months SHU time and 6 months loss of packages, commissary, and phone and recommended loss of 6 months good time.
The ten inmate case summariesset out above are representative of the twenty-five case
files reviewed for which I was provided comprehensive documents from both DOCS and OMH
files. They are also generally consistent with the other voluminous documents I reviewed that
were provided for hundreds of other offenders with mental illness confined to SHU and other
forms of isolated confinement. TOvarying degrees, the documents are indicative of a system of
punitive sanctions that are harshly, frequently, and indiscriminately applied to offenders who fall
within the category of special needs inmates because of their mental illness. In too many cases,
the Sanctions are applied to such a degree that they are rendered rneanino,less. In other cases, the
sanctions have been exhausted to such a degree that oficials are left only with such extreme
punitive measures as feeding inmates with mental illness for weeks at a time a food loaf which
by design is nutritious but unpalatable, while the inmates having been deprived of ail possessions
resort to using the food loaf as a projectile to throw at staff. An often cited refrain on orders
authorizing the food loaf is: "Disposition is appropriate as inmate is a long-term SHU inmate

who is disruptive and who has lost all other available privileges and Good Time." (DCSCOF0018463) Punitive measures frequently go beyond the loss of "available privileges" through the use of deprivation orders that can suspend even basic hygiene necessities, e.g., showers, cell cleanup supplies, and water supply. (DCSCOF0017753 & DCSCOFOO17742).
When such measures are routinely applied to prisoners with mental illness, the correctional manager unwisely has created a substantial population of hopeless and/or senseless offenders who descend into a self-perpetuatingcycle of continuallyescalating and intense actions by both staff and offender. This punitive culture that continually reinforces itself leads to inordinate and needless burdens on correctional staff to process an enormous number of disciplinary infractions, (e-g., 2,2 14 infractions in twelve months for 5 12 Level 1 SHU inmates, OMHCNY0080345), forces ill-equipped correctional staff to act as defacto mental health workers, and places correctional staff in the untenable position of attemptingto manage a sizeable population of special needs inmates in a strict and rigid high-security custody environment devoid of any meaningful treatment programming. Such a state of affairs not only puts the subject inmates at risk, but exposes the correctional staff to a dangerous setting in which their traditional methods of control have been exhausted or have proven ineffective, in large measure due to an equally ineffective mental health care delivery system.
Importantly, such a dangerous work environment exacerbates correctional officer stress normally associated with prison work. All DOCS training materials ax required to have a dedicated module on managing stress. (DCSCOF0006496) In the Special Housing Unit-Mental Health Training Program materials, it is noted in the introduction that "various studies indicated that stress and stress related illnesses have a tremendous impact on individuals working in
3 1

corrections." (DCSCOF0006496) Stress inducing factors for correctional staff associated with the typical prison environment such as fear, frustration and anxiety, are magnified in p u n i ~ v e segregation, especially in an environment like DOCS' SHUs in which large numbers of offenders with mental illness are concentrated for months and years with other inmates, some of whom are the most difficult to manage in the DOCS system. According to DOCS Correction Counselor Richard J. Woodward, 11, "Any SHU in a facility with a Satellite Unit is becoming a catchall for the seriously mentally ill and the most aggressive predators and that is a lethal combination." (DCSCOFOO15475) As a consequence of having to manage a difficult offender population in untenable circumstances, correctional staff must also take extra precautions to safeguard their own well being. Moreover, correctional staff need extensive and specialized training to manage this population. However, as Richard Harcrow, a representative of the New York State Correction Officers and Police Benevolent Association, testified before the New York State legislature on January 13,2004:
MR. HARCROW: We clearly need additional training. Currently we get a few hours in the academy. They give us a report where we check off the inmate is talking to himself, the inmate hasn't bathed, the inmate isn't eating, the inmate may be pacing. That's currently all the training we get. (Transcript, Page 18: 4-10) By any correctional standard with which I am familiar or have had experience, this is a failed system that causes incalculable harm to all those involved, be they staff or offender. B. The Mixing of Inmates with Mental Illness with Other Inmates in a Long-Term Punitive Segregation Unit 1. Inmate Classification and S~eciaNl eeds Offinders. The separation or classification of inmates by select categories is an essential component of prison management. According to a

former Director of the National Institute of Corrections ('WIG"):
Classification by definition involves separating inmates by their behavior and specific program needs. Devising eflicient differential programs for each subgroup of offendersmay remain a lofty ideal; effective management that creates a safe, secure, and humane correctional environment is not. (Managing Adult Inmates, NIC and the ACA, 1984, Preface xi)
The NIC's "Principles of Classification, " which specify the essential elements of any
classificationprocess undertaken by a prison system includes the following:
Principle 6. There must be provision for scieening and further evaluating prisoners who are management problems and those who have special needs.
In addition to screeningand W e r evaluating inmates who are management problems, the correctional system's central ofice must provide for prisoners who have special needs. Those individuals,who, through effective screening, are shown to require special program assignments and monitoring include, but are not limited to, the aged and infirm, the mentally ill and retarded, and those with special medical problems. (Managing Adult Inmates, at 58)
This principle minors the ACA's definition of a special needs inmate:
Special needs inmate-An inmate whose mental andlor physical condition requires special handling and treatment by staff. Special needs inmates include, but are not limited to, drug or alcohol addicts or abusers, the emotionally disturbed, mentally retarded, suspected mentally ill, physically handicapped, chronically ill, and the disabled or infirm. (ACA Srandardsfor Adult Correctional ]nsritu~ions,3&Edition, at 181)
The assignment of inmates with mental illness to a punitive segregation unit for months
and years of confinement with inmates who do not have mental illness, all of whom have
committed disciplinary infractions, constitutes an intentionalco-mingling of two incompatible
subgroups into a single population that results in an unsafe, unsecure and inhumane correctional
3 3

environment for both subgroups a d staff assigned to manage them. Admittedly, correctional systems often temporarily mix subgroups of offenders with appropriate safeguards for a variety of purposes such as short-term disciplinary detention, programming, and interlintra fitcility transfers. However, when such mixing occurs for months and years at a time, the maintenance of the appropriate safeguards and the sustained delivery of differential servi.cesfor large numbers of inmates with competing needs (both security and treatment), becomes an untenable scheme of inmate management. The following paradigm is thus transformed fiom:
identl~calionof incompatible subgroups + sevaration = reducedproblems to:
identification of incompatible subgroups + co-min.elin,o=heightenedproblems
As aforementioned, inmates with mental illness found guilty of disciplinary infractions may be confined in SHU with no limitations as to length of time. The DOCS SHUs are for d l important purposes comparable to "superrnax" confinement, both in terms of the degree of control over the inmates and the duration of confinement. In a 1999 National Institute of Corrections ('NIC") monograph on supemax confinement, Chase Riveland, a former director of two state prison systems, discussed the delivery of mental health care in a supemax unit and concluded that '"slecurity measures in most extended control facilities make such assessment and treatment programs difficult and expensive." (SupermaxPrisons: Overview and General Con.yjdera;ions, NIC, January 1999, at 12) Mr. Riveland further concluded that ''Insofar as possible, inmates with mental illness should be excluded from extended control facilities." (Id.) In a forthcoming book entitled Managing Special Populations in Jails and Prisons, Michele Deitch, the former court-appointed monitor of conditions in the Texas prison system in Ruiz v.

Estelle and author of the chapter on "Correctional Health Care and Special Populations-Legd
3 -
Considerationsand Context" concluded in discussing the housing of inmates with mental illness:
There must be some means for separating mentally ill inmates fiom the rest of the prisoner population. Mixing the two groups may violate the rights of both the mentally ill and non-mentally ill inmates. In designating housing for mentally ill prisoners, however, corrections administrators should take care to avoid placing them in housing situations that can exacerbate the symptoms of their mental illness. There is a recent trend of placing mentally ill inmates in "Supemax"-type settings, and courts are increasingly holding that such practices are unconstitutional. At best, the practice of confining mentally ill inmates in these highly restrictive and sensory-deprived settings is dubious, and has been criticized by mental health and legal experts alike.
2. The Effects of Inmate Incompatibilit~.While the majority of the over eighty inmates I
interviewed had been diagnosed with a mental illness, at least ten of this group of eighty had no
such diagnosis. The most consistent and pronounced consensus of both the inmates with mental
illness and the inmates who did not have mental illness related to the ill-effects and acrimony
engendered fiom mixing the two groups on a 2417 basis for weeks, months and sometimes years.
The inmates who did not have mental illness complained of such acting out behaviors by inmates
with mental illness as: spontaneous and persistent loud shouting, incessant banging, and
unhygienic practices so aggravated that unbearable odors and stench enveloped the surrounding
cells. What these inmates described was not unlike the conditions noted in a 1999court decision
involving the Iowa State Penitentiary where mentally stable inmates were intermingled with
offenders with mental illness:
...the pandemonium and bedlam the mentally stable inmates must
suffer because they are intermingled with the mentally ill inmates who either cannot or do not control their behavior. One particular portion of cellhouse 220 was so bad that it was commonly known

as 'the bug range.' ... 'Cellhouse 220 is noisy-lots of banging and
really dirty. Being on the bug range is very st~ess'fuli,t takes its toll. You can't sleep, you get high blood pressure and turn into a madman."' (The Mentally Disordered Inmate and the Law,2003
Cumulative Supplement, Fred Cohen, 9 11.I@], S11-3-4)
Conversely, the inmates with mental illness I interviewed complained of being constantly
subjected to the use of such offensive and degrading terms by inmates who did not have mental
illness as "bugouts, crazies, loons, bugs, and bugjuice."Such interchanges between the two
groups often lead to combative episodes in which fecal matter and urine are fashioned and
employed as projectiles that can be hurled at each other when they go to shower or recreation.
This weaponry likewise has its own SHUjargon, "cupbusting, gassing, shitballs, and shitdowns."
Time and again, inmates from both groups described daily and recumng events that constitute an
aberrant pattern of behavior directly attributableto the mixing of two such divergent subgroups
of offenders for extended periods of control, all of whom are locked down in their individual
cells for 23 hours a day with limited in-cell activities. The following actual quotes andlor
paraphrased passages from inmate interviews illustrate the perverse environment that emerges
over time when such an antithetical management scheme is employed:
An officer was heard to summon an inmate for his medications by ordering him to "come and get your bug juice."
"Some bangers go all night, it can drive you crazy when you can't sleep."
"I traded three showers for a new cell assignment to get away
from a bugout."
"I rub my cell down with BenGay to cover the smell of shit on the
walls of the cell next door."
"I use wet toilet paper in my ears to drown out the noise from the

bugouts who sometimes bang all night long."
"I'll do anything to get to a gallery with no bugouts."
'I cut a porter for calling me a bugout."
"I'd like to move to get away fiom the bugout next door but I don't want to catch a snitchjacket [labeled as an informer]."
'"I've been to MARCY ICNYPC] four times for hunger strikes."
"I've traded my meds [medications] for smokes."
"Gassing [throwing urine and feces] goes on all the time." "I keep my suicide thoughts to myself to stay out of the torture cells [observation cells]."
"He's so crazy, they [stam don't even stop at his cell."
"Some of them fools [inmates] don't know any better than to mess with them bugouts."
"I went to the observation cells just to get away from the hangers." Defendants themselves have acknowledged that mixing inmates with mental illness with
other inmates in a punitive segregation environment is problematic. In evaluation studies of the
STP programs at Attica and Five Points Correctional Facilities, it was noted that an important
and distinguishing feature of the Five Points STP was the creation of a dedicated housing area in
the SHU that contained only STP participants. The '"Five Points Specialized Treatment Program
(STP) Special Assessment for (S).fiT) InmatelPatientsW(OMHCNY 027806-027818), under the
heading of "Program Design," indicated that:
...the program contains only STP participants. There is never a
mixing [emphasis added] of STP inmate patients in a regular SWU.
One major benefit is the elimination of contact with inmates who

have a negative impact on treatment goals. (OMHCNY 027816)
In Attica's second report on their SIP program (OMHATT 0001085-0001089), it was noted that "STp staff have observed at times, more.functiona1 inmates directly and indirectly intimidate
others to the point of program refusal, or reduced participation." (OMHATT 0001088) This important difference between the two programs, in part at least, explains the disparity in the
inmate participation rates of the two programs: Five Points Participation in Mental Health Treatment. Seven per cent were rated a$ "participating fully" at intake compared to 66% at termination or their most recent rating if still in the program. (OMHCNY 042994) Attica Participation in Mental Health Treatment. Nine per cent were rated as "participating fully" at intake compared to 37 % at termination or their most recent rating if still in the program. (OMHCNY 042945)
It is important to note that every one of the six SHU facilities I visited had physical plants that would lend themselves to the creation of dedicated housing for inmates with mental illness
separate from other inmates. C . Rule Enforcement and Inmates with Mental Jllness in Punitive Segregation Along with the additional restrictions found in a high security punitive segregation unit
such as the SHU come an additional set of rules, some of which are particular to the punitive
segregation unit such as those related to property and commissary limitations, and some of which
are technical such as standing for a cell count. In addition to these formal rules, there are often
times local or informal rules employed on particular units, commands and even shies. Some
.staff enforce rules in a rigid sometimes hyper-technical manner while other staff ignore or
informally address minor or nuisance violations. Grasping and understanding these rule

enforcementdynamics is critical in order for inmates to exercise some very limited control over their conditions of confinement in a highly restricted setting. In other words, if an inmate has difficultyin conforming and mastering rules, or is subjected to uneven or hyper-technical enforcement of rules, it will be reflected by increased disciplinalry infractions and imposition o f even greater restrictions such that some inmates remain locked up twenty-four hours a day with no property and are fed a barely edible compacted loaf o f mixed food stuEs.
As I have observed over more than three decades of working with confined populations, offenders with mental illness by the very nature of their impairment can certainly find it more difficult,if not impossible, to klly grasp and master a complex and comprehensive set of rules such as are ever present in the SHU setting; hence, the need for multi-disciplinary management. Where there is no multi-disciplinary approach, dysfunctional patterns inevitably emerge; these patterns are evident in the DOCS SHUS.
In a 2003 study conducted by DOCS Program Research Specialist Leslie Kellam, she compared the average annual rates of disciplinary incidents for SHU inmates with a mental health diagnosis with the disciplinary rates of non-mentally ill SHU inmates. ("SHU Placement and OMH Levels," June 24,2003, DCSCOF0006726-0006734) The SHU inmates with mental illness had significantly higher rates of both total tickets and penalties imposed. The infractions resulting in further SHU penalties for inmates with mental illness was over two and one-half times that of inmates who did not have mental illness. (DCSCOF 0006733) While such data is certainly subjectto varying interpretations ("mad vs bad"), there clearly is some correlation between infractionsand mental illness that requires differential or particularized management.
Four particular categories of infractions s i q l e d out in the study merit comment due to

the nature o f the infraction and the disparities in the data. Inmates with mental illness were four times more likely to be charged with threats, ten times more likely to be charged with unhygienic acts, seven times more likely to be charged with flooding, and twice as likely to be charged with refusing a direct order. Regardless of whether these significantly higher ra$esof infractions among inmates with mental illness can be attributed directly, or in part, to 1) mental illness; 2) the multitude of rules in SHU; 3) the rigidfhyper-technicalenforcement of ruies; or 4) combinations thereof, treatment prerogatives have been subsumed by a mind numbing level of pnitive sanctions employed on inmates with mental illness in SHU. Such a punitive r,-'01men has given rise to a culture of ever-escalating intransigence on the part of both inmates and staE
In addition to the evidence of this punitive regimen-setout in the sections above, the inmate interviews provided a richly detailed view of how informal sanctions are sometimes used to make an already highly restricted regimen even more punitive. Inmates at five of the six facilities I visited described how often inmates get "burned" [deprived under the guise of a mk violation] on their scheduled recreation, showers, or meals if they are not in a prescribed position at precisely the right time when officers pass their cells. Inmates claimed that by "burning" enough inmates for their showers and recreation, officers could significantly reduce their workload. It is notable that in my review of DOCS facility log books there were certainly instances where very few inmates left their cells for recreation. Numerous inmates also complained of being ticketed for talking between cells, summoning offiers, not standing for count, and not standing at the rear of their cells when officers passed. inmates at four of the six facilities described how inmates could barter their shower and recreation time for such things as extra meals, getting an officer to pass a magazine from one cell to another, and for more

favorable cell assignments. One inmate expressed his anger over getting "burned" for recreation when an officer "creeped" down the run and he couldn't assume the position [stand at his gate] quickly enough. The inmates with mental illness described time and again how, when locked securely in their cells, angry or frustrating interchanges with staff resulted in disciplinary charges. While such a scenario is hardly limited to imprisoned inmates with mental illness, by the very nature of their impairments inmates with mental illness are less equipped to cope with the vagaries of inrnate/staffdynamics,especially in a strictly punitive environment.
While I cannot opine as to the adequacy or inadequacy of any particular mental health treatment program, it is obvious to me that even modest modifications of SHU practices as they relate to inmates with mental illness can significantly reduce the need to rely on a strictly
punitive regimen to manage them. A 2003 OMH report on the Specialized Treatment Program (STP)at Attica provides stark evidence that even a modest increase of structured mental health
services can reduce behaviors that result in serious disciplinary action. ("STP for Mentally 111 Inmates in SHU at Attica Correctional Facility, July 23,2003," OMHCNY 042943-042989) It should be noted that the 51 inmates in the Attica STP had "very serious mental health and disciplinary histories." (OMHCNY- 042944) The two components of the program that distinguished it from the regular Attica SHU were: 1) two hours each week day of outsfaell mental health services, and 2) a joint management committee to address needs and placement issues. A few of the results of this STP study are as follows:
There were major and statistically significant reductions in al)the disciplinary outcomes during the STP program. There were
statisticallysignificant reductions in the use of crisis mental health services as well as statistically significant improvements in Treatment Participation, Medication Compliance, and Mental

Health Functioning.
*Number of Tier 2 and Tier 3 tickets. These inmates had a total of 351 tickets in the 12 months prior compared to 45 while in the STP program. The decrease was statistically signijicant. (OMHCNY042945)
The same study was conducted at the STP program at the Five Points facility with very similar
results ("statjstically significant reductions in the disciplinary outcomes during the STP
program." ) (OMHCNY 042993)
Another program jointly administered by DOCS and OMH, the Intermediate Care
Program ("ICP"), should also be mentioned here. In an April 2003 review of ICP participants,
27% of whom had previous commitments to SHU, it was reported that the "Mean number of
Tier 2 or 3 Tickets in the last 12 months was 1.37." (OMHCNY 043079) This mean number for
ICP participants is 4.65 times kss than for inmates with mental illness in SHU.
lrrespective of whether the above two programs are adequate, what is clear is that
anything is better than SHU for inmates with mental illness. An OMH report entitied, ''Special
Housing Units in OMH Level 1 Correctional Facilities, Mental Health Needs Study, JuJy 16,
2004" (OMHCNY0080337-0080371), indicates that mental health contact hours in DOCS
SHUs increased "dramatically" since a similar 2002 study (OMHCNY 0080338). Even so, there
was no impact on the imposition of disciplinary sanctions in the SHU on inmates with mental
illness:
For mental health levels 1 through 4, the average number of tickets are slightly below 6, the same as the January 2002 study. The average number of tickets for inmates not on the rnental health caseload (mental health level 6) is 3; the sarne as the January 2002 study. The average number of SHU inmates receiving Tier 2 and Tier 3 disciplinary tickets was stable with mental health

inmate-patients having about double the number of tickets as
inmates not receiving mental health services. (OMHCNY
0080339) I have reviewed a number of DOCS and OMH studies that included data on disciplinary infraction rates, comparing settings in which heightened multi-disciplinary programming was provided to inmates with mental illness serving SHU commitments versus those settings which are strictly punitive with little or no specialized programming. All of these studies provide stark evidence of the harrnfbl and ineffective limitations of a punitive management model applied with a ferocity I have not witnessed in my thirty-three years as a corrections professional. It is of the utmost importance to note that mental health treatment programs may provide a menu of
incentives whereby participants have opportunities for advancing the quality of their confinement. Punitive segregation, in contrast, imposes a menu of harshly applied disincentives whereby inmates could only work to decelerate the imposition of further punishments. Inmates with serious mental illness who are subjected to an extended or long term punitive regimen such
as SHU in which they are isolated, both in terms of physical space and program services, will all
too often find themselves in a downward and destructive spiral that is antithetical to every legitimate correctional management goal with which I am familiar.
Respecthlly Submitted,
Steve J. E\b&-tin

Exhibit 1

NAME : ADDRESS : TELEPHONE : DATE OF BIRTH: EDUCATION:
1973
EMPLOYMENT :
1987-Present

CURRICULUM VITAE
Steve J. Martin
8513 Adirondack Trail Austin, Texas 78759
Office (512)346-7607 Fax (512)794-8883 E-Mail sjmart@onr.com
August 27, 1948
Bachelor of Science Criminology and Corrections Sam Houston State University Huntsville, Texas
Master of Arts Correctional Administration Sam Houston State University Huntsville, Texas
Juris Doctor University of Tulsa School of Law Tulsa, Oklahoma (admitted Texas State BarCard #13106550)
Self-employed Corrections Consulcant and Attorney.
Gray & Becker, Attorneys at Law. General practice law firm engaged in litigation, administrative law, civil rights 6 legislative work.
Texas Attorney General's Office Special Assistant Attorney General; worked as an consultant to the Chief of Enforcement Division on litigation involving the Texas Department of Corrections

(Vita current as of January 2 0 0 5 )

STEVE J. MARTIN VITA PA= 2 employment (continued)
Texas Department of Corrections Executive Assistant (1984-85) General Counsel (1983-85) Legal Counsel . (1981-83) Huntsville, Texas
As Legal Counsel I served as the in-house attorney on class action litigation. in 1982, I was given the responsibility for providing the primary case administration of RUIZ v ESTELLE (class action conditions suit in which virtually all operational
. aspects of the prison system
subject to court orders) From 1983-85 I served as the chief legal officer of the department. I also served as the liaison to the Office of the Special Master in RUIZ as well as liaison to the Attorney General's Office and the legislature. From 1984 I also served as the Director's Executive Assistant, an operations position in which I was the third ranking official in the department.
Tulsa County DA's Office Assistant District Attorney Tulsa, Oklahoma
As an Assistant District Attorney provided representation to county jail officials on civil rights litigation filed by county jail prisoners. I also drafted a set of jail standards adopted by the district judges for operation of che jail.

STEVE 3. MAEtTIN VITA PAGE 3 Employment (continued)
US Probation and P a r o l e O f f i c e US Probation and P a r o l e O f f i c e r McAllen, Texas (1975-77) T u l s a , Oklahoma (1977-80)
As a probation officer I superv i s e d an average c a s e l o a d o f 50 t o 75 probationers and parolees in addition t o conducting presentence and p r e - t r i a l d i v e r s i o n reports
Federal Bureau of Prisons Federal Corrections Institution
. Casework I n t e r n
Ft Worth, Texas
A f t e r my f i r s t y e a r o f g r a d u a t e s c h o o l , I worked a s a summer c a s e work i n t e r n f o r t h e D i r e c t o r of Mental Health Programs a t t h e facility.
Texas Department of Corrections Correctional Officer Huntsville, Texas
I was a s s i g n e d t o t h e E l l i s U n i t which was a maximum s e c u r i t y p r i s o n . I worked r o u t i n e s e c u r i t y posts such as cellblocks, control center, hall officer, and d e a t h row. I a l s o worked a t t h e Goree Unit f o r female offenders.
REPRESENTATIVE PROFESSIONAL ACTIVITIES:
Appointed a s J o i n t Expert, US v NASSAU COUNTY; m o n i t o r i n g S e t t l e m e n t Agreement on u s e - of force, Nassau County Corrections C e n t e r ; Long I s l a n d , N e w York.
Appointed a s Court Expert, CARRUTHERS v. JENNE; t o examine t h e c o n d i t i o n s o f confinement f o r Broward County Department of fletention, Ft. Lauderdale, Florida.

STEVE J . MARTIN VITA PAGE 4 ~epresentativeProfessional Activities (continued)
Retained as a consultant by Georgia Attorney General's Office to review use of force practices at the Phillips State Prison, Buford, Georgia.
Retained by U.S. Attorney's Office, San Francisco, as an expert in U.S. v Lewis; criminal civil rights prosecution for civil rights violations at the Pelican Bay State Prison.
Retained as an expert by the U.S. Department of Justice, Civil Rights Division, Special Litigation Section; investigation a-nd monitoring of prison and jail facilities: Maryland, Mississippi, Georgia, Guam, Saipa.n.
Retained as an expert witness in DISABILITY ADVOCATES, INC. V. NEW YORK STATE OFFICE .OF MENTAL HEALTH; et-al.; class action civil rights claims for treatment of mentally ill inmates confined to disciplinary segregation, New York State Department of Corrections.
Retained as an expert witness in ALEXANDER v. TARRANT COUNTY; wrongful death of detainee committed to the Tarrant County Community Correctional Facility, Ft. Worth, Texas.
Member of Editorial Board, CORRECTIONAL LAW REPORTER, Civic Research, Inc., Kingston, NJ.
Retained as expert, GATES v. BARSOUR, to assist parties in determining capacity limits for the Mississippi Department of Corrections and to monitor implementation of capacity limits.
Retained as expert witness, INGLES v. TORO, class action use of force litigation involving New York City Department of Corrections.
Retained as a consultant by Georgia Attorney Generalrs Office in BURNS v. WETHERINGTON; civil rights claim for failure to protect inmate at the Lee Arrendale State Prison, Alto, Georgia.

STEVE J . MARTIN VITA PAGE 5 R e p r e s e n t a t i v e P r o f e s s i o n a l A c t i v i t i e s (con&,d)

Retained as consultant t o t h e Ohio Department of Youth S e r v i c e s on s t a f f u s e of f o r c e .

Retained a s a c o n s u l t a n t by Los Angeles County, Special Counsel, t o a s s i s t i n a r e p o r t t o Los Angeles County Board o f S u p e r v i s o r s on inmate v i o l e n c e i n Los Angeles jails.

Appointed a s C o u r t Monitor, DOES v STEWART; monitoring system-wide c l a s s a c t i o n remedial order on protective segregation for the Arizona Department o f Corrections.

J o i n t E x p e r t C o n s u l t a n t , SHEPPARD v PHOENIX; monitoring court order on use o f force i n New York C i t y Department of C o r r e c t i o n s , R i k e r s Island,

Retained by U.S. Department of J u s t i c e & U. S. A t t o r n e y ' s O f f i c e , Brooklyn, t o a s s i s t i n the development of remedial p l a n f o r Nassau County s h e r i f f ' s Department, Division of C o r r e c t i o n , Use o f Force.

Retained by U.S.. A t t o r n e y ' s O f f i c e , San F r a n c i s c o , a s a n e x p e r t i n US v POWERS & GARCIA, criminal c i v i l r i g h t s prosecution f o r c i v i l r i g h t s v i o l a t i o n s a t t h e P e l i c a n Bay State Prison.

Retained by Los Angeles County Board of Supervisors t o evaluate in-custody restraint death of detainee.

Member o f r e s e a r c h team o f Serkman C e n t e r ,

Harvard Law S c h o o l ,

t o evaluate

r e h a b i l i t a t i o n programs i n two Jamaican

maximum s e c u r i t y p r i s o n s .

Retained a s expert witness and consultant, FELICIANO v COLON; c o n d i t i o n s l i t i g a t i o n involving the Puerto Rico prison system.

R e t a i n e d a s e x p e r t , MULDROW v KEOHAME, u s e of r e s t r a i n t s , USP, A t l a n t a , Georgia.

R e t a i n e d a s e x p e r t , SABATINO v AMENN; c l a s s a c t i o n l i t i g a t i o n on use o f r e s t r a i n t s , Erie County Prison, Pennsylvania.

STEVE 3. MARTIN VITA PAGE 6 Representative Professional Activities (continued)
Retained as consultant to review INS Detention Standards, US Depl. Of Justice.
Retained as expert, LEE v COUGHLIM; litigation involving punitive segregation at Sing Sing/Southport prisons, New York.
Retained as expert, SPAT;ES v IOWA CORRECTIONAL INSTITUTION FOR WOMEN ; conditions litigation.
Retained as expert witness, MADRID v GOMEZ; conditions litigation involving Pelican Bay State Prison, California.
Retained as expert witness, COLLINS v ALGARIN; litigation involving excessive force at Montgomery County Jail, Pennsylvania.
Retained as expert witness, ALLEN v CHISHOLM; excessive use of force litigation involving Montana State Prison.
Retained as expert witness, W L T O N v W M B E ; litigation involving double celling practices at Woodbourne Correctional Facility, New York.
Retained as expert witness, SOLOMON v DELLANA; litigation involving excessive use of force at the Allegheny County Jail, Pittsburgh.
Retained as expert witness, B L A C W N v McCOTTER; litigation involving stabbing death of inmate at the Central Utah Correctional Facility.
Retained as expert witness, CLARK v CALIFORNIA; litigation involving treatment of developmentally disabled prisoners in the California DOC.
Retained as expert witness, TATE v M E Z ; litigation involving lethal force at the Corcoran State Prison, California.

STEVE J. MARTIN VITA PAGE 7 Representative Professional Activities (continued)

Retained as expert witness by the New York Attorney General's Office, BIN-WAHAD v COUGHLIN; litigation involving claim of retaliatory transfer in the New York Department of Corrections.

Retained as consultant to the Texas Comptroller of Public Accounts; Performance Review of the Texas Department of Criminal Justice.

Gubernatorial appointee to the Texas Punishment Standards Commission. Vicechair, Policy Development Sub-committee.

Retained as consultant and expert witness by Texas ~ttorneyGeneral's Office on prison and jail litigation.

Retained as consultant, BENJAMIN v ABATE; principal author of Reports of Plaintiffs' Expert Consultants on Conditions in the New York Citv Jails, Legal Aid Society, New York.

Staff Director, Study Committee on

Judicial Education, Texas Supreme

Court; principal investigator for

ReDOrt on Education

JPurdoiucriaamls.6

Court

Personnek

Retained as expert witness and consultant, JENSEN v CLARKE; crowding litigation involving Nebraska State Prison, Lincoln, Nebraska.

Retained as consultant on litigation involving numerous county jails including Detroit, Seattle, Houston, Austin and San Antonio.

Assisted Texas Legislature on the development of criminal justice legislation, 7 l S C and 72"* Sessions.

Gubernatorial Appointee to Texas Council on Offenders with Mental
. Impairments; Chairman of Legislative
Sub-cornmittee

STEVE: J. MARTIN VITA PAGE 8 Representative Professional Activities (continued)
Retained by Corrections Corp-of America, Nashville, Tenn., to assist in the development and operation of private prison facilities in Texas.
Employed as expert witness by Prison Law Office, San Quentin on litigation . involving Vacaville, San Quentin and Tracy prisons.
Employed as expert witness by Prisoners Legal services of New York on litigation involving Attica and Elmira prisons.
Employed as expert witness by NAACP Legal Defense Fund, New York on death row conditions litigation in Missouri and Arkansas.
~echnical.Assistance Consultant, National Institute of Corrections Boulder, Colorado.
Symposium on Prison Reform, Pace Law School, Judicial Institute and the Open Society; moderator and presenter for "Effective PostPLRA Settlement Models; October 2003.
Presenter, SMU School of Law, Colloquium on the Judicial Work of Judge William Wayne Justice, May 2001.
Guest Lecturer, University of Minnesota Law School, Institute of Criminal Justice;
"IRsessupeosn.d"ing to the Crowded Jail, Legal
Visiting Scholar, Institute of Criminology and School of Law, Queen's University, Belfast, Ireland; Seminar: "Punishment as Big Business: The Iron Triangle," October 1999.
Guest Lecturer, New York University School of Law, New York City.
Guest Lecturer, ~ational Association of Attorneys General Annual Conference; "The Role of Experts in Prison Litigation."

STEVE J. MARTIN VITA PAGE 9 Teaching/Lectures (continued)
Testified before the United States Senate Judiciary Committee as a panel member on the Prison Litigation Reform Act.
Southwest Texas State University San Marcos, Texas; adjunct facultytaught corsections course.
St. Edwards University Austin, Texas; adjunct faculty-taught course on American prisons.
University of Texas School of Law Austin, Texas; visiting faculty-. taught seminar on institutional reform litigation.
Langston University Tulsa, Oklahoma; adjunct faculty-taught probation and parole, corrections, and criminology courses.
Pan American University, Edinburg, Texas; adjunct faculty-taught corrections courses.
Sam Houston State University Huntsville, Texas; Graduate Fellowtaught course in social problems.
PUBLICATIONS AND PAPERS:
Martin, Steve J. , and Sheldon Ekland-Olson
Texas Prisons: The Walls Came Tumblinu Down, Austin: Texas Monthly Press, 1988.
Ekland-Olson, Sheldon and Steve J. Martin, "Organizational Compliance with Court-Ordered Reformm, 22 Law and Society Review 359, 1988.
Martin, Steve J., "Prisoners' Rights1', Texas Tech Law Review,
Volume 20, Symposium 1989, Number 2.
Martin, Steve J., "Texas Prisons: A Brooding Crisis Behind Bars", Texas Lawyer, March 13, 1989.
Martin, Steve J., and Sheldon Ekland-Olson, "Ruiz, A Struggle Over Legitimacy", Courts, Corrections and the Constitution: The Xmact of Judicial Intervention on

STEVE J. MARTIN VITA PAGE 10 publications (continuted)

Prisons and Jails, edited by John J. DiIulio, Jr., Oxford University Press, 1990.

Martin, Steve J., "The Celling of Texas", Texas Observer, January 11, 1991.

Martin, Steve J., "An End to Ruiz: Shifting the Debate from Rhetoric to Reason", Texas Public Policy Foundation, April 1995.

Martin, Steve J., "Prison Reform Litigation: Shifting the Debate From Rhetoric to Reason," Alan Fortunoff Criminal Justice Colloquium, Center for Research in Crime & Justice of New York University School of Law, February 26, 1996.

Grant, Darlene and Steve Martin, "Should Prison Reform Litigation Be Curtailed?", National Council on Crime and Delinquency Focus, May 1996.

arti in, Steve J., Perspectives on Justice, "Inmates Haven't Changed, Prisons Have," Los Angeles Times, July 1998.

Martin, Steve J., "Sanctioned Violence in American Prisons," Buildinq

l

e

, edited

by John May, Sage Publications, Inc., January 2000.

Martin, Steve J., "Corrections in the New Millennium: The &an =ason," Voice for the Defense, Texas Criminal Defense Lawyers Association, Vo1.29 Number 2, March 2000.

Martin, Steve J., "Introduction," Frontiers of Justice,Volume 3: The Crime Zone, Biddle Publishing Co., Brunswick, Maine, March 2000. -

Martin, Steve J., Book Review: Goina UP The River: Travels in a Prison Nation, "Punishment & Society, International Journal of Penology," Vol 4, Number 1 January 2002.

Martin, Steve J. Book Review: Punishment & Democracy: Three Strikes and You're Out in California, "British Journal of Criminology," ~01.43, Number 1 Winter 2003.

Martin, Steve J., Book Review: Maconochiers Gentlemen: The Story of
orf folk Island and the Roots of Prison Reform, "British Journal of
criminology," Vo1.43, Number 4 Autumn 2003.

Hill, Debbie, Larry Hammond, Bruce Skolnik, Steve J. Martin and Donna Clement; Effective Post-PLRA Settlement Models: A Case Studv of Arizona's Protective Searesation Lawuit; 24 Pace Law Review 743 {Spring 2004).

STEVE J. MARTIN--TESTIMONY/DEPOSITION/AFFIDAVIT January 2001 thnu December 2004
.1. BRISSETTE V GOMEZ USDC/N~RTHERN DISTRICT CALIFOWIA, C92 -
3619VRW; retained by plaintiff's counsel Edward J. Tafe, Hanccxk,
. ~othert& Bunshoft, 4 Embarcadero Center, l o t h Floor, San Francisco,
CA 94111; testified at trial and through deposition regarding excessive force and inmate protection from harm at Pelican Bay state prison.
2. HARDY V OHIO DRC, COURT OF CLAIMS OF OHIO, 99-11875; retained by
la in tiff's counsel Margaret Blackmore, Tyack, Blackmore & Liston,
536 S. High St., Columbus, Ohio; testified through deposition regarding inmate protection from harm at Mansfield correctional ~nstitution,Mansfield, Ohio.
3 . ELMAROUK V SANTA CLARA COUNTY, USDc/ND CA, SAN JOSE, C- 99 201514;
retained by plaintiff's counsel Charles Jenkins, 417 Montgomery St., San Francisco 94104; testified through deposition regarding excessive foxce claim at Santa Clara County Department of corrections facility..
4. KNOX V JENKINS, et-al., USDC/SD TEXAS, HOUSTON, 4:99CV 03317; retained by plaintiff's counsel Yolanda Torres, 4000 Republic Center, Dallas 75201; testified through deposition and trial regarding excessive force claim at Texas prison.
5 . REAGIN V NICHOLS, USDC/ND GEORGIA, 1:99-CV-2383-RLV;retained by plaintiff's counsel Kenneth Lander, 310 N. Broad st., Monroe, ~eorgia;testified through deposition regarding suicide of detainee at Newton County Detention Center.
6. BROWN V HARDY, USDC/WD LOUISIANA, CV 6:00 401; retained by plaintiffs' counsel David Benoit, 420 Benard St., Point Breaux, Louisiana; testified through deposition regarding conditions of confinement at City of Abbeville detention facility.
'7. ELDER V STATE OF LOUISIANA, lgTH JUDICIAL DISTRICT COURT NO. 332918; retained by plaintiff's counsel Christopher Bruno, 855 Baronne St., New Orleans, LA 30113; testified through deposition regarding inmate protection from harm at the Angola State Prison.
8.DOE V BOWLES, et-al., USDC/SD OHIO, C-1-98-476; retained by plaintiff's counsel Jennifer Branch, 617 Vine St., Cincinnati, Ohio; testified at trial regarding inmate protection from harm at the Warren Correctional Institution, Ohio Department of Rehabilitation.

9. STATE V WILLIAMS, HARRIS COUNTY, TX., retained by defendant s attorney, Robert Morrow, Texas Defender Service, 412 Main Street, Houston, TX., to testify on Texas prisons during the punishment phase of death penalty trial.
10. RODRIGUEZ V ROSELW, USDC PUERTO RICO, N0.99-2270 (CC); retained by plaintiff's counsel Alexandra Lopez-Bird,Civil Action & Education Corp., Mercantil Plaza Bldg., San Juan, Puerto Rico; tegtified through deposition regarding inmate protection from harm litigation at Ponce Maximum Security Facility.
11. STATE V BURTON, 338fhJUDICIAL DISTRICT, HARRIS COUNTY, TX., CAUSE NO. 760321; retained by defendant's attorney, Robert Morrow, Texas Defender Service, 412 Main Street, Houston, TX., to testify on Texas prisons during the punishment phase of death penalty trial.
12. NEW TIMES V JOHN SUTHERS, USDC COLORADO, CIVIL ACTION NO. 00WM-612; retained by plaintiffs' attorney Gwen Young, Wheeler Trigg & Kennedy, 1801 California St., Suite 3600, Denver, CO.; testified through deposition regarding censorship practices of Colorado Department of Corrections.
13.MIRANDA V COUNTY OF SAN DIEGO, SUPERIOR COURT OF CALIFORNIA FOPi THE COUNTY OF SAN DIEGO, GIC 780640; retained by plaintiff's attorney Mirian Birge, 2240 5 ch Ave., Suite 200, San Diego, CA. ; testified through declaration and deposition regarding use of force by officials of the San Diego county jail.
14. HOEVENAAR V LAZAROFF, USDC, SOUTHERN DISTRICT *OF OHIO, NO. C2 -
03-190; retained by plaintiff's attorney David Singleton, Prison Reform Advocacy Center, 1301 Enquirer Bldg., Cincinnati, Ohio; testified through affidavit, deposition and trial regarding free exercise of religion (grooming regulations) at the Madison correctional Institution, London, Ohio.
15. USA V HARRISON COUNTY, MISSISSIPPI, USDC, SOUTHERN DISTRICT OF MISSISSIPPI, NO. 1:95CVS (GR); retained by the U.S. Department of ~ustice;testified through declaration regarding inmate protection from harm at the Harrison County Detention Center, Gulfport,
~ississippi.
16. FRAZIER V ANGELONE, USDC, WESTERN DISTRICT OF VIRGINIA, NO. 7:02-CV-1208; retained plaintiff's attorney, John Fishwick, P.o. BOX 601, Roanoke, VA 24004; testified through deposition regarding in-custody death of inmate at Wallens Ridge State Prison.
17. HARGETT V ADAMS, USDC NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION, NO- 02 C 1456; retained by plaintiffs* counsel, Mike ~ullins,Schiff Hardin & Waite, 6600 Sears Tower, Chicago, Illinois 60606; testified through deposition and trial regarding conditions of confinement at the Joliet Treatment & Detention Facility.

18.STATE OF TEXAS V TOMAS G U L O , 182~' JUDICIAL DISTRICT COURT OF HARRIS COUNTY, TEXAS, CAUSE NO. 896514; retained by defendant's attorney, Robert Morrow, 6630 Cypresswood Drive, Houston, TX 77379; testified on Texas prisons during punishment phase of death penalty trial.
19. EX PARTE RICKY EUGENE KERR, 290TH DISTRICT COURT OF BEXAR COUNTY, TEXAS, CAUSE NO. 94-CR-7019W-2;retained by Texas Defender Service, Kathryn Kase, 412 Main, Suite 1150, Houston, Texas 77002;testified on Texas prisons during rehearing punishment phase of death penalty trial.
20. 0RAFA.N v GOORD, USDC, NORTHERN DISTRICT OF NEW YORK, 95-CV-318,
00-CV-2022 (Magnuson) (GJD); retained by plaintiffs 8 aktorney, Carolyn Flintoff, Sullivan & Crornwel1, 125 Broad St., New York City; testified through deposition regarding free exercise of religion in New York Department of Corrections.
21. GATES V BARBOW, USDC, NORTHERN DISTRICT OF MISSISSIPPI, 4 :41cv6-JAD; retained by plaintiffs' attorney, Ronald R. Welch, P.O. BOX 4589, Jackson, MS 39296; testified at hearing on capacity limits for the Mississippi Department of Corrections.

Inmates Interviewed by Steve J. Martin During Rule 34 Inspections at New York State Department of Correctional
Services Facilities Great Meadow Correctional Facility -Auwst 26 & 27,2003
Wende Correctional Facility - Se~tembe2r2 & 25.2003

Attica Correctional Facility- September23 & 25.2003

Albion Correctional Facility - Seutember 24.2W3

Auburn Correctional Facility - October 29,2003

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Auburn CorrectionalFacility- October 30.2003

Five Points Correctional Facility - October 31.2003

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Bates Range

Documents Reviewed by Steve J. Martin Description

DCSCOF 0006726-0008383, DCSCOF 0008443-0009075

Disciplinary History Printouts

. .

- -,-

OMHPR 0276415-0276501 OMHPR 0425469-0425750
OMHPR 0276060-0276414
OMHPR 0561316-0561389 r
OMHPR 0247971-0248599
OMHPR 0261702-0261867
OMHPR 0257890-0258559 OMHPR 0260524-0260773
OMHPR 0558753-0558947
OMHPR 0566983-0567776
OMHPR 0259429-0259610 OMHPR 0267897-0268783
OMHPR 0542704-0543 164 OMHPR 0545442-0547I58 OMHPR 0606226-0607334
I

7
OMHPR 0270228-0270577
OMHPR 0577874-0577891
OMHPR 0005740-0005898 OMHPR 0170405-0170712 OMHPR 0258979-0259149

I I OMHPR 0448551-0448855
OMHPR 0593356-0593547
' OMHPR 0565126-0566981, OMHPR 0570244-0571585 OMHPR 0748226-0748807

OMHPR 05833 16-0583347

" -

OMHPR OMHPR

0276502-0278479; 0591598-0591682

OMHPR 0569110-0569464, OMHPR 0578953-0579252

OMHPR 0217333-0217392
/ OMHPR 0089544-0089890
OMHPR 0258757-0258978 OMHPR 0281506-0282813 OMHPR 0698877-0699236 OMHPR 0730830-0731007

OMHPR 0605958-0606225

OMHPR 0325792-0327655 OMHPR 0751651-0752117

OMHPR 0285270-0285427 OMHPR 0287230-0287543 OMHPR 0594026-0594299

OMHPR 0217551-02 18206 OMHPR 0278879-0279985

OMHPR 0046245-0046366 OMHPR 0539042-0539187, OMHPR 0572890-057293 1
OMHPR 0569949-0570243
OMHPR 0550181-0550463 OMHPR 0600184-0600535
OMHPR 0547367-0547483, OMHPR 0584523-0584767
OMHPR 0540758-0540973
OMHPR 0540311-0540625 I OMHPR 0538779-0539041 OMHPR 0601336-0601747
OMHPR 0599588-0599634
. OMHPR 0250726-025 1719 OMHPR 03 I 3590-03 13818 OMHPR 0314041-0314395
OMHPR 0561308-0561315
OMHPR 0256159-0257769 OMHPR 0258560-0258756
OMHPR 0561390-0561455
OMHPR 0548371-0548805, OMHPR 0571586-0572257
OMHPR 060203 1-0602034
OMHPR 0431504-0431690 OMHPR 0594300-0594428
OMHPR 0536894-0537116, OMHPR 0541027-0541065, OMHPR 0551532-0551731, OMHPR 0564226-0564410 OMHPR 0600536-0600744
OMHPR 0217166-0217332
8

OMHPR 0280436-0280709
OMHPR 0379651-0379767 OMHPR 0379790-03 79791 OMHPR 0477399-0477765 OMHPR 0697 125-0697507 OMHPR 0730322-0730470
OMHPR 0257770-0257889 OMHPR 0261380-0261454
OMHPR 0218790-0219738 OMHPR 0296450-0296650 OMHPR 0297695-0298002 OMHPR 0298461-0298723 OMHPR 0591998-0592149
OMHPR 0260911626160 OMHPR 043543 1-0436039 OMHPR 0728101-0728378 OMHPR 0710053-0710257
OMHPR 0537 154-0537389 OMHPR 0541123-0541165
OMHPR 0561872-0562331
OMHPR 0586854-0587286

HPR 0218615-0218789
OMHPR 0547159-0547245 OMHPR 0585905-0586160
OMHPR 0561456-0561486
OMHPR 0218389-0218614 OMHPR 0596184-0596256
OMHPR 0599887-0600183

I
9

.,----. OMHPR 0555200-0556638
OMHPR 02881 82-0288383 OMHPR 0594754-0594933
OMHPR 0550719-0551531, OMHPR 0551732-0552576, OMHPR 0588237-0590326
OMHPR 0604292-0605736 OMHPR 0755357-0755378
OMHPR 0591755-0591838
OMHPR 0431383-0431503
, OMHPR 0595863-0595990
OMHPR 0268784-0268945 OMHPR 0275761-0275879
OMHPR 0561593-0561871
OMHPR 0557806-0558250 OMHPR 0564411-0564543
OMHPR 0561528-0561592
OMHPR 0603992-0604011
OMHPR 0216738-0216970 OMHPR 0382386-0382599
OMHPR 0251978-0251986 OMHPR 0262022-0262047
OMHPR 0248600-0249481 OMHPR 0259I 50-0259428 OMHPR 0272746-0273629
OMHPR 0558569-0558752
I I OMHPR 0255457-0256158 OMHPR 0278746-0278878
OMHPR 0281264-0281504
OMHPR 0600745-0601335
--

QMHPR 0558948-0559114
OMHPR 0562733-0563656 .

OMHPR 0262672-0262685

OMHPR 0561487-0561527

OMHPR 0541066-0541 122

OMHPR 0540974-0541026

OMHPR 0583690-0583721

Deposition Transcripts

Adams, Maureen

1/28/04

Barry, David

811 7/04

J,

Bea, JeEey

611 6/04

Carroll, Takarla

U17105

Culki, John

6/9/04

Devito, Anthony

611 5/04

Gordon, Charles

1 I20104

Greene, Gary

IU4/04

Hemnann, Charles

613 0104

Kellam, Leslie

8/20/04

Key, Nancy

311 7/04

Keyser, Sharon

811 9/04

Klein, Loretta

311 2/04

Lamy, Frederick

2/25/04

Langbart, Mitchell

10/22/04

Lape, William

3/3/04

1

I 8

Leclaire, Lucien

5/26/04

1 Lord, Elaine

2/27/04

Pace, Adele

8110104

Rosado, Maria

8 17/05

Russell, Peter

3/25/04

. Sawyer, Donald

2/15/05, 2/16/05

Selsky, Donald

74/04

, Shimkunas, Aligmantus 6/3/04

Smith, Hal

4/28/05,4/29/05

Van Bramer, Jayne

1 011 104

Way, Bruce Way, Bruce

810/04
1
2/3/05

Woodward, Larry

3/24/04

Wright, Lester

9121/04

Suicide Related Materials

OMHCNY 0064740OMHCNY 0064818

Risk Management reports on Elmira suicides

PL 069593-069626

DOCS Inmate Suicide Report 1997-2003

OMH SHU Studies

plaintiffs Exhibit 25

SHU Mental Health Needs Study, B. Way, May 17,2002

OMHCNY 043300OMHCNY 043333
-
OMHCNY 042322
OMHCNY 0061379-006 1393

Special Housing Units Mental Health Needs Study Conducted by CNYPC Abstract
OMH 2002 SHU Study back-up data

Plaintiffs Exhibit 43 DCSCOF 0006726-0006734

Memorandum fiom Leslie Kellarn (Program Research Specialist 111) to John Culken (Dir MH Services), Doris Ramirez-Romero (Assistant Director MHS) and Torn Goetz (Senior Attorney) re: SHU Placement 1 and OMH Levels dated June 24,2003

'Plaintiffs Exhibit 411

SHUs in OMH Level 1 Correctional Facilities: Mental Health Needs

Study, B. Way, July 16,2004 OMHCNY 0080337-0080380

a1
"4 r i

No Bates

Tables created by DPW detailing inmates whosSzdiagnoseschanged between the publication of the OMH 2002 SHU s h d y and the OMH 2004 SHU Study

DOCS Directives

Plaintiffs Exhibit 40

October 1995 Guidelines for Disciplinary Dispositions

No Bates
- PL 055289 055307
- ' PL 055161 055166

12/30/98 DOCS Directive: Special Housing Units (Manual) 4/24/98 DOCS Directive: Central Monitoring Cases (Manual)

PL055144 -055160
PL 055308 - 055314
- PL 055318 055334 - pL 055282 055288
- PL 055335 055344
PL 055315 - 055317

11/24/99 DOCS Directive; Policies: Chapter V,Standards Behavior
& Allowances
I
10/31/00DOCS Directive- Special Housing Reports
12/20/01DOCS Revision Notice: Unusual Incident Report
10/2/02 DOCS Directive - Mental Health Satellite Services &
Commitments to CNYPC
1/3 1/03 DOCS Revision Notice -The Use of Force
5/21/03 DOCS Revision Notice: Transfers - Special Needs Unit

No Bates

DOCS Directive: Classification Procedures
-Training- Anderson

Plaintiffs Exhibit 256 No Bates
L

Anderson Training Document: 4/14/04 e-mail from A1 Shimkunas to Wuxzberger et al. re: OMH Testimony in Tier Hearings(PowerPoint Presentation attached)
- Training General

DCSCOF 0006414-0006453; Special Housing Unit-Mental Health Training Program DCSCOF 0006473-0006550 .

OMHCNY 106938OMHCNY 106990

Documents concerning training in connection with the DOCS disciplinary system

SHU Audit Inspections

DCSCOF 0015484DCSCOF 0016089

SHU Audit Reports and documents related to such reports

OMHBH 0002751-
OMHBH 0002853; OMHBH 0000205-OMHBH 0000508; OMHBH 0001886-OMHBH 0002189; OMHBH 0002190' OMHBH 0002492; OMHBH 0000186-OMHBH 0000204

Facility Log Books Log Books: Bedford Hills: SHU (1/25/02-4/ 1/03)

OMHBH 0002854OMHBH 0003157; OMHBH 0003306-OMHBH 0003608; OMHBH 0003158- OMHBH
0003305

Log Books: Bedford Hills: ICP (]Of11/02-4/1/03)

OMHSS 0000870OMHSS 0001473
OMHSS 0000189OMHSS 0000608
OMHSS 0000609OMHSS 0000869

Log Books: Sing Sing: SHU 1&2Gallery (10/12102-2/15/03)
Log Books: Sing Sing: GalleryIPSU(10/24/02 - 12/08/02) Log Books: Sing Sing: HBC (10/24/02 - 12/29/02)

OMHBH 0000509OMHBH 0001885

' Log Books: Bedford Hills: Satellite Unit (10/24/02-313 1/03)

OMHBH 0001003OMHBH 0001 138
OMHBH 0002751-
OMHBH 0003157

Log Books: Bedford Hills: Satellite Unit (Observation) [10/24/02313 1/03)
Log Books: Bedford Hills: SHU (10/25K32-11/10/02)
Log Books: Bedford Hills: ICP (1011 1m2-12/17/02)

OMHSS 0001474OMHSS 0001963

Log Books: Sing Sing: HBC OIC (10/25/02 -03/23/03)

OMHBH 0001747-OMHBH 0001885; OMHBH 0001139OMHBH 0001442;OMHBH
0002493-OMHBH 0002750; OMHBH 000 1443-OMHBH . 0001746; OMHBH 0000813OMHBH 0001002

Log Books: Bedford Hills: Satellite Unit (10/25/02-4/1/03)

OMHSS 0001964OMHSS 0002268; OMHSS . 0002269-OMHSS 0002732

Log Books: Sing Sing: SHU 1&2 Gallery (10/25/02-4/24/03)

. OMHGM 0001003OMHGM 0001436

Log Books: Great Meadow: MffU OBS/F-Block Log/B-1 S W (1 1/3/02-5/20/03)

OMHBH 0000186OMHBH 0000508

Log Books: Bedford Hills: SHU (1 1/10/02-12/25/02,3/29/03-4/1/03)

OMHGM 0000520OMHGM 0001002
I OMHAUB 001927-
OMHAUB 002195

Log Books: Great Meadow: HospitaVMHU ICPIF-Block (11/19/025/20/03)
- Log Books: Auburn: SHU (1 2/0 1/02 08131103)

OMHBH 0003158OMHBH 0003608

Log Books: Bedford Hills: RMU ICP (12/18/02-3131/03)

OMHBH 0001886OMHBH 0002750

Log Books: Bedford Hills: SHU (1X25/02-4/1/03)

: OMHGM 0001437-
OMHGM 0001574

Log Books: Great Meadow: Hospital (1/19/03-4/17/03)

OMHGM 0000008OMHGM 0000519
OMHSUL 0000102OMHSUL 0000120
OMHSUL 0000356OMHSUL 0000454

Log Books: Great Meadow: MHU Dad-Block (2/26/03-5/29/03)
Log Books: Sullivan: MHLJ (04/01/03-04/25/03) Log Books: Sullivan: MHU.(04N)11Q3- 04/25/03)

OMHSUL 0000121-
OMHSUL 0000211-
OMHSUL 0000014OMHSUL 0000101
OMHSUL 0000212OMHSUL 0000355

Log Books: Sullivan: SHU Control (04/01/03 - 04/25/03)
Log Books: Sullivan: Infirmary (04/01/03 - 04/29/03) Log Books: Sullivan: Control and Keeplock (04101103- 04/30/il3)

DOCS Institutional Files

DCSCOF 0016090-0022064 DCSCOF 0022335-0022541

. Restraint Orders, Cell Shield Orders, Restricted Diet Documents,
. Deprivation Orders, Referrals, Disciplinary Hearing Packets, Time
Cut Documents and Cell Locator Cards for the following inmates
from January 1,2002 - February 28,2005:

- 3 ---, LJ xe$L L C,

n
% a id

I

tz*__I s

(2 Js

--
Jc\-4dJ

9
- d
- X I
L s % " - _ s <cqr."* " a i

6. rt, J -*

8'

-\

'

L s d K e S w%'*

5; -x z m * B *

- ' 4 - : * 4 L_X *

J

."---.
c k

L'-$ J d *

4

.isL-2;

--

# -

ir

da,

\I
td

Srli L-3"

dbJ\:*,ge2%e

J

No Bates No Bates No Bates No Bates Plaintiffs Exhibit 3
PL 000570-PL 000622

Publications, Studies, and Reports
Manual of Correctional Standards, The Americq Correctional Association, 1966
Managing Adult Inmates, The American Correctional Association, 1984
Standards for Adult Correctional Institutions, 3rdEdition, The American Correctional Association, 1990
Prison Health Care: Guidelines for the Management of an Adequate Delivery System, National Institute of Corrections, US DOJ, 1991
January 31, 1997NYS OMH Task Force o n the Future of Forensic Services Report of the Subcommittee on Prison Mental Health Services

No Bates

Standards for Health Services in Prisons, National Commission on Correctional Health Care, 1997

No Bates

S. Martin Declaration in Clark v. State of Calfornia, C-96-1486 FMS, NDCA, June 29,1998.

No Bates No Bates

1998 Standards Supplement, The American Correctional Association
Excerpts from Prison Jail Adminish.ation: Practice and Theory,by P. Carlson, 1999.

No Bates

Superrnax Prisons: Overview and General Considerations, Chase Riveland, 1999

--
No Bates
OMHCNY 041968-041981 Plaintiffs Exhibit 111 No Bates

2/00 Correctional Association of New York-report: Health Care in. New York State Prisons
Administrative Segregation Maintenance Psychiatric Program, UT Medical Branch, Managed Health Care, June 21,2001
Draft: Mental Health Observation Cell Usage in the Mental Health Satellite Units Operated by Central New York Psychiatric Center Report July-December 2001
August 2002 Bedford Hills Technical~ s s i s t h cFeinal Report prepared by Angela Bro-me,"Addressing Self-Harm Among the : Mentally I11 and Traumatized Women in Prison: Avenues of ' Systematic Collaboration Between Mental Health and Correctional Personnel"

Plaintiffs Exhibit 70 OMHCNY 043117OMHCNY 043140 Plaintiffs Exhibit 418 Uo Bates \lo Bates
'laintiffs Exhibit 107 do Bates qo Bates

11/13/02Suicide Risk Factors in New York State Prisons
7/03 - 3/04 Bureau of Mental Health Quality AssurancetQuality
Improvement Report
NYS DOCS Inmate Records Coordinator Manual, revised September
2003, Chapter 14
-
lot03 Report by the Correctional Association of New York, "Lockdown: Disciplinary Confinement in New York State Prisons"
2003 Human Rights Watch Report: Ill-Equipped: U.S. Prisons and Offenders with Mental Illness

17

OMHCNY 082070OMHCNY 082104 OMHCNY 086773-086795
OMHCNY 108180, OMHCNY 108196
No Bates
OMHCNY 108030OMHCNY 108067
No Bates Plaintiffs Exhibit 359
PL 062682 - 062769
OMHCNY 08 1790OMHCNY 081833 OMHCNY 108161OMHCNY 108179
. No Bates OMHCNY 108015OMHCNY 108025
OMHCNY 108068OMHCNY 108094 OMHCNY 108146 OMHCNY 108450OMHCNY 108452 OMHCNY 108453

Corrections Based Servicesflnpatient Operations Annual Report for 2003
Report on Outpatient Mental Health Services Provided by CNYPC in NYS Prisons in 2003
Report on Outpatient Mental Health Servirses Provided by CNYPC in , NYS Prisons in 2003
Mental Health Considerationsfor Segregated Inamtes by J. E/letzner, Appendix G to NCCHC 2003 Standards for Health Services in % Prisons
Selected Management Indicatorsfrom Three Subgroups of OMH Units and Two Individual OMH Units which Provide Mental Health
r Services to SHU Inmates in NYS CorrectionalFacilities: January
2003 &rough January 2005
A Death in the Box, NY Times Magazine, 10131/04
Correctional Association 2004 Report: "Mental Health in the House of Corrections"
CNYPC Patient Demographic and Diagnostic Profile (2004)
: Computed Selected Management Indicators for OMH Level 1 Menta Health Units in NYS Correctional Facilities: Yd,3rdand 4' Quarters
of 2004
Correctional Mental Health Report, MayIJune 2005
Draft - DOCSIOMH Mental Health S w i m Development 1977 -
' 2005/2006 Prepared by NYS Department of Correctional Services and the NYS Office of Mental Health
CNYPC System Overview
SHU and SHU200 NYS Prisons
SHU Mental Health Statistical Tables
Current Bed Capacities & Planned Expansion Data Spreadsheet

No Bates

8
Managing Special Populations in Prisons and Jails, Michele Deitch,
publication upcoming

No Bates

S. Martin Declaration in Lee v. Coughlin,93 Civ. 8417, SDNY

No Bates

Settlement Agreement in State of Connecticut Oflce of Protection and Advocacyfor Persons with Disabilities v. Choinski, 3:03CV 1352

State of the Prisons: Conditions of Confinement in 25 New York Correctional Facilities

No Bates OMHCNY 054353-054371 No Bates

Report Regarding Conditions and Mental Health Services at Supemax Correctional Institutions and Mental Health Correctional
institutions by Terry Kupers, MD,MSP.
Draft Quality Assurance Review of Suicides in New York State Correctional Facilities
Exclusion Criteriafor hmates Recommendedfor Ohio State Penitentiary, Bureau of Mental Health Services, Standard Operating Procedures No. 2 and Program Overview, Southern Ohio a Correctional Facility, Intensive Mental Health Treatment Uriit

Documents Related to Specific Mental Health Programs

BHU

No bates stamp

Great Meadow BHU Manual, December 16,2004

No bates stamp

Behavioral Health Unit Program Operations Description, 2005

No bates stamp

Sullivan BHU Manual, February 24,2005

OMHCNY 108239OMHCNY 108297

Email from David Barry to D. Sawyer re: BHU Presentation (Behavioral Health Unit Training Agenda For Great Meadow BHU Draft 4/3/05 attached)

ICP

No Bates Range
PL 055167- 055209
. OMHSS 0002775-0002781

Intermediate Care Procedures/ Guidelines-"The Marcy Plan"
512U98 SHU Manual; "The Marcy Plan" Marcy C.F. Letter from Roland Cote to Doris Rarnirez-Romero, re: Sing Sing .ICP Monthly Report

Plaintiffs Exhibit 9

5/21/02 Review of the Intekediate Care Program at CNYPC

OMHCNY 043262OMHCNY 043299

Plaintifl's Exhibit 27
OMHCNY 034219OMHCNY 034220

: 5/24/02 E-mail from Dan Abreu with attached notes from the special
meeting on SHU and ICP

Plaintiff's Exhibit 33

1/03 Intermediate Care Program Plan of Correction

OMHCNY 0057521OMHCNY 0057528

Plaintiffs Exhibit 1 1

4/17/03 Review of the Intermediate Care Participants in 9/1/02

OMHCNY 043072-

OMHCNY 043099

i

OMHCNY 108005OMHCNY 108014 OMHCNY 043040-043071
OMHSS 0002772-0002774
DCSCOF 0006044 -
DCSCOF 0006056

. Review of Intermediate Care Program (ICP) Participants in Program on 311105 Preliminary Report of Selected Variables
Memorandum from Sawyer and Culkin to Units Chiefs, ICP Clinical , Coordinators, DSP and ICP Senior Counselors re: Revised ICP - Manual
ICP Correction Meeting Minutes Sing Sing Correction Facility
STP
6112/00 Mental Health Services Plan for Special Housing Unit . Patients at Attica Correctional Facility

OMHCNY 043347 -
OMHCNY 043376

2/3/01 draft: Mental Health Services Plan for Special Housing Unit : Patients at Attica Correctional Facility
DrafS Mental Health Services Plan for Special Housing Unit Patients at Attica Correctional Facility Submitted by the NYS Office of Mental Health and the NYS DOCS

OMHCNY 0013884 OMHCNY 0013938
OMHCNY 027803 -
OMHCNY 027837
PL 063079-PL 063084

514101 Policy and Procedure Manual for Attica Satellite Unit
4118/02 Mental Health Services Plan for Five Points SHU
Draft Summary of Prison Visiting Committee Tour of Attica (for 9117/02 & 9/19/02 tours)

OMHCNY 043 175 -
OMHCNY 043222

10/2/02 Attica Special Treatment Program Preliminary Report
-

1QMHCNY 043141-
OMHCNY 043 174
PL 052467-PL 052470
I
OMHCNY 028921 -
OMHCNY 028927

1 10111/02Five Points Special Treatment Program Preliminary Report
1 10/28/02Correctional Association of New York Letter to Five Points
Superintendent
12/30/02 CorrectionalAssociation of New York letter to Attica Superintendent

Plaintiffs Exhibit 5

I OMHCNY 042991.-
.OMHCNY 043034
Plaintiffs Exhibit 75
I' OMHCNY 042943 OMHCNY 042990 1OMHATT 0001054OMHATT 0001084

- t

OMHATT 0001085-

!'OMHATT 0001118

7121/03 SpecializedTreatment at Five Points Interim Report
I
7/23/03 Specialized Treatment Program at Attica - Interim Report
IhSpieccaiaCli.zFe.d-T1re2a/t2m0e/0n0t -Pr4o/6g1ra0m1
Specialized Treatment Program
Attica C.F. - 4/23/01 - 7/13/01

' OMHATTOOO1119OMHATT 0001155

ASptteicciaaCliz.Fe.d-T7re/2at3m/0e1n-t P1r0o1g1r9a/m01

OMHATT 0001156-
OMHATT'0001184

Specialized Treatment Program
Attica C.F. - 11/5/01- 2/5/02

. OMHATT 0001185 -
OMHATT 0001253

Specialized Treatment Program
A t t i a C.F. -2119/02 - 511O/O2

OMHATT 0001254-
OMHATT 0001325

t
Specialized Treatment Program
Attica C.F. - 5/28/02 - 8/26/02

1

DCSCOF 0006044-0006056 MH Services Plan for SHU Patients at Attica, 6/12/00
DCSCOF 0006057 - DCSCOF Special Treatment Program - Five Points C.F.

000606 1

OMHFPO 0000014-

Orientationto Five Points STP

OMHFPO 0000016
OMHFPO 0000022 -

STP Screening Form

OMHFPO 0000027 OMHCNY 027803-027837
I
I

- - I

Memorandum from Sawyer to Miraglia et al, Description 5 Points Correctional Facility

re:

STP

Program

Miscellaneous Memoranda and E-mail

No Bates
OMHCNY 0010405OMHCNY 0010449
PL 000653-PL 000654
PL 000655-PL 000656
Plaintiffs Exhibit 76 OMHCNY 041968OMHCNY 041981 Plaintiffs Exhibit 26 OMHCNY 034215OMHCNY 034218 Plaintiff's Exhibit 77 OMHCNY 043223OMHCNY 043261 Plaintiffs Exhibit 72 OMHCNY 043035OMHCNY 043039

Information on OMH and SHU Housing at Attica, Wade,and
Albion 7120199 Memorandum of Uriderstanding between the New York State Office of Mental Health and the New York Department of Correctional Services 9/1/99 Letter from CommissionerGoord to Commissioner Stone . regarding recent meeting on mental health service delivery system in the DOCS 2/23/00 Letter fiom Commissioner Goord to Commissioner Stone regarding mental health services to inmates
- 2/20/02 Mental Health Observation Cell &age in Mental Health
Satellite Units operated by CNYPC (7101 12R1 report)
5/22/02 Satellite Roundtable Meeting Minutes
9/26/02 Mental Health Crisis Observation Cell and Dormitory Bed . Usage in Mental Health Satellite Units Operated by CNYPC Finding
. 6/25/03 Memorandum from Donald Sawyer to CNYCP Unit Chiefs re: SHU Plan of Improvement

OMHCNY 0077640-0077641 8/1/01 E-mail from L. Farago to multiple people re: Diagnosis

PL 065779

8/21/02 Grievance from R.J.Woodward to Superintendent Bennett
' re: MHU Inmates in SHU

PL 065772 PL 065775

9/24/02 Grievance fiom R.J.Woodward to Superintendent Bennett a
Elmira re: OMH Inmates in SHU
,
. 10/9/02 Grievance from R.J. Woodward to Superintendent Bennett a Elmira
4

P L 065776

5/9/03 Grievance fiom R.J. Woodward to Whom It May Concern at Elmira re: SHU Conditions

PL 065778

5/9/03 Grievance fiom R.J. Woodward to Whom It May Concern at Elmira re: SHU Conditions

Plaintiffs Exhibit 492
OMHCNY 090522 -
OMHCNY 090567

7/15/03 E-mail fiom Arnsler-Nunziato to Ellermann & Way re: DMHIS Analysis of my Shu Sample

PL 065777

8/20/03 Grievance fiom RJ. Woodward to Superintendent West at Elmira re: M W S H U Issues

Plaintiffs Exhibit 399 OMHCNY 0080491
- PL 065773 065774

9/2/03 E-mail from Sawyer to Unit Chiefs re: Case Management Committees
12/5/03 Grievance from R.J. Woodward to SuperintendentWest at Elmira re: Special Housing Unit Issues

; PL 065771

1/23/04 Grievance from R. J. Woodward to SuperintendentWest at Elmira re: MHU vs. DOCS

OMHCNY 108454; OMHCNY 108457

4/15/05 Memorandum from Donald Sawyer to CNYPC Unit Chiefs : re: Special Housing Unit Plan of Improvement

OMHATT 0001338-1368, 1 OMHATT 0001374-1377,
OMHATT 0001403-1408, OMWATT 0001414-1443, OMHATT 0001468-1485, : OMHAIT 0001497-1509, OMHATI' 0001516-1532, OMHATT 0001558-1565, OMHATT 0001695-1699, OMHATT 0001725-1729, OMHCLI 00001960000197, a OMHCLI 0000305-0000306, OMHFPO 0001272-1277, OMHFPD 0001639-1640, OMHFPO 0001917-1919

' Select CMC Meeting Minutes for Attica, Five Points, and Clinton Correctional Facilities

No Bates " OMHCNY 036787-036801

MH Housing by Facility Table prepared by Legal Aid Society
Letter from Dr. Goyal, M.D.,Dir. Medical Services to Dr. Menon,
Clinical Director re: DOCS Medical ClearanceForm

orandun from Aileen Townsend, ACSW, DPA to Dr. Buscema

4

,,Investigation

OMHSS 0000088
OMHSS 0000092
OMHSS 0000123 OMHCNY 053434
OMHCNY 025976

1Meeting, 11/25/98
Letter from Jurgen Karker, to Unit Chiefs, Level 1 Facilities re:
Follow up of Patients discharged from RCTP to S W
E-mail from Bradigan to Devito, et al. re: Change in Mental Health Level Policy
1 Sing Sing Satellite Unit Goals and Objectives
5/4/00 Memorandum from DeVito to Donnelly re: Breakdown of No
Show/Callouts - Mental Health Month of April 2000
1/26/00 Letter from Smith to Miraglia re: CNYPC Overtime

OMHCNY 047045

Memorandum from Buscema to Physicians et al. re: PCM's on
i Patients Discharged from CNYPC & Returning to a SHU
: Environment

OMHCNY 044770-

CNYPC Incident Reporting Policy and Procedure Manual re: Filing : of Criminal Charges Against a Patient

OMHCNY 0010405-0010449

Memorandum of Understanding Between the New York State Office ' of Mental Health and the New York State Department of Correctional

Services

- OMHBH 0003636-0003643 Bedford Hills Evaluation, Bedford Hills Satellite Unit Evaluation of

Operating Systems
OMHGM 0000158-0000160 1 Great Meadow Satellite Unit Principal DSM IV Diagnoses

DCSCOF 0005732-0005733 ' Justification for the Need for Additional Nurses at Level 2 Facilities
OMHCNY 053410-053419 : CNYPC Performance Improvement

\ Proposal, Callout Compliance Rate
DCSCOF 005734-0005735 Memorandum to M.Prisco from C. Frater re: OMH inmates on

Psychiatric medications
1 OMHCNY 026023-026024 7/20/00 Letter from R. Miraglia to A. Holmes R E Forensic Overtime

OMHCNY 047164-0471 72 * 8/00 IRC Meetings

OMHCNY 056580-056584 Performance - Imp-rovement Forum Meeting 8116/00

OMHCNY 053389-053391 ' CNYPC Outpatient ~erforrkance~rn~rovemePnrtojects (2000),

>
OMHCNY 056826-056836 OMHCNY 047116-0471 18 OMHCNY 056568-05657 1

;
CNYPC Outpatient Performance Improvement Cover Sheet ; Incident Review Committee Meeting 11115/00
Performance Improvement Committee Meeting 11/16/00

OMHSS 0002733-0002740 OMHCNY 053303-053309 OMHCNY 053443-053447
OMHGM 0000013-0000015 OMHBH 0000165 OMHCNY 030773-030839 OMHBH 0000159-0000164 OMHBH 0000158 OMHCNY 056868-056884 OMHCNY 056860-056867 OMHCNY 056885-0569191; OMHGM 0000130-0000131 OMHCNY 056535-056538 '- OMHCNY 047703-047706 ,' OMHCNY 056820-056825 : OMHGM 0000149 OMHCNY 047720-047729 OMHCNY 043334-043339 " OMHCNY 045180-045185;
oMHCNY 043340-043346 OMHCNY 047681-047683 oMHCNY 04775 1-047760
OMHGM 0000016 OMHCNY 090350

12/5/00 Memorandum from Bord to Adams re: JCAHO Mock Survey

CNYPC Outpatient Performance Improvement Projects (2000)

(Updated 12111/00)

12/13/00 Memorandum from Lauve to Performance Improvement
' Committee Members re: Performance Improvement corkittee I Meeting Minutes 11/16/00

Performance Improvement Forum Committee Meeting

Incident Review Committee Meeting 12/13/00

, 12/21/90Memorandum from Boyd to Perilli re: SHU Training

Feedback

Memorandum from Greasley to Shimkunas re: Justification for Sixth

---

Letter from Michelle A. Petrino Unit Chief OMH to Capt. Ballte and

Capt. Gladding re: SHURMH Training

CNYPC Environment of Care Performance Program Report

Monthly/Quarterly/Annual Report
SHU Rounds Schedule - 2001

Memorandum from Sheryl L. Salaris to Michelle Petrino re: Langley

Stipulation

CNYPC Performance Improvement Proposal Coversheet:

: Improvement of Patient Escort Rates

' CNYPC Performance Improvement Proposal Coversheet: Reducing Redivison of Patient Transfers to RCTP
CNYPC Performance Improvement Proposal - Callout Compliance

' Rate; 5/7/01 Memorandum from Shirnkunasto Dimcan re: Continuation of Restricted Diet in Observation Cells

- ,Performance Improvement Forum Committee Meeting

' Psychological Autopsy of

A 5,

CNYPC Performance Improvement Proposal Coversheet: RCTP

Release to Departure Study

E-mail from Shimkunas to Don (Sawyer) re: OMH Levels in SHU

. . Memorandum from Herrmann to Smith,. Farago, Sawyer, &
Buscema, re: Psychological Autopsy Report - Patient C1 L

Clinton Satellite and Catchment Evaluation of Operating Systems

Memorandum fiom Spnggs to Hernnann re: Shane Maxwell,

attaching Root Cause Analysis & Action Plan in Response to Sentinel

Event

Memorandum from Sawyer to Smith re: Clinton Satellite Unit Visit

Reports and Recommendations

Morbidity/Mortality Review Committee Meeting Minutes

Documents re: death of H q Figueroa, including Incident Review

Committee Meeting Minutes, e-mails, and Report of Special

Investigation

E-mail from Shimkunasto Smith re: OperationalProblems

Re SHU

OMHGM 0000154 OMHCNY 034140-034153
OMHSS 0002758-0002761
OMHGM 0000152-0000153
OMHCNY 056471-056477 OMHCNY 034215-034218 OMHSS 0002756-0002757 OMHCNY 047742-047744
OMHSS 0002754-0002755
OMHCNY 047730-0047733 OMHGM 0000148
OMHSS 0002763-0002771
OMHCNY 056451-056460 OMHCNY 043223-043261
OMHGM 0000146 OMHSS 0000142-0000143 OMHCNY 053494-053497
OMHSS 0000101
OMHSS 0002762 OMHCNY 056428-056439 OMHCNY 028921-028927
OMHCNY 028928-028931
OMHCNY 043100-043116
OMHCNY 043037- 043039
OMHCNY 015730-015732 ' OMHGM 0000150-0000151 OMHMS 0000204 ' DGSCOF 0006279-0006280 OMHCNY 056679-056703

E-mail from A1 Shimkunas to Donald Sawyer re: SHU Follow-up

Memorandum from Herrmann to Miraglia, re: CNYPC Quarterly

Incident Statistic Report

Message from Superintendent, Sing Sing Correctional Facility to

David Boyd re: SHU Committee

E-mail from Shimkunas to Sawyer et al. re: Great Meadow

. Observation Overflow Reduction

Performance Improvement Forum Committee Meeting Minutes

Satellite Roundtable Meeting
1 E-mail from Culkin to Boyd re: Reply to Sing Sing SHU

. Letter from H e m a n n to Farago re: Incident Investigation

Fe 5 Recommendation(s) re: death of

6,

E-mail from Spriggs to CN Unit Chiefs k SHU Private Interview

Letter, Monitoring Form and Progress Note

. MorbiditylMortalityReview Committee Meeting

Memorandum from Shirnkunas, to DMH Clinicianson SHU Rounds

re: 24 Hour Screenings

Special Housing Unit Multi-Agency Review Committee on Inmates

with Active Mental Health Cases

Performance Improvement Forum Committee Meeting

Mental Health Crisis Observation Cell and Dormitory Bed Usage in
the Mental Health Satellite Units Operated by CNYPC July 2001 -

June 2002 Draft

E-mail from Shimkunas to Privett re: SHU ContactslOperations

' E-mail from Mahoney to ICP Coordinators re: DOCS ICP Budgets : CNYPC Outpatient Performance Improvement Projects (2002),

(Updated 10/25/02)

: Email from Leclaire to Wilhem et al. re: OBS Cell Discharge Procedure

E-mail from Key to Fischer and Kikendall re: 1118 Meeting

Performance Improvement Forum Cornittee Meeting Minutes

Letter from Peter Swords & Jennifer Wynn to James Conway re:

Summary Observations from the Prison Visiting Committee

CNYPC Mental Health Services in Special Housing Units Initial P4at

of lmprovement

Transfers to Civil Psychiatric Inpatient Services from a Maximum
Security Forensic Hospital - Draft

Documentation requirements (Management Indicators, Functional

Assessment, Record Reviewnreatment Plan Modification, Case

Management Committee, PrivateIC~~dentiSaelssions)

CNYPC Capital Budget Request Justification

SHU Confidential Interview Survey - Great Meadow

Inmate Characteristics

Inmate Disciplinary Issues

CNYPC Quality Cube and Performance Improvement Projects

OMHCNY 047765-047769 Special Housing Unit (SHU) Admissions 1999

1 OMHELM 0000368-0000376 Overview of Mental Health: DisordersFrequently Found in DOCS Inmates. Case Review of 282 Inmates

Videotapes

1

Anderson training video: "Considerationof Mental Impairments in the Inmate Disciplinary Program" ,

10/26/99 13b.\S. (93496135): Cell Extraction and Strip Frisk

3/5/00 ' F . 2- '98A5780): Interview with OMH

7/25/94 K.K . - (93A3824): Removal to Hospital

5/21/03 v-@-

(956 1036): Observation

11/10/4 V * a s

<1)1A1808): Removal to Observation

5115/01 ' bl. c.\. (98A0441): Disciplinary Hearing(audiotape)

r-

Case Filings and Exhibits

No Bates
1 No Bates

DAI v. OMH Complaint filed 5/28/02
1 Document Requests:

Plaintiffs First Request filed 9/6/02 Plaintiffs Second Request filed 4/1/03 Plaintiffs Third Request filed 5/1/03 ' Plaintiffs Fourth Request filed 6111/03 Plaintiffs Fifth Request filed 7118/03 Plaintiffs Sixth Request filed 8/20/03 Plaintiffs Seventh Request filed 9/26/03 Plaintiffs Eighth Request filed 11110103 Plaintiffs Ninth Request filed 11/21103

No Bates

1/13/04 Testimony Before the Assembly Standing Committee on Correction and Assembly Standing Comrnitke on Mental Health, Mental Retardation and Developmental Disabilities in re: Disciplinary Confinement and Treatment of Prison Inmates With Serious Mental Illness

No Bates
INo Bates

Case Management Order dated 6/23/04
I New York Penal Law, 5240.32

DISCIPLINARY DISPOSITIONS FROM DOCS INSTITUTIONALFILEREVIEWSOF 25 INMATES

Percentage of inmates receiving over 6 montbs of SHU time: Percentage of inmates receiving over 1 year of SHU time: Percentage of inmates receiving over 3 years of SHU time: Percentage of inmates receiving over 5 years of SHU time: Percentage of inmates receiving over 10years of SHU time:

92% (23125) 84% (2 3125) 72% (18125) 48% (llU25) 24% (6125)

Total SHU Time Accumulated: Total Keeplock Time Accumulated: Total Recommended Loss of Good Time:

59,259 days 21,563 days 39,715 days

Average SHU Time Accumulated per Inmate:

2,370.36 .days

Average Keeplock Time Accumulated per Inmate:

862.52 days

Average Recommended Loss of Good Time per Inmate: 1588.6 days

Page 1

Page 2

JA 1018

Page 3

Page 4

Page 5

JA 1021

Page 6

JA 1022

Page 7

JA 1023

Inmate Name

Keeplock

SHU Time per SHU Time Keeplock Time Time

Loss of Rec. Loss of

Date of

incident

TOTAL per incident TOTAL ~ a ondme per GOO^ Time

Incident 311311999
41911999 812011999 121311999

(days) 0 0
365 300

(days)

(days)

(days)

30

30

0'

0

incident (days) TOTAL (days)
01 0, 18 4
0"

6/28/2000

0

30

0

2 l l 012001 511412001 911 112001, 12/28/2001 5/29/2002

300 90 180
180 .
180

0,

90,

0

01

0,

01

0

0

0

d

Page 8

Page 9

Page 10

Inmate Name

Keeplock

SHU Time per SHU Time Keeplock Time Time

Rec. Loss of Rec.Loss of

Date of

incident

TOTAL per incident TOTAL G& rtme par ~ o a Tdime

Incident

(days)

(days)

(days)

(days) incident (days) TOTAL (days)

3/4/1999

90

0

0

311 711 999 4/16/1999 5/30/1999 713011 999 8/16/1999 11/27/1999 1 1128/1999 12/10/1999 111 9/20001

90 60 30 220 180 0
0, 30 270

0

1

0,

0

1

0,

0

01

Oj

la)/

01

90

141

0

301

0

01

30

120

- -
' UdO*

911 712002 911 812002 9/5/2003 1 1/8/2003 1211 012003 1/25/2004
412911 997 511 611997 5/19/1997 7/10/1997 7/13/1997 812711 997 911 211 997 91261 1997 9/30/1997 10/2/1997 10/20/1997 10/20/1997 1 1/26/1997 7/15/1999 9/28/1999 1011 811 999. 11/1/1999 3/4/2000 411 712000 5/8/2000 511 112000 511 512000

601

01

0'

I

01

30j

0

0

30j

0'

365

0

360

0 60
-7 7 3803

60

f

O]

0

6Oj

0 0 0 0 0 180 0 180 90~

30,

01

15

01

14

01

1 51

o!

1 51

0

01

180.

30j

0,

01

270"

C

0

90

--

0 .

0

20'

0

30

0

3(Y

0

71

0

3'

0,
-
01 OJ 01 0 0'

0

30

0

53

37'

0

0

30

0

0

39

O1

0

15

01

0

3C

0,

180

01

90,

Page 11

JA 1027

Page 12

Page 13

'Keeplock

Inmate Name

SHU Time per SHU Time Keeplock Time Time

Date of incident

TOTAL per incident TOTAL

Incident

(days)

(days)

(days)

(days)

211 21 996

0

30

Rec- Loss of .

Loss of

G- ~i, p r ~ o o rdime

incident (days) TOTAL (days)

0

2/17/1996

0

10

0

31611 996

0

60

0

31711 996

0

40

0

3/81?996

180

0

90

311 511 996

60'

0

0

311 611 996

60

0

30

312011 996

0.

301

0

4/71?996

90

301

180

8121I1 996'

30

I

01

O]

1 1/30/1996

0

1

151

O]

11611 997

30

0'

0

91511997

0

15

0

9/18/1997

0

15

0

3/3111998

0

30

0

612611998

0

812711 998

0

,

1 112711998

0

-

p p

119/2000

0

1/11/2000

0

15'

0~

11

0

20

0.

14

0,

3.

4

0

4/23/2000

0

7

0

'

51212000 7/24/2000

0 01

10/612000

@

la1 812000

30,

7/28/2001

0

21

0

1 5'

0,

30

0

0.

0

70

0

1 1 16M001,

0

91412002~

0'

1018/2002

0

-1012912002 1 013 112002

0 0

1Rl2003

0

11912003

0

30,

0

31

0.

601

0

601

0

91

0'

7,

0

28

0

31612003.

90,

4/25/2003

90

14

Oj

30.

0

4/25/2003

180

0

0

5/21I2003

90

9/25/2003

90

0

0,

30

0

1012312003

0

15

0

-- 12/4/2003

0

t

20~

0

11a2004‘

0-06-

41912004

0

4/30/2004

0

511 012004

0

1 5/26/2004

180

1 512712004.

120

"L 5,

811012002~

90,
0

30,

01

60

0~

30,

Os

0

180

0

120

341'

0

30'

0

1271 612002]

0

30

0

112312003~

0

1

30,

0

3/6/2003
1 311712003

0 0

I

301 15)

0 0

Page 14

Page 15

Page 16

Page 17

Page 18

Percentage of inmates receiving over 6 months of SHU time: 92% (23l25) Percentage of inmates receiving over 1 year of SHU time: 84% (21n5) Percentage of inmates receivingover 3 yean of SHU time: 72% (18/25) Percentage of inmates receiving over 5 years of SHU time: 48% (lU25) Percentage of inmates receivingover 10 years of SHU time: 24% (6125)
Page 19

 </s> UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YOW
DISABILITY ADVOCATES, INC.

- against -
NEW YORK STATE OFFICE OF MENTAL HEALTH ("OMH"), et al.,
Defendants.

02 Civ. 4002 (GEL)
:

Report of Plaintiffs Expert Dr. Terry Kupers, MD, MSP
June 1,2005
Confidential

TABLE OF CONTENTS

Executive Summary

PAGE

I. Qualifications and Experience............................................................................... 5

II. QuestionsPosed ...................................................................................................... 7

III- Preparation .............................................................................................................. 8

A. Prison Tours and Interviews ............................................................... 8

B. Review of Documents.......................................................................... 9

IV. The Path to Isolated Confinementfor Prisoners with Mental Illness ...................10

A. A SignificantNumber of Prisoners with SeriousMental Illness are in Isolated Confinement................................................................ 10

B. Institutional Dynamics and Rules Place Prisoners with Serious Mental Illness at Risk.......................................................................... 16

C. Prisoners with Serious Mental Illness Also Have Difficulty with Unwritten Rules...................................................................... 18

D. Harmful Policies and PracticesLead to Prisoners with Serious
Mental Illness Being Placed in Isolated Confinement........................ 20

1. Prisoners with seriousmental illness escape detection because of inadequate mental health assessment.................... 23

2. Inadequaciesof Mental Health Treatment.............................. 29
3. Inadequacy of CNYPC Space and Criteria for
Admission ............................................................................ 29

4. Observation Cells are Another Fonn of Isolated Confinement............................................................................ 30

5. Insufficient ICP Beds ........................................................... 30

6. The Unavailability of Vocational. Educational and Other Rehabilitation Programs. as well as Substance
Abuse Treatment Programs.....................................................30

7. Prisoners Who Exhibit Serious Mental Illness as well as Serious Discipline Problems are Excluded from IGP and other Treatment Programs; and are subject to longer periods of isolated confinement and even more time in
prison................................................................................ 3 1
8. The DisciplinaryProcess Fails to Give Sufficient Consideration to Mental Health Issues ................................... 33
E. Prisoners with SeriousMental Illness Acquire Ever Longer SHU terms........................................................................................... 37
F. Prisoners with SeriousMental Illness in Isolated Confinement
are Not Diagnosed or are Un-diagnosed............................................ 38
G. Prisoners with SeriousMental Illness Cycle Repeatedly From SHU to Observation or CNYPC and Then Back to SHU ................... 41
V . The Effect of Isolated Confinement on Prisoners with SeriousMental Illness ....43
A. The Phenomenon .............................................................................. 43 B. The Literature...................................................................................... 45
C. My Findings fiom Interviews and Chart Reviews of Prisoners
in Isolated Confinement in New York ................................................ 47
D. Deterioration in Isolated Confinementis not limited to Prisoners with Psychosis and Severe Mood Disorders ....................... 51
E. The DisproportionateNumber of Suicidesin Isolated
Confmement Demonstrates the Risks of Placing Prisoners with
Serious Mental illness in Isolated Confinement ........................... ..... 52
W. The Mental Health TreatmentPrograms in DOCS Facilities ............................... 64
A. Mental Health Care in General ........................................................... 64 B. Inpatient PsychiatricUnit at CNYPC ........................................... 66
C. Lack of Adequate Crisis InterventionISuicide Prevention in Satellite Mental Health Programs ..................................................... 71
1. The ObservationCells.............................................................71 2. Clinical Principles that should applyto Observation..............72
3. Underutilizationof Dormitories...................................... 8 1

4. Lengthy Stays in Observation. Failure to Admit to
CNYPC ................................................................................... 81 D. Intermediate Care Programs (ICP)...................................................... 84 E. Outpatient............................................................................................ 86 F. SpecializedTreatment Programs (STP) ............................................. 90
G. SubstanceAbuse Treatment Programs ...............................................98 H. SpecialNeeds Units (SNUs) and Other Programs............................ 100 I. General TreatmentIssues.................................................................. 102
1. Confidentiality...................................................................... 102 2. The Diagnostic Process and the Process of Un-
Diagnosis............................................................................... 105 3. Behavior ManagementPlans and the Proposed
Behavioral Health Units........................................................ 130 4. PrescribingPractices and Record-Keeping........................... 139 5. Medication Over Objection................................................. 143
6. Staff Training and Collaborationbetween Mental
Health and Security Staff.................................................. 145
7. Use of Force on Prisoners with SeriousMental Illness ........147 8. Post-Release Planning........................................................... 149
VII. How New York's Prisons Compare with National Trends................................. 150
VIfI. The Problems are Longstanding and Well-Known by Defendants.....................153
IX. Recommendations.............. ........,. ................................................................... 157

Executive Summary
The most striking feature of mental health services in the NY prisons I toured is the large number of prisoners suffering Eom serious and persistent mental illness (henceforth referred to as "serious mental illness" or "SMI") who are housed in some form of isolated confinement, where they are kept isolated from other prisoners, have minimal contact with staff, spend nearly 24 hours per day in their cells, participate in very few if any programs, eat alone in their cells and are mostly idle.
It has been known for as long as segregated housing has been practiced in prison that human beings suffer a great deal of pain and mental deterioration when they remain in isolated confinement for significantlengths of time.
As I will explain below, it is my strong professional opinion that prisoners with SMI should not be housed in isolated confinement (SHU, Keeplock, Administrative Segregationor Protective Custody when it involves lockdown),' and that the isolation and idleness of observation should be amelioratedbecause:
P isolated confinement tends to worsen the prisoner's mental illness and prognosis;
P prisoners' mental impairments prevent them Eom remaining fkee of disciplinaryinfractions long enough for them to gain release from isolation; and
P prisoners with serious mental illness need more intensive mental health treatment and programming than is available in isolated confinement settings.
For prisonerswith serious mental illness, the consequences for unacceptable behaviors must be determined in the context of mental health assessment, diagnosis, and treatment. This requires a high level of collaboration between security staff and mental health staff. For example, when a prisoner breaks a rule or gets into an altercation in response to command hallucinations, he likely needs a more thorough psychiatric evaluation and more intensive mental health treatment, rather than a longer sentence to isolation and idleness.
I have found that the following policies and practices result in the imposition of isolated confinement, often with excessively long terms, for many prisoners suffering from SMI:
> prisoners with SMI escape detection because of inadequatemental health
assessment;
P inadequacies in the mental health treatment program increase the likelihood that prisoners suffering fiom SMI will be punished with isolated confinement;
' My recommendationsas to SHU,Keeplock,PC and other forms of isolated confinement are set forth in
Sect. IX,Recommendations.

P a shortage of beds at CNYPC, and restrictive admission criteria, preclude admission of many prisoners in need of psychiatric hospitalization;
P observation cells, as currently operated, are equivalent to isolated confinement, and do not provide adequate assessment and treatment;
9 there are insufficient Intermediate Care Program (ICP) beds for the population in need;
P there is a lack of vocational, educational, and other rehabilitation programs, as well as substance abuse treatment programs, especially for prisoners in isolated confinement;
P prisoners with SMI as well as serious disciplineproblems are ejected, or excluded from treatment programs;
> the disciplinary process fails to take mental health issues into sufficient
consideration;
9 inadequaciesin mental health treatment programs at medium security facilities mean that prisoners with SMI will be sent to maximum security facilities for needed treatment, where they are subject to harsher conditions (and disciplinary sanctions);
> prisoners with SMI, often because of their psychiatric symptoms, acquire more
tickets in isolated confinement, and, as they cannot control their behavior well enough to receive time cuts, they accumulate ever longer terms in isolated confinement;
9 because staff often decide prisoners are "bad" and not "mad," many prisoners with SMI in SHU are not diagnosed or are un-diagnosed; and
P a vicious cycle ensues wherein prisoners with SMI cycle repeatedly fiom isolated confinement to observation or CNYPC, and then back to isolated confinement, accumulating more tickets in the process.
My interviews with prisoners in NY DOCS entirely confirm this general
understanding of what happens to prisoners prone to mental illness in isolated confinement. In prisoners with a history of or vulnerabilityto psychiatricbreakdown, irrational thoughts and primitive, disorganized behaviors often emerge. Internal impulses linked with anger, fear and hopelessness grow to overwhelming proportions. Many, if not all of the prisoners discussed in this report, demonstrate these reactions. The suffering and decompensation (psychiatric breakdown) experienced in isolated confinement is common among, but not limited to, prisoners with Schizophrenia, Major Depression or Bipolar Disorder.

Suicide is a huge problem in isolated confkement - and despair, depression, and thoughts and plans of suicide are widespread among prisoners in NY DOCS SEW'S.
OMH statistics for 1998 through 2000 (Report of June 4,2002) reflect that in 1998 there were 14 suicides statewide; five occurred in SHU and one in Keeplock. In the same time period 3% of prisoners were housed in SHU and 5% in Keeplock. Thus, 36% of all the successful suicides in the entire department occurred among the 3% of prisoners confined in SHU.
The s%hjectivesense many p i c ~ n c rshared with me is a lnss nf all hope of ever leaving SHU. This kind of hopelessness adds to the despair and depression and drives many prisoners with SMI in SHU to contemplate self-destruction, and then to act on their suicidal ideas. When prisoners sense that staff do not take their pain and despair seriously, but rather view them as "malingerers" or "problem prisoners" whose only a mental illness is AntisocialPersonalityDisorder, they experience even more despair.
In terms of suicide prevention, crisis intervention and the use of observation cells, NY DOCS' very punitive approach to suicidal prisoners is much more harsh than the ' evolving standards in the field require (Hayes, NCCHC).
There are well established clinical guidelines for the assessment and treatment of individuals who have attempted suicide or seem intent on taking their own life. Little or none of this occurs in the observation cells I inspected, in the accounts of observation I heard during my interviews, or in the charts I reviewed of both currentcases and successful suicides.
One finds among the cases of successfil suicides prisoners who were not diagnosed adequatelyor were "un-diagnosed" while incarcerated in DOCS, and then eventually proceeded to ]rill themselves. Residents of SHU are vastly overrepresented among successll suicides, as are individuals who have a very long sentenceto serve in SHU. Among successful suicides, there are individuals who were discontinued &om the OMIH caseload even though they continued to suffer fkom SMI. There are also individuals who accumulated a large number of tickets while confined in SHU, and many of those tickets may well have been driven by their mental illness. There are individuals who cycled [or "ping-ponged") between SHU and observation and CNYPC and back to SHU. Finally, there are individuals who had been in ICP and were discharged on account of unacceptable behaviors. In fact, a snapshot summary of the stories of
prisoners who successfully committed suicide in NY DOCS between 1995 and 2004
would look very much like a snapshot of the 183 prisoners I interviewed and describe in this report.
The fact that the OMH program has received accreditation by the Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO) does not eliminatenor ameliorate the presence of very serious problems in the mental health can: delivery system. The JCAHO process, by its nature, fails to take into account many of the problem at issue in this litigation.

CNYPC is accredited by JCAHO, and is a quality psychiatric hospital. Still, there are problems with inpatient psychiatric service programs at CNYPC. The admission criteria for CNYPC are too stringent in that it serves as the only psychiatric inpatient facility for DOCS. Another problem is the severe shortageof beds at OWPC.
There are also too few aftercare options for patients being discharged from CNYPC. The
most obvious reflection of this problem in NY DOCS is that prisoners who need intensive services remain in observation cells too long in the Satellite Mental Health Units or are returned to isolated confinement cells instead of being sent to CNYPC. I discovered many prisoners in observation who warrant immediate admission to an inpatient psychiatric unit, but languish in observation. In observationcells located in the prisons, treatment is entirely inadequate for the severity of the prisoners' psychiatric condition.
The conditions of confinement are harsh and punitive - in contrast to the much more
humane and therapeutic conditions at CNYPC.
In this report I outline many other deficiencies I discovered in the mental health treatment program in DOCS, including deficiencies in the screening and diagnostic process, a lack of adequate confidentiality,inadequate record-keeping {clinicalcharts), inadequate prescribing practices, too little non-medication treatment intervention with prisoners suffering fiom SMI, inadequate substance abuse programming for prisoners suffering fi-om Dual Diagnosis (co-occurring mental illness and substance abuse), damaging use of force with prisoners suffering fi-om SMI, and inadequate post-release planning.
According to the Corrections Yearbook 2001, between 1994 and 2001, the average percentage of prisoners in segregation and protective custody nationwide increased from 4.5% to 6.5%.2 According to a Human Rights Watch report, New York's reported 7.8% of prisoners in segregation (SKU and Keeplock) is well above the average for the 36 states reporting on the number of prisoners in segregation.3
Litigation has led to the exclusion of prisoners with serious mental illness from longtenn isolated confinement in California, Wisconsin, Texas, Connecticut, New Mexico and Ohio. Illinois DOC, by policy, excludes prisoners with SMI from the isolated confinement unit, Tamms. Even states that do not exclude prisoners with SMI &om isolated confinement report, on average, that approximately 12%of the prisoners in
isolated confinement suffer &om SMI. NY DOCS and OMH report that the proportion
of prisoners in SHU and Keeplock suffering from SMi is far abovethat national average, with as many as 64% of prisoners in SHU on the OMH caseload.
2 Camp, C.G., & Camp, G.N.,CorrectionsYearbook 2001:Adult Systems, Connecticut,CnhuhalJustice
Institute, 2002, p. 38.
Human Rights Watch, Illl-Equipped: U.S.Prisons and menders with Mental I l ~ sN,ew York: Human
Rights Watch, 2003.

I. Qualifications and Experience
My name is Teny A. Kupers, M.D., M.S.P. (See curriculum vitae, including forensic cases of past four years, Appendix A). I am Institute Professor in the Graduate School of Psychology of the Wright Institute in Berkeley and maintain a clinical practice in Oakland, California. I am a Diplomate of the American Board of Psychiatry & lu'eurology(Psychiatry, 1974, ful lifkj. I liii~eserv~eczls Fiesidcnt t f the East Eay
Psychiatric Association (local branch of the American Psychiatric Association); I am a Distinguished Fellow of the American Psychiatric Association; I served for several years
as Co-Chair of the Committee on the Persons with Mental Illness Behind Bars of the American Association of CommunityPsychiatrists; I am a Fellow of the American Psychiatric Association and I am a member of the American Academy of Psychiatry and Law. I am on the staff of the Alta Bates Medical Center in Berkeley, and serve as consultant to several public mental health agencies. I recently served for two years as consultant to Connections, a collaboration between the San Francisco Sheriffs
Department, Jail Psychiatric Services,the SanFrancisco Court's Jail DiversionProgram
and several community health agencies.
I received a B.A. in Psychology &omStanford University in 1964, with Distinction; an M.D. from UCLA School of Medicine in 1968 where I was elected to Alpha Omega Alpha Honor Society; I have been licensed to practice medicine in the State of California since 1968; I completed Internship at Kings County Hospital/ Downstate Medical Center in Brooklyn in 1969; I completed residency training in Psychiatry at
UCLA NeuropsychiatricInstitute (NPI), with a year elective at Tavistock Institute in London, in 1972; I did a fellowshipin Social and CommunityPsychiatry (including Forensic Psychiatry) at UCTA NPI fkom 1972 to 1974; and I received a Masters Degree
in Social Psychiatry (M.S.P.) from UCLA at the conclusion of that fellowship. Between 1974 and 1977, I was Assistant Professor in the Department of Psychiatry and CoDirector of the Psychiatry Residency Training Program. of the Charles Drew Postgraduate Medical School in Los Angeles, and I was a staffpsychiatrist and Co-Director of the Outpatient Clinic at Martin Luther King, Jr. Hospital. From 1977 to 1981, I was staff psychiatrist and Co-Director of the Partial Hospital Program at the Richmond (California) Community Mental Health Center (Contra Costa County Mental Health Services). I have conducted a private practice of psychiatry since 1974, and have been on the faculty of the Wright Institute since 1981. I received a 2005 Exemplary Psychiatrist Award fkom the National Alliance for the Mentally Ill at the annualmeeting of the American Psychiatric Association on May 23,2005.
I have written four books: Prison Madness: The Mental Health Crisis Behind Bars and What We Must Do About It (Jossey-BasslWiley, 1999);Ending Therapy: The mean in^ of Termination (New York UniversityPress, 1988);RevisioningMen's Lives: Gender. Intimacy and Power (Guilford Press, 1993); and Public Therauy: The Practice of

Psychotherapy in the Public Mental Health Clinic (Free Press, 1981). I am a co-editor of and contributor to Prison Masculinities (Temple University Press, 2001). I have written over two dozen articles, including "Malingering in Correctional Settings," (Correctional Mental Health Report, 5,6,81-, MarcidApril, 2004), 'Toxic Masculinity as a Barrier to Mental Health Treatment in Prison" (Journal of Clinical Psvcholonv, Vol. 61,6,2005), "The Mental Health Crisis Behind Bars," (Harvard Mental Health Letter, July, 2000), 'The SHU Syndrome and CommunityMental Health" (The Cornunity Psychiatrist, S m e r , 1998), "Trauma and Its Sequelae in Male Prisoners" [American Journal of Orthopsychiatry, 66,2,1996, pp. 189-196), Jail and Prison Rape, (TIE-Lines, February, 1995), and "Contact Between the Bars: A Rationale for Consultation in Prisons" @Jrban Health, Vol. 5, No. 1, February, 1976). Among book chapters I have written are "Psychotherapy with Men in Prison" (in A New Handbook of Counselinn & PsychotherapvApproaches for Men, eds. GaryBrooks and Glenn Good, JosseyBassIWiley, 2001), "Posttraumatic Stress Disorder (PTSD) in Prisoners," (in Manazing Special Populations in Jails and Prisons, ed. Stan Stojkovic, Civic Research Institute, Kingston, NJ, 2005), "Schizophrenia, its Treatment and Prison Adjustment" (in Mana~nrrS,pecial Populations in Jails and Prisons, ed. Stan Stojkovic, Civic Research Institute, Kingston, NJ, 2005). I wrote a Foreword for David Jones (Editor), Working
with Dangerous People: The Psvchotherapy of Violence (Oxon, UK:Radcliffe Medical
Press Ltd., 2004).
I am Contributing Editor of Correctional Mental Health Report, and I am on the Editorial Advisory Board of The Juvenile Correctional Mental Health Report and three other professional journals. I was invited to give a keynote address at the International Association of Forensic Psychotherapists in Dublin, Ireland on May 20,2005; and I have been invited to give a lecture at the 2005 Institute on Psychiatric Services of the American Psychiatric Association in San Diego, October 7,2005, on 'Prisoners with Mental Illness: Their Plight, Treatment, and Prognosis."
I have testified in over twenty criminal and civil proceedings, including state and federal courts, regardingjail and prison conditions, their effects on prisoners, and the quality of mental health services (see Appendix A and Appendix B for case citations). Cases concerningjails include Rutherford v. Pitchess (1977); Hudler v. Duffie (1979); and Branson v. Winter (1981). Cases concerning prisons include Toussaint. Wright1 Thompson v. Enomoto, 1983 (regarding conditions of confinement and effects of doublecelling in the SecurityHousing Units of the California Department of Corrections); Gates v. Deukmeiian, 1989 (regarding the availability and quality of mental health services at the California Medical Facility in Vacaville); Coleman v. Wilson, 1993 (about conditions of confinement and the quality of mental health treatment for prisoners with mental illness in the California Department of Corrections); Cain v. Michigan Dept. of Corrections, 1998 (about conditions of confinement and their effect on mental health); Bazetta v. McGinnis, 2000 (about the effect of visitation and its restriction on Michigan prisoners); Jones 'El v. Gerald Ber~e2,001 and 2002 (about the effects of isolated confinement on prisoners suffering fiom serious mental illness); and Willie Russell v.

Mississippi De~artmenot f Corrections, 2003 (about the conditions of confinement on Death Row at Parchman and the treatment of prisoners with serious mental illness).
I have served as a consultant regarding prison conditions and the quality of correctional mental health care to the U.S. Dept. of Justice, Civil Rights Division, and to Human Rights Watch and Amnesty International. I consulted to Hurnan Rights Watch during their investigationsand compilation of the report, Cold Storage: Super-Maximum Security Confinement In Indiana (1997). In 2002 I was asked by the Ohio Attorney General to serve as mental health monitor for the Austin et al. v. Wilkinson et al. litigation involving the exclusion of prisoners with serious mental illness from the isolated confinementunit at Ohio State Penitentiary, but I declined because of time constraints. I have participated in successfit1settlement negotiationsin New Mexico (Avers, et al. v. Perrv, et al., No. CIV 02-1438 BBNVWD, 2003) and Connecticut (Office of Protection and Advocacy v. Choinski, et al., NO. CIV 3:03CV1352 RNC,2004), both cases involving the removal of prisoners with serious mental illness from isolated confinement and the improvement of correctional mental health services. I have conducted trainings for correctional and mental health staff in departments of corrections, includingNY DOCS and OMH ('The Role of Trauma in the Lives of Incarcerated Men and Women," Central New York Psychiatric Center, August, 1999).
I have been retained by Plaintiff and its counsel, and my rate of compensationis $150/hour for all work except Deposition and Testimony at Trial; for Deposition and Testimony at trial, my rate is $3OO/hour.
11. Questions Posed
I have been asked by counsel to consider five.questions as I prepare this report, subject to my o& emendations or revisions and any additional questions that may arise. The five questions are as follows:
Why are there so many prisoners suffering &om serious mental illness (SM)in SHU and other locations of isolated confinementwithin the NY DOCS? (See Section W.)
What are the effects of isolated confinement on prisoners suffering &om S W ? (See Section V.)
Is the mental health treatment provided to prisoners with serious mental illness throughout the system adequate, and if not, do the deficiencies place large numbers of prisoners with serious mental illness at risk of psychiatric harm? (See Section VI.)
How do New York's prisons compare with national trends? (See Section VIT.)
What recommendations can I make to improve the situation? (See Section IX.)

111. Preparation
A. Prison Tours and Interviews
I inspected 13prisons and interviewed 183prisoners as follows:
Elmira Correctional Facility on 3111/03 and interviewswith 9 prisoners;
Southport Correctional Facility on 3/12/03 and interviews with 6 prisoners;
Five Points Correctional Facility on 3/13/03 and interviews with 8 prisoners;
r Sullivan Correctional Facility on 5/5/03 and interviews with 10 prisoners;
* Bedford Hills CorrectionalFacility on 5/6/03 and interviewswith 11prisoners;
Clinton Correctional Facility on 7115 and 7116/03 and interviews with 21 prisoners;
Upstate Correctional Facility on 7117 and 7118/03 and interviewswith 19 prisoners;
Sing Sing CorrectionalFacility on 517 and 5/8/03 ind interviewswith 21 prisoners;
r Great Meadow Correctional Facility on 8126 and 8127103 and interviews with 25 prisoners;
r Wende Correctional Facility on 9/22/03 and 9/25/03 and interviewswith 19prisoners;
Attica Correctional Facility on 9/23/03 and interviews with 7 prisoners;
r Albion Correctional Facility on 9/24/03 and interviews with 9 prisoners; and
r Auburn Correctional Facility on 10129 and 10130103and interviews with 18prisoners.
Nearly all the 183prisoners I interviewed were on the OMH caseload.
At each facility, I inspected as many housing units as time would permit. I was able to observe the various types of housing units (cellblocks, cells, dormitories, drug treatment programs, libraries, recreation facilities, eating halls, vocational programs, and others), and I inspected the areas where prisoners with mental illness are housed, programmed and treated. I also inspected general population housing and program areas. In particular, at each facility (with the exception of Upstate and Southport) I inspected the OMH SatelliteMental Health Units (hereinafterreferred to as "Satellite Units"), where mental health treatment services, observation cells, and dormitories are located; at Upstate and Southport (which do not have Satellite Units), I inspected the Mental Health Unit, including the areas utilized for mental health treatment. At each facility I inspected

the Special Housing Unit ("SHU"). I also inspected the Intermediate Care Program ("ICY) or AVP; the Special Needs Unit ('LSW7)at Sullivan and Wende; the APPU and Meryl Cooper Unit at Clinton.
At every facility I inspected, I observed the physical plant and ongoing activities, asked staff and those prisoners I interviewed about the programs, asked p r i s o m about their psychiatric histories and current experiences, and performed mental status examinations of the prisoners. In a few cases, I discussed the clinical situation of prisoners with mental health staff,with the consent of the prisoner (and defendants) to do so. During these inspections, to the limited extent permitted by defendants, I spoke with superintendents, assistant superintendents and security officers; and to the limited extent permitted by defendants I spoke with representatives of OMH who accompanied me on tours, including Harold ("'Hal")Smith, Dr. Donald Sawyer, Peter Russell, Dr. Algimantas Shimkunas, Dr. Anthony DeVito, and other staff and managers.
B. Review of Documents
I reviewed a large volume of documents, including DOCS and OMH operational policies, studies conducted by OMH of various components of its programming, and internal agency documents produced in this litigation. Among these documents are the ICP Manual, CNYPC Outpatient Medical Records Policy & Procedures Manual, CNYPC
Outpatient Program Guide for 1995, OMH StudyMid-Late go's, 1997 0;MH Task Force Report, 2000 Corr. Assoc. Health Care Report, 6/12/00 MH ServicesPlan for SHU at
Attica, 6/12/00 Plaintiffs Declaration Re: MH ServicesPlan for SKU at Attica, 11/00 Commissioner's Policy Paper on Prison Safety & Inmate Programming, 12/4/00 Testimonyby SarahKerr to N Y S Democratic Task Force on CJ Refonn, 12/11/00letter re: Double Occupancy Housing Units, 1/17/01 Double Occupancy Housing Units, Feb., 2000 and June, 2002 Reports by the Prison Visiting Committee. I reviewed reports and accompanying correspondenceby the State Commission of Correction for 41 suc~esshl suicides that occurred in the NY DOCS or OMH between 1996and 2003. 1reviewed clinical charts and custody files of almost all of the 183prisoners I interviewed, approximately 60 cartons of files. I reviewed at least four additional cartons of clinical files of the prisoners who successfbllycommitted suicide. I was provided transcripts of depositions in thismatter of Maureen Adams, Dr. David Barry, Jeffiey Bea, Takarla Carroll, John Culkin, Dr. Anthony DeVito, Charles Gordon, Gary Greene, Charles Herrmann, Leslie Kellam, Nancy Key, Sharon Keyser, Loretta Klein, Ram Lall, Frederick Lamy, Dr. Mitchell Langbart, William Lape, Lucien Leclaire, Elaine Lord, Richard Miraglia, Adele Pace, Maria Rosado, Peter Russell, Dr. Don Sawyer, Donald Selsky, Dr. Aligmantas Shimkunas, Harold Smith, Jayne Van Bramer, Dr. Bruce Way, Larry Woodward and Dr. Lester Wright. I reviewed all of these transcripts, some in fbll and some in part.
'This and other acronyms, psychiatric terms, and other unfamiiiar words used herein are defined in the
accompanyingglossary,attachedhereto as Appendix G.

I also reviewed Minutes of the CNYPC Ethics Comittee &om 1997 through April, 2004; the Final Report of a 2002 Technical Assistance Intervention Project at Bedford Hills Correctional Facility by Angela Browne; 7/29/02 Overview memo to the Operations Committee re Behavioral Management in the Outpatient Correctional Setting; OMH Annual Reports for 2000 and 2003; Anderson Training power point images, 4/21/04, and accompanyingvideo presentation; training materials for suicide prevention; videos of several "take-downs"/security operations. I reviewed many internal memos of DOCS and OMH as well as many studies of CNWC, Satellite Units, observation cells, suicide, outpatient services and STP. I reviewed proposals for the Behavioral Health Unit (BHU). I also reviewed several cartons of miscellaneous documents generated in this case. A 111list of the documents I had available are attached to this report as Appendix C.
IV. The Path to Isolated Confinement for Prisoners with Mental Illness
A. A Significant Number of Prisoners with Serious Mental Illness are in Isolated Confinement
The most striking feature of mental health services in the New York prisons I toured is the large number of irknates suffering from serious and persistent mental illness (referred to henceforth as "serious mental illness" or "SMJ?') who are housed in some form of isolated confinement, where they are kept isolated from other prisoners and have minimal contact with staff, spend nearly 24 hours per day in their cells, participate in very few if any programs, eat alone in their cells, and are mostly idle. Serious mental illness or SMI means a substantial disorder of thought or mood which significantly impairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life.' New York's Mental Hygiene Law Section 1.03 (Definitions) 52 defines SMI as follows:
There are various definitions of serious mental illness. The 1986 federal Public Law 99-660 mandates that federally-funded public mental health programs prioritize services to individuals suffering from serious and persistent mental illness ("SPMI"), and this includes those who are disabled by a chronic mental illness, possibly exacerbated by co-occurring substance abuse or another condition such as AIDS. The federal government required the states to define SPMI for the purposes of fheir mental health plans. The courts have also proposed definitions; for example, the Michigan Department of Corrections, in USA v. Michigan (No. G84-63CA WD. Mich, 1996), adopted this definition of serious mental illness: "Serious Mental Illness means a substantial disorder of thought or mood which si&icantly impairs judgment, behavior, capacity to recognize reality, or ability to c o p with the ordinary demands of life." The Madrid v. Gomez court (889 Supp. 1146,N.D. Calif., 1995)ordered that the California Department of Correctionsbe ''permanently enjoined from confihing in the Pelican Bay State Prison Security Housing Unit those 'at risk' inmates who meet one or more of the following def&tionsm:
a. Inmates found to have current symptoms or who are currently receiving treatment for the following types
of Diagnostic and Statistical Manual N (DSM-IV) Axis I diagnosis:
(1) Schizophrenia (all sub-types)
(2) Delusional Disorder

"Personswith serious mental illness" means individuals who meet criteria established by the commissioner of mental health, which shall include persons who are in psychiatric crisis, or persons who have a designated diagnosis of mental illness under the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and whose severity and duration of mental illness results in substantial functional disability. persons with serious mental iliness shall include children and adolescentswith serious emotional d i s ~ b a n c e s .
Special Housing Units (SHUs) and Keeplock are both forms of punitive disciplinary confinement wherein the prisoner generally remains in his or her cell a minimum of 23 hours per day, with one hour allocated for recreation (23 hour
(3) SchizophreniformDisorder
(4) SchizoaffectiveDisorder
(5) Brief Psychotic Disorder
(6) Substance-InducedPsychotic Disorder (excluding intoxication and withdrawal)
(7) Psychotic Disorder Not Otherwise Specified
(8) Major Depressive Disorders
(9) Bipolar Disorder I and II
b. Inmates diagnosed with a mhtal disorder that includes being actively suicidal.
c. Inmates diagnosed with a serious mental illness that is frequentlycharacterizedby breaks with reality, or perceptions of reality that leads the individual to si@cant functional impairment.
d. Inmates diagnosed with an organic brain syndrome that results in a significant functional impairment if not treated
e. Inmates diagnosed with a severe personality disorder that is manifested by fresuent episodes of psychosis or depression, and results in significant functionalimpairment.
f. Inmates diagnosed with mental retardationwith significantfiinctionalimpairment.
In correctionalpsychiatry, the designation"major mental illness" has traditionallybeen defined in relation to a number of "Axis I" diagnoses, including Schizophrenia, bipolar disorder, major depressive disorder, delusional disorder and so forth. The weakness of the last variety of definition is that there are many individuals who suffer from a mental illness that is not on the short list of diagnoses qualifyingfor major mental illness (for example, they suffer from Borderline Character Disorder or Posttraumatic Stress Disorder), but they are significantlydisabledby mental illness. The definitionI have adopted in this reporf the Michigan definition,is consistentwith the federal definitionof SPMI, and is inclusiveof the Madrid
legal definition. From my review of documentsin this case, it appears that OMH and DOCS do not consistently use any particular defmition of serious mental illness. Thus,for example, Richard Miraglia,
Director of the OMH Bureau of Forensic Services, testifled that Serious Mental Illness, Serious and Persistent Mental Illness (SPMI), and Major Mental Illness are all used interchangeably, and they are defined as a "a psychotic disorder or major mood disorder" (IvfiiagliaDeposition, pp. 151-157). In other words, for Mr. Miraglia, there is no distinction between SMI, SPMI and Major Mental Illness, and all of
these terms refer to a few diagnostic categories without regard to functioning. Others in O M H definethese
terms differently.

confinement is also known as "lockdown"). In ll?T DOCS, SHUs are housing areas
where all the prisoners in a given area are held in such 23 hour ~ o n f i e m e n t .K~eeplock status prisoners may be held in lockdown confinement in a general population unit, a long-term Keeplock unit (where all prisoners are on Keeplock status), in general population, in an Intermediate Care Program (ICP), or in a SHU. There are also prisoners who are held in lockdown or isolated confinement conditions based on their status as Protective Custody or Administrative Segregationprisoners.
In some facilities, SKU cells measure 6x10 square feet, in some they are a little larger, and in some, for example at Sing Sing, SHU cells can be 6x8 square feet. The
majority of prisoners in isolated confinement are housed in SHU cells. (As of December,
2001, there were 5,469 SHU cells system-wide, approximately 12% of DOCS total
capacity at that time, 68,000 - see SHU Mental Health Needs Study by Dr. Bruce
Way/CNYPC, 5/17/02).
In the course of inspecting 13 facilities and interviewing 183prisoners, I interviewed well over 100prisoners who were housed in SHU, Keeplock, or some other form of isolated confinement, and I concluded that more than 75% of prisoners I interviewed in isolated confinement settings suffered from serious mental illness or were at very high risk of suicide. Most of them are on the OMH caseload, are being seen briefly by OMH staff at cell-kont with occasional private meetings, and are being prescribed psychiatric medications, but in almost every case they are undergoing very little or nothing else in the way of mental health treatment. Some prisoners with SMI have been placed in observation in the SatelliteUnit or have been admitted to an inpatient
psychiatric ward at CNYPC on one or more occasions, and then were returned to prison -
often back to isolated confinement. Further, many prisoners suffering from serious mental illness repeatedly cycle between isolated confinement and observation and/or CNYPC and back to isolated confinement. CNYPC is an (JCAHO) accredited psychiatric hospital, and the treatment prisoners receive there is very different than what
happens in the prisons. But the observationcells I toured in the SatelliteUnits are similar
to isolated confinement cells. There are more frequent rounds by correctional and nursing
staff - the prisoners who are in observation are watched more closely than in SHU or
Keeplock. These patients in observation see the psychiatrist, usually as he or she passes briefly by the front of the observation cell. But often the prisoners in observation have fewer amenities than they did in their isolated confinement cells, limited to a smock (Ferguson non-destructiblegown) and a thin mat Inmates in observation usually do not get to go out of their cell for recreation, even for the one hour that is generallyavailable to
SIFU and Keeplock prisoners7.
The only very limited exception are prisoners in the Special Treatment Progam ("'SIT"),which will be discussed subsequently.
'Indeed that one hour of recreation often does not take place, giventhe many times when a prisonerwith
SMI is unable to respond immediately to the officers' call out.

As I will explain below, it is my strong professional opinion that prisoners with serious mental illness should not be housed in isolated confinement ( S m , Keeplock, Administrative Segregation, or Protective Custody when it involves lockdown)', and that the isolation and idleness of observation should be ameliorated, because:

isolated cod~nernenttends to worsen the prisoner's mental illness and prognosis, causing unnecessary suffering;

prisoners' mental impairmentsprevent them from remaining free of disciplinary Fnfi-actionslong enough for them to gain release from isolation; and

prisoners with SMI need more intensive ongoing mental health treatment and programming than is available in isolated confinement settings.

Many prisoners I met have not been evaluated adequately by the mental health staff. Others are considered by OMH staff to be "malingering" or to have "merely an "' Axis 11personality disorder" with no bona fide mental illness, and in other cases the
O m staff believe that a prisoner's psychotic disorder or severemood disorder is
controlled sufficientlyby psychiatric medications that the prisoner is "hctional" or "stabley'in an isolated confinement setting. But while a prisoner who is actively hallucinating or actively contemplatingsuicide in his isolation cell may appear to acasual
observer hurriedly passing by his cell to be relatively "functional" -perhaps he dresses himself, eats his meals and does not cause a commotion - he can still be suffering
tremendously on account of his seriousmental illness and the conditions of his confinement. I will discuss the conditions of confinement and lack of prograrnmbg in observation later in this report. For now, I should merely note that the prisoners in observation with whom I spoke consider observation to be an even more noxious setting then their isolated confinement cells.

In this section, I will focus on prisoners in isolated confinement (as defined above). Consider this illustrative case (for this and all other cases summarized in the text of this report, see Case Studies, Appendix D, for a more complete picture):

M aP.
Southport, 3/12/03).

(Interviewed while housed in SHXJ at

History: This man has been in prison for eight years, and has been in SW
for seven of those years at various institutions. He said he has taken
psychiatric medications "for the voices," but has been off his medications
since coming to Southport one year earlier -he discontinued them because

8 My recommendationsas to SKU, Keeplock, Protective Custody and other forms of isolated continement are set forth in Section IX, Recommendations.

they made him too sleepy and caused weight gain. Then he was dropped fiom the OMH treatment list. He was actively hearing "voices," he was depressed and for significant periods he would not eat. He has attempted
suicide on multiple occasions. He rewived many tickets when he was in
"The Box" (SEW), for example for flooding his cell or setting fires;he explained he does these things because, ''In the Box the voices become stronger, I get depressed, it feels like the walls are closing in on me, and I just want to die." In the past, he has been prescribed the anti-psychotic agents Haldol and Zyprexa, as well as mood stabilizers, and the medications had good effects on his mental condition. His history of serious mental illness long pre-dates his incarceration. He says that a big part of his reason for not taking medications is that the officers call prisoners who take psychiatric medications "bugs."

Mental status examination: This prisoner had flat affect, stared in bizarre fashion and had obvious internal preoccupations, indicative of auditory hallucinations. He seemed depressed but was not currently suicidal. When I asked him why he had momentarily broken off communicationwith me and seemed preoccupied, he averred hearing voices. In other words, this man's presentation is consistent with active psychosis and depression.

Clinical chart:

!d 0 +

chart is consistent with the history he

presents. He was admitted from SHU to CNYPC on 4/1/99 and his

diagnosis was downgraded to Adjustment Disorder with mixed features,

but his discharge medications, as he returned to SHU, were Depakene 750

mg. b i d . (a mood stabilizer prescribed to patients suffering from Bipolar

Disorder) and Zyprexa 10 mg. (an anti-psychotic medication). A Nursing

Assessment on 1/23/01 stated he was admitted to observation for "danger to

self and others," after he ingested pills and reported it was because "the

voices keep screaming at me" and "the voices tell me what to do." He was

noted to have "disintegration of thought process as evidenced by impaired

insight and judgment and auditory hallucinations." There were multiple

transfers to observation for serious suicide attempts, each followed by a

return to SHU. Strong psychiatric medications were prescribed. Mental

status on a 11/21/01 Core Evaluation included: "Unshaven, unkempt,

preoccupied with 'voices,' claims he hears voices telling him 'kill himself,

depressed, agitated, attempted OD (overdose) in SHU, oriented X3,

somewhat confused."

This case illustrates several themes I will discuss in more detail below:

This prisoner was suffering from a serious mental illness and has been known to suffer from a serious mental illness since childhood;

he had been confined to S W for at least a year;

he was not functional in SZrU as demonstrated by his repeated suicide attempts and psychotic breakdowns necessitating transfer to observation and, in one instance, the psychiatric hospital;

his mental illness was almost certainly exacerbated by isolated confinement, but then O M .staff repeatedly "re-cycled" him back to SNU, notwithstandinghis severe symptoms and continuing danger to self;

his diagnosis was changed fiom serious mental illness-@sychosisNOS and Major Depressive Disorder) to the less serious diagnosis "Adjustment Disorder" (this downgradingis the phenomenon I term "un-diagnosis");

he was continued on psychiatric medications that are indicated for psychosis and severe mood disorders and not for Adjustment Disorder;

he was eventuallydropped from the 0MH caseload because he refused to comply with medications in spite of continuing hallucinations and other signs of psychosis and depression;

his continuing signs of serious mental illness were not detected at periodic mental health screening evaluations done without privacy at cell-front;

he was assigned a lower mental health needs level and transferred to a facility (Southport) that was inappropriate for his level of psychiatric disorder?

4 , Unfortunately,

case is neither isolated nor rare. Of the 183prisoners

I interviewed during my visits to 13 DOCS facilities between March 11,2003, and

October 30,2003 (including prisoners I interviewed in observation and elsewhere), mom

than 150 had spent significant periods in SHU and over 140 suffered fiom serious mental

illness. Many of the themes I listed in relation to this prisoner are widespread among the

prisoners I interviewed.

There are many reasons why prisoners suffering from SMI end up in disciplinary isolation in disproportionatenumbers, some having to do with the nature of mental illness and institutionaldynamics, and others that result fi-omill-advised and harrnll policies and practices within DOCS and OMH.

9 OMH has designated mental health levels of need ranging &om1 to 4 in descending levels of need for services; level 1 signifies a need for the most intensive services, level 6 signifies no need for services (there is no level 5). The "mentalhealth level" assignedto a prisonerreflects that such prisoner mustbe housed in a prison that has adequate mental health treatment capabilities. Thus prisoners with mental health level 1 must be housed in a prison with a Satellite Unit, andfor officiallyprecluded %omconfinementat Southport which does not have a Satellite Unit Prisoners with Mental Health Level 1 or 2 are precluded &om confinement at Upstate.

B. Institutional Dynamics and Rules Place Prisoners with Serious Mental Illness at Risk

Mental illness and the institutional dynamics of a correctional setting do not mix well. Prisoners suffering firom serious mental illness are especially vulnerable to problems arising out of prison life. They are prone to victimization by other prisoners, are disproportionatelyvictims of rape, and tend to break rules, get into fights, and get into disciplinary trouble. These tendencies have much to do with their mental illness. For example, individuals suffering fkom Schizophrenia and other chronic mental illnesses, on average, are not very alert to social cues and are not as capable as others of conforming their behavior to social expectations. This is true in the homes and neighborhoods where they grew up, but even more true in prison, where the rules are more stringent and more rigorously enforced. The nuances of prison rules and expected behaviors escape them. For example, most prisoners learn that there are many more rules than the staff could possibly enforce, and as long as they follow the rules staff seem to be enforcing they can get away with breaking the ones staff less diligently pursue. In contrast, prisoners with serious mental illness are often unable to make this distinction. Often they are written up for breaking rules that other prisoners know they must follow. It can be a sim le thing such as failing to clean themselves or their cell or failing to stand for a count!' However even these simple rules can pose a problem for prisoners who suffer from serious mental illness andor experience side effects of their strong psychotropic medications.

Some prisoners suffering from SMI get into disciplinarytrouble because other prisoners take advantage of them and "sucker" them into stealing or holding contraband, and then leave them to take the rap. Or, either as aggressor or as hapless victim, they get into physical altercations. A mood disorder such as Bipolar Disorder, especially during a manic mood swing, can be expressed in temper outbursts or uncontrollable rule-breaking behaviors that may lead to isolated confinement. The following two cases are ill~~strative.

k&l?

(Interviewed while housed in General

Population at Great Meadow on 8/26/03.)

History: This man has been in prison since his teens. He was taken to observation after trying to hang himself and cut his wrist. He had been in ICP prior to that. He was taking Depacote (mood-stabilizer typically

'O A comparable example from the comrmmity involves homeless people sleeping illegally in a public park. Typically in the community, the police might perform a sweep through the park in the middle of the night once every couple of weeks. Most of the homeless people sleeping there see the approaching lights of the police vehicles, pick up their sleeping bags and possessions, and leave before the police can roust them
But homeless people suffering fkom mental illness - either because their medications prevent them from waking when the light. come near, or because they do not think of getting up and leaving - are the only
ones left for the police to arrest. And too often they get into squabbles with the police, and arrests follow. Equivalent scenarios occur in prison, resulting in a disproportionate number of tickets for prisoners suffering fiom serious mental illness.

prescribed for Bipolar Disorder), Zyprexa (anti-psychotic), Paxil (antidepressant) and Vistaril (anti-anxiety). He was in SHU from Dec., 2001 through April, 2002. He told me: "Wen I was in the Box the demons
came through the walls - the wall of fire - and then the voices came and tormented me - then I cut my right cheek with a staple - then I wrapped
myself in a sheet and set myself on fire." He went to observation for several months beginning in August, 2002. He was in the dorm and then he was sent to ICP. He was expelled fkom ICP in June because he had tickets.
He was placed in general population (GP), where he has a lot of trouble - he
gets picked on and threatened and just doesn't know what to do. He described his experience in observation as painful and humiliating because he was stripped and left without clothes Eor long periods.

Mental status examination: This man stared bizarrely, was internally preoccupied (consistent with reported hallucinations) and seemed frightened, especially about being returned to GP. His memory was very deficient. He is distnrstful of mental health staff and explained that that is
why he rehses to tell than about his fears.

Clinical chart: There were notes in his clinical chart about anxiety, paranoia, and one diagnosis of PTSD, another of Paranoid Schizophrenia (12/26/2000). He was discharged fkom the Auburn Satellite Unit on 10116/01 after a three-month stay, with a note that his paranoia was diminished. While in ICP, he was prescribed Depacote, Zyprexa, Paxil and Vistaril on 5/6/03. Subsequently it was noted he has been kicked out of ICP for non-compliance with rules. There was a note about his being attacked while in GP, and that he had a cut on his face.

This man suffers from SMI, is victimized and does not know how to behave in GP. He needs to be in a relatively safe and therapeutic setting such as ICP, but he is kicked out of ICP for not followingrules. His illness was already severelyworsened in general population at the time of our interview. In essence, OMH and DOCS bar necessary treatment for prisoners who commit hfkctions that are driven by the very mental health conditions ICP is designed to treat.

4-2.

(Interviewed while assigned to SHU and

in observation at Bedford Hills on 5/6/03).

History:

was handcuffed and wore only a Ferguson gown

during my interview. She claimed she is denied food in observation, is

denied a shower, and that the officers harass and threaten her. She has been

staying up all night, talking to herself in observation (generally this can be a

sign of mania). She had been in observation for 15 days. Last year she was

in observation for 34 straight days. She has been in SHU for a year. Being

in SHU causes her mental illness to be worse. She has severe insomnia in

SKU and is unable to concentrate or read, and becomes very agitated because of the constant screaming and noise, and harassment by staff (her story is consistent with an episode of mania exacerbated by SHU confinement). She has smeared feces on the wall, something that she was ashamed of and never did previously. She has made multiple suicide
attempts. Inobservation she was never taken out of her cell to talk to
anyone. Most of the behaviors that resulted in tickets and an even longer SHU term occurred when she was in a manic state, and often when she was in S W . Her mental illness makes it impossible for her to control her temper.
Mental status examination: She exhibited pressured speech, flight of ideas, agitation and anger. She was not actively hallucinating, nor was she delusional. She credibly described cycles of mood consistent with Bipolar Disorder. She was not psychotic at the time of our meeting, but she presented a credible history of transient psychosis during angry or manic periods. She was intelligent, had a significant arnount of insight, and was angry about the way she was being treated.
Clinical chart: The chart contained many notes about manic mood and pressured speech, diagnoses of Bipolar Disorder, mania and Delusional Disorder, and she has been prescribed mood stabilizing medications as well as antipsychotic medications. Despite these medications her symptoms worsened in SHU. She was admitted to CNYPC for the third time on 7/10/03 (two months after our interview). She had many admissions to observations fiom SHU, with discharge back to SKU.
This prisoner quite clearly suffers fiom severe mood swings consistent with a diagnosis of Bipolar Disorder, and it is likely that the manic behaviors she described and the manic state I observed during our interviewplay a large part in her being given tickets
and repeatedly being sentenced to SHU terms - i-e. her mental illness causes her to be
incapable of controlling her inappropriate outbursts. She seemed during our interview to be in an acute manic state, and the appropriate treatment would be admission to a psychiatric hospital. Yet she was kept naked (except a gown) and idle in an observation cell for weeks at a time, she was handled harshly, and she received very little in the way of mental health treatment.
C. Prisoners with Serious Mental Illness Also Have Difficulty with Unwritten Rules
There are also unwritten rules in prison, and prisoners with serious m t a l illness have difficultyunderstanding and conformingto this second set of rules. An example is the unwritten "prison code" in men's institutions. Men are not supposed to show any sign of weakness and they are absolutely prohibited fiom "snitching" to staff. A prisoner who suffers from SMI is labeled a weakling because of scars on his wrist fiom previous

suicide attempts; he may be more prone to attack because he is considered unlikely to have friendswho would retaliate. Ifhe is seen talking too long to an officer, he may unwittingly be labeled a "snitch." Even if the prisoner suffering from SMI was not "savvy" and was not the instigator, he is more likely than others to receive a ticket when altercations occur. The staff's impatience with prisoners whose mental illness leads them to do strange and disruptive things may result in these prisoners being placed in isolated
confinement as well. In the NY DOCS, prisoners with serious mental illness account for
a disproportionatenumber of disciplinarytickets that lead to SHU confinement.

Of course, prisoners suffering fiom serious mental illness also misbehave willfblly
- I am not advocating excusing their willfbl unacceptable behaviors, nor am I suggesting
that there should be no consequences for their deliberate de-breaking or assaultiveness. There have to be fair consequences for misbehavior and violence. But here I am attempting to explain why an inordinate number of prisoners suffering from serious mental illness runafoul of that disciplinary system and land in isolated confmement. For prisoners with SMI, the consequences for unacceptable behaviors must be determined in the context of mental health assessment, diagnosis and treatment, and this requires a high level of collaboration between security staff and mental health staff. For example, when a prisoner breaks a rule or gets into an altercation in response to command hallucinations, he likely needs a more thorough psychiatric examination and more intensive mental health treatment rather than a longer sentence to isolation and idleness. The vulnerabilities I am describing make it essential that prisoners suffering h m seriousmental illness be provided a relatively safe and therapeutic setting to serve their prison term. Absent that kind of setting, it is predictable they will decompensate, get into disciplinary trouble, and be sent to punitive isolated confinement. I will briefly describe another prisoner I interviewed.

&-@Ia
311 3/03),

(Interviewed while in SHU at Five Points on

History: This man has been in SHU for ten years, and told me he has received 100tickets, mostly while in SHU. He has been in observation approximately 30 times, at CNYPC a number of times and has been in ICP several times. He was in STP for three months, and when asked why his stay was terminated he said with a bizarre grin, "I'm too wise for it." He hears voices. He told me that other prisoners are always knocking on the
walls around him. He has temfylng dreams. He talks to himself. He believes the officers play tricks on him, and poison his food. He told me the voices tell him to do things that get him into trouble, or he gets so angry at the officers who are playing tricks on him that he "acts the fool." He is taking Depacote, Haldol and Zyprexa.

Mental status examination: This man appeared bizarre, looking around and making faces. His thought process was loose and tangential. He was

agitated and his affect was inappropriateat times. He was concsete. He said he was hearing voices, and did seem internallypreoccupied. He had clear ideas of reference (paranoid delusions). He said he has psychic powers. He was obviouslytrying to concentrate and cooperate with the interview, but he was confitsed and unable to track the conversation. He
went off on tangents repeatedly, but was cooperative when the interviewer
gently tried to lead him back on subject. His presentation is consistent with acute psychosis, and the presence of fixed delusions, that took years to form, point to chronic psychosis as well.
Clinical chart: A. chart is consistent with the picture he presents.
He has been repeatedly admitted to observation for self-harm, burning his cell, etc. He has been prescribed Haldol decanoate (injection, an older antipsychotic medication) 100 mg. every three weeks. He was also prescribed Depakene 1500 mg. (a mood-stabilizer prescribed for Bipolar Disorder and other Mood Disorders), Zyprexa 5 mg. (a newer, "atypical" anti-psychotic medication) and Cogentin. He had been in SHU a long time, and went to STP in Jan., 2002, at Five Points. He had multiple admissions f?om SHU to CNYPC and observation, and then cycled back to SHU each time.

This case serves to illustrate the problem (among others) that confining

individuals with SMI in SHU (or Keeplock or other forms of isolated confinement) often

leads to deterioration in their condition and more tickets (and more serious ones) because

of the conditions of isolation and idleness. OMH inappropriately relies primarily on

medications to treat psychiatric symptoms, without removing them &omthe noxious

conditions and without supplying the other treatment modalities that are indicated. I
have already observed a similar pattern in the cases of d ,0 , NSP

and

T;" \$#Z. ,Seealsothecasesof !de!* , d*/+- I V,M.

, 4
D,aXa

, ,

P*k. 9
L.k 9

@ D,bJ-*2 , Q!, * * I 9 * 6,-Na$*J*3

L.V,

3 0%V a , v-3- 9

f l * P*

E-H, 9

x T 3

,and X

in this Report; and the cases of @ N, ,

OrE -, FaLJb

I,M,

- 4 , 1q7$,p&' 4 , k . ¶ E&Z*

E,E, Pd, , 23. ,

a T*

C h C & I,
a-*Wl- >p" -L *

*E ,
l, 3JAk , ,. L 6 E s", P6-c

in Case Studies, Appendix D.

D. Harmful Policies and Practices Lead to Prisoners with Serious Mental Illness Being Placed in Isolated Confinement

The most obvious reason why so many prisoners suffering £?om serious mental
illness are relegated to isolated confinement is that NY DOCS and OMEl permit them to
be there. This trend is reflected in O M . studies and in statistics about suicides within DOCS. Thus, 64% of prisoners in SHU in OMH Mental Health Level Onecorrectional

facilities are on the OMH caseload," and as many as 45% of successfil. suicides within DOCS involve prisoners assigned to isolated confinement, even though only approximately 8% of DOCS prisoners are housed in isolated confinement at any time. 12
The September4,2003, Minutes of the N Y S Commissionof Correction Medical Review
Board, summarizing a presentation to the Board by Richard Miraglia, Dr. Donald Sawyer and Harold Smith, go so far as to designate the housing of prisoners with serious mental illness in SHTJ a s a method for managing them: "[An] intensive case management model is underway. This will provide special intensive case management for some 550 Level I seriously mentally ill state prison clients who are r e k t o r y to traditional treatment and
are managed primarily in SW's."'~ (See P1. Exh.574.) Thus, by design [or default],
Special Housing Units are utilized to manage prisoners suffering fkom serious mental illness.
Many states have enacted policies that preclude isolated confinement for prisoners suffering h m serious mental illness, reflecting a growing consensus among mental health professionals that isolated confinement can be very harmfir1to prisoners suffering
from SMI. Several mental health professionals in OMH agree with that consensus,
1'1 accordingto statementsmade in depositions or documentsby Drs. Sawyer, Shimkunas, DeVito and Tucker. l4 Nevertheless, New York DOCS and OMH have continued to consign a large number of prisoners suffering fiom serious mental illness to its SHUs, to Keeplock status and other forms of isolated confinement, and to extended time in harsh observation cells in Satellite~ n i t s . "
The following policies and practices result in the imposition of isolated confinement for many prisoners suffering &om SMI:
l1 Kahjekian and Way, "SpecialHousing Units in OMH Level 1 CorrectionalFacilities: Mental Health Needs Study," 7/16/04.
'*See The CorrectionalAssociation of New York, "Mental Health in the House ofCorrections," 2004, p
57; NY DOCS "Inmate Suicide Report: 1995-2001" & "Inmate Suicides: 2002-April 17,2004. " Plaintiffs counsel in this case prepared a chart of suicidesbetween 1995and mid-2004, which demonstratesthat in
those years 53 of the 119known suicides, or 45%, involved prisoners assigned to some form of isolated confinement (See Appendix D). NY DOCS reports the figure of 34%. I have reviewed counsel's list of actual cases, and I find the 45% figure to be more accurate.
l3 Hal Smithdisavowsthe claim that OMH is actually embarking on intensive case manaf~ernenwt ith prisoners in SHU who have SMI (4129105 Deposition, pp. 336-338).
l4 See my discussion in SectionVI.I.3, below.
l5 There are aspects ofthe isolationand idleness in Keeplock and observationthat lead to even worse dwws and emotional damage than obtains in SHU.For example, in Keeplock there are no regular mental health rounds and periodic mental health evaluations are not required (see DeVito Deposition, p. 142); and the prisoners in observation, some. of whom remain there for months, are often denied clothing and other
amenities and are not permitted out-of-cell recreation- see discussion of observation in SectionW.

* Prisoners with serious mental illness escape detectionbecause of inadequate mental
health assessment.
Inadequacies in the mental health treatment program increase the likelihood prisoners suffering from serious mental illness will be punished with isolated confinement.
A shortage of beds at CNYPC, and restrictive admission criteria, preclude admission of many prisoners in need of psychiatric hospitalization.
Observation cells, as currently operated, are equivalent to isolated confinement and do not provide adequate assessment and treatment.
There are insufficient ICP beds for the population in need.
There is an unavailability of vocational, educational and other rehabilitation programs, as well as substance abuse treatment programs, especially for prisoners in isolated confinement.
Prisoners with serious mental illness as well as serious disciplineproblems are ejected &om treatment programs.
The disciplinary process fails to take mental health issues into sufficient consideration.
Inadequacies in Mental Health Treatment Programs at medium security facilitiesmean that prisoners with serious mental illness will be sent to maximum security facilities for needed treatment, where they are subject to harsher conditions, which tend to exacerbate their mental illness, which leads to violations of rules and the implementationof disciplinary sanctions, often meaning more time in isolated confinement.
Prisoners with serious mental illness decompensate in isolated confinement and acquire more tickets, which makes them ineligible for time-cuts, and they accumulate ever longer terms in isolated confinement.
Prisoners with serious mental illness in SHU are not diagnosed or are un-diagnosed, and at some point staff decide they are "bad" and not "mad."
A vicious cycle ensues where prisoners with serious mental illness cycle repeatedly from SHU or Keeplock to observation or CNYPC and then back to S W or Keeplock, accumulating more tickets in the process.
I will brieflydescribe each of these policies and practices and provide illustrative cases.

1. Prisoners with serious mental illness escape detection because of inadequate mental health assessment.
I found problems with case-finding or screening and diagnosis at everystage of prisoners' progression through the DOCS system. Prisoners entering DOCS are screened
for mental health issues at Reception, and approximately40% are seen for a face-to-face clinical assessment.16 But a certain number of prisoners with a history of serious mental illness will deny they have emotional problems when they are screened in Reception and will therefore avoid clinical evaluation by OMH. There are various reasons for this. Some are afiaid of the stigma that goes along with a diagnosis of mental illness, and that stigma can be especially intense in prison, where scars &ompast suicide attempts give
one a reputation as a "weakling" or a "bug," and can result in victimization. Other
prisoners fear being medicated or hospitalized against their will. And still others are intent on killing themselves and do not want to tell staff because staff would try to stop them. Afcer the prisoner leaves Reception, there are limited other opportunities for mental health staff to discover cases requiring mental health treatment. There are screening mental health assessments conducted when security staff report a potential problem, periodic mental health evaluations for prisoners confined in SKU, and so forth. However, I discovered flaws in the screening and diagnostic procedure at each step. The result is that many prisoners who are suffering from serious mental illness and require mental health services are not on the OMH caseload.
The fact that prisoners suffering from SMI escape detection can also have much to do with the life course of serious mental illness, which follows a waxing and waning course over a life-time. On average, a first breakdown will likely occur in the late teens
or early 20's - i-e., at the beginning of adulthood. Between acute breakdowns, the
individual might appear fairly sane and healthy, especially when younger and not yet scarred heavily by the traumas of chronic mental illness. People typically enter prison in their late teens or early twenties. Some will have already sufiered fiom psychiatric breakdowns or will have attempted suicide, will have been admitted to a psychiatric hospital, will have been treated with psychiatric medications, or might even have been approved for Social Security Disability (SSI) on psychiatric grounds. But a significant number of young men and women enter prison without yet having suffered a psychotic or manic or depressivebreakdown, and of these, the ones who are going to suffer from SMI will experiencetheir first breakdown some time after enteringprison. All of these possibilities have to be considered by clinicians if they are going to diagnose mental illness. The past history is important, and must be reviewed, as a prior episode of serious mental illness makes a recurrence more likely. But since some prisoners will experience their first breakdown behind bars, the clinician cannot rely solely on past history either, and must conduct a careful mental status examinations in a private setting.
l6 Staffing Plan, Downstate CorrectionalFacity, August, 2001.

In my review, past clinical records were not reviewed or were not sufficiently considered by OMH clinicians. In other cases, an unremarkable current mental status examination was erroneouslyrelied upon to downgrade a diagnosis or question a prisoner's credibility. And in far too many cases, a very superficial examination was performed, typically at cell-front. These evaluations fall far short of acceptable diagnostic practice, missing many obvious signs of serious mental illness. These prisoners are then deprived of necessary mental health treatment, since OMH claims such treatment is not indicated. Predictably, many of these prisoners decompensate and suffer immeasurably.
Stress worsens mental illness, and removing an individual from the stressful situation can result in fewer symptoms. Thus, when a prisoner hears voices or thinks seriously about suicide under the duress of isolation and idleness in SHU, and then he or she is transferred to CNYPC where there is more social contact, more meaningfbl activities and less stress, many of the symptoms might diminish in intensity or resolve. This does not mean he was "faking" the voices or suicidal plans he reported when he was experiencing the stress of isolated ~onfinernent.'~
Many prisoners I interviewed are clearly suffering fiom serious mental illness but at some point in their tenure within DOCS they ars:"un-diagnosed." By this I mean that their diagnosis is changed from "Schizophrenia" or Major Depressive Disorder" or "l3ipolar Disorder" on Axis I of the DSM IV18to "no Axis I Diagnosis," "malingering," or "Antisocial Personality Disorder (ASPD)" on Axis 11, or to a less serious diagnosis such as "Adjustment Disorder7'on Axis I. I employ the term "un-diagnosis" to mean that an individual's diagnosis is downgraded in this fashion, even though it is often my finding that he or she actually suffers from SMI. In some cases prisoners who are thus un-diagnosed are removed from the OMH caseload entirely.19 Another reflection of a lack of concern about case-finding is the fact that required periodic mental health assessments in isolated confinement are usually performed at cell-front, where the prisoner is not likely to share with the clinician anythingsignificant about his or her emotional condition. It is widely known that prisoners will not discuss private matters under these conditions for fear of being overheard, and that such p e h c t o r y cell-front contacts do nothing to forge a therapeutic alliance. Here is an illustrativecase:

l7Another danger of staff presuming a prisoner is faking is that prisoners who are

to access OMH

services decide it is &tile because they will not be believed. Alternatively, prisoners may decide that the
only way to access needed mental health services is to do somefhing - anything - to get staff to notice tbem

'' Diamostic and StatisticalManual of the American Psychiatric Association, 4' Edition, Washington,
D.C.: APA, 1994.

l9 1 will discuss this problem in greater detail, including the use of the Psychopathy Checklist in the process of un-diagnosing, in Section IV.

why %
7/17/03).

. (Interviewed while housed in Upstate SHU,

History: This man has been in DOCS since 1992, and told me he has been at Upstate since Christmas (2002). He is being seen by mental health staff and has spent much time in "the Box." He finished the eighth grade in Special Education, and has heard voices commanding him to do things for many years. He had at least two psychiatric hospitalizations, at Khgs County Hospital and at Brookdale, prior to incarceration.

Mental status examination: I could not remember his birthdate, was confused and was disoriented as to place, time and person. He exhibited loose and tangential associations. He was clearly internally preoccupied with hallucinations, and was not coherent enough for me to determine whether his thinking was delusional. He told me he takes "a pint of Haldol a day" and yet still was hearing voices, even in his sleep.

Clinical chart: The chart was surprisinglythin. On 1/16/98it was noted he was naked in the Attica SHU, but no mental health services were
requested -the plan was to monitor him because of his appearance. An
outpatientprogress note of 10113/98 at Attica reflects he was in the SHU, being evaluated by OMH because of inappropriate sexual acts including masturbating in fkont of staff, and he had no psychiatric history [sic]. On OMH Admission Services forms for 4/15/99, 10/23/02, 11/13/02, 1/3/03, and 3/3/03 there was no diagnosis, he was designated Mental Health Level 6 (eventually removed fkom the caseload), and the box was ticked for "no services indicated." A filler clinical note on 10/23/02reflected no evidence of mental illness. Elsewhere it was noted that he had been on SSI total disability on psychiatric grounds in the community, was in Special
Education, and had an IQ of 81.

bizarre behavior, noted as fbr back as January and October, 1998,

raises a serious question whether he was acutely psychotic even then, but there was no

real psychiatric treatment given. There is no thorough psychiatric evaluation in the chart,

and the 90 day mental health screenings seem very superficial, as if a clinician passed by

this prisoner's cell-fiont and checked off that there was no problem. Based on my

assessment, Ll/.i($ very likely suffers kom an organic brain disorder and/or

developmentaldisabihty as well as functional psychosis, and has been quietlypsychotic

in his cell for a long time. His case demonstrates, among other things, the dangers

associated with failure to diagnose co-occurring disorders, such as organic brain disorder,

in someone with functionalpsychosis that is co-occurring with low intellectual

functioning or mental retardation. Had OMH staff engaged in more than brief cell-fkont

y! \/ encounterswith W ,they would have noticed that somethingwas very wrong.

(Besides $J

see other cases in this Report that reflect this issue, including

- D R , J 0 - P , D O X . , H f u a and7 Tp- ;and
many more cases in Appendix 11,Case Studies). Here is another case, like that of' 4 uhere SMI was not identified by OMH:

Cd;.o
SHU on 7/18/03).

. (Interviewed while housed in Upstate

History: '

came to Upstate in May, 2003, fiom the Sf-fU at

Southport. He was prescribed Cogentin, Risperdal (anti-psychotic), Prozac

(antidepressant)and Atarax (anti-anxiety). The medications were stopped

at Southport. He averred hearing voices and talking to himself, especially

since being off his medications and at Upstate, and that recently a

correctional officer gave him a ticket for talking to himself. He reported

seeing people in the back of his cell who he knows aren't there. He

reported the correctional officers put ideas in his head and make him do

things to them. He said he asked for medications over a month ago, and

Dr. Kemp, the psychologist, agreed he needs them, but he has still not been

to telemedicine yet. Previously, he was on Risperdal and other psychiatric

medications and they helped, but he was on no medications when I

interviewed him.

Mental status examination: This man had a bizarre, flat stare, erdibited ideas of reference (paranoia) and strong First Rank Symptoms (a set of signs indicating that an individual cannot discriminate between inner and outer reality, which is a strong evidence of active psychosis). He said he experiences comrnand hallucinations that tell him to do some of the things he gets tickets for

Clinical chart: This prisoner's thin clinical chart contains diagnoses of
"deferred," "Major Depressive Disorder" and "Adjustment Disorder" - i.e.
his obvious psychosis is undetected. A 1/9/01Progress Note states that he had suicidal ideation and he is then sent to observation for six days before
being returned to SHU. A 3/18/01 Progress Note states that the prisoner feels hopeless and suicidal due to an additional six-month S W sentence
(on account of refusing to double-bunk and he is sent to observation for six days before being returned to SHU.) On 5/2/01 his medications included
the anti-psychotic agent, Risperdal, the antidepressant Seraone, the mood-
stabilizer Neurontin, and minor tranquilizers - this is inconsistent with his
diagnoses, since he does not have a diagnosis reflecting psychosis or mania.

This prisoner suffers firom a serious mental illness with psychosis, but he is inadequately diagnosed. This leads to his confinement in a facility, Upstate, where &re are not adequate mental health treatment resouxes for him and where prisoners with his level of mental health service needs are not supposed to be housed. Then he becomes suicidal and cycles repeatedlyto observation fiom SEW and then back to SEW.

It is cause for concem when O W administrators note their concern with the size of the OMW caseload, given their limited staffing resources.20 While it of course makes sense to limit OMH caseload to prisoners actually in need of services, at the same time, if there are more prisoners in need of services than current staff can serve adequately, there is a need to expand the staff. Moreover, because the damage tiom missing serious cases can lead to tragic results, a correctionalmental health department should err on the side of being more inclusive in the case-fmding process. I discovered many other prisoners who are suffering fiom significant emotional symptoms or serious mental illness whose disorders are being missed by mental health evaluations and who are therefore denied services. Here are two of many examples:

KbF

Interviewed while housed in Keeplock on D

Block at Clinton on 7/16/03).

History: This man who speaks broken English was not receiving mental health treatment, but he had been on psychiatric medications in the past because of "voices." He told me he cannot control the tendency to fight. He has not been to CNYPC, has not been in observation, and was not suicidal. In segregationhe gets very anxious, cannot concentrate, and has "a lot of trouble remembering things." He has requested more than once to see Dr. Melendez and to receive psychiatric medications for his deprasion and voices, but he had not been seen. He reported that when isolated in a cell he cannot sleep, he gets agitated and he is unable to control the anger
that grows in him.

Mental status examination: This man was quite depressed and cried during our interview. There was psychomotor retardation (slowed thinking and behavior) and low self-worth. He gave credible reports of auditory hallucinations.

Clinital chart: k$.E c very thin clinical chart contained no diagnosis and few visits with OMH. A 7/9/03 screeningnote mentioned his problems sleeping and other signs and symptoms of depression and mental illness. But the clinician decided not to put him on the active OMH caseload, noting he would send for his mental health records -but there was no follow-up about those records. An 8/13/03 ScreeninglAdmission Note reported he complains of not sleeping and hears voices. Because he "smiled" the clinician opined there is no mood disorder.

20 For example, Dr. Don Sawyer writes in the Annual Report for 2000, "System wide caseload has fhllen to
7250 cases (February, 2001). This represents a more manageable total caseload given the staffing resources availableto CNYPC Corrections Based Programs...".

- 6.F. -, is very depressed and seeks to be in mental health treatment with
medications, but is not accepted as a patient by O m .

N-Ok

-

V

(Interviewed while housed in SHU on D

Block at Clinton on 10/17/03.)

History: fi 0- had received SSI disability on psychiatric grounds
since 1986, and entered custody in 1994. He was prescribed Mellaril (antipsychotic), Haldol (anti-psychotic), Cogentin (an anti-Parkinson agent that is given to treat neurological side effects of the older anti-psychotic agents) and Valium (a minor tranquilizer) prior to incarceration. He had been admitted to the psychiatric ward at Kings County Hospital, and he suffered from EPS (extrapyramidal syndrome, a Parkinson-like neurological problem caused by the older anti-psychotic medications), but he has not been in mental health treatment in DOCS. He has had only a few disciplinary tickets, and the ones that resulted in his SHU term had to do with refirsing to program. He had attempted suicide by overdose twice prior to incarceration. He reported he heard voices telling hirn to jump out of the window. He was feeling anxious and sufkred fiom insomnia He had not felt that mental health treatment was helphl in other settings, so he has not participated nor requested it while in DOCS.

Mental status examination: This man's flat affect, concreteness and akinesia (listlessness, lack of spontaneity and energy), along with his history, were very consistent with a diagnosis of chronic Schizophrenia

Clinical chart: His thin clinical chart contained no diagnosis, but OMH screening on 8/1/95 noted history of several inpatient hospitalizations and SSI disability. SHU mental health assessments contained almost no information.

This man appears to suffer from SMI, and is being ignored while he remains in SHU.

There are other problems with the diagnostic process in DOCS and OMH, including insufficient neuropsychological assessment, too little attention to closed head injuries and other neurological deficits, cell-fiont screening assessments in SHU that produce little useful clinical data and often miss cases of serious mental illness, and a tendency to "un-diagnose" prisoners suffering fiom serious mental illness who are also disruptivebehaviorally or seem manipulative. I will touch on each of these problems later in this Report.

When prisoners suffering from SMJ escape detection, they are at the mercy of the disciplinaryprocess and because their mental illness leads to misbehavior, many wind up in isolated confinement.

2. Inadequacies of Mental Health Treatment.
This is a topic I will discuss in more detail in Section VI. For now, I will merely summarize the problem very briefly. Clearly, if mental health services are inadequate, prisoners with serious mental illness will be left to their own devices, and it is in that context that many find their way into isolated confinement, where usually their psychiatric condition deteriorates fi.uther. One scenario I discovered in many cases was a failure of Oh433 staff to spend sufficient time with a psychiatric patient to fonn a trusting therapeutic relationship, and then, because of the lack of a therapeutic relationship, the patient refbsed to comply with treatment, failed to go to appointments or discontinued needed medications. Lacking treatment, the patient then engaged in inappropriate behaviors, leading to tickets and isolated confinement. (See Sections IV.Dand V.)
3. Inadequacy of CNYPC Space and Criteria for Admission
Today, there are approximatelythe same number of beds, approximately200, in the inpatient psychiatric hospital, CNYPC, as there were when OMH began providing mental health servicesto DOCS in 1977. This is in spite of the fact that the DOCS population has multiplied many times over to the current population of approximately 65,000. In the intervening 28 years, the percentage of total prisoners suffering fiom
serious mental illness has also grown.21This means that there are not enough beds &r all prisoners whose condition requires admission to an inpatient psychiatric ward. In
addition, the criteria for admission to the inpatient unit at CNYEY: are essentially
equivalent to the criteria for involuntary psychiatric hospitalization in the community -
i-e., the patient has to be declared a danger to self or others. This is a very high standard for hospitalization. In the community, many people are admitted to psychiatric wards "voluntarily" because they are experiencing a suicidal crisis or a psychotic breakdown, but they do not meet the criteria for involuntary admission. Clinicians should be able to admit a patient to the hospital in order to perform a thorough clinical assessment, adjust his or her medications, or, for example, to provide early and intensive treatment for an impending breakdown.
As a result of the bed shortage at CNYPC and the overly strict admission criteria, many prisoners who are acutely suicidal or suffering from a breakdown (psychotic decompensation) are managed somewhere else, usually in observationin a SatelliteUnit or in isolated confinement.
21 Hal Smith, Donald A. Sawyer, and Bruce B. Way, "Central New York PsychiatricCenter: An Approach to the Treatment of Co-Occurring Disorders in the New York State CorrectionalMental HealthSystem," Behavioral Sciences and the Law,20: 522534,2002-

4. Observation Cells are Another Form of "Iolated Confinement
The observation cells I saw are, in essence, another form of isolated confinement, and many of the prisoners I identified as suffering from acute suicidal crises or acute psychotic episodes are kept in observationcells for extended periods without being admitted to CNYPC. In observation there are few activities. The prisoners are rarely removed &omtheir observation cells, except perhaps to meet with a treatment team for a few minutes. There is no recreation, there are rarely visits, and there are extremely restricted amenities. In other words, prisoners in acute psychiatric crises are consigned to another version of severe isolation, with very limited treatment provided. There are no "programs" in observation. As I will discuss in Section VI, OMH staff tend to view too many patients as "merely malingering." Malingering is the feigning of illness to achieve secondary gain. The harshness of the observationcells should dispel the notion that prisoners "malinger" to gain access to observation. Many of the patients I interviewed in observation told me they preferred their S W cell to a cell in observation, and thus, in the many cases where the patient knows he or she will merely be sent to observation, there really is no secondary gain for reporting suicidal thoughts or hallucinations.
5. Insufficient ICP Beds
There are Intermediate Care Programs connected with the Satellite Units (an AVP
at Green Haven is roughly the equivalent of ICPs in other institutions), and this is an important component in a comprehensive mental health treatment program. But the 551 beds in the ICPs at 11 institutionswith Mental Health Satellite Units is much too small a number relative to the need for an intemediate or "stepdown" level of care 22 In addition, in many of the ICPs I inspected, the prisoners are idle much of the time. (OMH is aware of this problem and documents that postdate the inception of the current litigation indicate that OMH is attempting to ameliorate this problem.)23
6. The Unavailability of Vocational, Educational and Other Rehabilitation Programs, as well as Substance Abuse Treatment Programs
In addition to the shortage of activities for prisoners in the ICPs, there is a shortage of vocational and educational and drug treatment programs throughout DOCS. In the community, educational programs such as community colleges and night schools, drug treatment programs and government-run vocational rehabilitation pcograms, are an indispensable adjunct to comprehensive mental health services. Reductions in recent years in educational, drug treatment, and vocational programs within DOCS has a
22 "Stepdownlevel of care" is intermediatebetween inpatientpsychiatric care and outpatient-see Sect VI
for fiuther discussion.
See "Reviewof Intermediate Care Program Participants in Programon 9/1/02" by CNWC.

negative effect on the mental health treatment program. Moreover, these programs are not available to prisoners who are in isolated confinement or observation. There are some cell-study materials, but this is not an adequate substitute for congregate, staEfacilitated and supervised programming. Many prisoners are fbnctionally illiterate (40% according to research24)and not capable of studyingwritten materials; many others are so anxious and have such impaired concentration on account of the conditions of isolated confinement that they are not able to make use of cell-study materials. In any case, cellstudy is not an adequate substitute for the social interactions that are a critical component of any mental health treatment.
7. Prisoners Who Exhibit Serious Mental Illness as well as Serious Discipline Problems are Excluded from ICP and other Treatment Programs; and are subject to longer periods of isolated confinement and even more time in prison.
Shortfalls in the mental health delivery system result in inadequate treatment
- of prisoners suffering from serious mental illness. One glaring effect of this
8') inadequate treatment is that prisoners suffering from SMI when left to their own devices, or when their medications are not monitored closely enough, o r when they
are left idle and insufficiently supervised -tend to get into trouble. I n NY DOCS,
trouble frequently means getting tickets and winding up in SHU.
A SHU sentence has other major negative consequences. For example, disciplinary sanctions may jeopardize a prisonkr's chances for parole. Also, as a result of disciplinary infractions a prisoner can receive a disposition that recommends the loss of "good time." The impact of either parole denial or loss of "good time" is a longer period of incarceration.
I interviewed many prisoners currently confined in SKU in various facilitieswho are suffering from serious mental illness, only to discover that they have requested placement in an Intermediate Care P r o m (ICP), or that they were previously in an ICP and their mental condition was stable while they were in the program. I also discovered that afier they left the ICP, they received more tickets, they were re-admitted to
observation or CNYPC more often, and in general their condition deteriorated. When I asked them why they are not in ICP now they told me "I got a ticket." I also interviewed quite a few prisoners who eventuallywere admitted-toICP after serving long terms in
SHU, and they told me that they had to serve their SKU term &st before they could be
admitted to ICP. I learned that there is a policy that permits OMH staff, in collaboration
with securitystaff, to recommend "time-cuts" so that prisoners suffering from mental illness can be transferred from SHU to ICP where they are more likely to receive the treatment their psychiatric condition requires.
24 The Center on Crime, Communities, and Culme, "Education as Crime Prevention." Research Brief, Occasional Paper Series, Sept., 1997, VoL 2, New York: Center on Crime, Communities, and Culture.

My sense is that "tirne-cuts" are mentioned ofgen (and there are several

policies regarding time-cut procedures) yet in too many cases these do not result in

very significant reductions, if any, in the term a prisoner with SMI must serve in

SHU. For these and related reasons, I have concluded that, for the most part, IGP is

reserved for prisoners with SMI who are capable of behaving themselves and

avoiding Tier 3 tickets. Those who are less capable of behaving appropriately a r e

relegated to isolated confinement in SHU. I have already presented the case of:

0 who was discharged fiom ICP for bad behavior. Other illustrative cases to be

found in this Report include 4d , VJ

, b

,' E E . 2 and

1, and in Case Studies, Appendix D, includingt 6&

asd

X F - ,. Safe management of the expectable misbehaviors and outbussts of

individuals suffering fiom serious mental illness must be part of the range of treatment

interventions if a mental health system is to provide comprehensiveservices. NY DOCS

and OMH do not provide this as an option. In N Y DOCS, the patient is often expelled

fiom the treatment program that fits his level of need, for example ICP, if he misbehaves,

and he is sent to S W . The following case illustrates the problem:

D-k
Clinton on 7115/03).

:. (Interviewed while housed in SHU a t

History: This man came to the SHU at Clinton months earlier after discharge fi-om CNYPC, where he'd been admitted because he was not eating. He reported he had been to CNYPC 30 times. In the past he has been in ICP at Elmira and Attica, and says he did much better while in ICP. Because he acts out and receives tickets when he is emotionally unstable, he is discharged fiom observation or CNYPC to SHU rather than being returned to ICP. When he is in SHU he does not talk to anyone, but he walks on the yard for an hour when he is permitted to go there. He is unable to control his temper when he is in SEW, and typically gets into disputes with staff, often leading to additional tickets and a longer SHU term.

Mental status examination: This man has depressed mood with psychomotor retardation and a sense of worthlessness, consistent with severe depression. There are signs of a thought disorder, consistent with psychosis.

Clinical chart: His chart reflects that he was admitted for the 15th time (first admission was in 1984) to CNYPC on 2/14/03, having lasted "a day or two in SHU"before his condition deteriorated,his hygiene was temble and he was disoriented. His diagnosis was Depressive Disorder NOS, and he was prescribed the anti-psychoticmedication, Risperdal2 mg. He was sent to CNYPC &om SHU because of danger to himself, h a t e n i n g to hang up, disheveled appearance, refusal to eat, and "rapid mood cycling,

incoherent and illogical." He has made many attempts at self-harm, including hanging up. He had been in the past in ICP at Elmira and at Attica, and adjusted relatively well there, but he continued to be readmitted to CNWC, "disheveled," disorganized and appearing psychotic. A 3/12/03 note diagnoses Schizophrenia, Undifferentiatd Type vs. SchizoaffectiveDisorder. When discharged h m CNYPC in 3/03, the recommendation was that he be sent to STP. Instead he was returned to SHU without being admitted to STP.
suffers from Schizophreniaand is repeatedly admitted to W C . He is known to dd well in ICP, and yet he is returned from CNYPC to SHU, where he has repeatedly deteriorated.
8. The Disciplinary Process Fails to Give Sufficient Consideration to Mental Health Issues
The Disciplinary Process fails to adequately take a prisoner's mental illness into consideration in the meting of punishments, and there are disciplinary repercussions for acts that are driven by mental illness such as self-harm, failing to follow direct orders, unhygienic acts,floodingor setting fire to their belongings. Both of these unfortunate realities increase the number of prisoners with SMI who are given a SHU term as punishment for a disciplinary ticket, and when prisoners with SMI are serving a SHU term and receive another ticket, as they are prone to do, their tenn in SHU is effatively lengthened. There is a tendency for staff (security and mental health st@ to respond to rule-breaking and misbehavior on the part of prisoners suffering fiom mental illness with punitive interventions, disciplinarywrite-ups that can result in additional terms in SEW, cell extractions and other uses of force.25 Even when a prisoner is placed in observation for self-destructiveacts, the conditions are punitive and often there is a pending disciplinary ticket, perhaps for the selEharrn act itself, which will lead to an even longer term in SHU.
I spoke to many prisoners who claim symptoms of mental illness caused the
behaviors that led to tickets - hallucinated voices commanded them to do something wrong or attempt suicide, for example-and then either OMH staff provided thehearing
officer with an opinion that their mental illness did not have an effect on their rub-
breaking behavior or OMH was not involved in the disciplinaryprocess at all. Since my
tours and interviews, the Settlement Agreement in the Anderson litigation has been effected. According to that Settlement Agreement, OMH staff are required to intervene with Hearing Officers when prisoners on the OMH caseload have hearings for disciplinary infiactions. There are a prescribed set of questions about diagnosis, psychiatric medications, mental state at the time of an infi-actionand so forth, and I have
reviewed the relevant training documents. I am not in a position to assess the
As set forth below, I believe kuflicient trainingabout mntal illness and staffbumout are also contributing factors. See Section VI.

effectiveness of the procedures put in place since the Anderson Settlement Agreement was instituted, but in the followingillustrativecase, and in many other cases I describe in this report, prisoners' mental illness is not being taken into serious consideration during disciplinary hearings and prisoners are being given SHU terms as punishment for acts that are driven by their mental illness. Furthermore, for prisoners who accrued lengthySHU sentencesprior to the Anderson settlement and are presently serving these sentences, the settlement will have limited effect on the length of time they serve in SHU. I describe below one of the many relevant cases I encountered.

c -0
on 7/15/03).

(Interviewed while housed in SHU at Clinton

History: This man has been in and out of prison for seven years. He has been admitted to CNYPC three times. He says most of his tickets are for refising mental health call-out. He does not know why he is currently in SHU. He says he takes psychiatric medicationsbut does not know which ones. He denies hearing voices: rather, he says he talks to himself.

Mental status examination: .

has some problems with

orientation and memory, besides seeming flat and confused. While he

denies hearing voices, he seems internally preoccupied as if hearing voices,

his thinking is tangential and sometimes bizarre, and there is evidence of

paranoia.

Clinical chart: There is a 11/2/99 diagnosis of Schizophrenia, Disorganized Type, and a 7/16/02 diagnosis of Schizophreniawith prescription of Zyprexa and Prolixin, and on 7/24/00 Mild Mental Retardation is diagnosed with IQ 65. Psychiatric hospitalizations prior to incarceration are noted. He was at CNYPC fiom 12/02until 5/7/03, transferred fiom Great Meadow SKU and back to Great Meadow SHU. Memory problems are also noted.

0% . is clearly suffering fiom psychosis, probably Schizophrenia,but also
has limited intelligence (his IQ is listed as 65) and possible organic brain disorder. Indeed, Mr. Brown was identifiedat Reception as suffering fkom both serious mental ilkess and mental retardation, and was referred to SNU (the SpecialNeeds Unit for mentally retarded prisoners) -but the recommendation was never followed.26 Instead, he is given ever longer SHU sentences for impulsive behaviors that occur while he is disorganized and psychotic. He was considered and rejected for STP at Five Points because of his behavior problems and intermittent non-cooperationwith eeatment. Even after being accepted to STP, he sits in SHU without STP programming because t h e is a long waiting list for STP admission. OMH staff agree SHU is an inappropriate place for him,given his mental problems, and yet he is disciplined(and, further, prosecuted) for

26 See SectionVI1.H for more detailed discussionofspecial Needs Unit.

JA 285

actions that are symptomatic of his mental illness and his conditionworsens in SHU confinement.

Further details about 8 pe clinical course are contained in the Deposition
of Dr. Algimantas Shimlcunas p6/3/2004). From Mr. Shimlamas' deposition O>p. 167-
201), it becomes clear that this prisoner is viewed as presenting both treatment and
security problems. Dr. Shimkunasis aware that he had been admitted to psychiatric hospitals in the community prior to incarceration and had been repeatedly diagnosed Schizophrenic in OMHIDOCS, but his diagnosis was changed at some point to Impulse Control Disorder at CNYPC. Dr. Shimkunas has testified at disciplinary hearings about this prisoner, utilizing progress notes from the clinicians who see him. Dr. Shimlcunas
believes this prisoner would benefit from STP, and placed him on the list for
consideration. However, o ~ P siill waits for placement in STP, and will not be
admitted any time soon because, according to Dr. S h i a a s , "there are over 40 patients on the wait list." But Dr. Shimkunasbelieves any prisoner who has assaulted staEcannot be in ICP. Dr. Shimkunas agrees that a progress note by Dr. Faruki reflsted "The patient's speech and behavior are very disorganized. He smears feces in his cell. He has
(I,
been seen to eat his feces. His speech is incoherent and irrelevant. He refuses to take his
medications." Dr. Shimkunas acknowledgesthat similar behaviors, related to this prisoner's mental illness, led to an outside court prosecution and additional time in SHU. When (p. 188) Dr. Shimkunas was asked a summary question, "'So some of the similar behaviors of smearing feces or throwing or floodingmay indeed have resulted in an additional criminal charges for this individual?," Dr. Shirnkunas replied, "That's right."
Dr. Shimkunas offered no response to the questionwhether it is appropriate to criminally charge a prisoner for behaviors driven by his mental illness, except to repeat that DOCS prosecutes such cases. When presented with a 1/26/01 memo from Sullivan Correctional
Facility pre-dating 0 '5 transfer to Great Meadow, which ends with a statement
that there is a plan to get this man out of SHU because of his serious mental illness so he can receive proper treatment, Dr. Shimkunas acknowledges that that letter (documenting
there had been a plan in place to get Q p. .out of SHU for three and a half years)
was not considered by the clinicians working with Mr. Brown at Great Meadow when he faced disciplinaryproceedings. I will mention another case.

v 74

- (Interviewed while housed in SHU at

Elmira Correctional Facility on 3111103.)

History:

V 4

has been in prison for three years and says he is

due to be released in one month. In further conversation, it became clear

that he was quite delusional and believes that he will be released in a month

only because he did a heroic act for which officers are grateful. He has

been in the SKU for two years, and said he was transferred to CNYPC on

three occasions. He has not gone to recreation because there is no

equipment and nothing to do in the recreation area except walk around in

circles. He told me he must get up at 6 A.M. and request an appointment

with mental health staff, or he is not seen. He was taking Zyprexa (an atypical anti-psychotic medication), 10 mg./day.

Mental status examination: d.

was actively delusional

during the interview; he talked about oKcers putting something in his food

that disturbs his sexual function. He believes officers were sexually

abusing him and reported more detailed delusional material, mostly sexual

in content. He exhibited flat affect, delusional thinking with strong ideas of

reference and very poor reality testing, rigid thinking, and slowed

cognition. His judgment was poor and he was unable to abstract. His

delusional thinking invades his sense of orientation. In other words, there

is much evidence of active psychosis, which seems to reflect persistence of

a chronic serious mental illness.

Clinical chart: The chart confirms much of his history. A 2/26/02 note contains the diagnoses Delusional Disorder and Intermittent Explosive Disorder, and it is noted he believes "People reading his thoughts with machines. Grandiose delusions 'I'm supposed to be a famous rapist."' He was transfened to CNYPC, his first admission, where a 4/02/02 Core History notes a past history of psychiatric hospitalizationprior to incarceration for three weeks in 1998. Zyprexa, 15 mg./day was prescribed.

At the time of a disciplinary hearing following an alleged May 17,2001 assault on officer(s),this prisoner was thought to be sufferingfrom "Intermittent Explosive Disorder." He had been prescribed Neurontin (a mood stabilizer), 600 mg./day, but had not taken that medication for a week prior to the alleged assault. It cannot be ruled out that at the time of the incident he was either suffering h m acute symptoms of what would later emerge and be diagnosed as psychosis, or that he was having a transient psychosis-like reaction to rapid cessation of Neurontin. The fact that he developed a full blown psychosis months later, with organized paranoid delusions(which take quite some time to evolve, and were probably already evolving at the time of the incident), points to a strongpossibility that he was becoming paranoid in the week prior to the 5/17/01 incident. But his mental condition seems not to have been assessed prior to the disciplinary hearing.

Clearly :

suffers fkorn psychosis, probably delusional disorder, and

he decompensates in SHU. His SMI is not sufficiently considered when he f a a s a

disciplinary hearing.

E. Prisoners with Serious Mental Illness Acquire Ever Longer SHU terms.

There are many practices and policies (including, among others, those described above) that extend the time in SHU for prisoners suffering h m SMI. For example, many prisoners suffering from serious mental illness receive even more tickets after entering S W , very often because of deterioration in their psychiatric condition that results from SHU confinement, and then their term in SHU is repeatedlyextended. The case below illustrates the problem. Of course, many of the other cases I describe throughout this Report also illustrate this problem."
,

&18%
linto on on 7/15/03.)

(Interviewed while housed in SHU at

History: This man has been in prison for five years on his second prison term. He has been in SHU since 2001. He has a long psychiatric history. He is prescribed Zyprexa, 25 mg. per day, a relativelyhigh dose of a strong anti-psychotic medication. He entered SHU for a six month term but has received more tickets while in SHU. When I asked him why that is the
case, he said he gets tickets in SHU because being in SHU makes him lose
control of his temper and become paranoid and depressed. He reads a little, but is concerned about a very short attention span.

Mental status examination: There was flat aEect and concreteness, consistentwith history. No signs of acute exacerbation of psychosis. Gave credible account of hallucinations.

Clinical chart: His chart reflects a single CNYPC admission in May, 2003. He had a diagnosis Psychotic Disorder NOS at that time, and exhibited regression and ''word salad" (a nonsensical stream of words). Prior notes include an urgent transfer from Upstate to Clinton on 8/16/01: "Undifferentiated Schizophreniawith history of suicidal ideation, auditory hallucinations, (mental status:) unstable, not oriented to time, place, some delusional thinking, and a diagnosis of Brief Psychotic Disorder." Other notes date to 2000, and consistentlydiagnose Schizophrenia He has been prescribed Zyprexa and Paxil, among other medications.

Clearly Qz suffers from recurring psychosis and should not be in SKU, where his symptoms worsen; in SIKT, he cannot control his temper, and he receives more

" These include I U

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tickets that lengthen his term in SHU. It is inappropriate to confine "

in sw at

Upstate due to the limited mental health services at that facility (see Section vI.I). The

behaviors that lead to subsequent tickets are likely driven by his worsening serious mental

illness.

F. Prisoners with Serious Mental Illness in Isolated Confinement are Not Diagnosed or are Un-diagnosed

At some point, many prisoners suffering fkom serious mental illness in SHU are essentially "un-diagnosed," meaning their diagnosis is changed from a serious mental. illness such as Schizophrenia to a less serious diagnostic category such as Polysubstance Abuse or an "Axis II"personality disorder such as Antisocial Personality Disorder.

In other words, they are no longer viewed as "mad," rather they are considered "bad," and henceforth their unacceptable behaviors will be met with punishments rather than more intensive psychiatric treatment. I will discuss un-diagnosis, malingering, psychopathy and so forth in Section VI. Here, I will outline the sequence of events I
discoveredin many cases I reviewed in NY DOCS,and then I will provide one
illustrative case:

There is a long history of documented mental illness, including suicide attempts, psychiatric hospitalizations and treatment with psychiatric medications with good effect, in many cases dating back to childhood and pre-dating incarceration. Often the prisoner had been on Social SecurityDisability benefits for psychiatric impairment In the communityor had his competency questionedby the courts.

When the prisoner is treated in the community or in prison for serious mental illness he is relatively functional between "breakdowns" (the term of art is "decompensation"), but when treatment is discontinuedhe becomes dyshctional and unmanageable, even by correctional standards. He violates rules or becomes assaultive and receives disciplinary tickets.

He is transfenred to SHUjust prior to marked deteriorationof his mental health condition. Either he receives the ticket that sends him to SHU while experiencing evolving psychiatric symptoms such as corihsion or command hallucinations, or his psychiatric condition deteriorates after he spends period of time in SHU.

In spite of a clear and obvious history of serious mental illness, at some point a decision is made that he or she is not actually sufferingfrom serious mental illness; rather, he is merely suffering fkom a minor form of emotional distress such as "Adjustment Disorder," or is "manipulativeyyor ''malingering," or suffersmainly from
an Axis II diagnosis such as Antisocial Personality Disorder or Psychopathy. In other
words, prisoners who had been diagnosed with persistent serious mental illness are "un-diagnosed."

Treatment is de-emphasized or discontinued, the inappropriate or sg;lf-destructive behaviors are viewed as willliil manipulations, and the prisoner is subjectedto krther punishments, usually involving even more time in SHU and more deprivations. This problem is magnified when the Mental Health Level is inaccurate. I found many prisoners with active and disabling serious mental illness at Upstate and Southport. This should not happen, because they should be considered Mental Health Level 1 or 2, and therefore, by policy, excluded from Upstate, or Level 1 and therefore excluded from Southport.

He or she accumulates even more disciplinary tickets, many that appear as if they might be driven by symptoms of a worsening and inadequately treated mental illness. Included may be tickets and lengthy terms in isolated confinement for symptomatic acts, such self-harm, unhygienic acts, flooding and setting fire to belongings.
* Since his or her mental illness has been u n - d i a g n d and subsequent unacceptable
behaviors are attributedto "badness" rather than "madness," punitive measures are instituted. These are often codified in Behavioral Management Plans. For example, he might be forced to remain naked except for a gown in a cold observationcell with few if any amenities, and he may be required to eat cold "loaf' instead of hot meals, and he may be precluded from future admissions to the psychiatric hospital, and clinical interventions for subsequent emotional crises may be ordered delayed or withheld.

The harsh conditions of confinement and deprivations exacerbate the mental illness, and the prisoner acts out even more, but because staff have decided he or she does not suffer &om a serious mental illness, continuing pleas for help are viewed as further manipulations and the possibility that he or she has been erroneously un-diagnospd is not given much thought.

The following case illustrates this general sequence:

1

8 9

(Interviewed while housed in General

Population at Clinton on 7/16/03).

History: This man spent nine years in SHU (or other form of isolated confinement). French is his primary language. He believes he was drugged and that is why he is confbsed now. He has a history of drug abuse. He claims he was admitted to the psychiatric ward at Bellevue Hospital prior to incarceration, and he insists voices come into his cell through the vent.

Mental status examination: This man is quite delusional, tangential and incoherent. He tells a long delusional story about how he was drugged, he describes a device that was used to control his mind by a woman he met in Bangkok, and he explains various colors he sees. When asked about his

psychiatric history, he denies he has a mental problem, starts to talk about being in observation in Feb., 2003, and then the story drifts into tangential incoherence.
Clinical chart: There is movement back and forth between Mental Health Level 1 and Level 6; a stay in observation on 2/6/03 because of paranoid delusional thinking involving druggings and the FBk an admission to CNYPC on 2/14/03; notes documenting delusions and diagnoses of Delusional Disorder, Adjustment Disorder with Disturbam of Conduct, and possibly Bipolor Disorder; mental status reflecting odd thinking, illogical and incoherent speech; loud, rapid pressured speech, a delusional belief he was being brainwashed through his penis; no psychiatric medications because he refused to take them; and discharge &om CESYPC on 3/12/03. Even though he was admitted to CNYPC because of delusional thoughts and confusion, the discharge note changes his diagnosis to Adjustment Disorder with Disturbance of Conduct, and no medications are prescribed because he refuses. But even the narrative hospital notes reflect delusional thinking and other signs and symptoms of psychosis. There is no attempt in the chart to reconcile the observed signs and symptoms of psychosis with the discharge diagnosis.
8 (-a ,~ e r dyelusional and psychotic. He is obviously sufferingfrom a
serious mental illness, probably Paranoid Delusional Disorder (possibly Schizophrenia). He says he does not want mental health treatment, but he has been admitted to CNYPC and observation, and was evidently discharged fiom the OMH caseload on 4/3/03 after he was un-diagnosed, i.e. his diagnosis was inappropriately downgraded from Delusional Disorder (a serious mental illness) to Adjustment Disorder. No responsible mental health clinician would have discontinued the Delusional Disorder diagnosis in the face of
835% , symptornatologyand psychiatric history. As a result of this un-diagnosis, mental
health treatment efforts ceased, with obvious detrimental eff-ects on R Q ,who was
severely psychotic by the time I interviewed him.
Other cases wherein a prisoner's diagnosis is improperly downgraded or the prisoner is undiagnosed are discussed in some detail later in this I2epod8; like many of the other problems described in this section "The Path to Isolated Confinement for Prisonerswith Mental Illness," the problems that lead to so many prisoners with S M being housed in isolated confinement reflect serious problems in the delivery of mental
health care to all prisoners in DOCS. See Section VI.

< - 'a See. for example, cases such as

%

/-
+ ; 4a 3 G . 5

D3j3 A.L-

and others. Many of the above cases{and others like them) are included in SectionVI of this

Report.

G. Prisoners with Serious Mental Illness Cycle Repeatedly From SHU to Observation or CNYPC and Then Back to SHU
A vicious cycle evolves, in which a subset of prisoners s e e r i n g from serious mental illness are housed for long periods in S W on account of bad behavior, but periodically become acutely psychotic or suicidal and have to be transferred to observation or CNYPC. After they settle down, and their medications are adjusted, they are sent back to SHU, where their condition deterioratesuntil they need to be sentback to observation or CNYPC again. OMH's own clinicians recognize this
There is also another kind of vicious cycle that leads to heightened animosity between prisoners and staff. When human beings who are suffering from serious mental illness are subjected to extremes of isolation and idleness, and are denied social contact a and just about all lack the means to express themselves in a constructive manner, it is entirely predictable that they will resort to increasingly desperate and bizarre acts to achieve some degree of control of their situation and to restore some modicum of selfrespect. The disturbed prisoners in isolated codinernent who are suffering h m serious $0 mental illness are then likely to be perceived by officers as disrespectful or rule-breaking; the officers, in turn, become increasinglyinsensitive, punitive or even abusive toward the identified troublemakers.
Prisoners housed in isolated confinement have been deprived ofjust about all the amenities and freedoms we usually take for granted as basic human requirements. They continue to be dissatisfied with their plight and they get into M e r trouble with stafT. There is then little else that correctional staff can take h m them. Through the disciplinaryprocess, prisoners can then be put on a restrictive diet (the "loaf"). In addition, security staff can order a cell shield, a lexan cover over the front of the cell, which further restricts air circulation and communication. Such deprivations and humiliations cause suffering, and in many cases more symptomatic behavior, in prisoners with serious mental illness. Thus, a prisoner who is hearing voices or who is seriously contemplating suicide may find himself in an isolation cell behind lexan, eating cold "loaf," and his growing rage makes the voices in his head seem louder or his thoughts of suicidemore compelling. The scene is shockinglyreminiscent of the bedlam that prevailed in the back wards of state hospitals in the 1940s and 1950s.
Often it seems that the more prisoners cycle, the more firmly mental health staff are convinced certain prisoners are ubad'' and not Kmad,nthe more tickets these prisoners receive, and the longer their SHU term becomes. According to the Correctional Association of New York: "From our sample, the minimum SHU sentence was one month, the maximum sentencewas 12 years. Noteworthy is that the average
29 In a presentationdated May 27,2003, John S. Wilson, Ph.D., then chiefpsychologistof U W P C , describedthe followingcycle:disciplinary confinement, mental deterioration, transfer to CIWPC, stabilization and transfer back to disciplinary confinement,where the cycle begins again. (Pl. Ex.466).

SHU sentence reported by inmates with mental illness in our sample was six-and-ahalf times longer than that of inmates generally: 38 months compared to the Dep;utment9sfigure of 5 months for inmates generally "30

I have already described a number of such cases, but I will include one more here, a case that illustrates many of the points I have made in this section:

f

, . , . (Interviewed while housed in SHU at

Clinton on 8126103).

History: This man has been in prison since 1994. He explainedhe is in observationbecause he stopped taking his Lithium (mood-stabilizer prescribed for Bipolar Disorder) and Thorazine (older anti-psychotic). He believes the Thorazine made him see things on the walls, and he reported this to Oh4H staff. He was admitted to Mid-Hudson Hospital three or four times while in jail; he has been admitted to CNYPC twice since admission to DOC. He was in ICP at Clinton, but was placed on Keeplock and removed fiom ICP. He has a history of command hallucinations linked with suicide attempts prior to incarceration. He was placed on Keeplock for throwing cereal; he reports that he believed the staff were playing with his food and the cereal had hairs in it.
Mental status examination: 3:%% appeared agitated, confused,
disoriented, and internally preoccupied as he talks about voices. His speech was slowed, he stared in a bizme manner, and clearly suffered h m ideas of reference. He cannot abstract. He told me he cannot read because weird thoughts intrude into his consciousness. He had very strong First Rank Symptoms (signs of psychosis that are very difficult to feign - see Section VI.1.2).

Clinical chart: His chart repeatedly reflects many suicide attempts, depression and paranoia, with borderline or low intelligence. On 10131/02 he was admitted to ICP with diagnoses of Psychotic Disorder NOS and Borderline Intellectual Functioning. He was prescribed Risperdal(3 mg. bid.) plus Vistaril (a minor tranquilizer) and Benadryl, but took them inconsistently, so medications were discontinuedon 11/26/02. In an ICP Progress Note, it is reported that he has "extensive history of inpatient psychiatric treatmenty'dating back to 1995. On 3/23/03 he is discharged from ICP with a note he has been in four fights while there and will not be accepted back in ICP, even though the ICP discharge note reflects paranoia,
depression and hallucinations, and a diagnosis of Psychosis NOS. By 313 1 he was in observation. He is sent to Upstate, but a 4301 transfer to Great

30 See The CorrectionalAssociationof New York, "MentalHealth in the House ofComtions," June,
2004.

Meadows is arranged because "ere is no way he's going to make it in this facility" (Upstate). In June, 2003, he was sent to CNYPC with a diagnosis Psychotic Disorder NOS. Notes fiom CNYPC include a long psychological assessment by Dr. Michael Guariglia, with diagnoses of ASPD on Axis I1 and non-compliance with treatment on Axis I. Nevertheless, the psychologist claims there is no major mental illness. A 7/22/03 Behavior Management Plan recommends that he not be sent back to CNYPC. Still, he is given multiple injections and pills of Thorazine 150 mg, Haldol, etc. A 7/28/03 psychiatric consult notes he is not suAFering fkom Psychosis NOS, nor Mental Retardation, but has Antisocial Personality Disorder. Nevertheless, a few weeks later, on 9/2/03, it is
noted that he "seems to be listening to inner voices.. .and talking to
himself." Paranoia is noted on 9/16/03. He was subsequentlyre-admitted to CNWC and released in April, 2004 (per NY DOCS website).
was clearly acutely psychotic when I interviewed him on 8/27/03. He had recently returned fiom CNYPC where he was un-diagnosed and put on a Behavior Management Plan. Still, progress notes reflect active psychosis and paranoia, and he is on dosages of anti-psychotic and mood stabilizing medications that would not be appropriatefor someonewho does not suffer from a serious mental illness. In spite of the un-diagnosis, he continues to cycle fiom SHU to observation and CNYPC and then back to SHU. As a result of OMH staffs "un-diagnosing" him, a coherent treatment plan is lacking, leaving him little chance of maintaining emotional stability.
V. The Effect of Isolated Confinement on Prisoners with Serious Mental Illness
A. The Phenomenon
It has been known for as long as segregated housing has been practiced in prison that human beings suffer a great deal of pain and mental deteriorationwhen they remain in isolated confinement for a significant length of time. (I employ the term "isolated confinement" to include punitive segregation as well as restrictive housing of any kind,
including Special Housing Units or (SKU), Keeplock and other situations within NY
DOCS where prisoners are confined to their cells for nearly 24 hours per day, eat meah in their cells, and there is near total isolation and idleness). This is especially the case for prisoners who suffer fiom mental illness. Thus, in 1890, the U.S. Supreme Court found that "[a] considerable number of prisoners fell, after even a short confinement [in isolated confinement], into a semi-fatuous condition, fiom which it was next to impossible to arouse them, and others became violently insane; others still, committed suicide; while those who stood the ordeal better were not generally reformed, and in most cases did not recover sufficient mental activity to be of any subsequent service to the community.'"' In fact, New York's Auburn Correctional Facility was the location of an experiment with
3' In re Medley, 134 U.S. 160, 168 {1890].
JA 214

prolonged isolation in the Nineteenth Century, which was declared a "hopeless fiiilwe" by historian Harry Elmer Barnes, who writes that it "led to a marked prevalence of sickness and insanity on the part of the convicts in solitary ~onfinement."~~
Human beings require some degree of social interaction and productive activity to establish and sustain a sense of identity and to maintain a grasp on reality. In the absence of social interactions, unrealistic ruminations and beliefs cannot be tested in conversation with others, so they build up inside one's mind and are transformed into unfocused and irrational thoughts. Without social interactions, individuals have no way to test the reality of their fantasies, and thus there is a tendency toward paranoia and an inabilityto control the rage that mounts with each perceived insult.33
Productive activities serve as a basis for testing the reality of imagined thoughts, for maintaining a sense of one's worth or selfesteem, and for testing the wisdom of acting out inner impulses, and they provide a necessary outlet for physical and psychological energy. Where productive activities are severely restricted, the resulting idleness multiplies the effects of social isolation.
Prisoners in segregationdo what they can to cope. Many pace relentlessly. Those who can read books and write letters. But many prisoners are illiterate. Nationwide, at least 40% of prisoners are functionally illiterate," and evidence is accruing that illiterate prisoners fare less well than others in isolated confinement. This makes sense; if one is alone in a cell nearly 24 hours per day and cannot even read the newspaper or write a letter, the sense of unreality and isolation is likely to grow. Prisoners prone to or suffering fiom mental illness have even more difficulty concentrating than do others, and many,on account of anxiety or hallucinations or obsessions or despair, find it impossible
to read or write while restricted to a cell. I interviewed many prisoners in the NY DOCS
who cannot or do not read or write. Some are illiterate, some have been denied pen and paper for disciplinary reasons or because staff fear they might harm themselves, and some
''H. E. Barnes, ''ne Historical Origin of the Prison System in America, Journal of Criminal Law and
Criminoloz!y35-60, 1921, p. 53, cited in amicus brief by mental health experts to U.S. SupremeCourt in Wilkinson v. Austin, March, 2005, p. 8
33 An example fiom everyday life in the community: I walk into a room, two people are talkiug and lower their voices as I enter. I have the momentary fantasy they were talking about me and that's why they lowered their voices when I walked in,I approach them and their fiiendly greetings disabuse me of what I
now can judge to be an erroneous and paranoid fantasy on my part. This kind of reality testing goes on in everyone's daily life. We have suspicions, negative thoughts and fears, and our subsequent interactions with others permit us to test their reality. Prisoners in isolated confinelnenthave no opportunityto 'Lheck out" their possibly paranoid projections with a sympathetic fiiend. This is merely one example of the debilitating eEects of such confinement.
j4The Center on Crime, Communities, and Culture, "Education as Crime Prevention." Research Brief, Occasional Paper Series, Sepr., 1997, VoL 2, New York: Center on Crime, Communities, andCu1ture.

are so plagued by inner ruminations or so dominated by anxieties or hallucinated voices that they cannot sustain the concentrationrequired to read or write.
In the context of near-total isolation and idleness, psychiatric symptoms emerge in previously healthy prisoners. For example, a prisoner may feel overwhelmed by a strange sense of anxiety. The walls may seem to be moving in on hirn(it is stunninghow many prisoners in isolated confinement independentlyreport this experience). He may begin to suffer from panic attacks wherein he cannot breathe and he thinks his heart is beating so fast he is going to die. Almost all prisoners in SHU tell me that they have troubb focusing on any task, their memory is poor, they have trouble sleeping, they get very * anxious, and they fear they will not be able to control tbeir rage3' Other researchers report these symptoms in a large majority of prisoners in isolated ~onfinement.T~h~e prisoner may find himself disobeying an order or inexplicably screaming at an officer, *whenreally all he wants is for the officer to stop and interact with him a little longer than it takes for a food tray to be slid through the slot in his cell door. Many prisoners in isolated confinement tell me it is extremely dificult for them to contain their mounting rage, and they fear losing their temper with an officer and being given a ticket that will 1') result in a longer SHU term.
B. The Literature
Social scientists have been studying the effects of isolated confinement for many years. In an early study, Cormier and Williams studied 21 prisoners in prolonged segregated status and noted a marked increase in verbal aggression, physical destruction of surroundingsand development of paranoid ideas, in somecases related to evolving psychosis.37
Hans Toch summarizes the hundreds of interviews he did with prisoners, many in long-tenn isolated confinement in New York State DOCS correctional facilities3* He coined the term "isolation panic" for the symptoms he regularly discovered in the men, including panic, rage, a sense of total loss of control, an experience of emotional breakdown; many exhibited very regressed behavior and many resorted to self-
35 OMH has long known about this problem. See 10/15/03 Email from Don Sawyer to Richard Miraglia and Hal Smith [OMHCNY 089934-0899361.
See B., below.
"Bruno Cormier & Pad Williams, "Excessive Deprivationof Liberty, Canadian Psychiatric Association Journal, 11,470-484, 1966.
38 Toch, Ham,Men in Crisis:Human Breakdownin Prisons, Chicago:Aldine, 1975, pp. 20.

m ~ t i l a t i o n ~T~oc.h distinguishedbetween incarceration,which is diEiult but tolerable, and isolated confinement, which is not tolerable for many.
Social psychologist Craig Haney has conducted research with a large number of prisoners in isolated confinement. He randomly selected prisoners and found very high prevalence rates for a large list of emotional symptoms. Over 80% of the prisoners reported massive anxiety. Likewise, over 80% of the prisoners complained of headaches, troubled sleep, and lethargy. Over half complained of nightmares, h a r t palpitations, violent fantasies, depression or despair, and fear of impending nervous breakdown. Complaints of obsessive ruminations, confused thought processes, oversensitivityto stimuli (a strong startle reaction), irrational anger and social withdrawal were widespread.40
Psychiatrist Stuart Grassian examined a large number of prisoners during their stay in segregated, near-solitary confinement units and concluded that these units, like the sensory deprivation environments that were studied by psychologists in the 1960s, often induce psychosis, especially in prisoners who have histories of mental illness or a predisposition to psychiatric breakdo~n.~'
I will not review all of the research literature here, but there has been a substantial amount of research into the hannful effects of isolated confinement, especially if the prisoner thus copfined suffers fiom a serious mental illness or is vulnerableto mental illness. In their amicus brief in Wilkinson v. Austin, leading mental health experts summarize the clinical and research literature about the effects of prolonged isolated confinement and conclude: "No study of the effects of solitary or super-ax-like confinement that lasted longer than 60 days failed to find evidence of negative psychological effects" (p. 4).
It has been my experience, fiom tours and well over a thousand clinical interviews with prisoners in isolated confinement units in ten states, that the conditions that cause emotional distress in relatively healthy prisoners cause psychotic breakdowns, severe
39 Ibid., pp. 38-43.
40 Haney, Craig, "Mental Health Issues in Long-Term Solitary and 'Supemax' Coniinemnt," Crime & Delinquencv, 49,124,127,2003.
" Even prisoners who do not become frankly psychotic fkquently report a number of serious psychiatric
symptoms, including but not limited to: a. Massive fi-ee-floatinganxiety; b. Hyper-responsiveness to external stimuli, including a startle response; c. Perceptual distortions and hallucinations in multiple spheres (auditory, visual, olfactory); d. Derealization experiences; e. Difficulty with concentration and memory; f. Acute confusional states, at times associated with dissociative features, mtism, and subsequent partial amnesia for those events; g. The emergence of primitive, ego-dystonic aggressive fantasies; h. Ideas of reference (paranoia) and persecutoryideation, at times reaching delusionalproportions; i. Motor excitement, often associated with sudden, violent destructive or self-mutilatoryoutbursts; andj. Rapid reduction of symptomsupon termination of isolation. Grassian, Stuart, "Psychopathological Effects of Solitary Confinement," American Journal of Psvchiatrv, 140, 11,1450-1454, 1983.

affective disorders and suicide crises in prisoners who have historks of serious mental illness, as well as in a certain number of prisoners who never suffered a breakdown in the
past but are prone to break down when the stress and trauma become exceptionally severe. Also from my experience, I have determined that the longer the period of isolzted confinement, the more likelythat these negative effects will omur (although in some cases of serious mental illness, a particularly vulnerable prisoner will be unable to tolerate isolated confinement even for a day). Dr. Grassian's list of psychiatric symptoms that regularly appear in relatively healthy individuals provides a clue to why prisoners prone to mental illness suffer breakdowns and despair. When an average individual who is placed in an environment develops massive fi-ee-floatinganxiety, hyper-responsiveness, paranoid ideas, confusion,perceptual distortions, motor excitement and so forth, and becomes frightened he will not be able to control his aggressive fantasies,just imagine how difilcult it would be for someone who is prone to paranoid psychosis or suicidal despair to remain balanced. Dr. Orassian's last reported psychiatric symptom, the rapid
reduction of symptoms upon termination of isolation, may or may not occur -in my
clinical experience, once an individual crosses a line into psychosis or depressive despair, it is very possible that removal fi-om the harsh conditions of isolated confinement will not be sufficient to bring him or her back to a normal mental state!* I have reported my
findings to courts (see Appendix A) and published my finding^!^

C. My Findings from Interviews and Chart Reviews of Pris~nersin Isolated Confinement in New York

My interviews with prisoners in New York DOCS entirely confirm this general understandingof what happens to prisoners prone to mental illness in isolated confinement. In prisoners with a history of or vulnerabilityto psychiatric breakdown, irrational thoughts and primitive, disorganized behaviors often emerge. Internal impulses linked with anger, fear, hopelessness and other strong emotions grow to ovexwhelming proportions.

Many, if not all, of the prisoners discussed previously in this Report, demonstrate this suffering. A prisoner who suffers fi-omserious mental illness explained what happens to him in SHU:

Vd5

(Interviewed while housed in ICP at

Great Meadow on 8/27/03).

42 Once again, OMH officials have long recognized this problem. Richard Miraglia, Associate Commissioner of OMH Division of Forensic Services, testified in his depositionthat he does not support the conclusionthat the psychological effects of isolated codiuement are short-term (Miragiia Tr. 132-133).
"Kupers, Terry, Prison Madness: The Mental Health Crisis and What We Must Do About It. San
Francisco and New York: Jossey-BasdWiley, 1999.

History: This man had been in prison for five years and was planning for release in three months. He had been in ICP for one year. Before that, he had been in S W for 90 days, and before that in GP. He went from SHU to
CNYPC (five months) and then was transferred to ICP. in SHU, "I wasn't
myself, I was real paranoid - after I got out I was OK. The voices were
worse in SHU, I always thought people were talking to me." He was
prescribed Lithium and Zyprexa. He cycled several times between S E W
and observation before being sent to CNYPC. He said that in SHlJ he f e l s closed in, claustrophobic, and then he gets paranoid and angry. He likes ICP and does group therapy. He had been victimized as a "bug outy7in General Population. He went to yard in ICP, but never did in SHU because he didn't trust the others.

Mental status examination: There was a thought disorder, flat affect, concreteness, and other signs consistentwith a diagnosis of Schizophre~a.

Clinical chart: His chart corroboratedthe history he gave me.

Another prisoner with serious mental illness explained to me the effects of

isolated confinement on him:

.r5*.

. (Interviewed while housed in observation

at Sing Sing on 5/7/03).

History: This man had been in prison "off and on" for seven years, and was going home in 12 days. He had been at Arthurkill Correctional Facility, where he was put in "the Box" (SHU) and then transferred to "the Box" at Sing Sing. He had two psychiatric hospitalizations in the community, for a total of 18 months on psychiatric wards prior to incarceration. In spite of this history of pre-incarceration mental illness, he felt he was mentally stable in prison until he arrived at the Box, and then, as soon as the door to his cell was closed, "I began to feel the room was shrinking and I couldn't breathe." He described a panic attack. He said "I never felt claustrophobicbefore." As soon as "the hatch" of his Box -cell
was opened "I feel better!" He described worsening paranoia in the Box -
"every noise seems loud" -he had been hearing voices previously, only partially controlled by medications, but he said "The voices became much worse as soon as I was put in the Box -I 'lost fmm' - I couldn't concentrate on anything." Also, he experienced mounting rage and "I was afraid I wouldn't be able to control it." He told "the doctory'that he would have to hurt himself if left in the Box; the doctor talked to him about this at
cell-fiont (never in the privacy of an office). When the doctor failed to
return to see him, he put a sheet over his head - he proceeded to explain
that he did not have a bag, and he figured he could treat his trouble

breathing during a panic attack with a sheet as a substitute for a bag (it is true that one of the ways to counter the hyperventilation of a panic attack is to breathe into a paper bag, but a sheet would not serve as a substitute).

Mental status examination: He talked very fast, reflecting pressured
speech-there was a defmite manic feel to his presentation. Re seemed to
have some thought disorder and concreteness.

Emotional harm is made even worse by sleep deprivation, and very many of the prisoners 1interviewed in New York prisons report that on account of the noise, or due to ' increased agitation or anxiety they have suffered since being confined in SHU, they have suffered &om severe insomnia Loss of sleep intensifies psychiatric symptomsby interfering with the normal diurnal rhythm (the steady alternation of day and night that $provideshuman beings with orientation as to time), and the resulting sleep loss creates fatigue and magnifies cognitive problems, memory deficits, confbsion, anxiely, and sluggishness. In other words, prisoners vulnerable to psychiatric breakdown are more likely to suffer breakdowns in situations that cause sleep-deprivation, and many of the $4 prisoners I interviewed told me that they have been having serious problems sleeping since being confined in SHU, and their sleep loss is associated with worsening psychiatric symptoms.

Another prisoner suffering from serious mental illness explained to me that his mental disorder was aggravated by isolated confinement, while at the same time he experienced other symptoms that were not part of his mental disorder prior to SHU confinement:

-324-
Wende on 9/25/03).

J. (Interviewed while housed in SHU at

History:

- had been in prison for four years and in SHU since

July, and he spent six months in SHU at an earlier time. He suffers h m

Bipolar Disorder and has attempted suicide on multiple occasions. He

made several suicide attempts prior to incarceration and was admitted to

Bellevue psychiatric ward and at least one other hospital, for depression

plus auditoryhallucinations-he heard his mother's voice telling him to kill

himself. He was prescribed both anti-psychotic and antidepressant

medications. His symptoms became much worse in "the Box." Me made a

suicide attempt in S W , and he has received many tickets in SHU. He

cannot read in SHU because of concentrationproblems, but out of SEW he

is an avid reader. He had problems sleepingthat are much worse in SHU.

He described missed meals, showers and recreation because the

correctional ofilcer who announces them either does not call out that he is

coming by or ignores him. When he gets depressed, which is especially

likely in SKU, he gets into arguments with correctional officers. He

described himself as a perfectionist, trying to explain why he cleaned his

cell four or five times per day while in Sf-fU. He has been repeatedly admitted to observation and then sent back to S W , with continuation of anti-psychotic and antidepressant medications.

Mental status examination: This examination is entirely consistent with a diagnosis of Mood Disorder with Psychosis.

The architecture and policies in the SpecialHousing Units (SKU) of the W DOCS are designed to foster isolation and idleness. Sensory deprivation is not total officers pass by to give out food trays, make rounds or perform "counts," and there is the intermittent slamming of doors and it seems from the prisoners' stories and my own
observations that there is much loud yelling -but this kind of company and noise does
not constitute meaningful human communication. And by design, there is a minimum of programming, almost no educational activities, little if any substance abuse treatment, and what is termed recreation amounts to little but a trip to a small fenced-in area where there is no athletic equipment. The recreation pens are very small, the prisoners are in a pen by themselves (an exception is Bedford Hills where the exercise can be congregate), there is no athletic equipment, and many prisoners told me it is not even worth going to recreation since there is nothing to do.

Many of the prisoners suffering from serious mental illness in SHU reported deterioration of their condition as soon as they were transferred to isolated confinement. There are many examples. Here is another:

LLZ, on 7/15/03).

(Interviewed while housed in SHU at Clinton

History: This man was returned to prison on 7/25/00. He had been in general population at Attica and was taking psychiatric medications. Staff were fixing a toilet and found a "shank." He claims that they erroneously thought it was his; he was given a SHU term until 2007. He has many more disciplinary tickets, most of them received while he was in SHU. He was in the Attica SHU for 18 months with no time on the yard, he did tbe STP program but was "kicked out." He complained of claustrophobia, feels the world is against him, and told me when he gets angry he hears voices. He has been in psychiatric treatment since age 12, and was in a psychiatric hospital for evaluation during court procedkgs. He has been prescribed Risperdal in spite of being given a diagnosis of Adjustment Disorder. He stated clearly that his paranoia increases in SKU. He told me he does not like to take psychiatric medications because the correctional officers "hassle" guys who take meds. He described a '%reakdown" where
he becomes confused when frightened about a cell extraction. He used to
read when he was in GP, but he told me that inSIWJ he cannot comprehend what he reads.

Mental status examination: He seemed concrete, reported voices (giving some details) and exhibited ideas of reference and significant anxiety; here was some tangential thinking. It was difficult to assess paranoia because his claims about harassment by correctional officers might contain some reality- but he claimed people tamper with his mail and his thoughts. He is moderately positive for First Rank Symptoms, a very good indication of Schizophrenia.

D. Deterioration in Isolated Confinement is not limited to Prisoners with Psychosis and Severe Mood Disorders

The suffering and decompensationexperienwd in isolated confinement is not limited to prisoners with Schizophrenia,Major Depression or Bipolar Disorder. To cite one more example, the suffering of someone who is diagnosed PosttraumaticStress
Disorder - a condition with a high incidence in the DOCS population44- is made worse
by isolated confinement. For many prisoners, the trauma of isolated confinement replicates earlier traumas. I will present one case of many I encountered, where the trauma of isolation replicated earlier traumas and thus greatly exacerbated Posttraumatic Stress Disorder and other mental illnesses:

t4 k=-

Qnterviewed while at Albion on 9/24/03).

History: This woman was recently transfmed out of SHU. She has been in prison for several years and should be released in February. As a girl, she was put in a closet as punishment. She suffers flashbacks, panic, startle and other post-traumatic symptoms, all much worse in SHU. Shesaid OMH does not help her. She was takingno medications at the time of our meeting, but she had been taking Prozac, Depacote [mood stabilizer) and Celexa (antidepressant). She eventually r e h e d the medications because
they were given in too high a dose, causing side effects, and she was
receiving no counseling. She came to Albion in July, 2002. She had a terrible time in SHU, "flipping out" with anxiety attacks; she felt closed in, paranoid, and ignored. She associatedbeing in SHU with being in the
closet as a girl. Her mother beat her and locked her in the closet. She was
taken fiom her mother at 11.

In SHU, she cried a lot and had painful memories. And in SHU without medications, she got depressed and anxious, and became aggravated and

"Terry Kupers, "Trauma and its Sequelae in Male Prisoners," American Journal of Orthopswhiatnf, 66(2),
189-196,1996;Angela B r o w , Brenda Miller and Eugene Maguin, "Prevalenceand Severity of Lifetime Physical and Sexual Victimization Among Incarcerated Women," Int'l Journal of Law and Psychiatn, 22,3-4,301-322, 1999. Dr. Donald Sawyer testified that between 40 and 60%of male prisoners in DOCS and an even higher percentage of women have histories of signifcantprior sexual and physical abuse
(Sawyer Tr. 201-202).

got into fights, which led to tickets and more SHU time. She had migraine headaches in SHU. She tried to tell staff about the closet, but they didn't listen. She had flashbacks to abuse by her mother; in addition, she had nightmares, and she had phobias about rats and dogs biting her. She was better when taking Prozac 60 rng. She did not go to recreation when she was in SHU because she was afkaid the officers would tear up her cell doing a search. She told me officers use searches to harass prisoners, and they subjected her cell to more searches because they knew she couldn't control her temper. She was hoping she could stay out of trouble for the short time left in her term so she could leave without doing more time in
sm.
Mental status examination: This very intense woman was obviously anxious and became more so as she talked about painful subjects; she also became sad. She presented a credible history of the intrusive and constrictive symptoms that are consistent with the clinical picture of Posttraumatic Stress Disorder.
Clinical chart: Her chart contained a history of pre-incarceration psychiatric hospitalization and diagnoses of Psychosis, Depression and Posttraumatic Stress Disorder.
Dr. Angela Browne, who interviewed OMH and Corrections staff at Bedford Hills Correctional Facility at the behest of Commissioner Goord and Superintendent Lord in the wake of a rise in self-harmingconduct, expressed concern about isolation in SHU serving as a re-traumatization for women who had been repeatedly traumatized, both physically and sexually, prior to in~arceration.~'
E. The Disproportionate Number of Suicides in Isolated Confinement Demonstrates the Risks of Placing Prisoners with Serious Mental illness in Isolated Confinement
Suicide is a huge problem in isolated confinement- and despair, depression and thoughts and plans of suicide are widespread in NY DOCS' SKUs. OMH statistics for 1998 through 2000 (report of 6/4/02) reflect that in 1998 there were 14 suicides statewide, five occurred in SHU and one in Keeplock. In the same time period 3% of prisoners were housed in SHU and 5% in Keeplock. Thus 36% of all the successfiil suicides in the entire department occurred within the 3% of prisoners confined in SKU. As it turns out, in other years there was even a greater disproportionof suicides in isolated confinement. 1999 figures reflect that 50% of suicides in the entire population occuning in the 8% of prisoners confined in SHU or Keeplock, and 25% of all suicides
45 Angela Browne Report, 2002 (Pl. Ex.11I), p. 12; SuperintendentLord agreed that such re-traumatization may occur (Lord Tr. 109-111).
JA 223

statewide occurred in the 4% of the population confimed in SHU. In 2000,43% of suicides in the entire corrections department occurred in the 4% of the population in S W . Plaintiff's counsel in this case prepared a chart of suicidesbetween 1995and mid-
2004, which demonstratesthat in those years 53 of the 119 known suicides, or 45% ,
involved prisoners assigned to some form of isolated confinement.
Despair is bred by conditions of long-term isolated confinement, and this is a large part of the reason so many prisoners I interviewed in the SHUssuger fiom severe depression and so many are suicidal. To mention just one factor among many, a prominent sign of serious depression is hopelessness. Hopelessness is bred when the end a of an ordeal is not within view, and intensifies when the end of an ordeal becomes unimaginable. In isolated confinement units, depression is as prominent on the list of psychological symptoms as are anxiety, paranoia and rage.
But there is an additional aspect of isolated confinement in the NY DOCS that
exacerbates depression: the indeterminancy of SHU terms. By policy and practice, there
is no time limit to SHU confmement in NY DOCS. Mrhile there are some guidelines as to
'I' how much SHU time can be given for some inhctions, hearing officers have large discretion in determining how much SHU time to issue. While each sentence to SHU, determined by a hearing officer, has a finite length to it, in practice, prisoners in SHU tend to receive more tickets after they arrive in SHU, and this lengthens their term in SHU, often with no end in sight. This is especially the case if the prisoner suffers from a serious mental illness. Prisoners with serious mental illness have more trouble than nondisturbed prisoners remaining in control of their tempers when they are in isolated confinement. The typical pattern is for them to get more than their usual number of tickets after they are consigned to SHU. The result is that many prisoners with SMI feel hopeless about ever getting out of SHU, which magnifies their despair. That despair is further magnified because the presence of disciplinary tickets has a negative influence on a prisoner's chances for parole. Many prisoners with serious mental illness told me that they truly believed they would never be released from SHU -because they would receive
more tickets on account of behaviors they were incapable of controlling in SHU setting-
and they told me that they would lose "good time" on account of being sentenced to SHU, and they did not think they would be granted parole. All of these factors exacerbate their sense of hopelessness and despair, and no doubt increase the risk of suicide.
I am quite troubled that in a study of suicide risk factors in MY DOCS by CNYPC:~ there is hardly any mention of the fact that isolatedconfinement is a very significant risk factor for suicide. Whether one employs the OMH: figure that 34% of successful suicides involve prisoners consigned to SHU or Keeplock, or the 45% figure that I believe is more accurate, isolated confinement is a very significant risk factor for suicide. But in their study of suicide risk factors, OMH of£icials list such risk factors as mental illness, history of past attempts, substance abuse, bad news, and "prison
46 "Suicide Risk Factors in New York State Prisons." By Bruce Way, Richard Miraglia, Donald Sawyer, Richard Beer, and John Eddy, November 13,2002.

stressors," but they do not discuss the effects of isolated confinement- even though in
several of their depositions,these same officiats testify that S W confinement or isolated confinement exacerbate mental illness and despair.
It is not unusual to find a prisoner who received only occasional tickets prior to the one that landed him or her in SHU, but then, once in S W , that same prisoner accumulates dozens of tickets, many of them Tier 3 tickets that result in an even longer SHU term. I have explained some of the reasons for this, including the mounting rage that tends to grow out of control in SHSJ, the deterioration of one's mental condition, and the often resulting repeated hostile interactions with staff. Prisoners are correct in their perception that serious mental illness makes it very difficult, if not impossible, to control one's temper and conform one's behavior to expectations in a SHU setting so that one can remain free of tickets and eventually gain release &om isolated confinement. The subjective sense many prisoners shared with me is a loss of all hope of ever leaving SHU. This kind of hopelessness adds to the despair and depression and drives many prisoners with serious mental illness in SHU to contemplate self-destruction, and then to act on their suicidal ideas.
When prisoners sense that staff do not take their pain and despair seriously, but rather view them as "malingerers" or problem prisoners whose only mental illness is Antisocial Personality Disorder, they experience even more despair. It is no accident that as many as nearly half of suicides that occur in DOCS take place in isolated confinement, or involved prisoners who are serving a term in isolated confinement. Of course, the ultimate tragedy occurs when the despair becomes overwhelming for the prisoner, but over-concern about malingering or manipulations leads mental health staE to miss what would otherwise be clear signs of an impending suicide. When these two phenomena combine, a prisoner may succeed in ending his or her life. I have described many cases of prisoners with serious mental illness making suicide attempts and cycling from SHU to observation and C N W C and then back to SHU. I will mention a few tragic cases where prisoners have succeeded in their attempt, and the death is clearly connected with isolated
confinement. Of course, in these cases, I did not have an opportunity to interview th prisoner before his or her demise, and thus unlike in other cases presented in this report, I
did not have an opportunity personally to take a history and I cannot provide my own mental status examination. I did review the clinical chart and/or I reviewed reports of investigations of the deaths.
This 17 year old male had been admitted to Downstate Reception on 1/26/01, and he died by hanging in his isolated confinement cell on 3/16/01. Review of his clinicaI chart reveals he had a history of previous
psychiatric hospitalizationseeneciictine Hospital in Kingston, NY)in the
community since age 12 for behavior problems, for which he was prescribed anti-psychotic and mood-stabilizing medications. He grew up in

group homes and had a history of substance abuse. At Downstate he was on the OMH caseload and was assigned Mental Health Level 2. His diagnosis on 1/26/02 was linpulse Control Disorder NOS and Personality Disorder NOS. A core history on 1/26/01notes allergy to Thorazine, denial of past suicidal behaviors, and anxiety about being in prison. The note recommends follow-up by a psychiatrist and supportive psychotherapy. As of 1/30/01he was prescribed the anti-psychotic medication, Risperdal, 2 mg. per day. A Nursing Assessment on 2/6/01 notes depression, seizure disorder and head trauma, and provides this psychiatric history: "Psych. History since '95. Hospitalized a few times for clinical depression. Becomes 'explosive' when confronted with his issues." On 2111/01he is admitted to RCTP "Upset, c m g and stressed out," per a call from the Block Officer. A statement by the patient of 2/22/01: "The MH services have been helpful but I have not been seen often. The medication does its job, but I need to talk about my problems, too." The treatment plan includes a 15 minute meeting with a nurse when medications are started and then monthly. On 2/12/01 the Risperdal was discontinued and he was prescribed the anti-anxiety agent, Atarax. He was placed in Keeplock in early February, and released on 3/9/01. He was receiving supportive psychotherapy and Atarax, and was to return to see the counselor a week &om 319.
The NYS Commission of Correction Report of eL% tyssuicide (6119101) recommended that the prescription of Risperdal should have been
continued until the prisoner was transferred to his destination facility-
OMH, however, protested this would not be proper clinical practice. On the morning of his suicide, the prisoner was involved in an altercationwith an officer and knew he was facing a sentence in Green Haven SHU as a result of it, a prospect which, according to the investigation of his suicide, terrified him. That morning he was escorted to a cell in the Mental Health Unit or Protective Custody area that was designated for punitive isolated
confinement. A nurse saw him there and noted he had been crying-but
the RN had 130prisoners to see during morning rounds and admitted she knew nothing about this prisoner's clinical situation.
Because of RN * -2s young age (17), past history of psychiatric hospitalizations,prescription of anti-psychotic and mood-stabilizing medications, and anxiety and depression (noted in the clinical chart); because he was prescribed an antipsychotic medication (Risperdal); because he had a history of head trauma and seizure disorder; because he required admission to observation a short time after entering DOCS, and because he had been involved in an altercation with an officer and knew he was

facing a term in SHU - for all these reasons, this young man should have had a far more thorough mental health assessment.47

In other words, someone should have been paying attention. The fact that nobody did pay attention displays a callous disregard on the part of OMH staff to the welfwe of this seriouslyill young man whose troubled psychiatric history and current instabilitywas so apparent. This young man, who was in prison for less than two months, almost immediately found himself unable to comply with prison rules and ended up in isolated confinement. He should not have been placed in isolated c ~ ~ n e m e nant d, he should
have been provided with more intensive mental health treatment (which he told OMH he
needed) in a supportive environment such as an ICP. The diagnoses he was given, Impulse Control Disorder NOS and Personality Disorder NOS, do not capture the degree of anxiety and depression reflected in narrative progress notes contained in his clinical chart.

YxD

,died by suicide in Keeplock in ICP at

Bedford Hills on 9/22/00. She had entered DOCS on 1/4/00. She had a

long history of serious mental illness and suicide attempts, with many

psychiatric hospital admissions, including at CWYPC during prior terms in

DOCS. In fact, upon her release from DOCS following a prior term, she

was committed to a psychiatric hospital. She had been diagnosed with

SchizoaffectiveDisorder and was prescribed psychiatric medications. She

had disciplinaryproblems, she was angry, and she was not entirely

compliant with psychiatric treatment. Her clinical chart contains diagnoses

of serious mental illness since 1994,when she was diagnosed Bipolar

Disorder and treated with anti-psychotic and mood-stabilizing medications.

She entered ICP on May 12,2000. A 5/17/00 progress note reflects that

she does not want to take the anti-psychotic, Haldol, because it does not

help and it causes muscle stiffness. She was also noted to be ''bothered by

visions of her kidnapped son's face protruding from walls." She continued

to be disruptive and to attempt self-harm, with admissions to observation

followed by return to ICP. On 8/25/00 she was placed on Keeplock in ICP

for failure to follow a direct order. Conditions on Keeplock in ICP were

comparable to conditions in SHU. From 8/25/00 to 8/28/00, she was in

observation and was threatening suicide by jumping &om the sink in her

observation cell, or by setting her cell on fire. She cycled between

observation and ICP at least one or two more times.

47 The OMH Confidential Quality Assurance Document by Dr. Thomas Ryan notes a similar conclusion by
the Incident Review Committee: "The Incident Review Committee suggested a review of the possibility of
doing a clinical assessment on active patients post altercation" - OMHCNY 0060357. In my opinion, Dr.
Ryan's recommendation should have become CNYPC outpatient policy, but of course it did not become policy, and it is my impression that such clinical assessments are not part of DOCSIOMK standardpractice.

According to the N Y S Commission of Correction's investigation, on

9/22/00, two female prisoners entered into a suicide pact and cut

themselves with axazor. W l e staffwere working on their wounds,

$) hung herself in her Keeplock cell in ICP. SuperintendentLord

agreed during her testimony (see Lord Tr. 185-186)that in the two months

leading injuries

uapndtosuhiecridsaulicciodned, uct;?sfh,e

had engaged stabbed herself, tied

in numerous selfa strip of cloth

around her neck, tied paper around her neck, set herself on fire several

times, and on 9/22/00, the day of her death, stated that she was going to

"hang up."

The N Y S Commission of Correction's review of this prisoner's suicide

found: "OMH staff at the Bedford Hills Correctional Facility did not

y s p formulate an effective treatment plan for

Over a

tumultuous clinical course at BHCF, Q zepeatedly was moved

from one inadequate therapeutic setting to another without real

achievable treatment goals. O M staff failed to admit her to CNYPC for

treatment within a hospital setting, what plan there was obviously did not

modifyher manipulativeand self-harming behavior." A 2/5/01 letter h r n
-p. Miragiia to Lamy, a response by OMH to the SCOC's report on )!

suicide, includes the criticism that the SCOC finding that the settings were

inadequatetherapeutic settings for the patient "is ajudgment which fails to

recognize the complex features of' \.j P ' behavioral and clinical
features and is unduly critical of the therapeutic program at BHCF which

heretofore has effectively served the psychiatric needs of thousands of

inmates. OMH's ICP and RCTP at BHCF are fully accredited by the Joint

Commission of Healthcare Organizationsand are recognized as national

models for the delivery of psychiatric services to incarcerated women."

There are further exchanges about what went wrong, and what plans are
being made to improve treatment for difficultprisoners such a s :

Yo-

If one reads only the clinical chart and documents related to

5'

suicide, it might seem fair to attributeher demise to "the complex features of Ms.

"Jp ' behavioral and clinical features." The problem for this reviewer is that the

problems that appear in the management of this case are all too familiar &om other cases I

have reviewed in NY DOCS.

Thus, the dismissal of self-harming behaviors as manipulations,the failure to

establish a well thought-out and effective therapeutic regimen for prisoners who are both

"disturbed and disruptive," the utilization of isolated confinement(Keeplock in this case)

y .n y .$- to c'manage'~such troubled prisoners - all of these things are s tern-wideproblems and

not accidental contingencies in

ce

clearly needed more

intensivemental health treatment, not punishment. Superintendent Lord testified that it

y was her
'$

view that
. course

p- needed to
during her incarceration

be in CNYPC; she characterized as "an example of ping-ponging*+'8(Lord

Tr.

187-188). Thus, her death is instructivein terns of what is missing in the N Y

DOGS/OMH collaboration.

Furthermore, Mr. Miraglia's respoading to the SCOC's criticism by citing

q- JCAHO accreditation is beside the point, and does not respond to the criticisms of

treatment in

9 ' case that were expressed by the SCOC. If a prisoner who

previousIy suffered from serious mental illness is un-dagnosed and consigned to a

housing unit that does not provide adequate mental health treatment for prisoners with the

level of psychiatric pathology and disability that that prisoner truly evidences, there is

nothing in the JCAHO accreditation site visits that would detect the substandard care.49

_ . ,died by suicide at age 21 in her cell in
SHU at Bedford fiills Correctional Institution on Aug. 17,2002.

y - 6 , tied a bed sheet around her neck and strangled herself.
' Like ""J , r, she had a long history of serious mental illness and

"9 psychiatric hospitalizationsin the community. In

"s case, these

dated from her early teens, with diagnoses Bipolar Disorder, Major

Depressive Disorder and Borderline Personality Disorder. She entered

DOCS in May, 1999, and had five admissions to CNYPC. She is

firequently noted to be depressed, to bang her head, to repeatedly attempt to

kill herself, usually by hanging, and to be disruptive. She was passcribed

anti-psychotic and antidepressant medications. She had attempted to

"hang-up" many times, including an attempt in SHU on 6/26/00 that led to

a two month hospitalization at CNYPC. She had attempted suicide in SHU

several times. She had been returned to Bedford Hills on January 29,2002,

after spending two months at CNYPC. At first she was in ICP, and then

was transferred to SHU because of a ticket for setting fire to her cell.

Meanwhile there were several admissions to observation with return to ICP

or SHU. She attempted to hang-up, and was banging her head in her cell

on 4/17/02, which led to another hospitalization at CNYPC. She was

returned to SHU at Bedford Hills on 5/12/02. She went back and forth

between ICPKeeplock and SHU until she was transferred to SHU for the

last time on 8/15/02, two days prior to her death. In her final days, she was

"contracted" not to harm herself (the safety and efficacy of the notion of

contracting not to harm oneself was questioned by the Commission of

*' SuperintendentLord had explained earlier that "ping-ponging"is tbe same as cycling, discussed
throughout this Report (Lord Tr. 69-72).
y+ 49 Ms. Dw suicide is also significantbecause of C o r n Goord's acknowledgment that disciplinaxy
sanctions are meffective for self-harming behavior and may even exacerbate that behavior (see Jan. 19, 2001 response to SCOC.)

Correctionin their Sumrnary Report about her death), and she was evidently sent to observation and then back to her SHU cell. There were notes in her clinical chart about her being manipulative; her diagnosis was Borderline Personality Disorder or Mood Disorder NOS.

95 There were many reports and memos a f i a the demise of 7 6

discussing whether she actually intended to die, whether she should have

been admitted for a long-tenn stay on the inpatient unit at CNYPC because

of her history of repeated suicide attempts (recommended by SCOC, but

DOCS and OMH disagreed), and whether she should have been returned to

SHU when she was clearly depressed and had evidenced suicidal behavior

so recently. The New York State Commfssion of Correction (Final

Report), in its recommendations, wondered why

had been

transferred to SKU instead of being re-admitted to the RCTP, "considering

her self-injurious behaviors while being transferred to the facility SHU on

the day of her terminal event." The Commission also questioned the

practice of "contracting for safety," and recommended constant observation

for suicidal prisoners in observation, and more training about suicide for

security staff. In response to the Commission's report on 1

Commissioner Goord wrote (2110104) that DOCS already had procedures in

place for suicide watch, officers were already being trained, and clinical

decisions are the responsibility of OMH. Richard Miraglia responded for

OMH (2/4104), disagreeing with the Commission's recommendation that
- & should have been considered for long-tenn inpatient treatment;

o protested that she was doing fine in SIIU the day of her death and

there were no signs she might be self-destructive.

The response of Mr. Miraglia, the Associate Commissioner of Forensic Services, to the New York SCOC's Final Report, merely supports the short-sightedjudgment of the clinicians and gives little hope that high-level administratorswill leam the lessons of this kind of tragedy and will act to refonn the mental health service delivery system. Similarly, Commissioner Goord's failure to implement procedures for constant observation in the Satellite Units ignores the risk that suicidal prisoners might slip through the cracks created by interval watches.

\/ This contrasts sharply with the testimony of SuperintendentLord that she would

have preferred that

Like

p b - ,be sent to CNYPC, which she agreed

\r was a safer environment
testified that had she not

for been

awa,y

(Lord Tr. 195). Superintendent Lord fbrther (on vacation) at Bedford Hills at the time, she would

y . have tried to prevent

)s transfer back to SHU. O r d Tr. 196).

In a lllU04 letter to NYS Commission of Correction Chairman Frederick Lamy,

- Bedford Hills SatelliteMental Health Unit Chief C. Subin and AssociateDirector of

OperationsM.Petrino outline a plan

- lt allegedly made with a prisoner in a

neighboring cell to alert staff when she attempted to hang herself on 8/17/02. That other

u@ prisoner allegedly failed to alert staff, and her failure to do so kads Subin and Petrino to
conclude: "This was an accident and she had not intended to die." This is a

clinically unsound speculation and a cynical response by OMH, to the Commission's

Y*"* conclusions about the suicide of

-

Clinicians are wekome to offer speculative interpretations to a live patient in

psychotherapy, where the patient is free to reject or amend the interpretation in the

collaborativequest for profound psychological truths. But when the patient is deceased,

it is all too easy for clinicians and administrators to concoct interpretations that serve to

justify their action or inaction leading up to the death. Nobody really knows why G

killed herself. We do know from the record that she was very depressed, that she

was often overwhelmed by despair, and that she had made many serious suicide attempts

prior to the one in which she was successfU1. To suggest that it can be known that her

suicide was an accident is to negate the complexity and severity of her distress the day

y.that she opted to end her life. It is as if Subin and Petrino are trying to use (4's tragic demise to prove their point that prisoners' self-harmingbehaviors are

9 "merely manipulative." The statement by these OMH clinicians that

K k

suicide was accidental is speculative, clinically unsound, and actually quite cynical. The

statement also fails to acknowledge what OMH clinicians have known for a decade, and

been reminded of repeatedly, that just because behavior is, in part, manipulative does not

mean it will not lead to death by suicide."

BLX-

5 hung himself in the Auburn SHU on 1/25/96. He

had been discharged from C N W C with a diagnosis of psychotic disorder,

but was returned to SHU. In SHU there were delays in his being seen by

mental health s t a g he was seen mostly at cell-fiont and his medications

were discontinued. The SCOC raised the question whether he was being

treated in a punitive fashion at the expense of receiving the acute mental

health treatment his condition required.

- -

* hung himself while on Keeploek status at Sing Sing on

11/21/96. ' 9Q! d was known to experience auditoryhallucinations and

had a history of suicidal behavior. There were delays in his being seen by

mental health staff, and he accumulated several disciplinary tickets. Two

months prior to his death he set his cell on fire. He failed to keep several

appointments with mental health staff, or appointments were postponed, in

the period just prior to his suicide. The Commission recommended better

tracking procedures for prisoners with serious mental illness who fail to

keep OMH, appointments, and the development of a procedure whereby

prisoners on the OMH caseload who fail to keep appointments and receive

disciplinary tickets are seen by mental health staff immediately.

See Elaine Lord's 'The Prison Careers of Mentally Ill Women," (P1 Exh. 105, p. 368).

;".

killed himself while in Keeplock at

Attica on (B Block) on 5/15/01.

f+ 2; - had been doubk-bunked

at Orleans S-Block SHU, and had made a suicideplan and attemptedto

have his cellmate commit suicide with him. He had been admitted to he

SatelliteUnit at Attica on 4/6/01 because he seemed suicidal. He had just

been discharged &om Satellite Mental Health Unit observation on 4/12/01,

returned to Orleans S-Block SKU, and then transferred to Attica on

4/18/01. There were no notes about discharge fiom the Satellite Unit; he

was not on antidepressantmedicationsbut there was no note as to why not.

He had just received news of an adverse decision by Parole Board.

: &

's suicide was not the first time that prisoners committed suicide

after receiving adverse news.

&%i%Es committed suicide at Elmira

CorrectionalFacility in November, 1996, followingthe denial of his parole.

C committed suicide in May, 1999,in the SHU at Sullivan Correctional Facility the same day his parole was revoked. Yet it was not until several months aRer *
4-Gs suicide in 2001 that OMH instituted apolicy requiringDOCS to promptly

notify OMH regarding prisoners who receive news of adverse determinations. Even then,

the policy was only instituted regarding prisoners designated Mental Health Level 1 or

Mental Health Level 2. This policy would not have identified or protected either
S nor && G. ', who were both Mental Health Level 3 at the time of their

suicides.

Attorneys for plaintiff chronologicallylisted suicides h m 1995through 2004 in a chart ("Prisoner Suicides 1995-2004") which summarized and quoted documents relevant to each incident. The chart does not summarize or review the clinical records for any of the patients listed. I reviewed the clinical charts of many of the successfi~sluicides and reviewed NYSCOC reports and other documentationpertaining to some of the suicides. Although I did not review each document summarized in "Prisoner Suicides 1995-2004," for those documents listed that I did review, I found that the summaries and quoted language were accurate.

One finds among the cases of successful suicides examples of prisoners who were not diagnosed adequately o r were "un-diagnosed" while incarcerated in DOCS, and then eventually proceeded to kill themselves. Residents of SEPU are vastly overrepresented among successful suicides, as are individuals who have a very long sentence to serve in SHU. There are individuals who were discontinued from the OMH caseload even though they continued to suffer from serious mental illness. There are individuals who accumulated a large number of tickets while confined in SHU, and many of those tickets may well have been driven by their mental illness. There are individuals who cycled (or "ping-ponged") between SHU and observation and CNYPC and back to SHU. There are individuals who had been in ICP and were discharged on account of unacceptable behaviors. In fact, a snapshot summary of the stories of prisoners who successfully completed a suicide

attempt in NY DOCS between 1995 and 2004 would look very much like a snapshot
of the prisoners I interviewed and have been describing in this report. I will discuss in Section VI the problems I discovered in the way Crisis Intervention and Suicide
Prevention is done in NY DOCS.

It is tragic when a relatively young person who has spent much of his short adult life behind bars commits suicide and never has an opportunity to find out what life in the community as an adult might hold in store for him or her. We can debate whether someone who is daily terrorized by hallucinations in a prison cell is really suffering h m a bona fide mental illness or is "merely malingering." And we can argue about whether an individual who cuts his wrists is making a true suicide attempt or merely a "gesture."
But most significantly, the suicides of prisoners in N Y DOCS between 1995 and 2004
show the same inadequacies in treatment and housing of prisoners with SMI that manifest themselves repeatedly in my inspections, interviews, and document reviews regarding current prisoners. These tragic deaths thus provide an accuratewindow onto the problems that plague DOCS and OMH. As set forth above, nearly 50% of successful suicides occur in isolated confinement or involve prisoners currently sentenced to isolated confinement, even while only 8% of DOCS prisoners are in isolated confinement. Obviously, there is something about isolated confinementthat leads prisoners to take their own lives.

A large proportion of those who committed suicide were suffering from serious

mental illness. The individuals who eventually killed themselves had experienced all the

deficiencies in the mental health services within DOCS that I have summarized above,

and that I will discuss fiuther in Section VI. The fact that so many of the prisoners who

succeeded at killing themselves had been repeatedly admitted to observation and C W C

and then cycled back to SHU forces one to consider the problems inherent in that kind of

cycling. Quite a few prisoners who committed suicide had been identified as

manipulative by OMH, including ! &-@-@ , fl &- , UqV , I id= - .

.v,P O mL1*

y.P

9

; P~RJ

Q 4 and 4 H . And the other problems under scussion in this rgport -the

transfer of medium security prisoners to SatelliteMental Health Units in maximum

security facilities and their eventual receipt of Tier 3 tickets and a SHU term; the failure

of the disciplinaryprocess to discern the part played by serious mental illness in ticketed

infkactions; the failure of OMH to treat the anxiety and depression that predictably attends

a prisoner's receipt of bad news (such as receipt of a SHU sentence, a parole board

denial), etc. - all these problems crop up repeatedly in the stories of successful suicides

within DOCS. I will discuss appropriate interventions for suicidal prisoners in greater

detail in Section VI. For now, the main point is that the problems that are identifiable in

successful suicide cases are remarkably similar to the deficienciesI am pointing to in the

delivery of mental health services within NY DOCS.

It should be noted that not all prisoners suffering f?om serious mental illness claim to be negatively affected by SHU confinement. For various reasons, a small number of

prisoners prefer isolated confinement to being placed in a general population situation. For example, there are prisoners who fear for their safety, and &ause they are convinced there is no effectiveprotective custody unit at their security level, they purposely violate rules or get into a fight so they will be sent to punitive segregation and remain isolated fiom the prisoners they fear. Also, there are prisoners who prefer to be by themselves, and are willing to give up activities in order to have a cell by themselves. In my experience, the prisoners who adjust well to the conditions of isolated confinement units for any reason make up only a few percent of the prisoners confined in these units.
Among the 183prisoners I interviewed, I found five or six who say they do not mind
being in S W . But even this small group have a list of complaints, including the long delays it takes to see a mental health clinician and the short time the clinician spends with them. The vast majority of prisoners find the experience extremelytraumatic and painful, and their clinical charts (as well as OMH clinicians' repeated acknowledgments) attest to the worsening of symptoms and decompensation in SHXJ.
As I explained in Section V., SMI individuals typically exhibit a waxing and waning course over a lifetime that includes periodic acute episodes alternatingwith periods of relative stabilitywhen they comply with treatment, including the proper medication regimen. Research shows that the longer an individual's acute psychotic or depressive episode is left untreated, the worse his prognosis. Research also shows that early detection of serious mental illness, removal of the individual suffering &om mental illness from the noxious and traumatizing environment, and intensive comprehensive treatment greatly improve prognoses. Mental health clinicians in the community work hard to provide people vulnerable to SMI a sheltered and therapeutic environment, and the standardsin correctional mental health require the same commitment. Clinicians are required to try their best to provide intensive treatment, including but not limited to
medications, and to protect the individual fiom repeated traumas- all this in the hope of
improving his or her condition and prognosis. Conversely, and tragically, if the individual is left in a situation that is extremely stressfil and traumatic, the psychosis or depression worsens and the prognosis becomes more grave. (This is an underlying reason for the exclusion fi-om isolated confinement of prisoners who suEer &om serious mental illness in many correctional systems.)
If a prisoner suffering fiom psychosis is left to hallucinate and evolve a ifixed delusion in his cell as he suffers harsh prison conditions such as obtain in SHU, and is denied adequate mental health treatment, then his condition is likely to deteriorate fiirther until he reaches the point where he is laughing inappropriately,smearing feces, experiencing bizarre and fixed delusions, and exhibiting other signs of decompensation.
Sadly, this is the plight of many prisoners I met in the NY DOCS.

VI. The Mental Health Treatment Programs in DOCS Facilities
A. Mental Health Care in General
There were 19,408 prisoners in DOCS when OMH began providing mental health
services in 1977. Today, there are approximately65,000 prisoners in N Y DOCS , 7 1% of
whom have substance abuse hi~tories.~T' he inpatient psychiatric facility, CNYPC, has approximately200 beds, a number that essentially has not changed since 1977. At any given time, a portion of these 200 beds are filled with prisoners from countyjails. ICP has a capacity of 551 prisoners, including the AVP at Green Haven. STPs at Attica and , Five Points contain 25 and 18 beds, respectively (these are beds located in SKU housing). Additionally, there are a total of 56 observation cells at 11prisons (intended for shortterm stays for prisoners in crisis or danger of self-ham). There were 7,250 active OMH cases in February, 2001; Richard Miraglia testified that there were approximately 8,000 prisoners on the caseload in early 2 0 0 5 . ~ ~
Since OMH began providing mental health services to prisoners in DOGS in ,,, 1977, the approach to services has gone through several changes. Currently the system of
mental health services is described by OMH as a continuum of care providing comprehensive services equivalent to public mental health services available in the community. In published articles, OMH describes CNYPC as an inpatient acute psychiatric hospital with a 200 bed capacity, plus 11 Satellite Units in the maximum security institutions, which include Residential Crisis Treatment Programs (RCTPs). RCTP contains observation cells for very acute care and a dormitory for prisoners who are recovering from an acute crisis but are not yet ready to return to their regular housing unit. The SatelliteUnits provide mental health services to the Intermediate Care Programs (ICPs) (an equivalent program at Greenhaven is called the AVP), and outpatient services throughout DOCS, including services to inmates confined in Special Housing Units (SHU). In two maximum security prisons, Southport and Upstate, there are no Satellite Units. Instead, there are Mental Health Units which do not contain observation cells or dormitory beds. There are a few other programs scattered throughout the DOCS system that are not included in this list of system-wide programs, such as the APPU at Clinton, Special Needs Units (SNUs) at Sullivan and Wende and 99 Company at Wende. I will briefly comment about each component program, and then I will discuss some system-wide problem areas.
The Correctional Association of New York expressed concem about staE shortages and vacancies in OMWDOCS:
51 See New York State Department of Correctional Semites, "Identifiedsubstance abusers,"2001; and Hal Smith, Donald A. Sawyer & B~uceB. Way, "CentralNew York Psychiatric Center: An Approach to the Treatmentof Co-OccurringDisorders in the New York State CorrectionalMental Health System," Behavioral Sciences and the Law Behav. Sci. Law 20: 523-534,2002.
52 See OMH Annual Report for 2000 and Miraglia Deposition, p. 186.

The majority of correctional and mental health administrators we interviewed
reported that mental health units throughout the state prison system are
understaffed and under-resourced, resulting in overburdened clinicians, untreated inmates and a revolving door of admissions to Central New York Psychiatric Center (CNYPC). Many mental health employees reported feeling overwhelmed by burgeoning caseloads and inadequate time to treat individuals with serious psychiatric disorders. 'I'm supposed to say that current staffing levels allow us to meet the needs of our patients, but the truth is, they don't,' a mental health unit chief told

And staff shortages are reflected in many documentsI reviewed, including, for example, a 7/22/04 letter from Cheryl Giroux, Director of Personnel, to Nicholas
Vagianalis, Director of Classificationand Compensation for NYS Department of Civil
Service, where Ms. Giroux writes: ''The Office of Mental Health (OMH) has been experiencing great difficulty in the recruitment of qualified psychiatrists at all its facilities, for years."M Repeatedly I discovered mention in Psychological Autopsies and the New York State Commission of Correction's "Final Reports" about prisoner deaths that staff shortages played a part in the suicide or death.

For example, A Psychological Autopsy regarding the death by hanging of,

U @- on 8111/01,Drs. Charles Ware and David Frey write under Recommendations:

"2. To addressthe actual emotional and congitive issues with patients may be only

minimally feasible given patient case load. Until trust is obtained by patients in a

therapeutic relationship with staff we will not have access to their private thoughts and

feelings. Consequent decisions by them to end their lives cannot be prevented when they

are determined to do so. There must be continued efforts by staff to develop therapeutic

relationships with patients despite possible problems imposed by resource limitations.'y55

Or,in the case of R

,who died on 5/20/01, and the cause of death had

medical as well as mental health components, the Commission's Final Report includes

the following among its recommendations: "To review the current medical staffing plan,

specificallynursing and physician services, at the Elmira ReceptiodCorrectional Facility.

A health services s t f i g plan should assure a sufficientnumber of qualified health

personnel are available to provide adequate evaluation and treatment consistent with

acceptable community standards of practice."

The Correctional Association's findings and other documents match my own impressions in regard to a staff and resource shortage in OMH. Even more important than documentation is my direct observation that mental health staff are not spending
adequate time with prisoners suffering from serious mental illness. Prisoners in SHU reported to me that OMH clinicians spend only a few minutes with them at cell-fkont, and

53 The CorrectionalAssociation of New York, "Mental Health in the House of Coorrections:A Study of Mental Health Care in New York State Prisons," June, 2004,p. 28. 54 OMHCNY 087954-087959. 55 OMHCNY 0060264

even in twice monthly private sessions (mandated by the SHU Plan of Improvement) clinicians might spend less than ten minutes with a prisoner with SMI in S H U . ~T~he prisoners in observation at all the facilities I inspected reported that OMH staff spend a
mere few minutes per day with them - and this is during their acute crises. There must be
a serious staff and resource shortage if this little time is dev&ed to patients undergoing psychiatric crises.

As I mentioned in my discussion of the suicide of

- (Section V.E.),

the fact that the OMII program has received accreditationby the Joint Commission on the

Accreditation of Health Care Organizations (JCAHO) does not eliminate nor ameliorate

the presence of very serious problems in the mental health care delivery system. The

JCAHO review process, by its nature, fails to take into account many of the problems at

issue in this litigation.57For example, if a prisoner who previously suffered from serious

mental illness is erroneously un-diagnosed and consigned to a housing unit that does not

provide adequate mental health treatment, this huge and unacceptable gap in services

would not be detected by the JCAHO on its accreditation site visits.58

The JCAHO standards are not specific to correctional settings. For example, there are no JCAHO standardsthat address isolated confinement in a correctional setting. Likewise, JCAHO does not consider adequatelywhere a contact between mental health staff and a prisoner may have occurred, even if it was at cell-front within earshot of other prisoners and security staff. The fact that accreditation has been achieved does not in any way alter the deficiencies and unacceptable policies and practices I am outlining in this report.

B. Inpatient Psychiatric Unit at CNYPC.

I did not visit CNYPC in connection with this litigation, but I have, in the past, conducted a staff-training at CNYPC, and I have reviewed policies and other documents
describing CNYPC programs and practices. Also, a large number of the clinical files I
reviewed contain admission evaluations,progress notes, nursing notes and discharge summaries fi-om CNYPC. I have discussed the CNYPC program with Dr. Carl Fulwiler, who toured the facility on June 18 and 19,2003, and who interviewed 24 prisonerlpatients at CNYPC.

See also Takarla Carroll Deposition, p. 9; Ram La11Deposition, pp. 40-4 1.
''See Deposition testimony of Jayne Van Brarner, pp. 186-188 and 191-193.
58 Dr. Stuart Grassian states in his 10/7/99Eng Site Visit 1, 'Thus, the JCAHO process intrinsicallyhas
severe limitations on its applicability to SHU inmates - limitations which are in fact explicitly stated in the
December 14, 1998JCAHO report regarding CNYPC. For example, in regard to PsychiatricSatelliteUnits
at the various New York State Correctional Facilities, the XAHO report slatesexplicitlythat it will not review decisions to house S I N inmates in isolated mental observation cells on the SatelliteUnit, rather than in dorm settings, because such decisions arejustified by DOCS on the grounds of 'secwity"' @. 52).

CNWC serves as the inpatient unit for DOCS. Patients on civil commitments fjrornoutside DOCS are also confined there, including one ward for countyjail inmates.
Thus, the bed capacity available to DOCS is well below the approximately200 bed capacity of the facility. OMH Director Hal Smith told Dr. Fulwiler that the average
number of admissionsto CNYPC is 850per year, and the median length of stay is 43 days. All staff at the facility are O W employees, and DOCS does not provide security. Admissions are involuntary and must be court-ordered. This means the bar is high for admission -the prisoner must, on account of a mental illness, be a danger to self or others. After a complete evaluation a treatment plan is established which includes medications, group therapy and psychosocial rehabilitation.
Following admissionto CNYPC, that prisonerlpatient,regardless of whether he or she was in isolated confinement in DOCS, is placed in a congregate setting and is Sieeto enter and leave rooms and common areas. The assumption in DOCS is that prisoners in isolated confinement are incapable of behaving well enough to be released Siom a cell and to mix with others. This is one reason why prisoners fiom SHU are not housed in the
dormitory in the SatelliteUnits, and the dormitories are underutilized. But at CNYPC
these same prisoners are housed in a room with others, are pennitted out of their room and are encouraged to participate in group activities and treatment meetings. This
obvious contradiction brings'into question the assumption in DOCS that prisoners in
isolated confinement cannot be permitted congregate activities, and that in STP they need to be locked into "cages" to safelymeet as a group {seebelow for fkther discussion of STP, Section V1.F).
At CNYPC, prisoners are provided a variety of services through the '"Treatment Mall" including group therapy, psycho-education services such as education about their illness and about their treatment, and anger management. The goal is to provide patients with the skills they need to fbnctionin prison and in the c o m ~ t y D. r. Fulwiler found CNYPC to be a "clean and well-run" facility, and he reports: "Despite the fact that it serves the prison population it feels like a modem hospital. There are no bars or gates." Prisoners participate in conjugate activities in the day rooms and other areas. The rooms have regular doors, which are left open. Meals are served in dining rooms. There are seclusion rooms, for use in acute situations. There is an admission area, there are acute wards, and there are longer term wards and psychiatric rehabilitation services (such as occupational therapy and classes in stress management). Patients take part in 90 minute blocks of programs fiom the Treatment Mall each day, as well as 90 minutes of recreation.
CNYPC is accreditedby the JCAHO, and is a qualitypsychiatrichospital. Still, as the inpatient component of the DOCSIOMH comprehensive mental health service system, there are problems with the inpatient psychiatric program at CNYPC.
The admission criteria for CNYPC are too stringent, given that it serves as the psychiatric inpatient facilityfor DOCS. A psychiatric hospital serves important k t i o n s

when modeled as part of a comprehensivecommunitymental health program. Not all patients suffering from an acute psychotic episode or "breakdown" meet the criteria of danger to selftothers for court-mandated civil commitment. It is often the case that an individual experiencing an acute psychotic or manic episode will need to be hospitalized voluntarily so that his or her condition can be properly diagnosed and the acuteepisode can be treated in a safe place where there is adequate staffingto provide safety and intensive treatment. Also, when clinicians in an outpatient or residential treatment setting are puzzled by an individual's clinical course or there are problems with a medication regimen, they might want to admit that individual to an inpatient psychiatry ward in order to adequately diagnose him or to adjust his medications. When admission to the inpatient ward is limited to those meeting civil commitment criteria,many patients in real need of psychiatric hospitalization are denied that critical level of care. As I have noted repeatedly and illustrated with case examples, the most obvious reflection of this problem in NY DOCS is that prisoners remain in observation cells too long in the Satellite Units or are returned to isolated confinement cells instead of being sent to CNYPC. I discovered many prisoners in observation who warrant immediate admission to an inpatient psychiatric unit, but languish in observation. In observation cells located ' at the prisons, treatment is entirely inadequate for the severity of their psychiatric condition, and the conditions of confinement are harsh and punitive -in contrast to the much more humane and therapeutic conditions at CIYMC.

Another problem is the severe shortage of beds at CNYPC. In spite of the huge

expansionin the population of DOCS in the last thirty years and the rising proportion of

that population suffering from serious mental illness, the bed capacity at CNYPC has

remained approximately the same as it was when OMH began providing mental health

servicesto DOCS in 1977. This means that there is a long wait to be t r a n s f d to

CNYPC, even for patients suffering h m acute episodes of psychosis or severe suicidal

crises. Dr. Shimkunas states that the wait can be 30 to 45 days to have an acutely

disturbed individual admitted to CNYPC (Shimkunas Deposition, p. 34). Many prisoners

told me, independently, that OMH staff does not like to send prisoners from SHU to

CNYPC. Instead OMH sends prisoners to observationwhen they are acutely disturbed or

suicidal, and then the prisoners cycle back to SHU without ever being admitted to the

psychiatric hospital (CNYPC). I include case reports about many prisoners who are thus

"cycled" from SHU or Keeplock to observation and less kequently are sent to CNYPC,

including

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There are also too few after-care options for patients being discharged fiom CNYPC. After a stay in a psychiatric hospital, patients usually require a period of time in some type of "step-down" program. In the community, there are halfway houses and other forms of supported residential programs. These programs are "step-down" from the

hospital level of care, or "half-way" between the hospital and independent living. They supply a modicum of safety and support as well as an intermediate level of mental health care, between inpatient and outpatient. Some patients require some kind of residential treatment on a very long-term basis. As I will point out in the section on ICPs, there are too few ICP-level slots in DOCS, and patients are too often discharged &om ICP because of disciplinaryproblems.

I saw several situations involving prisoners who were admitted to CNYPC because of a psychotic breakdown or a suicide attempt and were facing a disciplinary hearing for a ticket that was issued during the psychotic episode or the suicide attempt. The result is that the individual who has been helped to resolve or transcend the acute psychotic episode or suicidal crisis while at CNYPC is then returned to SHU, where the stress can induce a repeat psychotic or suicidal crisis. This is the dynamic that drives much of the cycling between SHU and observation or CNYPC and back to SHU.

When clinicians at CNYPC recommend a certain housing and treatment location for a patient they are discharging, it is very important that their recommendation be followed, otherwise the therapeutic gains of hospitalizationcanbe lost because the patient is sent to a stressfil environment. I presented the case of V ,where STP was recommended by CNYPC upon discharge fiom the hospital but the patient ended up in SHU without being admitted to the STP. I will present one more case where the discharge recommendation fkom CNYPC not to return the patient to SHU was not followed, resulting in steady unremitting psychiatric deterioration:
- - bt z p.- * 3- ---.., ,- ---- -- - (Interviewed while housed in SHU at
Great Meadow on 8/26/03.)
History: When asked what it's like to be in S W , EJ .stated: "I
get my head busted open by correctional officers - mental health knows this and says I need more drugs." (He shows me his head with signs of recent bumps and lacerations.) "I can't take the solitude, and I'm getting abused by correctional officers.'He has not taken any psychiatric medications since November because they were causing side effects. He has been admitted to CNYPC twice, and he has been in observation three or four times. In SKU, he gets extremely angry and can't control himself.

Mental status examination: This intense man stared as he talked, exhibiting flat affect and concreteness. There was delusional material and credible reports of recurring auditory hallucinations with no sign of internal preoccupation at the time of our interview.

Clinical chart:

Es @ 3- 1

i was admitted to CNYI'C

&om 11/00 to

2/01, and again in 9/02. He came to Great Meadow from CNYPC in 11/02.

Command hallucinations and suicide behavior were noted. He has been

prescribed Depacote, Zyprexa, Risperdal, Zolofi and other psychiatric

medications. His diagnosis has been Paranoid Schizophrenia or other forms of psychosis. A 2/9/01 note at discharge from CNYPC to Clinton reflects staff recommendation that he be sent to 1CP and not returned to SHU. He was sent to RCTP awaiting a cell in ICP, but by 4/2/01, he was returned to SKU, contrary to discharge recommendation. By 7/01 he was
back in observation. He was re-admitied to CNYPC.(9/9/02- 11/12/02)
and on discharge again returned to SHU. A 1/30/03 OMH progress note reflects: "Again, this writer feels patient is becoming more agitated and paranoid. Speech is loud and pressured, restless in chair with many arm gestures. He will be referred to psychiatrist.. .." Dr. Faruki sees him on 7/3/03, finds him paranoid and agitated and recommends anti-psychotic medications. In spite of this record, he is discharged from the OMH caseload in 12/03.
There are numerous prisoners admitted to CNYPC, which requires certification by two psychiatrists that the individual is suffering from a mental illness severe enough to make him or her a danger to self or others, whose diagnoses are then downgraded while they are inpatients. Very often the downgrading or un-diagnosis is entirely inappropriate, since the individual has a long history of serious mental illness and prior hospitalizations,
and will subsequently experience repeated breakdowns or suicidal crises. In many cases,
after the individual is given a diagnosis at CNWC that does not indicate a serious mental illness, a Behavior Management Plan is developed that recommends against subsequent re-admission to CNYPC. I will discuss this kind of un-diagnosis in the section on diagnostic problems, below. (See VI.G.2.)
There is also too little integrated treatment programming for individuals who are "dually diagnosed," i.e. who suffer from both serious mental illness and Substance
Abuse. The staff at CNYPC rely too heavily on "twelve-step" programs - self-help
substance abuse meetings modeled on Alcoholics Anonymous and other leaderless programs. Twelve step programs should be available to prisoners who choose to partake. But since such a large proportion of prisoners have substance abuse problems (70-go%), and since federal standards mandate intensive treatment for individuals who are dually diagnosed, there need to be more clinician-facilitatedtreatment options for prisoners suffering fiom both serious mental i l k s and SubstanceAbuse. The fact that so many of the prisoners suffering fiom serious mental illness will be returned to SHU or Keeplock after they are discharged fiom CNYPC, and that there are few if any substance abuse treatment programs available for prisoners in isolated codinement (for most of these
prisoners cell study is not an adequate option - see Section V), makes this an even more
critical problem.

C. Lack of Adequate Crisis Intervention/Suicide Prevention in Satellite Mental Health Programs
I toured the Satellite Units in ten maximum security facilities. They contain observation cells, dormitories, ICPs and outpatient services. I will discuss the ICPS(joint DOCS and OMH programs) and outpatient services in separate sections (See Section V1.D. and E., below). Here I will discuss the obwation cells and dormitories.
1. The Observation Cells
According to a July -December, 2001 Report on "Observation Cell Usage" by
Dr. Bruce Way, there are 56 observation cells in 11 prisons in W . I inspected ten of the 11prisons. The general design was similar in all the satellites. There is a row of observation cells. Some units contain three cells, somecontain eight or more. The cells are practically bare except for a thin mat, which is usually on the floor. The prisoners are often naked except for a Ferguson (indestructible) gown. There are usually no bedclothes except for a Ferguson blanket, and the prisoner has no television, no radio, and few if any amenities such a s pen andpaper. The prisoner is usually laying on the mat, idle. The walls of the cells are bars, in most instances covered by a metal mesh material, or they are covered with a plexiglass material known as lexan. In the fiont of the cells there is a hallway where staff can pass or approach the cell, and in the rear there is another hallway
with access to the cells. The lighting in most of the observation cell areas is very low. In
some units there are windows across the hallway from the cells, or windows on a wall of the cells that cannot be opened by the prisoner. There is some variation in the architecture. The observation cells at Five Points are fairly representative of all the units I toured. They are inside the Infirmary (at other institutionsthe RCTP is a separate unit). The floor of the observation cells is concrete, the walls are bars covered by a strong transparent plexiglass or lexan material, and on other parts of the cell walls there is a metal mesh inside the bars. There were six observation cells in a row, sharing common walls, and all were occupied on the day of our tour.
At Eimira Correctional Facility there are three observation cells in the Satellite Unit. They have bare concrete floors, solid doors, and there are almost no amenities. The prisoners confmed therein lay on a thin mat on the floor, some have no clothes and cover themselves with a Ferguson robe, and they have no bedclothes except a Ferguson blanket on the bare mat. Most of the prisoners are entirely idle with no amenities. They are fed in their cells and do not go out of their cell for recreation or for any programs. In fact, quite a few prisoners in observation are given a restrictive diet as punishment. (See DeVito Deposition, p. 108.) Usually, during my tours, there were little if any staff interactionswith the prisoners in observation, and no kind words. It is my understanding the officersmake rounds fiequenttlty(every fifteenminutes by policy). Clinical staff visit prisoners in observation at their cell-ftonts at least daily or, in some facilities a committee of mental health staff meet with the prisoner on a daily basis for a brief tkne in a separate

room and evaluate the prisoner's course. At Elmira, the solid doors on the observation
cells obstruct observation.
I found the observation regimen in the SatelliteUnits to be deficient in the sense that high risk patients need to be in a hospital setting where they can be observed by clinical st* including constant observation where clinically indicated. When suicide risk is what led to the inmate's transfer to observation, the prisoner is kept in this setting until he or she professes he or she is no longer suicidal. Some prisoners are transfened from observation to the inpatient hospital, CNYPC. Often when prisoners return to an institution after being discharged from CNYPC, they re-enter the institution by being placed in observation or the dormitory. SHU prisoners are not generally housed in the dormitories, pursuant to DOCS policy. Many if not most of the prisoners are transferred after their stay in observation back to the unit from which they had arrived in observation, and for many prisoners I met that means a SHU or Keeplock cell.
Dr. Way ("Observation Cell Usage" December, 2001) reports that 23% of the observation cell admissions came from SHU (where, he reports, 12% of prisoners statewide were confined as of December, 2001); and 25% were discharged from observation to SHU. Further, Dr. Way reports that 69% of prisoners were admitted with "basic" amenities, meaning two mats and underwear, whereas only 52% of prisoners were discharged from observation with full amenities. Dr. Way writes: "A number of persons who stayed longer than clinically necessary were not restored to full amenities. Shouldn't full amenities be restored to all these clients?" (See my comments about recent policy changes regarding amenities in Section K.)
2. Clinical Principles that should apply to Observation
There are well-established clinical guidelines for the assessment and treatment of individuals who have attempted suicide or seem intent upon taking their own life. First, a thorough assessment is indicated. If there are indicators of very serious suicide risk, for example severe depression, a past history of suicide attempts, a note indicating sincere intent to commit suicide or command hallucinations (voices) ordering the individual to take his own life, then the individual who seems to be at risk of suicide needs to be placed in a safe setting. In thecommunity this usually means a psychiatric hospital, but in a prison an observation room might be adequate for a prisoner who does not pose a very serious risk -under specific conditions. A critical condition is that the stay in an observationcell be very brief (less than 24 hours or, depending on staECing considerations, 48 hours over a weekend).
In order to properly treat patients in observation, and not turn observationinto another form of punitive isolated confinement,staff's approach must be therapeutic rather than punitive, the prisoner's dignity and privacy must be respected, and the mental health staff must take the time to gain the suicidal prisoner's trust and offer the intensity of treatment that is required in such an emergency. The main component of treatment with a suicidal individual is one-on-one personal, confidential therapeutic contact. A trusting

relationship must be established in order to foster disclosure on the suicidal individual's part about the inner sense of despair and hopelessness that is driving the prisoner to seriouslyconsider taking his or her own life. Little or none of this occurs in the observation cells I inspected or in the accounts of observationI heard during my interviews.
Psychotropicmedications might also play an importantpart in the treatment of a suicidal individual, especially where there is severe depression or psychosis that includes hallucinated voices commanding the individual to harm himself or herself, but there are many problems and complexities in their prescription. For example, the most often
prescribed type of medication in suicidal crises-i.e. antidepressants- can take between
two and four weeks to reach full effect, so they are not very usefil in the acute situation. Another crucial part of the treatment of individuals intent on taking their own life is for the clinician to figure out what stressors are driving him or her to this level of despair, and then attempt to help him or her change that situation so that those stressors will not drive him or her to another suicide attempt after the immediate treatment for the current suicide crisis has ended. In a significant proportion of cases the individual must be referred to a hospital or crisis unit setting. Examples of this are when the suicide crisis is driven by serious mental illness and hallucinated voices are commanding the individual to kill himself, when the crisis cannot be quickly alleviated, or there is a high risk of self-harm.
According to Andre Ivanoff and Lindsay M. Hayes, national experts on suicide prevention in correctional settings:
In determining the most appropriate housing location for a suicidal inmate, correctional officials (with concurrence from medical or mental health staff) often tend to physically isolate and sometimes restrain the individual. These responses might be more convenient for all staff, but they are detrimental to the inmate because the use of isolation escalates the inmate's sense of alienation and M e r removes the individual &omproper staff supervision. To every extent possible, suicidal inmates should be housed in the general population, mental health unit, or medical infirmary, located close to staff Further, removal of an inmate's clothing (excluding belts
and shoelaces) and the use of physical restraints ...should be avoided
whenever possible, and used only as a last resort when the inmate is physically engaging in self-destructive behavior. Handcuffs should never be used to restrain a suicidal inmate. Housing assignmentsshould be based on the ability to maximize staff interaction with the inmate, avoiding assignments that heighten the depersonalizing aspects of incar~eration.'~
59 Andre Ivanoff and Lindsay M. Hayes, "Preventing, Managing, and Treating Suicidal Actions in HighRisk Offenders," Jail Suicidemental Health U~dateV, ol 11, No. 2, Summer, 2002, pp. 4-5.
JA 244

These are principles that reflect a consensus in the mental health field. They are not being followed by OMH, and OMH's failure to follow these guidelines has contributed to the disproportionatenumber of suicides in isolated confimment which have occurred even after the risk of suicide has been identified.

OMH's Violation of Basic Guidelines and Princioles for SuicidePrevention and Crisis Intervention:

The suicide prevention and intervention programs in the prisons I investigated violate at every turn the guidelines I have presented and the principles that Ivanoff and Elayes explicate. Prisoners are left in their observation cells for long periods, often with no clothes and in their observation cells they have minimal or no interaction with staff (hardly sufficient to establish a therapeutic relationship). The prisoners on observation have only daily brief cell-front contact with OMH staff, and perhaps a committee meeting that lasts several minutes, hardly sufficient to establish a therapeutic relationship. The
conditionsof confinement are excessivelyharsh - e.g. no recreation and few if any
amenities. The prisoners languish in their observation cells, idle and isolated. Many I, prisoners report that conditions are much worse in observation than in SHU, and
professional attention is not forthcoming. In fact, the "treatment" a prisoner receives after disclosing suicide ideation, on average, is more punitive than it is therapeutic.
Disciplinary tickets are routinely given to prisoners for self-mutiiation and other selfdestructive behavior, or for behaviors that are related to the suicidal crisis in less direct ways. @:this problem, which I encountered frequentlyin my interviews, is minimally addressed with the settlement of the Anderson litigation. I do not yet have sufficient data to assess recent changes in terms of disciplinarytickets driven by mental illness. I do know that the DOCS regulations still provide that a prisoner can receive a disciplinary ticket for self-harm behaviors.) On the mental health charts there are many notations about feigned or malingered suicide attempts. An example:

SB-.E-

- --.(Interviewed while housed in SHU at

Great Meadow i n 8/26/03.)

History: 6 BL i has been in prison for seven years. He stated he had
been at CNYPC with a diagnosis of Schizophreniaand Claustrophobia. He has cycled back and forth between SHU and observation because he is convinced he is being poisoned. He hears voices and believes he dissociates. He has been in observation for as long as a month at a time. He averred delusions, nightmares and intense fear that he will be set up by staff and this will result in his being attacked. Last December he burned his cell in a serious suicide attempt. He was sent to observation for two days and then transferred back to SKU. When I ask why he is repeatedly
transferred from SHU to observation and back to SHU, without being sent to C W C , he tells me it is because OMH staff don't believe him about being suicidal. Finally, in April, 2003, he was admitted to C W C . He

has been depressed all along, and thinks about suicide all thetime. Hewas discharged from CNYPC, then spent a month in observation, and then on June 26 he was transferred to S H U at Great Meadow. He had a psychiatric history prior to incarceration. When he is "behind glass" it feels to him like someone is trying to smother him. He gets disciplinarytickets for "bodily . harm" or destroying state property. He does not go to recreation became he is a£i-aid "they (of£icers) will jump me."
Mental status examination: His mental status was consistent with his history. There was some bizarreness and delusional thinking. He was depressed with psychomotor retardation and anhedonia (a lack of pleasure in anything - a sign of depression).
Clinical chart: 66 0 '3 chart includes a 5/2/03 diagnosis of
SchizoaffectiveDisorder plus various diagnoses given on other dates, including Paranoid Personality Disorder, no diagnosis and ASPD. 68'2s chart shows many admissions to satellite units, intennittent severe psychiatric symptoms and acting out. On 5/2/03he was admitted from SHU to CNYPC, not eating, paranoid, thinlcing his food was poisoned. His diagnosis then was Depressive Disorder. He has been prescribed Neurontin, Seroquel, antidepressants and other medications. He was repeatedly admitted to observation during suicide crises, and was very rarely transferred to CNYPC. The fact that on several occasions his diagnosis was changed to ''no diagnosis," or "Antisocial Personality
Disorderyywith no Axis I condition, serves to corroborate 1 5f? * 3#s report that OMH staff do not believe him about his symptoms and the
extent of his despair.
Clearly this man's psychiatric condition deteriorateswhen he is in SHU, but when he is seen at cell-front or in observation,he is not diagnosed with a serious mental illness and is sent back to SHU. After many repeated observation admissions and recycling to SHU, he wound up at CNYPC where they diagnosed psychosis. Subsequently he is not sent to CNYPC when his condition deteriorates,rather he is cycledbetween S W and observation, sometimesremaining in observation for extended periods without being admitted to CNYPC in spite of his acute breakdown.
In reality, when a person contemplates suicide, he has mixed feelings about actually ending his life. Often he is merely too depressed and hopeless to be able to imagine continuingin life. If one meets a suicidal patient on a psychiatric hospital ward and asks "Do you think you are actually going to kill yourself?" or "Are you feeling imminently suicidal right this moment?" the response is very likely to be that he or she is not actually feeling a strong impulse toward self-destructionjust now. But this does not necessarilymean it is time to dischargehim fiom the hospital. Later, after the day-shift leaves, that same individual might lay in bed feeling overwhelmed anew by depression

and might then begin planning a serious suicide attempt. In other words, suicidal despair is rarely constant, and there are moments between profound lows in mood where a suicidal individual might even appear cheerhl. In fact, we know from very tragic experiences in psychiatric hospitals in the community that individuals who were ambivalent about killing themselves until recently, but who have now decided definitely to take their own life, are very likely to appear to staff to be positive and not very depressed. Their resolve to take their own life momentarily trumps their depression, and they have a renewed interest in pursuing a purposeful plan, i.e. their self-destruction.

Consider the case where, at some point during the time when a depressed individual is equivocating between a decision to take his own life and a new resolve to go on, the psychiatrist asks him if he is actually going to kill himself, and he responds "No, I think I was just bottoming out and needed someone to talk to about the mess my life has become." What if, at that point, the psychiatrist accuses him of having "malingered" the entire suicide crisis or "manipulated" the staff into thinking he wanted to kill himself? The effect of the psychiatrist's punishing approach would not be therapeutic at all. But in fact, this is very often the scenario that is enacted in DOCS during prisoners' suicide crises. Another case is illustrative.

I

Ztj

on 9/24/03.)

. (Interviewed while housed in SHU at Albion

History: sfl-- as been in prison for three years, and has spent over
eleven months in SHU on separate occasions. She insisted that the officeas treat prisoners suffering from mental illness worse than they treat the othm in SHU. She said she is not at all assaultive. She has been in observation three times, on account of worsening depression and wanting to hurt herself, and each time she went to observation from SKU and then was returned to SHU, never being admitted to CNYPC. She reported she currently is prescribed Seroquel and Neurontin. She has never been admitted to CNYPC. She has been in psychiatric hospitals in the community, and spent six or seven years (between ages 23 and 29) involuntarilycommitted to a psychiatric hospital. Her current SHU term was to end a few days prior to her release from prison.
Mental status examination: ZX! - ,.wasobviously quite sad and cried
openly during our interview. She was intermittently agitated and emotional, she talked fast, and seemed quite dysfunctional. She reported auditory hallucinations since age five, when she was raped. She credibly described voices that appear frequently and order her to kill herself: "Kill, kill, kill!" She insisted, very genuinely and poignantly, that she is "not a bad person."

Clinical chart: 55% "hart reflects that she has spent time at f2edfix-d Hills. She has a diagnosis of Major Depressive Disorder, Recwent, with

Psychotic Features (318/01), Psychotic Disorder NOS (3/10103), and Posttraumatic Stress Disorder and Bipolar Disorder {9/4/03). She has been prescribed Seroquel, 400 mg., Zoloft 50 mg. and Neurontin 800 mg. A 3/3/03 note reflects "increase of psychotic symptoms on satellite-will adjust meds." She has been admitted to observation while acutely suicidal on several occasions, and then returned to SHU.
The problem with punitive and harsh conditions of confinement (for example lengthy stays in observation cells without amenities) and disciplinarywrite-ups for prisoners who attempt suicide is that these measures do not alleviate the prisoner's despair; indeed, they reinforce it. As soon as he or she is released fiom restraint, his condition may deteriorate further, or he might plan an even more lethal attempt. Meanwhile, the already suicidal prisoner is very likely to turn on himself the anger he feels on account of what he considers unfair and brutal treatment, for example a ticket for attempting suicide or very harsh conditions and deprivations in an observation cell. A clinician cannot punish a prisoner into transcending his or her despair. In fact, the prisoner knows that in order to get out of observation he or she needs to convince the mental health staff that he or she is no longer suicidal, so when the mental health staff member makes rounds and asks at cell front if the prisonerlpatient still wants to take his or her own life, or when the staff committee calls him in for a very brief conference about his condition, he is inclined to answer that he is no longer planning or &siring to kill himself. Then, back in his cell, he can make another attempt.
Quite a few prisoners told me that they do not tell the staff when they feel suicidal, because they know they will be placed in observation, possibly naked, and they will essentiallybe punished even more severely for admittingthey are suicidal. It is astonishing to find many prisoners in observation who report that theconditions are so
noxious in observation that they would prefer to be returned to their SHU cell - and these
same prisoners tell me that they had become suicidal only after finding life to be intolerable in SHU. The end result is that many prisoners who are feeling suicidal opt not to seek help &om mental health staff and not to report such feelings, and this dynamic contributes to the high incidence of suicidein isolated confinementwithin DOCS.
Prisoners who exhibit suicidal behaviors or express suicidal ideas are very likely sent to observation in the Satellite Unit. From there, they might be sent back to their unit and then, when another suicidalcrisis occurs, be transfenred to an observationcell again. In other words, they cycle fiom their cell to observation and back, until the mental health staff decide this prisoner is too serious about committing suicide, or too depressed or psychotic, to be retained in SHU, ICP or the general population. Then he or she may be transferred to CNYPC. But if the prisoner who has recently been through a suicide crisis is transferred &omCNYPC back to SHU, essentially the same kind of cycling is going on. I interviewed and reviewed the clinical charts of many prisoners who cycled repeatedly between SHU and observation in the OMH Satellite Mental Health Unit, with

occasional transfers to CNYPC and back again to the same SHU. I will illustrate the pattern with two cases:

6 hp-
Meadow on 8/26/03.)

(Interviewed while housed in SI-IU at Great

History: This man has been in SHU for over a year, and will go home by the end of 2003. The ticket that had him transferred from Keeplock to SHPU was written when he threw urine at another prisoner who had thrown excrement at him. He has been repeatedly suicidal in response to command hallucinations -he cuts, and displays scars on his neck and anns. He often hears his dead brother's voice telling him to cut himself. He was in the hospital one week ago for swallowing Ajax. He was depressed and hearing voices, and he was prescribed antidepressants. He has been in some form of psychiatric treatment since 1989, when he jumped out of a second story window with a noose around his neck in a serious suicide attempt. He was declared incompetent prior to trial, but then he pled guilty. In his SKU cell he mostly sits and stares, and ofien does not eat. He has been to observation a lot, often due to overdose or hanging attempts.

Mental status examination: This man displayed flat affmt, depressed mood, hopelessness and helplessness. He made no eye contact. He gave credible reports of c o m a n d hallucinations and exhibited bizarre thoughts. He was concrete with some cognitive blunting. There was strong suicide ideation and intention. This presentation is consistent with depression with psychosis, and suggests a high risk for suicide.

Chart review: Many psychiatric hospitalizations in the communityare documented. He has been prescribed Zyprexa, Prozac, Neurontin, Paxil, Benadryl, Vistaril and other medications, usually an anti-psychotic or mood stabilizingmedication plus an antidepressant. He is seen in SKU by psychiatrist Dr. Faruki, mostly cell-side, between admissions to observation
- and cycles from SKU to observation and back to S W fkquently.
. . @ 9 clearly severely depressed and psychotic, with command
hallucinations telling him to kill himself Yet he is left in SHU and never even sent to CNYPC for thorough evaluation. He cyles repeatedly from SHU to observation as he repeatedly tries to kill himself. OMH and DOCS have done nothing to alleviatethe risk of harm to this patient; indeed, in spite of their knowledge of the risks, they have
continued to maintain - 8-$ in isolated confinement, where he has attempted suicide
many times, and have failed to adequately treat his depression in a therapeutic setting.

9 .d-

(Interviewed while housed in SHU [STP

Program) at Five Points on 3/13/03.)

*- History: g - has been in prison for 12years and in SHU for four
years. He has been in STP for 15months, and expects to be released from SHU in 2008. He has been prescribedSeroque1, Zolofi and Vistaril, he reports all in relatively high doses since his last ticket. He resents that the psychiatrist in SHU and in observation see him only at cell-front, so "you have to broadcast your problems." He also complains that the mental
health staff talk to him or about him in fiont of correctional officers. He
does not trust his therapist because of this breach in confidentiality. He cries and has flashbacks at the anniversary of his crime.

Mental status examination: This man was very anxious, he talked obsessively about side effects of the medications he was taking, he was not well-oriented regarding time, and he told me his disorientation adds to his confusion in SHU.

Clinical chart: The chart is quite thick. With no pre-incarceration psychiatric history, he attempted suicide at Rikers Island. He was sent to SHU in 2000. He has been prescribed strong dosages of anti-psychotic, antidepressant and mood-stabilizing medications for quite some time. His Diagnosis is Depressive Disorder NOS. He is admitted to observation repeatedly for suicidal ideation and intention, and then returned to SHU.

This man is repeatedly suicidal in SHU, even when he has participated in the STP while housed in SHU, is not admitted to CNYPC except once for a few days, is treated with anti-psychotic and antidepressant and mood-stabilizing medications and cycles very often to observation, where he remains for days or weeks and is seen only at cell-front and then returned to SHU with or without the STP.

Either because there are not enough beds at CNYPC, or because O M clinicians
often prefer to keep prisoners h m SHU in observation for lengthy stays rather than transferring them to CNYPC, quite a few prisoners repeatedly cycle between SHU and observation and back to SHU. I will briefly mention another illustrativecase. Notice that this prisoner is one of many individuals who prefer a SKU cell to an observation cell. This speaks to the harshness of conditions in observation, one of the reasons I have concluded that observation is designed as punishment rather than as treatment. Another reason I have concluded that observation is more punitive than therapeutic is the lack of meaningfbl therapeutic contact with OMH staffwhile patients are in observation - a few minutes of contact per day at cell-front or in a staff conference is not what I would call adequate clinical contact. No wonder so many prisoners feel that conditions in observation are so dreadfbl that they prefer SHU to observation, even when SHU is "pretty awfil":

$6.:
Wende on 9/22/03.)

(Interviewed while housed in SHU at

History: This young man has been in prison for ttxe years. Me has been in SKU for four months, and prior to that did four months in Keeplock. He has had 20 or 30 tickets, many accrued while he was in "the Box." He is diagnosed Depression and AD311CD7and is prescribed Wellbutrin. He has never been to CNYPC. He was in observation for 22 days recently. He prefers SHU to observation, where there is nothing to do, not even recreation. He feels worse in observation than in S W , andcut his wrist in observation.
Mental status examination: This young man was obviously depressed, with downward gaze and psychomotor retardation. He reported hearing voices and obsessed about "hanging up." He told me he is hesitant to tell mental health staff about his emotional problems because he fears they will take advantage of them. He is saddened by what he perceives as a loss of intelligencewhile in SHU.
Clinical chart: His chart is eight inches thick. He is diagnosed Bipolar
Disorder II (hypo-manic rather than manic swings alternate with depression
- in other words, the "highs" are not as high as in mania). He has a history
of depression and ADHD/Conduct Disorder from childhood. He cycles fiom SHU to observation and back on account of self-hafin. Medications include Wellbutrin, Remeron and Depacote. A CNYPC inpatient screening note on 10/23/03diagnoses R.0 Adjustment Disorder with substance abuse and ASPD. An 11/5/03psychiatric consultation continues the "no SMI diagnosis on Axis I" and recommends Seroquel or Zyprexa for behavior problems. But the commitment notes from psychiatrists admitting him to CNYPC after he "hung up" and nearly died all reflect serious Depression.
In summary, prisoners who report suicidal crises are treated in a fashion that is more punitive than therapeutic. It is likely that this contributesto the high incidence of suicide. Conditions in observation cells are unnecessarily harsh, the prisoner is left idle and isolated, sometimesfor extended periods, and there is little or nothing in way of actual treatment except observation, medications usually prescribed by a psychia&ist visiting briefly with the patient at cell side, and daily very brief meetings with a clinician at cell side or with a treatment team in an office. Whether or not this is the intention of staff, the overall effect of this punitive regimen in many cases is to coerce the prisoner into falsely claimingthat he is no longer suicidal so he can be transferred out of the harsh environment in observation. The fact that so many prisoners told me they prefer their SHU cell to the observation cell reflects the harshness of what should be a therapeutic program. A comparison between the stark deprivation and inattention that prevails in SatelliteUnit observation cells with the humane and very decent treatment patients receive at the inpatient hospital, CNYF'C, tells the whole story.

3. Underutilization of Dormitories
The dormitories in the SatelliteUnits I toured in 10 facilities, forthe most part, are empty or grossly under-utilized. For example, when I toured Sing Sing on 5/7/03, there were three patients in a dormitory that has a capacityof 16. In a few facilitieswe came upon one or two prisoners who were being housed in a dormitory with six or eight beds. Dormitories in other institutionsI toured were entirelyempty. OMH reports 14% occupancy for dormitory beds, system-wide, compared with 69% to 79% occupancy rates for observation cells.60 This seems a waste of desperatelyneeded beds in Satellite Treatment Units. I asked OMH staff repeatedly why the dormitories were so vastly a under-utilized, and they explained that most of the prisoners who are in observation were transferred fiom SKU and still have a term to serve in SHU. DOCS does not permit OMH to house SMJ-designated prisoners in a non-isolation setting, so they cannot be placed in the dormitories.
Something is tembly amiss here. Many of these sameprisoners havejust returned fiom CNYPC, or they may soon go to CNYPC, and at the hospital they will be in a room "I with an unlocked door and they will be taking part in group activities. Yet just before they go or as soon as they re-enter DOCS through the SatelliteUnit they are suddenly not capable of being housed with other prisoners? This under-utilization of dormitory beds must contribute to an over-reliance on observation cells. In other words, there needs to be another form of confinement in the Satellite Units for prisoners from SHU who need crisis intervention services. Not everyone who is in crisis needs to be placed in observation. When individuals experience an acute psychotic breakdown or a manic episode, they need intensive mental health treatment but they may not require as close observation as someone who is at high risk of self-harm. Why should a prisoner who is suffering an acute psychotic breakdown be subjected to the deprivationsof observation?
4. Lengthy Stays in Observation, Failure to Admit to C N M C
Finally, whether the prisoner presents a high risk of suicide or is sufferingan acute psychotic breakdown, he or she should not remain in observation, or even in the dormitory, for an extended period. The standard of care in the cornunity dictates that stays in crisis intervention settings be very short-term. The purpose of the crisis intervention unit is to provide rigorous assessment and very short-term intensive treatment. Most such units in the communityhave a 24-hour limit. The patient can either be assessed and it can be determined within 24 hours that he or she does not pose a risk of self-harm, or where there is anotherkind of crisis such as an impending psychotic breakdown it can be managed with rapid medicationtreatment and the patient can be returned to a stable state within 24 hours, or else the patient needs to be admitted to the psychiatric hospital for M e r assessment and more intensive treatment. Crisis
B ~ c We ay and Robin Nash, "Mental HealthCxisis ObservationCell and Dormitory Bed Usage,"July
2001 - June, 2002.

intervention units are not designed for prolonged stays, and it is cruel to keep a patient deprived of amenities and activities for longer than it takes to make a rapid assessment or accomplish a rapid treatment. In practice, many patients in the community can be returned to their homes safely after they are assessed and treated in a crisis intervention unit for less than 24 hours, and the smaller number of patients who cannot be stabilized in that time Erame can then be admitted to the hospital. The crisis intervention unit thus cuts down on hospital admissions by screening out the patients who can be treated in a short time and returned home. Of course, in NY DOCS, many of these prisoners arrived in observation tkom isolated confinement, and it is not acceptable to return them to an environment as stressful as isolated confinement (in contrast to returning a patient home in the community) immediately after they have suffered a crisis.

In his July-December, 2001 Report, "Observation Cell Usage," Dr. Bruce Way reported that the median length of stay in observation was three days in July and four days in the other five months of data collection. Dr. Way writes: "Reasons for higher median
lengths of stay need to be explored, and, if applicable, corrective actions taken.. ." In a
subsequent, July 2001 to June 2002 study of bed usage by Bruce Way and Robin Nash, they report an average length of stay in observation of four days, with variations between institutions, including a greater than six day average (in contrast to the median length of stay cited in the July-December, 20001 report) stay at Sullivan and a three day average length of stay at Great Meadow and Bedford Hills. These average lengths of stay are far too long. And why has OMH not heeded Dr. Way's statement in the earlier cell usage report, that "reasons for higher median lengths of stay need to be explored and corrective action taken"? A six day average means that approximately half the patients admitted to observation remain there for more than six days. And what these averages fail to reflect is that quite a few prisoners are admitted and discharged fiom observationin less than 24 hours, so there are a significant number who remain much longer than the three or six day recorded average. I encountered prisoners who were retained in observation for
weeks or even months, without amenities - and that means they had no clothes
except a Ferguson gown, no bedding except a Ferguson blanket, almost no possessions, no recreation, and almost no social contact and no real face-to-face psychotherapy. This is entirely unacceptableby all standards; it constitutes harsh punishment and in most cases is not therapeutic at all, but rather worsens the patient's condition. Another case will illustrate the point:

I

y.r'

Wende on 9/22/03.)

. (Interviewed while housed in observation at

History:

t

has been in prison for nine years. He was placed in

observation 28 days ago because he cuts himself He showed me scars on

his arms. He has been at CNYPC four times, he was depressed and heard

voices (his mother saying bad things since approximately age 12), and Jx

was hearing voices commandinghim to cut himself 28 days ago. He has

been in SHU for seven years with multiple admissions(approxirn&ely ten)

to observation and four to CMYPC. He described mounting anxiety which was relieved by cutting and by seeinghis blood, and he calmed down. He reported that in observation he has remained naked except a blanket and gown, the cell lights have stayed on all the time, and he has only been interviewed by mental health staff three times in the entire 28 days. He was put on loaf in observation without receiving a ticket -he was told he would receive the ticket after he gets out of observation. He told me staff make rounds at cell-front, but he does not want to talk under those conditions and merely says "I'm OK."
Mental status examination: This man had a gross tremor (involuntary movement). He was depressed with psychomotor retardation and gave a credible history of hallucinations. He told me he cannot read or write, and this makes his time in SKU more diacult to bear.
Clinical chart: His chart reflects admissions to CNYPC (core history
10/24/01),danger to self, and visual and auditory hallucinations including commands from grandmother. There are many notes in thechart about depression, command hallucinations and self-harm. He has been admitted to observation repeatedly for self-harm. He had a psychological assessment by Dr. John Wilson and a Behavior Management Plan dated 6/28/02. The plan recommended such things as delaying visits with psychotherapist after he attempts self-harm, returning him to SHU when medically cleared after self-harm, etc. He was discharged with a diagnosis of ASPD (primary), borderline intellectual functioning, substance abuse and old closed head injury (no neurological or neuropsychological assessment is reflected in the
chart). There were subsequent admissionsto observationand to CNYPC
for continuing self-hann and depression, and, in spite of having been undiagnosed, he continued to be prescribed Depakote 1,500 mg. bid, Seroquel 900 mg. per day and Zoloft 300 mgJday (hardly a medication regimen for a non-depressed, non-psychotic individual). But then a 10/8/03progress note, evidentlyby a psychiatrist, reflected a diagnosisof Major Depressive
Disorder with ASPD and borderline intellectual h c t i o n - and the same
medications.
J*d' clearly depressed and likely psychotic, even as he is manipulative
and disruptive, and he has spent a long time in SHU with very detrimental effects. He has been to observation many times for self-harm, and when I met him he had been in observation for 28 days. He is "un-diagnosed," and yet he continues to receive strong anti-psychotic and antidepressant and mood-stabilizing medications. But clearly his long stay in observation, while punitive, has not been therapeutic.

D. Intermediate Care Programs (ICP)

The Intermediate Care Programs (and AVP at Green Haven) provide a very
important component of the comprehensivemental health treatment program within NY
DOCS. Essentially, they are "stepdown" units. They provide less intensive supervision and treatment then the psychiatric hospital (and thus staffing is less expensive), but they provide more intensive mental health treatment than are available through outpatient services in the general population or isolated confinement units. The OMH studies of ICP programs correctly point out that programming is uneven at the various institutions some ICPs provide more activities and treatment than others. I noticed quite a lot of idleness on the part of prisoners in the ICPs during my tours. I support the plan to make the ICP programs more even from institution to institution, and to enhance the programming and diminish the idleness.

In spite of problems, the ICPs (and AVP) are good programs and constitute an essential component of mental health services. Many more slots in ICP are needed, however. The relative shortage of ICP slots means that many prisoners with serious mental illness are not able to benefit fi-om this "stepdown" component program. One of the ways that DOCS and OMH seem to justify their failure to provide intermediate care programming to very prisoners whose mental illness and disability require that level of care is to expel a significant number of prisoners deemed to have behavior problems. This does not make sense, clinically. Mental illness is a disorder of behavior, among other things. So how can a mental health system deny individuals suffering &om mental illness the services they need by citing their inappropriatebehavior as a reason for the denial?

In other Sections of this report I cite case after case of prisoners with serious mental illness being discharged from ICP, even though they require a mental health program of this level of intensity and longevity (i.e. ICP is the right program for them), because they are given a disciplinary ticket. Here I will cite three cases of prisoners with serious mental illness who have had the experience of landing in SHU, deteriorating in SHU, receiving more tickets, possibly cycling to observation or C'fSYPC and back to SHU, and then eventually being transferred to ICP, or returning to ICP, where their mental health stabilized. The fact that they were eventuallyable to re-compensate or stabilize, benefit firom the ICP treatment program, and remain stable in ICP speaks to the need to keep prisoners with this kind of serious mental illness out of isolated confinement, and the need to provide them with the kind of treatment and relative safety
that is available in ICP. Of course, to do this, OMH would have to develop many more slots in ICP - and if there were sufficient capacity in ICP, maybe there would not med to
be as many prisoners discharged for disciplinaryreasons. Here is an example of a prisoner who did poorly in DOCS until he was transferred into ICP.

H.d.
Elmira on 3/11/03.)

. (Interviewed while housed in ICP at

a History:

4Q+ has been in prison for six years. Be seemed

intellectuallyquite impaired, and when asked what changes he would like

to see in DOCS and O M , he said "better chips in commissary.'' He was in

SHU for six months at Sing Sing, and then transfined to ICP. He told me

he gets mental health help because he hears voices. He has been to

CNYPC once, and did well on Haldol -but he reported he is "OK"without

medications now.

Mental status examination: vi -4_ -.-did not look at the interviewer.
He seemed quite impaired in cognitive hctioning, had impaired intellectual fbnctioning, exhibited signs and symptoms of psychosis, and seemed to be managing currently in ICP.

Clinical chart: The chart documents Delusional Disorder and Mental Retardation. Voices were reported. He had been cycling repeatedly between SHU and observationuntil he was admitted to ICP on 12/24/01.

I have described many other cases in this report of risoners who do well in ICP,

but then are discharged because of poor behavior. @

,discussed in Section

IV.,is a good example. Poor behavior, rule-breaking and assaultivenesscan be part of

the clinicalpicture of SMI. In fact, these behaviors can constitute symptomsof the SMI,

or be driven by the mental illness. It is not appropriate to discharge a large number of

patients from the treatment program their condition requires merely because they behave

badly. Their inappropriate behaviors must be managed as part of their treatment plan,

where mental health and security staff collaborate closely in devising an overall

management plan. The management of inappropriate behavior inside a treatment setting

is standard psychiatric practice; to do otherwise - to discharge them from the treatment
program -places them at great risk for further deterioration, and indeed I found this h d

of deterioration in many cases I reviewed.

In a correctional setting, it is the responsibility of the mental health staff to identify the prisoners who require very long term or even permanent intermediatecare programming, and to do all they can to avoid discharging them &om a program such as ICP. I will present another example of someone whose SMI requires long-tern assignment to ICP, but whose repeated breakdowns and behavioral problems lead to his recycling between SHU and CNYPC.

=g2-%, .__--

.._.(Interviewed

while

housed

in

ICP

a

t

Great Meadow on 8/27/03.)

= History: I

has been in prison since 1991. He was in SHU

between 1996 and a recent admission to CNYPC. He felt the officers

harassed him in SKU. He was seeing things and crying a lot in SHU, and

was charged for multiple assaults on ofltcers. He believed that staff moved

him from SHU to ICP because we were coming on this tow, and he was convinced they would move him back as soon as we left.

Mental status examination: LEx- was incapable of giving a
coherent history, exhibited loose and tangential associations, and was incapable of reality testing. His afffxt was flat, he was concrete and he was agitated.

Clinical chart:

P-
C+&

2-1's chart is relatively thick. He was admitted to

CNYPC with a diagnosis of psychosis, hallucinations were noted, and he

was treated with Haldol. There are multiple admissionsto CNWC, d l of

which involve decompensation. In 2002, he was diagnosed Major

Depressive Disorder with Psychotic Features, other times he was diagnosed

Schizophrenia. He has also been prescribed Prozac and Risperbal. On

6/25/03, he discontinued his medications. In August, 2003 he was

transferred to ICP. (I met him on August 27,2003). On 9/29/03, he was

still in ICP. He was admitted to CNYPC in February, 2004, in a psychotic

state due to non-compliance with medications, and again on 11/24/04,

regressed and psychotic, with a diagnosis of Schizophrenia,

Undifferentiated Type. By 3/25/05 he had been discharged from CNWC,

was in SHU at Sing Sing, was non-compliant with medications and became

acutely psychotic and had to be re-admitted to CNYPC. He was also

plagued by hypertension and related medical emergencies, and had to be

transferred to a medical hospital in the community for medical treatment.

f E - 2a suffers fi-oma recurring psychotic condition, probably
Schizophrenia. His condition deteriorates in isolated confinement. He was trans&n:ed to ICP just prior to my inspection, but he did not last long in ICP. He was admitted to CNYPC in an acute psychotic state, and then returned to SHU. He should have been returned to ICP after recovering &om an exacerbation of his SMI.

E. Outpatient

Outpatient treatment is available to prisoners in many settings throughout DOCS. Thus there is no "site" to inspect in order to assess the quality or availability of outpatient mental health services. Rather, one learns of the services availableby reading policies and other documents, by interviewing prisoners about the care they receive, and by reviewing clinical charts. Besides the observations and opinions I provide throughout this report, the aspect of outpatient mental health treatment within DOCS that warrants fiuther comment here is the treatment available to prisoners in SHU.

Historically NY DOCS Satellite Mental Health Services have only been
available at maximum security facilities. As a result, some prisoners who should be confined at medium security or minimum security facilities are sent to maximum security facilities, not because of any security reason, but solely because they are

suffering from mental illness and need more intensive mental health services than

are available at the medium (or minimum) security facility. Two illustrative cases

are as follows:

6-Gd.

(Interviewed while housed in observation at

Sing Sing on 5/7/03).

History: This man has been in prison for a few years and in observation for two weeks. He says he has no prior psychiatric history, and was in SHU for only a few weeks prior to having "strange" psychiatric symptoms and being transferred to observation. He is serving a six month SHU term, and prior to SHU he was at Washington Correctional Facility, a medium securityfacility. He says he sits in his cell in SKU getting nervous, he f i l s " h y " and his body fmls unusually "light." In observation, the only staff he talks to is the group of mental health staff who take him to a room to talk for five or 10minutes on weekdays.

Mental status examination: This man seems acutely psychotic. He laughs inappropriately, he seems internallypre-occupied and does not establish normal contact, and his thoughts are tangential and there are loose associations. His presentation is consistent with a psychotic episode.

Clinical chart: Progress notes reflect pre-psychotic symptoms by 4/23/03, and he is transfmed to Sing Sing RCTP from Washington to WO psychosis. There is a diagnosis Brief Psychotic Disorder on 5/2/03, and reported auditory hallucinations on 5/6/03. Notes continue to 5/7/03, as he remains in observation and rehses medication. A 5120103 note reflects transfer to Clinton CorrectionalFacility, where OMH staff suspect he is concealing his psychosis. But he remains in a cell (Keeplock), r e k i n g treatment. In other words, he is left to ride out his psychotic episode in maximum segregation in a Keeplock cell with little or no treatment and only monthly reviews.

DC~.

(Interviewed while housed in

observation at Clinton on 7/16/03.)

History: This man has been in prison for 23 months. He is HIV positive, and has "mental problems." He was at Bare Hill Comtional Facility, a medium securityinstitution, in a general population dorm. He was transfemed to observation at Clinton, a maximum security facility, when he had persistent suicidal thoughts. Prior to inci~~ceratiohne, had been admitted to Bellevue psychiatric ward for 13months afterjumping off a sixth floor roof in a suicide attempt. He has been suicidal on and off ever since, and becomes suicidal when he receives bad news. He has never been

admitted to CNYPC. He was in observation during a previous incarceration.
Mental status examination: There is sadness, psychomotor retardation, insomnia, and obsessions about his wife, who died of AIDS in 2001. There is hopelessness, anhedonia (a lack of pleasure in anything), and low selfesteem.
Clinical chart: His chart contains the diagnosis Major Depressive Disorder, Recurrent and Psychotic (1122104). He has a long history of repeated suicide attempts, &om 1977, with several admissions to observation at maximum security facilities, including the admission to observation at Clinton on 7/14/03 due to suicidal ideation. Medications include several antidepressants. He seems to manage at times in medium general population, on antidepressants, between episodes. Outpatient progress notes &om 1/9/04 and 1/12/04 and a treatment plan review fiom 2/6/04 show him confined in the SHU at Fishkill, a medium security facility.
The fact that prisoners with mental health service needs must be transferred to a maximum security facility to receive the appropriate level of care means that they are being disadvantaged on account of their psychiatric disability.
Outpatient mental health treatment in SHU is very thin, in spite of a concentration of prisoners suffering from serious mental illness in SHU. According
to Dr. Bruce Way's 2002 study, 65% of prisoners in SHU are on the OMH caseload, and
32 % of prisoners in SIFU are on Mental Health Level 1; this is in contrast to 1l%'of the total DOCS population who are on the OMH caseload. According to the Special Housing Units Mental Health Needs Study Conducted by CNYPC (5/17/02), Level 1 patients received 1.6 hours of mental health contact in one month, consisting of 1.2 hours cellside, and 0.4 hours in a private space. The discussion in that study continues: "Clearly
there is little mental health clinical contact time with most being 'cell side' - a noisy,
non-confidential environment." As it turns out, these figures are actually underestimates of the true number of prisoners in SHU who are on the OMH caseload, as indicated by a 5/18/04 Memo to Roger Klingman, in which Richard h e r explains that as of 11/30/03,
"there were a total of 540 SHU inmates on the OMH caseload,. ..480 of these inmates
were considered seriously mentally ill. In addition to the 540 inmates in SHU who were
on the OMH caseload, there were 281 inmates in SHU-200 cells6' who also were on the
6' SHU-200 cells are freestanding isolated conffnemcntunits that exist in medium security facilities throughout the state. They are constructed as double-cell isolated confinement.

O W caseload.. .. Thus, the total number of b a t e s in SHU and SW-200 cells who
were on the 0Mf-Tcaseload at that time was 821.'&*

Since there is very little in the way of mental health treatment in SEW except

medications, cell-fkont interviews and occasional interviews in a confidential settiig, a

prisoner with serious mental illness who is not transferred to observation or CNYPC must

remain in his cell almost 24 hours per day with little to do and the constant threat of

getting into trouble with officers and having his term in SKU extended. A philosophy of

punishment substitutes for a philosophy of treatment, and prisoners with serious

mental illness suffer immensely from the harsh conditions, lack of meaningful

activities, punitive practices and inadequacies in the treatment program. In short,

confinement in a cell, 23 or more hours each day, even with the prescription of

psychotropic medications, does not constitute adequate mental health treatment,

and causes deterioration in the psychiatric condition of prisoners suffering from

mental illness. Dr. JeffreyMetzner, a recognized expert on correctional mental health

care, has been quoted saying: "If the conditions of confinement involve being locked in a

70-square-foot cell 23 hours a day for months at a time, it is unlikely that patients with

mental illness could receive adequate mental health ~ervices."~I have presented many

ar,-a - - &Q-+q relevant cases to illustrate the inadequacies of mental health servicesin isolated

confinement, in-.c.-lu-d- ing'

td -D% - ,
full;.

bl p
.

)
<

3'-22T.R,

&-..@ >

j

will

'& .6 1 - IJ.

D

present

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w e addaional

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defrcietnciea~m n\-hjalpgat,lr1is

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services in SHU:

F.%L;
Sullivan on 5/5/03.)

(Interviewed while housed in SRU at

F History:

LIS psychiatrichistory pre-dates incarceration. He has

been in SHU at various institutions. He explainedthat at Clinton he could

not get any help for his mental health problems, so he stopped eating in

protest. He was experiencingsevere anxiety with t a t n e s s and pain in his

chest and abdomen. He suffers anxiety attacks when he is locked in a cell

and idle, and believes that his current emotional problems became disabling

two months after he was locked up in the SKU at Auburn. He was

transferred fiom the Clinton SHU to CNYPC. He reported that in SHU, the

mental health staff see him briefly at cell-fiont and provide no help at all.

For example, he told them he was in trouble and needed mental health help

fiom September, 2001 through January, 2002, but only in January, 2002,

Exhiiit NO.460,1/11/05 63 In the American Psychiatric Associationpublication, PsychiatricNews, September21,2001, g.6.

did they really talk to him, and then they decided to transfer him to CNYPC. He described anxiety, a feeling the walls are closing in on him, conhsed thinking and trouble sleepingwhenever he is confined in SEW.

Mental status examination: Examination revealed some confusion, tangential thinking, very poor concentration, selficontradiction, delusions about being hypnotized and otherwise controlled by others, and poor contact with the interviewer. He did not seem to be suicidal, nor was he experiencing hallucinations during our meeting.

Clinical chart:

8- 9' thick chart confirms he was at CNYPC from

9/18/02 through 11/21/02, and he was diagnosed Psychotic Disorder NOS

on 8/28/02. He had at least two other CNYPC admissions. He has

evidently been assaultive toward staff, and has spent long terms in S W

and on Keeplock. He is noted to be delusional and paranoid on 9/18/02,

not eating for extended periods, and unable to walk for unknown causes.

Later notes relate inabilityto walk due to muscle loss secondary to reksal

to eat. He was discharged from CNYPC on the anti-psychoticmedication

Zyprexa 20 mg. per day. A certificate for transfer to CNYPC in 2002

describes him as "nearly catatonic." He was returned to Sullivan on

11/21/02,briefly evaluated in the mental health unit observation area, and

then was returned to SHU, still psychotic and taking Zyprexa 20 mg./day.

The psychiatrist opined that he was still delusional, but "hctional" in

SHU, taking Zyprexa 20 mg. A 6/27/03 Admission Note from CNYPC

states he is in SHU, "He is delusional. He has missed 13meals. He is

taking fluids. He thinks if he eats that the FBI will take fluid samples &om

his body for 'testing'." On 3/25/04he was housed in SEllU and

participating in the STP. My concern is that, given the severityof'
F G c - ' mental illness, the fact that he remains in isolated confinement and

receives only two hours of programming per day (if he is in STP), this is

not the proper setting for him and the mental health treatment is not

adequate.

F. SpecializedTreatment Programs (STP)

According to OMH Preliminary Reports about the STPs at Attica (18 cells) and Five Points (25 cells), these programs (which were started by OMH as part of the
resolution of Enff litigation) were intended to provide enhanced mental health services for
prisoners with serious mental illness who do not adjust well in SHU. The components of the STPs are "a. mental health services including group therapy for each inmate for two
hours each week day; and b. a joint management committee to discuss the
needs/placement issues of SHU inmates." The goals of the STP are to "A. Reduce
inpatient admissions and discipline, and B. Stabilize mental health .symptoms and

f ~ n c t i o n i n ~T. h"e~p~rograms are housed inside the Attica and Five Points SKUs. At Attica the STP prisoners are housed among the pods of the SHU, while at Five Points they are housed in a separate SHU block. In both STPs, the prisoners are subject to the same daily routines and security protocols as are the other SHU inhabitants, with the
addition of the two hours of programming and thejoint management committee. The
stated duration of the STP program is 12weeks, but I met prisoners who have completed one twelve weeks stint in STP and then were begun on a second. I also met prisoners who had been in STP and were returned to regular SHU. For the STPs to be useful programs, the time a prisoner spends in STP must be brief, and the aim of the brief treatment must be preparing that prisoner for exit &om isolated confinement. I will present an illustrative case:

ii 6
Points on 3/13/03.)

(Interviewed while housed in ICP at Five

History: V p- .told me he has been in prison for six years and will be
released next year. He likes ICP. He said he is Bipolar and hears voices. He was arrested (while in DOCS), charged and convicted for throwing in response to command hallucinations, and was given an additional three year prison term. He has been at CNYPC four times, usually returning to SHU when discharged. He says time in SHU has made his mental illness much worse, mostly because there was nobody to talk to. He also told me "If you suffer from depression like I do, you become really, really depressed
in SHU - and you start thinking about suicide." He says he has been
mentally ill since childhood, and was on SSI for Depression prior to incarceration. He told me that in SHU he tended to stop taking his medications and then his mental illness worsened, but in ICP he is being helped by mentai health staff to take his medications regularly.

Mental status examination: He was concrete, flat, and his reports of symptoms of psychosis and depression were quite credible.

Clinical chart: Multiple volumes of' d *p -'s clinical file fill a carton.
There were psychiatric hospitalizations prior to incarceration. From December, 1999,through February, 2000, he spent most of the time in observation at Auburn while doing a SHU term - he was belligerent, swearing, smearing feces, flooding cell, throwing things, etc. He was not transferred to a hospital because staff felt his behavior was not driven by SMI; yet he continued to be prescribed strong anti-psychotic, moodstabilizing and antidepressantmedications. He cycled repeatedly between SHU and observation and CNYPC and back to SKU. A 5/02 note reflects he is in STP. A 9/5/02 note reflects a plan to transfer him to I D , and by

"Drafts 10/2/02for Attics and l OJl1/02 for Five Points.

10/15/02 he is admitted to ICP. He is retumd to the s&elliteunit at least once, but recovers and returns to ICP. On 6/2/03 he is scheduled for transfer to discharge planning.
J FL had been an extremely diEcult management problem in SHU, likely because his Bipolar Disorder was exacerbated by isolated confinement, had spent much time in SHU, and had been transferred to CNYPC and observation multiple times and back to SHU. Eventually he succeeded in getting out of SHU after a several month stint in SHU enrolled in the STP and then by transferringto ICP, where he has been able to remain on his medications (anti-psychotic, antidepressant and anti-psychotic) for severe Bipolar Disorder with Psychotic features and remain free of tickets.
I toured the Special Treatment Programs at Attica and Five Points, and I witnessed an ongoing program in the room set up for STP group activities at Five Points. The most striking physical feature of the STP is the "cages," individual enclosures for each prisoner while he is taking part in group activities. One of the group rooms (on A-2 housing for STP, low side) at Five Points contains five cages spread along two of the four walls in the living-room sized special room. Each enclosure is approximatelythe size of a phone booth, they are separated from-eachother by their lexan walls. Each prisoner is brought in separately and placed in an enclosure, and then the group leader talks to the group. There are a variety of formats, including some that are considered therapeutic and some that are considered educational. OMH s t d a t Five Points t d d me that participation in the STP requires medication complianceon the part of the prisoner. Interim Evaluation ~ e p o r tfsor~th~e STP note good propess. For example, Attica STP participants had fewer Tier 3 tickets while in STP than they had accumulated previously, there were far fewer admissions to observation, and there was better compliance with psychiatric medications. However, there was no significant reduction in the frequency of admissions to CNYPC and no significantreduction in the number of suicide attempts.
According to the Special Housing Units Mental Health Needs Study Conducted by CNYPC (Draft 5/17/02), prisoners in STP received 21-4hours of mental health contact in one month in the 43 program slots. However, these prisoners in STP received an average of only 0.9 hours of individual clinical contact in a private setting per month. For prisoners with SMI, this is insufficient treatment to maintain stability in the SHU environment.
Placing human beings in cages can be very degrading. Prisoners I interviewed in STP told me that they have graver concerns about confidentiality and humiliation in STP then they did in SHU. At least in SHU they can choose not to talk to the OMH clinicians who ask them potentially embarrassing questions at cell-hnt, within earshot of other prisoners and officers, but in STP groups they are required to expose vulnerablematerial, and offiws are either present during the group sessions or
Drafi for Five Points STP 7/21/03;Draft for Attica S T P 7/23/03

might come barging in at any time. Then, several prisoners told me indqendently, the officers use the personal material they have learned in the STP groups to ernbmass the prisoner in front of fellow prisoners at a later time. The prisoners in the STP are confined in the SHU, and at Attica their cells are scattered throughout the SKU.

I will present two illustrativecases of prisoners whose STP treatment is compromised by the fact that they are housed in SHU and that officers intrude on their treatment and education in the cages:

p-,3- - ---

..-------_a

(Interviewedwhile housed in SHU and

assigned to the STP at Attica on 9/23/03.)

History: Q 3 has a history of seriou mental illness and psychiatric
treatment since childhood. He told me the correctional officers are in the
room with the prisoners and therapist during therapy group in STP. He has
been prescribed Haldol, but was not taking it because he did not trust the correctional officers. He reported hearing voices and feeling very suicidal. He was r e k i n g to go to the yard because he was afraid "the correctional officers will do somethingto me." He has made approximately20 suicide attempts. He complainedthat the correctionaloEcers are privy to treatment in STP and then use the clinical information against the prisoner. He awakes crying fkequently.

Mental status examination: This man was agitated and angry, with some pressured speech. He gave credible reports of auditoryhallucinations, he was delusional, and his affect was depressed. He was concrete and there was some evidence of thought disorder.

Clinical chart: His very thick clinicalchart contains diagnoses of Delusional Disorder, Paranoid, and Organic Personality Disorder. At other times he is diagnosedPsychotic DisorderNOS. When he agrees to be medicated, he is given injections of long-acting Haldol, 150 mg.per three weeks, and oral Depakene 1,250 mg. per day. He has been admitted to CNYPC many times since 1989, always being returned to SHU at discharge. He is admitted in a psychotic state, medicated, often ~strairred, and then returned to SHU, supposedlynon-psychotic, taking intramuscular anti-psychotic medication, and re-compensated. However, he repeatedly breaks down again in SHU.

f

suffers fiom a chronic psychotic disorder, is paranoid, agitated and

suicidal,he has continuallycycled between SHU and observation,CNYPC since 1989;he

decompensates in SHU repeatedly and goes to CNYPC where his medications are re-

initiated. f?$. is currentlyin STP with no current medications. He isc-ntly

provided very little psychiatric treatment, in spite of the fact that he has a history of

serious mental illness and was a d w l y symptomatic at the t h e of our interview.

G %"--

. (Interviewed while housed in SHU and

assigned to the STP at Attica on 9/23/03.)

History:

x - has been in prison since age 17. He has been in

SKU since 1996. He told me he has seizures, blacks out, cannot remember

the event, but wakes having soiled himself. He takes Dilantin for the

seizures (not reflected in chart), and he wears a helmet. He was taking

Prozac and Risperdal, but "they stopped my psychiatric medications." He

has been admitted to CNYPC twice since being in SHU. He has also tried

to hang himself in SHU. He was in observation March 6 - 13 at Attica. He

told me it is cold in SKU, and officers leave the windows open. He has

been behind glass (Lexan) the whole time he has been in the Attica SHU.

He did not know why. The noise that continues all night was keeping him

fi-omsleeping. He was in the STP program, but he worried about

confidentiality since the correctional officers come barging in to groups all

the time and talk outside about what prisoners say in groups. He expressed

a need for confidential therapy sessions. He said he would like a break

with his SHU term, but none had been offered.

.'Cs Mental status examination: @

was wearing a helmet, he had

deep bags under his eyes, he exhibited ideas of reference and tangential

thinking, and he gave credible reports of depression, suicidality and '

auditory hallucinations. I observed psychomotor retardation, depressed

affect, self-castigation and hopelessness

Clinical chart: The thick chart contains many diagnoses. He was prescribed Zyprexa in 12/99, with a diagnosis Attention Deficit Disorder (Zyprexa is a medication for psychosis, not ADD). On 1111/01 he was diagnosed Adjustment Disorder with Mixed Anxiety and Depressed Mood and treated with Zoloft 100 mg. (an antidepressant). A 4/4/01 SHU cellfront OMH note reflects that correctional officers say he has not been eating, note reflects depression. Periodic notes in the chart report his claim of auditoryhallucinations, he is prescribed anti-psychotics, but his diagnosis is adjustment disorder. Medications are changed periodically, but
he has been prescribed anti-psychotics(EPrsperdal,Zyprexa, Seroquel -one or other, not together) and antidepressants (Prozac, Zoloft - one or the
other). He has been in SHU, cyclingto CNYPC or observation since 1996, with a long term ahead.

*- g

was un-diagnosed repeatedly, and then notes in his clinical chart

reflected psychosis and severe depression even when the diagnosis does not, and he was

prescribed medications for psychosis and severe depression. Current placement in STP

while housed in SHU is better than what he has had previously, but I am concerned he

will complete STP and remained housed in SKU. A CNYPC discharge note reflects that

his extensive SHU term prevents his referral to a treatment setting. He continues to be

unpredictable and suicidal. He is in STP, but the Risperdal and Prosac that he says help

his mental illness are not currently prescribed. @

is clearly not receiving

adequate nor effective mental health treatment for his serious combination of disorders

and cognitive deficits. His lack of a diagnosis of serious mental illness, despite his

obvious needs, means he has no adequatetreatment plan in place. For this patient, STP

will provide no more than temporary respite from his SHU 1.~11.

I strongly question whether the cages the men are placed in for group even&, and the very tight security measures in STP, are really necessary. Consider the fact that at CNYPC many of these same SHU prisoners are permitted to mix with other prisoners in the day room, group meetings, etc., without restraint. Additionally, at the inception of the STP, before the enclosures or cages had arrived, the plan was to conduct STP group sessions without cages, but in smaller groups.66

Further, the potential negative effects of treatment incages or enclosures must be

weighed against the therapeutic and securitybenefits. This is a complicated calculation.

The critical variable is whether participation in time-limited STP programming makes it

possible for prisoners who had been inSHU for a long time and were likely to remain

there indefinitely (since their mental illness is exacerbated and they repeatedly receive

tickets in SKU), are able to be transferred out of SHU and remain out of SHU. No matter

how rosy the picture painted by OMH preliminary studies of STP outcomes, this aspect of

the outcome is as yet undetermined. I met several prisoners who had participated in the

STP and then were returned to SKU, including A -4b (discussed in this Report,

above) and

5 (see Case Studies, Appendix D); and I met \/. G; in

ICP (see beginning of this section), who had been in SHU for a long time, and then went

through the STP and was able to exit SHU and be transferred to ICP. Part of the

determinationof outcome depends on how significant are the "time-cuts" given to

prisoners with serious mental illness. There is a policy permitting OMH and DOCS staff

to reduce the time a prisoner with SMI must serve in SHU in order to effect a more

optimal placement in a therapeutic program. This policy is implemented through Case

Management ~ o m m i t t e e sI.n~p~ractice, from my interviews and chart reviews, patients

with lengthy SHU terms are still not provided with sufficient SHU time-cuts, and are not

referred in a timely manner to needed treatment pr0gpm-s.

The 7/23/03 (Draft) "Specialized Treatment Program at Attica Comtional Facility Interim Report" and the 7/21/03 '3pecialized Treatment Program at Five Points CorrectionalFacility Interim Report" provide some outcome data for prisoners entering the two STP programs between late 2001 and early 2003. Disciplinary infractions are

-

-

CNYPC GoverningBody Meeting Minutes, Dec. 1I , 2000.
''Case Management Committees (CMCs) were establishedby regulation pursuantto the settlement
agreement in Anderson. CMCs are discussed in finther detail in Section M.

decreased to some extent, participants in the program were still admitted 40 Satellite
Units and CNYPC,but at a statisticallysignificant lower rate, and so forth. Timecuts
(for S W terms) were given to 40% of "ST participants at Five Points, and the median time cut was 262 days. At Attica, time cuts were given to 53% of the STP participants, but the median time cut was only 60 days. In terrns of housing assignments, at Attica 9 of the 30 STP participants were in general population or ICP six months later, while another 11were in SHU (one assumes that 10 more were still in STP within SHU). At Five Points, 10 of 22 STP participants were in general population or ICP while 10 others were in SHU.

Since SHU terms can be cumulative and run into many years, and since between a third and a half of STP participants were in SHU six months after they participated in STP, it looks like quite a significantnumber of prisoners are going through the STP programs and then remaining in SHU after leaving the STP, and it looks like the time cuts are not having a very significant impact on the SHU terms of many STP participants. While such outcomes as the reported decrease in disciplinary infi-actions and the improved participation in treatment constitute positive developments, the suicide rate did
not decline-remember, STP is inside the SHU, so the prisoners are subject to the same
harsh conditions (other than two hours per day of STP programming) as other prisoners in SKU. The fact that so many prisoners who go through the STP program remain in SHU means the STPs are not an effective antidote to the problem of prisoners with serious mental illness being in isolated confinement.

I am not optimistic the STPs will succeed in helping many prisoners be released &om SHU absent basic changes in the philosophy that guides the use of isolated confinement in DOCS and the attitudes and practices towards prisoners with serious mental illness that I have outlined in this report. After all, the STPs are located in SHU, the prisoners are subject to the routines and discipline of SHU, albeit with two hours in the cages or enclosures that permit group programming, and the enclosures themselves are degrading and not conducive to the fonnation of a trusting therapeutic relationship. Listening to the complaints about conditions registered by STP participants, they are the same complaints I hear from non-STP SHU inhabitants. In other words, the most important factor is confinement in SHU. The extra programming that comes with ST]? participation is relatively less important to these men. And the STP participants I interviewed all seem very pessimistic about ever getting out of SKU. One wonders how much meaningfultreatment or education can go on in such a setting. Meanwhile, STP participants are still housed in SHU, and suffer all the negative effects of isolated confinement. The two hours per day of programming is not actually sufficient to counteract the negative effects of the SHU confinement that continues while the prisoners
are taking part in ST??.I will present a case of someone whose mental condition
continues to deteriorate in SKU in spite of his being in the STP:

- hq

(Interviewed while housed in SHU and

assigned to the STP at Attlca on 9123103.)

History: A-\i ihas been housed in SHU, with or without STP for
three years. He Said he receives no mental health care in DOCS and he rarely goes to recreation in SHU because if you are not up when the CO comes around you miss recreation. He avenred taking anti-psychotic medications, which he said help, but he said he'd rather not be taking medications because they cause sedation and he does not trust the doctor.
Mental status examination: This man exhibited an obvious tangential thought process, loose associations, pseudo-logic, perseveration, thoughtblocking, searching for words, credible auditory hallucinations with internal preoccupation, a flat stare, concreteness and cognitive impairment. In other words, his mental status pointed to a diagnosis ofSchizophrenia, pending confinnation by history and chart review.
Clinical chart: Contrary to his denials, this man was treated for Schizophrenia earlier in his prison term, at Arthurkill and another facility. The voices he hears get worse when he is in observation. A 1/2/02 note reflects that he had not been on his psychiatric medications when he was accused of assaulting an officer,the offensethat landed him in SHU. He was in the Attica STP in February, 2002, and seems to have continued to be renewed for 12 week STP courses through at least 10124103. He is prescribed Zyprexa and Celexa when he complies with treatment. His motivation for STP is erratic, but notes continuouslyreflect disorganization and thought disorder.
84%- suffers &om chronic Paranoid Schizophrenia, deteriorates in isoiated
confinement and it does not seem to matter whether he is in SHU with or without participation in STP.
Dr. Shimkunas and Dr. DeVito, in their depositions, admit that there is a long waiting list for admission to the STPs, so there are many prisoners in SKU who are in need of more intensive mental health services who cannot gain admission to STP (See Shimkmas Tr., p. 183; DeVito Tr., pp. 165-166). If STP programming is not significantly enriched and out of cell time increased, and if prisoners are permitted to remain in SHU or return to SHXJ after completion of the STP program, then the STPs will not succeed in helping prisoners withstand the tremendous stress of being in SHU.
The 2004-2005 Executive Budget Forensic Mental Health Initiatives (Plaintiff's
Exhibit 238,5126104) proposes tripling the STP bed capacity, increasing it from 43 beds to 118beds. Most of the beds will be added at Five Points, and 50 will be in another facility. If prisoners are permitted to be housed in SHU either immediately after completing a stint in SHU with STP, or even after a period of time has elapsed s k e they completed the STP program, then the STP program will fail in its aims and merely constitute another form of harsh isolated confinement.

G. Substance Abuse Treatment Programs
At least 71% of prisoners in DOCS have a problem with substame abuse by selfreporL6* "Dual Diagnosis" is the co-occurrence of mental illness and substance abuse. Probably the percentage of prisoners suffering from serious mental illness who also have a problem with substance abuse is significantly higher than the 71% of all prisoners who have a substance abuse problem. Thus, for individuals suffering from serious mental illness, concurrent treatment of the mental illness and the substance abuse is required. This requirement is recognized in legislation and practices that govern the Federal CMHS Block Grant Funds that 0RN-Iand other state mental health agencies receive to establish Mentally Ill Chemically Addicted (MICA) programs.
There are at least three types of substance abuse: treatment programs available to the DOCS population: ASAT (Alcohol and SubstanceAbuse Treatment); CASAT (Comprehensive Alcohol and Substance Abuse Treatment); and RSAT (Residential Substance Abuse Treatment). Some of the programs are run by DOCS, and some by contracting not-for-profit agencies such as Phoenix House. According to DOCS figures, approximately20,000 prisoners complete drug treatment programs annually.
The Prison Visiting Committee of the Correctional Association of New York, in its June, 2002, "Report: State of the Prisons," states:
Many of the DOCS-run programs we observed were compromised by either staff vacancies, lengthy waiting lists or less than enthusiastic counselors. Inmates in
most DOCS-run programs reported a @eat deal of down time -cancelled classes,
movies instead of instruction or pro&ssionally facilitated groups - and little material of therapeutic value. Unfortunately,the Governor's 2003 budget calls for the elimination of all remaining prison drug treatment programs rur~by outside agencies.
The Visiting Committee was very concerned that the Governor's budget proposes closing the not-for-profit drug treatment programs that provide for prisoners spending part of their time in treatment within DOCS and then part of their time in treatment in the community. They were also concerned that the 2003 budget eliminates 48 substance abuse counselingpositions, reducing the number of slots &om76 to 28. The report continues:
Moreover, the state's primary substance abuse program - ASAT - has been
eliminated in most maximum security prisons, a cutback that has creaed serious
problems.. .. At Great Meadow Correctional Facility, for example, there is not a
68 See New York State Department of CorrectionalServices, "Identifiedsubstance abusers," 2001; and Hal Smith, Donald A. Sawyer & Bruce B. Way, "CentralNew York Psychiatric Center: An Approach to the Treatment of Co-Occurring Disorders in the New York State CorrectionalMental Health System,"
Behavioral Sciences and the Law Behav.5ci. Law 20: 523-534,2002.

single drug treatment counselor for 1,680 prisoners. Some of the maximum security prisons have replaced ASAT with RSAT, or Residential SubstanceAbuse Treatment, but in at least six maximum security institutions there is no substance abuse treatment.
The Visiting Committee points out that prisoners need substance abuse treatment to gain treatment for Hepatitis C, to earn parole or to participate in the Family Reunion Program. The Visiting Committee is also very concerned about the long waiting list {or drug treatment. For example, RSAT at Attica accommodates 85 prisoners in a six-month cycle and there are nearly 600 men on the waiting list.
The Visiting Committee's report is in stark contrast with an article Hal Smith, Don Sawyer and Bruce Way published about substance abuse treatment and the treatment of dually-diagnosed prisoners,69They accept national epidemiologicalfigures that show that 71% of prisoners have a substance abuse problem, and 90% of the prisoners who suffer fiom Schizophrenia, Major Affective Disorder and Antisocial Personality Disorder also have a co-occurring drug or alcohol problem. Thus, according to them, 28% of outpatients on the 0MH caseload within DOCS, and 33% of inpatients, have a cooccurring substance abuse problem. They proceed to describe the ASAT, CASAT and RASAT programs available to this population within DOCS, as well as pre-release treatment planning. The authors speak in glowing terms of the programs available to prisoners with a substance abuse problem. This assessment is belied by what I observed and what I learned from my interviews with prisoners suffering from serious mental illness and from my review of their clinical charts. CNYPC's own data fiom 2004 found that 48% of CNYPC outpatients have co-occurring mental illness and substance abuse. This is far higher than the comparable figuresin the 2002 report, in which they admitted problems with ~nder-re~ortingIn.~m~y view even the 48% figure still seems low.
I inspected several RSAT programs, and other activities related to substance abuse treatment were pointed out to me when I visited DOCS facilities. For example, there are substanceabuse groups in some of the ICPs I visited. But in general, I discovered that there is a shortage of substance abuse treatment programs in maximum security institutions. Prisoners in S W , and most who are on ICeeplock7' are precluded from substance abuse treatment. The exception is that in some of the ICPs, prisoners on Keeplock status in ICP, are released fiom their cells to participate in drug treatment and/or or other ICP programs. Most of the prisoners I interviewed informed me they had not been provided the opportunityto partake of substanceabuse treatment while in DOCS. Self-study materials, for prisoners in SHU, are next to useless because, as I have
69 Hal Smith, Don Sawyer & Bruce Way, "CentralNew York PsychiatricCenter: An Approach to tf2e Treatmentof Co-occuning Disorders in the New York State Correctional Mental HealthSystem,"
Behavioral Sciences and the Law, 20,523-534,2002.
70 'It is clear that not all patients with substance abuse were identified," Ibid, p. 527.
" Keeplock is generally 23 hour per day isolated confinement.

explained, they are not able to concentrate and are too emotionally upset to do the lessons. They need professional interventionto attend to their substance abuse problem, and this is not available in SHU.

Prisoners suffering from serious mental illness tend to accumulate in maximum security facilities (for example, they are transferred there for mental health services not available at lower security level institutions) and in SHU; and then they are denied substance abuse treatment which they very much need.

Dr. Fulwiler points out that even at CNYPC, where most of the psychiatric patients suffer from polysubstance abuse by history, substance abuse treatment is mostly limited to self-helpltwelvestep activities. There is nothing wrong with including 12-step programs in a comprehensive substance abuse treatment program, but they must not be substituted for professionally run groups and treatments. When the population being treated is well-known to have a high rate of co-occurring substance abuse and SMI, and that co-morbidity is known to exacerbate serious mental illness and make treatment more problematic, patients need to be provided a robust substance abuse treatment program that is run by well-trained professionals, and this program has to be continuous with similarly intense substance abuse treatment after the patient is discharged fiom CNYPC. Since so many patients leaving CNYPC return to a SHU in a maximum security prison, they would not be able to take part in a continuation of the substance abuse treatment, even if such treatment were to be made available at CNYPC.

H. Special Needs Units (SNUs) and Other Programs

w). Special Needs Units are designed as separateunits with full programming for

prisoners with Developmental Disabilities (DD), including Mental Retardation

I

toured the SNUs at Sullivan and Wende. These units serve the subpopulation with

Developmental Disabilities very much like the ICPs serve the subpopulationwith SMI.

In fact, a large proportion of prisoners with DD and MR also suffer from co-occurring

SMI. The main problem I discovered with the SWUs is that there are not enough beds in

them to house all of the prisoners in need. I found many prisoners among those I

interviewed in SHU, for example, who suffer fiom Mental Retardation in addition to

SMI. They were not housed in SNUs when they received the ticket(s) that led to a SHU

term. Had they been in a SNU, as would be indicated for a prisoner with their intellectual

deficit, they possibly would not have gotten into the trouble that led to their isolated

confinement. Examples of this problem that I have presented in this Report are the cases

of 7s , uui c, 0.9 1 D-F-1

8,.hidI and

0 4 1- Other relevant cases are included in Appendix D, dase Studies. In the case of

G .O . he was identified at Downstate Reception with a learning disability and

Schizophrenia, and SNU placement was recommended, but he was never transferred to

SNU and wound up in SHU instead. (See Selsky Deposition, pp. 1237-198.)

There are other programs that serve useful mental health treatment functions, but are not as prominent in the documents describing the mental health programs. My

discovery of 99 Company at Wende was quite acidental. I was interviewing several prisoners in general population and asked them where they bunked, only to be told by several different individuals who seemed to suffer from chronic serious mental illness that they are from 99 Company at Wende. They receive outpatient mental health services, but 99 Company provides a relatively safe and supportive living environment for these very disabled individuals. Dr. DeVito thinks of 99 Company as a "stepdown" program from ICP @eVito Deposition, p. 118). Indeed,it functions in that way, even if not officiallydescribed thus in OMH:literature. In the community, a program such as 99
Company would be called a "three-quarter way house" -i.e. a slightly less richly staff&
and less supervised "halfway house" designed as a "stepdown" for patients progressing fiom a psychiatric hospital to a halfway house to a three-quarter way house and then on to independent living. It seems that 99 Company is known as a cellblock where prisoners with psychiatric disabilities are housed, and the staff are somewhat more helpN to these chronicallydisabled prisoners then are some others. Stepdownprograms serve as an important component in a comprehensive mental health system, and appear to be largely lacking in DOCS facilities. I will present the story of one of the men housed in 99 Company, a stepdown unit:

Lg:- 7 .

.. (Interviewed while housed in general

population at Wende on 9/25/03.)

History: LN has been in prison since 1991. He has been in SKU six times and has been admitted to CNYPC 20 times. He has been in observation often. He was not on medications at the time of our meeting* but he had previously been prescribed Haldol and Risperdal. He had a long psychiatric history. He was on 99 Company, and felt the correctional officers picked on him. He was going to school and seeing mental health staff every other week.

Mental status examination: He was fairly incoherent, he mumbled, he was flat and concrete, he denied he had anymental health problems and he slumped in his chair. This man was obviously ssufering fiom chronic and persistent serious mental illness; his presentation is consistentwith Schizophrenia.

Clinical chart: The thick chart is consistent with this history. He was admitted to Kings CountyHospital in 1991with paranoid ddusions. By 2000 he had been admitted to CNYPC nine times and was considered for a long-term care ward. He also had many tickets, during the early years of his prison term for assaults. He was consistently considered paranoid and delusional and was prescnied psychiatric medications throughout his prison term. His diagnosis is usually Paranoid Schizophrenia. He has been prescribed Haldol and Wisperdal. The last admission to CNYPC in the

chart I reviewed was February to March, 2003, when he was discharged to Wende with Zyprexa 20 mg. b i d . He is relatively stable in 99 Company.
The APPU and Meryl Cooper Units at Clinton Correctional Facility are other unique programs that could serve as important components in the mental health delivery system. APPU is on the upper floor of the Satellite Mental Health Unit and its inhabitants are prisoners in need of some degree of protection, and they might need that protection because they are suffering fiom mental illness. In any case, there is some separation from general population, but there is also ikeedorn to move around the unit and there are enhanced program opportunities. Meryl Cooper is a therapeutic community in the Annex Building that prisoners progress through if they are motivated. There are only a few prisoners in the program who suffer from serious mental illness, and mainly the program is designed to help prisoners prepare for post-release life in the community. I mention these programs as examples of alreadyexistingprograms and locations that have some potential to serve the population of prisoners with serious mental illness, but are currently underutilized.
I. General Treatment Issues
1. Confidentiality
Confidentialityis a basic prerequisite to mental health treatment, and a basic right of the patient.72 The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry dedicates its largest section to confidentiality, requiring the psychiatrist to "safeguard patient confidences within the constraints of the law."73 There must be confidentialityif there is to be mental health treatment as we know it. No person wants what he or she tells a mental health clinician to be shared with others. Prisoners have a right to privacy during a clinical interview, and confidentialityto the extent that is practical in a prison setting. The 1990 Code of Ethics of the American Correctional Health ServicesAssociation (ACHSA) state that the correctionalhealth professional must "provide sound privacy during health services in all cases and sight privacy whenever possible."74 There are relatively rare instances when securityconcerns override the confidentialityrequirement, for example when a clinician hears ftom a patient about a serious threat to the safety of others or the security of the institution. These are exceptional cases; the rule is to take great pains to respect confidentiality.
72 Hippocrates proclaimed for all physicianai: "All that may come to my knowledge in the exercise of my profession or outside of my profession or in the daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal."
73 American Psychiatric Association, The Principles of Medical Ethics with Annotations Especially for Psychiatry, 1995.
74 Cited in Psvchiatric Services in Jails and Prisons, a publication of the Amexican Psychiatric Association, 2000.

Security staff and administrators often ask about a prisoner's mental status. Where policy permits mental health staff to share such information, that is appropriate. But to the extent possible, confidential information in clinical charts should not be accessible to non-clinical staff, conversationsbetween clinicians and prisoner/patients should be protected from breaches in confidentiality, and security staff must be trained to understand that confidential informationis shared for specific purposes only and that they, too, must protect the confidential nature of clinical information.

In this regard, cell-front clinical interviews done in isolated confinement units are very problematic. Confidentiality is too easily breached because the sessions are conducted within earshot of prisoners in neighboring cells and corrections officers may be present. As a result, the patient is unlikely to report information that clinicians need to know in order to provide treatment or protect the prisoner fkom self-harm; the mental health staffs willingness to conduct cell-front, non-confidential interviews is likely to create distrust of mental health staff. In all of the isolated confinement units I toured within NY DOCS, cell-front interviews and meetings occur quite regularly. Of course, mental health staff must make rounds on the tiers if they are to know who would like to talk to them, and they must go see a prisoner who is in SHU or other form of isolation at his c e l l - h n t to find out why he failed to come to an appointment. But these meetings should be very brief, no queries about the specifics of the prisoner's emotional condition should be made, and an arrangement should be quickly made to meet in a private and confidential ofiice or room in order to explore further the prisoner's condition and needs. Unfortunately, documentation that I have reviewed suggeststhat mental health screening evaluations are typically conducted at cell-front in the SHU and Keeplock units, and even medication management by the psychiatrist and counseling sessionsby OMH and DOCS
staff are conduct& at cell-front. (See cases of' pi 3. ..and J T- .m this
report, or any of a large number of prisoners who have hadtthe psychiatrist visit with them only at cell-ikont in o b s e ~ a t i o n ~T~hi)s practice violates the prisoners' right to a private and confidentialmental health assessment.

The SHU Plan of Improvement that has been introduced by CNYPC into the

outpatient operations requires OMH primary therapists to see SKU prisoners on the O M

caseload in a private, confidential setting at kast twice per month, and for the psychiatrist

to have a monthly private meeting with each patient on the OMH caseload, whether or

not medications are

This requirement permits patients more easilyto

request a private interview, and when they are seen in a private room at regular intervals,

they may develop some confidence that they will be able to speak confidentially to a

clinician. In this context, "rounds" made by OMH staff on isolated confinement units can

serve to set up private interviews with prisoners who desire them, or to check on

76 See 4115/05Memo from DonSawyer to Unit Chiefs, "SWJ Plan of Pmprovement"

prisoners who are not appearing for scheduled private interviews. However, this new

policy does not address the same problem as it occurs for patients held in Keeplock

confinement, and provides for only one contact per month with their primary therapist

(not a psychiatrist) for patients in the S-Block SHUs and the SHUs at Upstate (where

patients are double-celled in 23 hour isolated confinement) and ~ o u t h ~ o rTt h. i~s ~is a

significant gap in provisions for confidentiality, both for prisoners in SHU-200 cells

(there were 281 prisoners in SHU-200 cells who were on the OMH caseload as of

11130103)~a~nd for prisoners in Southport and Upstate SHUs. In addition, there are

some indications that the SHU Plan of Improvement requirement that prisoners on the

OMH caseload be seen by clinicians in a private setting does not filly address the

problem of confidentiality. For example, prisoner

testified that cell-hnt

interviews with clinicians last for only two minutes, while private sessions last for five

minutes @ deposition, pp. 40-41).

As I observed during my tours of isolated confinement units, when mental health staff conduct cell-fiont interviews the prisoners on the tier can definitely hear what is being said, as can security staff as they pass by. Thus, a prisoner is put in a position ' where, if he wants to talk to a mental health staff member, he must essentially disclose his emotional experiences and the treatment he receives 40 fellow prisoners and officers. Tn order to assess the need for medications or a change in medication dosage, a clinician would have to ask the prisoner "Are you still hearing voices?" or "How depressed (or anxious) are you feeling now?" Or, if a prisoner chooses to report that he is experiencing suicidal ideation and needs to talk to someone, he must do that within earshot of other prisoners and custody staff. This is not acceptable by any correctional standard and it falls far beneath the standard of practice in the community.

Great harm is done when confidentiality is breached. For example, when a male prisoner admits to his peers that he is suffering from emotional difficulties or a mental
illness, or when he admits he is suicidal, he is likely to be labeled a weakling or worse -
derogatory terms such as "crazy" and "bugy'are used in many prisons - and then that prisoner is vulnerable to attacks by other prisoners after he is released fkom isolated confinement. The more obvious negative effect is that prisoners who are in need of urgent mental health care will decide not to let the mental health staff know of their suffering or their suicidal inclination because they do not want to expose themselves to ridicule by other prisoners and non-mental health staff. Prisoners are likelyto opt to suffer in silence rather than risk exposure and humiliation. Talking to prisoners at cell-

77 Similarly,the problems I describedin observationcells within the Satellite Unib are not affwted by the SHU Plan of Improvement. Contactwith mental health staff for patients in observationcells occur at cell£rant in the Satellite Unit. This is especiaIly inappropriate since they are the most acutely disturbed patients in the system at the time they are placed in observation This lack of confidentialityis especially inappropriate since these patients are experiencing acute psychiatric crises at the time they are placed in observation cells.
78 5/18/04 Memo fkom Richard Beer to Roger Kbgman

front does not provide a context in which sufficient trust can be engendered for the clinician to find out what the prisoner is feeling and whether he is planning self-harm. Most of the mental health assessments I reviewed contain very little information, and I have reported in this report many cases where the prisoner was clearlymassively depressed or psychotic while the mental health assessment form was ticked 'cumemarkable"in regard to all signs and symptoms of mental distress. One wonders how many suicides might have been prevented simply by permitting prisoners in isolated confinement to meet privately with the clinician conducting the 90-day mental health screening asses~ments.I~n~many tragic cases of suicide, the assessment forms do not reflect the depth of the prisoner's despair, and in very many cases that would be because the assessment was conducted at cell-front in SHU, within earshot of others.
2. The Diagnostic Process and the Process of Un-Diagnosis
Diagnosis is the first step to mental health treatment. Absent adequate diagnosis, competent, effective treatment is not going to occur. This section focuses on a disturbingpattern of under-diagnosis or un-diagnosis that I found in a large number of cases, as a result of O m ' s misuse of concepts such as "malingering." I will comment on clinicians' repeated failure to conduct a thorough psychiatric assessment, which should include a 111psychiatric history, review of the clinical record, and a mental status examination, in order to arrive at an accurate diagnosis. Further, there is a misuse of psychological assessment (testing) in order to discount the existence and severityof mental illness. These practices fall far below accepted psychiatric practice. As a consequence, prisoners with serious mental illness are denied necessary treatment.
a. Making a Diagnosis
Prerequisitesto adequate diagnosis include an opportunityto hlly evaluate a prisoner's mental health record, a meeting between the individual and a qualified and competent clinician in a confidential setting that engenders sufficient trust for the individual to share his or her experience and difficulties, additional psychological testing
or medical tests as indicated, and follow-up assessments as n&. In NY DOCS mental
health screening typically occurs at Reception, with a face-to-face interviewprovided to a subgroup (approximately40%) of prisoners in Reception. Further opportunities for mental health assessment occur when prisoners request mental health services, during 90-
day screenings in SHU and other locations, at the behest of security staff who are
concerned about the mentai status of a particular prisoner, and during crises requiring emergency evaluations, crisis intervention at satellite mental health unitdobsavation, or hospital admission at CNYPC.
I have mentioned, in this Section, problems that I discovered in NY DOCS at each
step in this process. For example, some prisoners with serious mental illness are missed
79 The ACA requires 90 day xnental heal&screening assessments forprisoners in isohted confinement.

at Reception for a variety of reasons (some related to the prisoner's denial of symptoms, some to the lack of thoroughness of the examination). Ninety-day mental health screening assessments in SHU often miss the prisoner's obvious illness and disability because they are done quickly at cell-front, prisoners' reports of hallucinations and suicidal intent are downplayed and disbelieved by staff who are too focused on "bad behavior'' and its punishment at the expense of thorough diagnostic assessment. Much of the contact clinicianshave with prisoners in observation is very brief and occurs at cellfront where there is a lack of confidentiality and insufficient time to form a trusting therapeutic relationship, or the prisoner's wish to be transferred out of observation because of the stark deprivations there motivates the patient to deny symptoms so he or she can attain transfer out of observation. I presented a number of cases in Section VI of this report that illustrate these problems. Here I will focus on a disturbing pattern of under-diagnosis or un-diagnosis that I have found in a large number of cases. I will examine what I consider a misapplication of the concept of "malingering" by DOCS and OMH, and I will comment on what I consider a misapplication of psychological assessment in the diagnosticprocess (i.e. the disqualificationof prisoners &omthe ranks of those suffering fiom serious mental illness as soon as psychological testing uncovers "'Antisocial Personality Disorder" andlor "psychopathy").
Adequate diagnosis obviously requires clinical acumen, objectivity and a lack of bias, as well as a certain amount of sensitivity on the part of the clinician to the emotional suffering and disability of the prisoner. Regarding the very critical issue of staff bias, I
have discovered a clear pattern in many of the cases and clinical charts I reviewed in NY
DOCS, a pattern that is cause for grave concern. OMH and DOCS, in far too many cases, are too quick to doubt the authenticity of a prisoner's complaints of emotional symptoms. Once Oh4H decides that the prisoner has 'Wo Axis I Diagnosis," or is suffering mainly from Antisocial Personality Disorder or Borderline Character Disorder on Axis 11, or is malingering or manipulating, DOCS and OMH express insufficient concern about the prisoner's subsequent reports of mental anguish and ruminations about self-harm, and they tend to dismiss or downplay that prisoner's complaints of emotional pain and disability. In the course of interviewing many prisoners in isolated confinement, I found quite a few to be suffering from active psychosis, mania, or depression, or seriously contemplating suicide, only to read in their charts that these same prisoners suffer fkom "NoAxis I diagnosis" or that they score high on the psychological test known as the psychopathychecklists0;or that they suffer mainly from an Antisocial Personality Disorder. The implication seems to be that since they are "antisocial" or psycho pat hi^'^ their reports of psychiatric symptoms are entirelyunreliable, and almost by definition they
are feigning mental illness in order to gain something, perhaps a transfer out of SHU.
Nathan Hare's Revised PsychopathyChecklist, or PCL-R - see Hare, R.D.,"A Research Scale for the
Assessment of Psychopathy in Criminal Populations," Personalitv and Individual Differences, 1, t 1 1-1 17, 1980;and Hare, RD,Hart, SD, & Harpur, TJ, "Psychopathyand the DSM-IV Criteria for Antisocial
Personality Disorder," Journal of Abnormal Pswhology, 100,391-398 (199 1).

b. ''Mad" vs. "bad"
The problem is magnified by the tendency within NY DOCS and OMH to think about "bad-ness" and Lcmad-ness"in terms of either/or dichotomies rather than the botWhnd complexities the phenomenon warrants. Are a particular prisoner's unacceptable acts the rcsult of mental illness or merely reflections of his badness, antisocial personality or psychopathy? According to this overly reductionist logic, if the prisoner is "bad," treatment is unwarranted and a waste of time, and he deserves to be punished. Ifhe is "mad," for example truly suicidal or hearing voices commanding him to cany out illegal acts, he needs more intensive treatment, and there is some degree of mitigation for his bad acts. Reality is a lot more complicated. Not only are people suffering from serious mental illness perfeGtly capable of manipulating and exaggerating sy~nptomsb, ut often their tendency to do so is actually symptomatic of their mental illness. And in correctional settings, including W DOCS, there is a significant population of individualswho are suffering from serious mental illness as well as an Axis
IIdisorder such as Antisocial Personality iso order" -the Axis I and Axis D:disorders are
not mutually exclusive. These prisoners need effective treatment which addresses both disorders. Of course, even prisoners who are recognized as suffering fiom serious mental illness are not spared the disciplinary procedures in DOCS ,and they are sent to isolated confinement. In fact, many of the prisoners I interviewed in acute psychiatric crises in the Satellite Units informed me that they were faci~gdisciplinary hearings upon their return to SHU.
My findings in this regard are entirely consistent with those of Dr. Angela Browne, who was asked by Commissioner Goord and SuperintendentElaine Lord at Bedford Hills CorrectionalFacility, in the wake of several suicides,to investigatethe mental health program at that institution. In her Final Report in 2002, Dr. Browne comments: "During the TA Team's visit to the BHCF OMH Satellite Unit, we were impressed by the extent to which the Axis I1 diagnoses of 'Borderline Personality Disorder' and 'Anti-Social PersonalityDisorder' were used by OMH staff to describe
virtually all women referred to OMH because of s e l f - h d g and suicidal behavior.. ..
Clinical members of the TA Team were particularly concerned that the application of one or both of these Axis I1 diagnoses often did not seem to be accompanied by a compassionate treatment plan.'2 My own fundings in all the institutions I toured entirely matched Dr. Browne's conclusions, in men's as well as women's institutions.
c. Un-Diagnosis
I employ the term ccun-diagnosisnto describe the process whereby the diagnosis for a prisoner who had been diagnosed and treated for a serious mental
" However, I found in many of the cases I reviewed that ASPD is diagnosed without sufficient basis. 82 See "AddressingSelf-Ham Among Mentally Ill and TraumatizedWomen in Prison: Avenues of Systemic Collaboration Between Mental Health andCorrectionalPersonnel"by Dr. Angela Browne et al., 2002, p. 10 (PI. Ex. 111).

illness is changed to reflect ''no serious mental illness." Usually this change is reflected in a new diagnosis of "no diagnosis on Axis I." Either a less cLserious" mental illness such as "Adjustment Disorderyyor "Polysubstance Abuse by history" is entered under Axis I; or the V o diagnosis on Axis I" tag is accompanied by the diagnosis of a personality or character disorder on Axis 11.s~Clinical phenomenology is actually quite a bit more complicated than this simplistic characterizationcaptures, and
in many cases an Axis II diagnosis such as Borderline Character Disorder, if the condition
results in sufficient disability and suffering, can constitute a serious mental illness -but I will stay with the simplified characterization for a moment in order to make a point about the process of un-diagnosing.
Where un-diagnosis occurs, there are usually inconsistencies in subsequent clinical chart notes. For example,there are many cases where a prisoner had been assigned a diagnosis for many years of a SMI, such as Schizophreniaor Bipolar Disorder or Major Depressive Disorder, with many psychiatric hospital admissions on bis record, and possibly he or she received Social Security disabilitybenefits in the community on psychiatric grounds, and continuallyreports that the prescription of strong antipsychotic medications are helpful; and then his diagnosis is changed to "no diagnosis on Axis I" or downgraded to "Adjustment Disorder" or "Polysubstance Abuse" on Axis I, but the antipsychotic or antidepressantmedications are continued in dosages that would only be appropriate for patients suffering from psychosis or severe depression.
High doses of antipsychotic (or mood-stabilizing)medications are not indicated in the treatment of '$0 diagnosis" or "Adjustment Disorder" or "Polysubstance Abuse." As if the clinicians recognize this inconsistency, there are notes about the medicationsbeing prescribed "for sleep" or "for behavior management only." This makes no sense. High dosages of antipsychotic medications only help control behaviors if the behaviors are driven by mental illness. Of course, if high enough doses of an anti-psychotic medication are given to an individual who does not suffer from a relevant mental illness, that individual's behavior will be affected in the sense that he or she will be drugged into
sleep or at least into a sluggish, zombie-like state - but using medications with potentially
dangerous side effects in this way is entirely unsound clinically and constitutes a serious violation of professional ethics.
I discovered a widespread pattern in NY DOCS, namely, an individual who has a
long history of serious mental illness is incorrectly "-diagnosed" (i.e. his diagnosis is significantlydowngraded so as not to reflect the true severity of his mental illness); he is continued on medications that are appropriate (but not suflicient treatment) for his actual serious mental illness and not appropriate for the downgraded diagnosis; and then he is returned to SHU, where he decompensates anew because of the harsh conditions and inadequate treatment in isolated confinement. All the while, there is no treatment plan,
83 Axis I1 is the slot in a DSM-IV diagnostic formulation where such diagnoses as Antisocial Personality Disorder (ASPD), or BorderlineCharacter Disorder are recorded.
JA 279

and the un-diagnosis and the prescription of medications are not justified in the chart. It is my strong impression that after a prisoner has been un-diagnosed, he or she is much less likely to be subsequently admitted to the inpatient facility at CNYPC, regardless of his or her clinical needs.

In the followingcase, the diagnosisis changed from Bipolar Disorder to no diagnosis on Axis I except a history of polysubstance abuse:

v I-,
7116/03.)

. (Interviewed in observation a t Clinton on

History: 4 3 1had been in observation for nine or ten days when I
met him. When asked why he was in observationhe said "they stopped my medications at Auburn for no reason." He had been in long-term Keeplock until he received a ticket for fighting and was sent to SHU. Previously he had been in ICP at Auburn because he was "very depressed and suicidal.'" Dr. Melendez refused t:, prescribe medications when he first arrived at Clinton, but when I met him he was prescribed Seroquel200 mg. twice per day (a newer, "atypical" anti-psychotic medication), and he was scheduled to begin taking antidepressantson the day of our meeting. In Mmh/April, 2001, he was admitted to CNYPC where his diagnosis was Bipolar Disorder and he was prescribed Zyprexa, Haldol (both anti-psychotic medications) and Benadryl. He told me he cries a lot, he is very sad, he cuts himself, he cannot sleep, and he had lost a lot of weight, but on the anti-psychotic medication, Zyprexa, he gained back the weight. Even
though he knows the medication helps him,in SHU he often stops taking it
and then his condition deteriorates. He says it is difficult to stay on his medications in SHU and he only sees mental health staff for a k w minutes at cell-fiont.

Mental status examination: This man was sad, displayed psychomotor
retardation (slowing of thought, speech and activity - a sign of depression),
was self-castigatingand expressed a lack of hope. He credibly described auditory hallucinationstelling him to harm himself, which he called his conscience. My mental status exam is consistent with a diagnosis of severe depression and psychosis.

Clinical chart: The chart corroborates his history. Pre-incarceration psychiatric hospitalizationis noted. A 3/2/01 Progess Note at Five-Points reflects recent transfer &omCollins C.F. because of suicide threat. He is agitated or anxious, a history of auditoryhallucinations is noted as well as a pre-incarceration history of hyperactivity disorder in childhood. Diagnosis is Bipolar Mood Disorder NOS. Medications prescribed include the antipsychotic agent Zyprexa, 5 mg. b i d . (This is within the range of dosages of this medicationprescribed in the treatment of Schizophreniaand other

psychotic disorders.) On 3114/01 he was admitted to CNYPC with the diagnosis Bipolar Disorder with Psychotic Features, and medicated with Zyprexa 20 mg. per day (a strong dose, even for someone suffering from psychosis). On 4/4/01 he was discharged fiom W C to Wende, and on 4119/01 his diagnosiswas Bipolar Disorder I with Psychotic Features, and he was prescribed Zyprexa 10mg. twice per day. A S W mental health Assessment on 8/6/03 reflects crying so hard that the clinician is unable to assess orientation. He was moved to observation. An 8/19/03 admission to CNYPC followed his assault on a CO and 2 weeks in observation. Then, in stark contrast to all of this history, a 9/5/03 Psychological Evaluation by Dr. Michael Guariglia at CNYPC finds this prisoner to suffer from "no Axis I diagnosis except polysubstance abuse," finds he scores very high on Hare's Psychopathy Checklist, diagnoses Antisocial Personality Disorder, opines that psychiatric hospitalization would not benefit him, and suggests possible malingering. Afier being thus un-diagosed, he is discharged from CNYPC, but his discharge medications include Seroquel300 mg. twice per day, "for sleep," and Celexa 20 mg. per day "for depressed feelings," and it is noted that his admission diagnoses, Bipolar Disorder and Intermittent
Explosive Disorder, had been "ruled out." In September - November
2003, he was in SHU at Clinton, often refusing his Celexa but accepting Seroquel. A 2/27/04 Progress Note reflects he is in SHU and continues to be suicidal. And by 2/29 he was in observation in the RCTP. By 10/2ZO4 he had been re-admitted to CNYPC, and would be returning to SHU.
Thus,this man with a long documented history of Bipolar Disorderwith Psychosis, a long documented history of psychiatric hospitalizations, and treatment over many years with anti-psychotic and antidepressant medications with good therapeutic effect, was "un-diagnosed" by psychological testing while at CNYPC in September, 2003 (after our interview), but then was discharged with Seroquel300 mg. twice per day "for sleep." Seroquel is an atypical or new generation, very strong antipsychotic medication with many negative side egects, and 600 mg. per day is a very strong dosage even for an individual suffering from Schizophrenia or Bipolar Disorder with Psychosis. It would certainly not be appropriate to prescribe this medication at this dosage for someone who is not psychotic. The fact that it is noted in the chart the medication is being prescribed "for sleep," implies to me that the prescribing psychiatrist understood that the prescription of this medication at this dosage would signify to any psychiatrist reading the chart that the patient suffers f?om psychosis, and thus the denial implicit in the words "for sleep"is either a disingenuous ruse to support the inappropriateun-diagnosis, or it reflects unacceptably poor clinical practice. Similarly, Celexa 20 mg. per day is a full therapeutic
dose of that antidepressant medication -if this prisoner is not depressed, why is it
prescribed? In fact, when he was transferred to observation in the Satellite Unit on 2/29/04, he should have been almost immediately transkmd on to CNYPC. It m s clear that his un-diagnosis played a major part in clinicians' decision to keep him in

observation and return him to SHU instead of transferring him to CNYPC where he could have undergone the treatment his condition required.

Here is another illustrative case, where the diagnosis is downgraded from

=&- - Bipolar Disorder to Antisocial Personality Disorder:

-P
b

(Interviewed while housed in SHU at

Auburn on 10/29/1)3).

History: 1 6% had been in SKtT for the recent six months. He was prescribed Seroquel300 mg. b.i.d. (a strong dosage of an anti-psychotic medication), Neurontin 400 mg. b i d . (a moderate dosage of a moodstabilizing medication), and Paxil (an antidepressant medication). He has been on psychiatric medications for three years, and they help some, but being in SKU makes his mental symptoms much worse. He told me he gets
depressed, then he gets mad, then happy, then he cries - and all the while
he doesn't know why. He was in a psychiatric hospital for three y a m prior to incarceration -he was paranoid and hearing voices. He had a lot of trouble in GP because of being paranoid. He reported that if he doesn't take his medications he fmds himself cussing out the correctional officers and then he gets in trouble. Command hallucinations and paranoia were prominent in all the trouble he gets into.

Mental status examination: This man was very intense, his right eye drifted outward, he gave credible reports of auditory/command hallucinations, was clearly experiencing ideas of reference (paranoia), had a thought disorder that led to very poor reality testing, and exhibited hypomanic agitation and pressured speech. He was incapable of abstracting and displayed poor judgment.

Clinical chart: This prisoner's chart contains OMH notes as far back as 1992, when his diagnosiswas Manic Depressive Disorder (another name for Bipolar Disorder), and a history of multiple pre-incarceration psychiatric hospitalizations with ECT (ehtric 'shock' treatment, usually administered only in very serious cases of psychosis or depression) and the prescription of anti-psychotic medications (Haldol, Thorazine). By 1995, he was diagnosed Adjustment Disorder with disturbance of wnduct (i.e.,he had been "un-diagnosed" in spite of the long history of serious mental illness and intensive psychiatric treatment). By 199711998, his Mental Health Level was 1 or 2 and he was diagnosed Bipolar or Mood Disorder, and his diagnosis on an outpatient treatment plan of 4/15/99 was "Depressed with some psychotic symptoms." A 7/16/01 Treatment Review Plan from Upstate noted "Client has struggled to adjust to his S W environment. Reported increase in auditoryhallucinations, increase of &pression and mood swings." He took Seroquel,Paxil and Newontin at

least through 8/3/02. But on 4/14/83 he is at the Auburn O M Satellite and his diagnosis is changed by the psychiatrist and therapist to Antisocial PersonalityDisorder. On 6111/03he is refused for STP because his illness is not serious enough, i.e. he does not have a Mental Health Level 1nor a diagnosis of SPMI. In 4104, he is transfened to another facility to serve a 12 month SHU sentence for self-harm and destruction of state property. (It seems very likely that this man's un-diagnosed serious mental illness, i.e. Bipolar Disorder, drove the behaviors that resulted in disciplinary tickets.) The psychiatrist continues the Paxil and Seroquel and Neurontin, but claims there is no Axis I diagnosis.
This man is clearly suffering fiom chronic psychosis with a severe mood disorder.
Like 'd 3 _ _ --- and many others 1 interviewed, he is prescribed atypical anti-psychotic
medications (Seroquel), antidepressant (Paxil) and mood-stabilizing medications (Neurontin), even though he has been un-diagnosed (after many years of documented serious mental illness he is deemed to suffer fiom "No Axis I diagnosis").
Even if 7 E 3 had been properly diagnosed, the prescribed medications would likely
not be effective in overcoming the negative effects of isolated confinement on someone with serious mental illness.
I am left to wonder how OMH staff have succeeded in "curing" a serious mental illness that typically follows a waxing and waning course over a lifetime, and I am left to wonder what these strong and potentially toxic medications are being prescribed for. In SHU, his condition worsens, so the un-diagnosisputs him in harms way.
Sometimes an individual who is sufferingfiom serious mental illness will say somethinginaccurate, such as "I am only fooling, I don't really hear voices," when in fact he is hearing voices and, as an additional sign of his psychosis, he changes his mind
frequentlyand says inappropriate things- Ifthe clinician grabs hold of the one statement
that he is "only fooling," and looks no further for signs that he is truly s u f f a fiom psychosis, then he is at risk of being un-diagnosed and having needed treatment discontinued. It is unprofessional and below the standard of practice for a clinician to take the prisoner's statement at face value and to look no further at the psychiatric history and other signs of serious mental illness. Indeed, Dr. Shimlcunas found in a study of suicides in NY DOCS in 2000 that virtually every prisoner who committed suicide had denied suicidality shortly before death." Often statements such as "I was only fooling about hearing voices" constitute blatant denial on the part of a patient who is frightened that he might be insane, and this kind of denial is often seen amongprisoners who kar that the stigma of mental illness will lead to victimization and other negative
84 Dr. A. Shimlcunas "Division Paper on Prison Suicide," Aug.29,2000. He notes that: "...patients may hide their true suicidal intention to convince staff to pennit them the freedom they seek to carry out their final act."

consequences in prison. I will describe such a case, where the diagnosis was downgraded from Psychotic Disorder to Adjustment Disorder:

D i)NB

(Interviewed while housed in SHU in a single

cell at Upstate on 7/19/03.)

History: Dp.6 had been in SHU for four consecutive years. He had
no history of psychiatric treatment until he was treated at Rikers Island at age 21, hearing voices and paranoid, and he was prescribed Risperdal. He complained he has been trying to get psychiatric care at Upstate and is not able to get help. Ne was admitted to CNYPC in 1999, when he believed that there was a conspiracy between police and correctional oflicers to "gety'him. His medications were discontinued at CNYPC. In 2001 he came fiom Clinton PC to Upstate SKU. He had lit his cell on fire three or four times at Clinton, and had been to observation many times. He has also been to observation at Upstate many times. He has tried to hang himself and bum his cell, usually because he is intent on killing himself, but also-he is very angry. His emotional problems are much worsened "in the box." He was in observation for 16or 17days in November and December, 2W2 following a serious suicide attempt. At that time he pleaded for
medications to help him with his depression, but was not prescribed
anything.

Mental status examination: He reported that he regularly talks to himself,
feels paranoid - as if others are out to harm him - and he avers several First
Rank Symptoms (signs of psychosis), including thought insertion and broadcast. He reported hearing voices, but his main problem was depression. He was clearly very depressed, with psychomotor retardation. He felt worthless and hopeless, and thought often of suicide.

Clinical chart: The chart confirms the history he presented. Upon admission to Upstate on 4124103 he carried a diagnosis of "Adjustment Disorder with Disturbance of Conduct," and he was admitted to OMH outpatient serviceswith a MH Level 3, but on 5/22/03 his level was
changed to 6 and he was discharged fkom the OhrM caseload. There is an admission to CNYPC on 6110199, when he was found to be having auditory hallucinations, confused, regressed in behavior, and delusional, with a diagnosis of Psychotic Disorder NOS. He was prescribed Prolixin and
Risperdal. He cooperated in treatment at CNYPC, but then, evidently because he wanted to stop taking his medications, he told staff he had fabricated his symptoms. He was given a two week trial off of medications and was deemed to be doing well, and was sent back to Clinton. His discharge diagnosis was Adjustment Disorder. There were six observation admissions between 1998 and 2002, auditoryhallucinations were

documented on 11/29/02 and 12/5/02,depression off and on documented in 11/02 and 12/02, and he was returned from observation to Upstate S H U without medications on 12113102. A psychiatric evaluation in the Progress Notes for 7/24/01 documented history of hallucinations, delusions and psychotic episodes in the past while incarcerated, with no signs of psychosis at that time and no medications indicated.
DQ-6 is intermittentlyvery depressed and psychotic and has a history of
psychotic episodes dating to age 21 when he was at Rikers Island. He suffers ftom serious mental illness but is viewed by OMH as malingering because, after convincing several clinicians that he was in fact psychotic and being sent to CNYPC, he claimed to be faking his psychiatric symptoms in order to get off medications. OMH staff have relied upon this episode to rule out serious mental illness, a step that is clinkally inappropriate. OMH has disregardedhis psychiatric instability, and instead he is repeatedly admitted to observation with no treatment p!an capable of alleviating the repeated exacerbationsof his mental illness. He continues to cycle repeatedly to observation and has been prescribed very potent and potentially toxic psychiatric medications. It is likely that he is manipulative, and either exaggerates or denies symptoms for secondary gain, but this does not mean he is ftee of serious mental illness. A two week trial off of medications is not long enough to determine that he no longer needs medications. Usually when someone suffering &omchronic psychosis stops taking medications, we can predict another decompensation in a matter of months, not weeks. In
B addition, 36- was being returned to SHU, where the conditions would be likely to
induce another psychotic episode after the medicationswere discontinued. 3 P-f3 ,,is
clearly someonewho both suffers fkom serious mental illness and exaggeratesor falsely denies symptoms, especiallywhen he fkels threatened and needs protection and when he wants to stop taking medications.
ORen very disturbed individuals attempt to "feign sanity" for various rwons. They may want to avoid hospitalization, they may want to discontinue medications that cause bad side effects, or, particularly in prison, they may want to avoid the stigma of mental illness. But OMH staff seem to grab hold of any momentary indication from these prisoners that they are falsifying their symptoms, and then, they tend to write off all future complaints from these individuals as inauthentic manipulations. Thus, as soon as OMH staff begin to believe that a prisoner is "merely malingering," and too often OMH staffjump to this conclusion when a prisoner scores high on Hare's Psychopathy Checklist, the prisoner's subsequent complaints about psychiatric problems and suicidal inclinationsare not taken seriously. In some of these cases, the stafiCliterally write in the progress notes something like "the inmate informed me he was faking the voices"; the subsequent notes reflect a drastic downgrading of the diagnosis on account of that admission (to "no diagnosis on Axis I," or "primary diagnosis: Antisocial Personality
Disorder on Axis II"),and then the prisoner continues to exhibit psychotic, manic or
depressive symptoms, and continues to be prescribed strong psychiatric medications. However, his or her signs and symptoms are not believed by staff and the real signs and

symptoms are labeled as manipulations, malingering or both. When I examine the prisoner, he or she is clearly psychotic or depressed and suicidal on mental status examination. Because OMH staff do not sufficiently acknowledge their patients' illnesses, and the symptoms and behaviors associated with the illnesses, they do not intervene appropriatelyin the disciplinaryprocess on their patients' behalf,

NY DOCS prisons each have a designated OMH service kvel. Patientswho are un-diagnosed and have their service level altered may then qualify for a transfer to a facility that would not accept the prisoner were his serious mental illness c o m t l y diagnosed. For example, policy precludes confinement of prisoners at mental health needs level 1 and 2 at Upstate and level 1 at Southport. But when I inspected those two facilities, I met quite a few prisoners whose obvious serious mental illness and psychiatric disability should have placed them at Mental Health Level 1, and should have precluded their transfer to these i n s t i t ~ t i o n s . ~ ~

Prisoners with SMI who are designated Mental Health Level 1 or 2 are precluded fkom confinement at Upstate, where prisoners are generally doubk-celled. Prisoners are also generally double-celled at Five Points and in medium security facilities with SHU SBlock Units. Prisoners with serious mental illness should be exempted fkom doubiecelling. For SMI prisoners, double-ceilingcreates an intolerable stress and is likely to exacerbate their mental illness. In the minority of cases where the "fit" between cellmates is optimal, the company a cellmate provides can serve to alleviate some of the stress of isolated confinement. For the large majority of prisoners with serious mental illness, however, the "fit" between cellmates is far from optimal, and is often toxic or even deadly. As a consequence of bad fits or because some prisoners with mental illness cannot get along with any cellrnate under segregation conditions, tensions mount, fights erupt, sexual assaults and rapes occur, and the company of another prisoner in one's cell becomes as severe a stress, or an even more severe stress, than the isolation and idleness. Thus, prisoners with serious mental illness who are un-diagnosed are at risk of being double-celled and getting into trouble. I will present an illustrative case.

Q -4-

-_ (Interviewedwhile housed in SHU at

Upstate on 7/17/03.)

History: I @-H-_-had been at Upstate SHU for one year, with one more year of SHU to go. He was on the OMH caseload, he said, with a diagnosis of Schizophrenia. He told me that when he gets angry, he gets codbed and hears voices, and much more so in the Box. He shared that he did not think it was right for him to have a cellmate, given his mental illness, but he had one. He told me he had to work very hard at not getting angry so he would not get into more trouble, but it was much, much more difficult for

Including at Upstate: '
Southport:. F 0 ,

f

-

d-,and N.@-

- J

, O b F:-,at

- see Case Studies for complete notes.

JA 286

him to control his anger in SHIJ, and with another guy in his -cell. He has seen lots of prisoners lose their tempers in their cells in SHU, and this fzghtens him. He told me he ignores his cellmate when either of them. gets angry.

Mental status examination: This man exhibited concreteness, flatness, a thought disorder, and credible history consistent with chronic Schizophrenia, including hallucinations and delusions.

Clinical chart: The chart shows he is or has been prescribed Thorazine, Sinequan and Remeron, with a diagnosis of "Ha11ucinogen Persisting Perceptual Disorder." It is noted he is hearing voices in the period 12/01 through 2/02. He is noted to be "paranoid" in 1989. His diagnosis on screening forms on 9/2/99 and 1/8/02is Paranoid Schizophrenia There are also less serious diagnoses. He is also noted to suflfer from tardive dyskinesia (a serious neurological side effmt of older antipsychotic medications, involving involuntary movements).

This man suffers from chronic psychosis and is prescribed psychiatric medications, but his diagnosis is down-scaled and he is confined in a double-cell. The prison does not have mental health services for prisoners requiring Level 1 or 2 services.

d. Subsequent Events Disprove the Un-Diagnosis

In a number of cases, the clinical course following the change in diagnosismakes very apparent the incorrect diagnosing of these prisoners. I found several cases where a prisoner was un-diagnosed, returned to SHU, and subsequently given less intensive treatment (or given psychiatric medications inappropriate for the downgraded diagnosis and then inadequately monitored). Because there is no treatment plan sufficient to manage the prisoner's mental illness, the prisoner ultimately decompcma.tes and requires to observation or CNYPC. The following two cases illustratethis point. In h e Fist, the diagnosis was downgraded from Schizophreniato no serious mental illness on Axis I, and in the second the diagnosiswas downgraded from Schizophreniato no serious mental illness on Axis I.

%p

(Interviewed while housed in

observation at ~ u b u r non 10/29/03.)

History and mental status examination: I passed this man's observation cell at Auburn, and he was eating his own fmes at the time. He had been in observation since 10127 (three days). He shuffled into the interview room saying "I'm eating my shit, and that's all." He was in a Ferguson gown (a one-piece frock designed to be indestructibleby hand). He refixed to be interviewed (but he had to have agreed to come to see me in an office), he closed his eyes and kaned forward. At his request, I ended our encounter.

Clinical chart: This man's chart reflects a long psychiatric history, admission to O W in 1997,a diagnosis of Schizophenia, Undifferentiated Type and ASPD, and he has been taking medications off and on since 1993, including Bald01 and Zyprexa (an older anti-psychotic medication and a new, atypical anti-psychotic medication). He had been admitted to C W C
approximatelyten times. He is noted to eat his feces and set fire to hiscell,
and he is repeatedly admitted to observation and then returned to SHU. By 12/30/03,he was back in observation/RCTP for smearing feces, and the treating psychiatrist opined that his behavior was purposefil and not psychotic, he was started on Remeron (an antidepressant medication), "as a management response, rather than the treatment of a mental illness." On 1/2/04 he was returned to SKU, and by 1/8/04his medications were discontinued because "he does not want them." He continued to have medications started and stopped, and be re-admitted to RCTP, until he was seen by another psychiatrist, Dr. Lieu, on 3/8/04, and she must have found enough signs of Axis I pathology (e.g. thought blocking, a sign that indicates active psychosis) to recommend sending him to CNYPC with a
diagnosis of Schizophreniaby history. A 6/5/04 note at RCTP reflects his
return from CNYPC and the fact that he no longer wishes to take medications.

This man clearly suffers fiom Schizophreniaand requires antipsychotic medications, other modalities of psychiatric treatment that are not available in SHU, and a non-stressful setting if he is to remain in remission. But the treating psychiatrist thinks he has no Axis I diagnosis and is merely manipulatingto get to CNYPC. After several months of cycling between SHU and observation and going on and off medications, he is sent to CNYPC by another psychiatrist with a diagnosis of Schizophrenia( C m C noks not available), thus exposing the inappropriateness of the treating psychiatrist's earlier clinical opinions.

hL
Auburn on 10/29/03).)

(Interviewed while housed in SHU at

History:

th L- began his SHU term with 45 days of Keeplock at

Sing Sing, and he was sent to Upstate to do the 45 days. He acquired more

tickets in SHU. He came to Auburn in February, 2003, and explained to

me, "they stopped my medications without giving me a reason." He has not

been seen by mental health staff at Auburn except at cell-side on rounds,

and has not seen a psychiatrist. He has told staffhe is suicidal and needs

the anti-psychotic medication, Seroquel. Last Septemberhe attempted

suicide by overdose in response to command hallucinations. They stopped

his medications when he was in the hospital, and after that there he reported

that there was an increase in his hearing voices.

Mental status examination: This man was clearly quite depressed, delusional, gave credible reports of command hallucinations, exhibited psychomotor retardation and some bizarreness, and was quite concrete.
Clinical chart: The chart corroborates much of the history this prisoner presented. He is prescribed (anti-psychotic) Seroquel, 300 mg. twice per day, plus (antidepressant) Paxil. He had a diagnosis of Schizophrenia, Undifferentiated, and ASPD in Screening at Downstateon 5/31/91, and a diagnosis of Paranoid Schizophrenia on several other occasions early in his term. Evidently, it was decided during a CNYPC admission in May, 1993,
after he was sent there for 'bizarre.. . agitated paranoid behavior," that he
had no serious mental illness. But on 9/25/96, he was at the Green Haven Psychiatric Satellite Unit/observation and the anti-psychotic medication Haldol, plus Cogentin, were prescribed. He was given a diagnosis of
Schizophrenia,Undifferentiated- thereby reversing the un-diagnosing that
had occurred at CNYPC three years earlier (again, Schizophrenia pursues a waxing and waning course, this does not mean that an individual afflicted
with this serious mental illness has "no diagnosis on Axis I?' during
remissions, rather he should be diagnosed "Schizophrenia, in remission" and be continued in treatment). He was transferred to Auburn on 2/19/03 while being prescribed Paxil20 and Seroquel600 per day. The psychiatrist
saw him on 3/3/03, doubted he was psychotic, and discontinued Seroquel -
there is no mention of concern about overdose. By 3/12 he was in observation for suicide ideation and a report that voices were telling him to harm himself. The psychiatrist continued to see him monthly, at cell-side or in a private interview room, with a therapist who saw him every two weeks. His diagnosis was changed Erom depression with psychosis to an Axis Ll problem. A 9/3/03 STP screening form contains the diagnoses Depressive Disorder and ASPD. By 9/22 he was in the hfinnary for a hunger strike which he began when placed on loaf for a disciplinary offense. He was adjudged by OMH not to have a psychiatric problem, but by 9/26 he had overdosed on several different medications and stated the voices told him to do it. The psychiatrist, who doubted there ever were hallucinations, discontinued the medications because of the overdose {this is not clinicallyindicated if he needs an antidepressant- rather, the
medication should be continued but with close monitoring - an overdose is
preventable if a prisoner in isolation is monitored and not permitted to accumulate a large supply of pills).
Because serious mental illness tends to follow a waxing and waning course over a lifetime, with periods between acute breakdowns of relative quiescence, a lack of obvious symptoms does not mean the patient no longer suffers fiom SMI and no longer needs treatment. In fact, continuous treatment provided during remissions is crucial for maintaining stability and preventing recurrences of acute episodes. Based on the large

number of cases I reviewed that reflected a pattern of un-diagnosing followed by provision of less intensive and inadequate mental health services, it is my belief that undiagnosingis a serious problem within OMH, and that the foregoing cases are not rare or exceptional.

e. Malingering

Malingering, the fabricationor exaggeration of psychiatric symptomsfor secondary gain, certainly occurs in prison.86 There is a strong desire to escape culpability for certain behaviors or to gain placement in a more tolerable setting. The clinician must be aware of the possibility of malingering so that scarce mental health resources will not be squandered on prisoners who are not in fact suffering fiom a psychiatric disorder. On the other hand, over-utilization of attributionssuch as crmalingering,""merely manipulating,'' or "no diagnosis on Axis In by frustrated clinicians can blind the clinician to the presence of serious mental illness. The unfortunate result of such over-reliance is often un-diagnosis or erroneous under-diagnosis which in turn can lead to inadequate treatment. Repeatedlyin the cases that I revimed, OMH staff referred to a prisoner as manipulativeor "faking" or "'willllly"breaking rules, when in fact that prisoner suffers fiom serious mental illness.

What clinicians often fail to realize about the problem of malingering is that those prisoners who f e i p or exaggerate symptoms often do simultaneouslysuffer &omserious mental illness. Particularly within the prison environment, because prisoners have limited control over their resources and limited access to clinical staff, there is a strong incentive to exaggerate or manipulate in order to get help. For instance, a prisoner who is genuinely ill but is unable to access treatment, may exaggerate symptoms so he will be "noticed" by staff who can secure treatment for him. I have already provided several illustrative cases, but I will add anotherparticularly illustrativeof this problem, where the diagnosis was downgraded from Schizophrenia to "no diagnosis" on Axis I and Antisocial Personality Disorder on Axis 11.

$A-

_- _,-. (Interviewed while housed in SHU at Five

Points on 3/13/03, and enrolled in STP.)

History: . -1.%4- had been in SHU for about eight years and received
approximately 100 disciplinarytickets. He was taking &pacote (a mood
stabilizer utilized by psychiatristsmainly for the treatment of Bipolar Disorder), Haldol and Zyprexa (both anti-psychotic agents). He has been at CNYPC and in ICP. He told me he believes he has "'psychic powers." He told me of talking out loud to himself, and the other prisoners and staff
making bof him.

86 Kupers, Terry,"Malingeringin Correctional Settings," Correctional Mental Health Report, 5,6,
MarchIApril, 2004.

JA 290

Mental status examination: ; I 4-_ _ exhibited obvious loose
associations, internal preoccupation related to halQucinationst,hought insertion and projection, agitation, and severe ideas of reference including the conviction his food was being poisoned. His gestures and facial expressions were bizme. In other words, his presentation is consistent with active psychosis.
Clinical chart: The clinical chart corroborateshis history. A 9/26/01 Core History from Auburn OMH Satellite Unit includes a Diagnosis Psychotic
Disorder NOS, R/O SchizoaffectiveDisorder. He was admitted to CNYPC
on 2/2/01 and again on 3/26/01due to danger to self. It was n&ed he had a history of psychosis, delusions and paranoia, and had made two prior serious suicide attempts, one a hanging in prison on 9/8/00, the other an attempt to shoot himself in 1994. He was not eating for six days, believing his food was poisoned. He was also put on "loaf' as a disciplinary penalty. He was delusional, and had poor hygiene. Dr. John Wilson did a psychological assessment and diagnosed Paranoid Delusional Disorder (1/23/01), R/O Paranoid Schizopbenia; and ASPD, Rs/O Paranoid Personality Disorder. He was readmitted to CNYPC for the third time on 5118/01, and discharged on 8/9/01. His diagnosis early la the third admission to CNYPC was PsychosisNOS, and he was treated with antipsychotic medications Rsperdal and Haldol). But this time his discharge
diagnosiswas Axis I, 'XToDiagnosis," and Axis IZ "Antisocial Personality
Disorder." His diagnosis was switched kom Psychosis NOS to ASPD and back again several times through 2001. He had to be re-admitted to CNYPC fiom 11/30/01through 1/23/02,his fourth CNYPC admission, and psychological testing reflected poor prefrontal lobe functioning, neologisms, autistic thinking, oddities of association, psychotic thinking, and so forth -he also registered high in psychopathy. When he was
admitted to CNYPC on 2/7/02, his fifth admission, paranoid, mute, acting
bizarrely, decompensated and repeatedly assaultive, he was medicated over
objection with Risperdal - disproving the theory that he did not suffer from
a serious and persistent mental illness. He was eventually admitted to STP. Until then he had been left essentially untreated despite his psychotic condition, apart from involuntarymedications during his repeated acute psychotic crises.
A well-documented history of SMI prior to incarceration should alert the staff that such illness is likely present, even if the individual is currently in remission. When such a prisoner has been seen in observation for multiple suicide attempts or referred to a correctional psychiatric facility, it becomes even more likely that this inmate in fact suffers &om a serious mental illness and may pose a significant risk of self-hann. In each of these situations, the prisoner is likely suffering &om SMI even if he may be simultaneouslymanipulating or exaggerating his symptoms. If theclinician

diagnoses malingering continues to prescribe strong anti-psychotic or moodstabilizing medications, or continues to place the prisoner on suicide watch in observation, then something is very wrong with this picbe. The followingcase m h e r illustrates the detrimental effects un-diagnosis (downgrading the diagnosis from Schizophrenia to no mental illness in this case) can have on the prisoner.

\ !7
Auburn on 10/30/03.)

(Tnterviewed while housed in SHU at

History: 1 p- came to prison in 1988. He was being prosecuted in
court for "throwing" an unhygienic substance. A psychiatrist examining
him for the court in that case declared him incompetent to stand trial. He
had a strong psychiatric history prior to incarceration, including admission to Kings CountyHospital G Ndg. (the psychiatric ward) on multiple occasions. He took psychiatric medications for quite some time in prison. He brought a file of documents with him to our interview, and showed me the report of a court-related psychiatric evaluation with a diagnosis of Paranoid Schizophrenia, and a conclusion that he is not competent to stand trial. He also showed me a letter h m Executive Director Hal Smith of CNYPC, 7/2/03, declaringthat he had at CNYPC for a competency program and is no longer incapacitated as of 3/21/03. Meanwhiie, he had been sitting in SHU without the benefit of significant mental health treatment since returning f?om court and the finding of incompetence. There is a note in one of the documents about a "competency restoration program" at Auburn, per Dr. Langbart, but he says he has only seen Dr. Langbart a few times, for a few minutes each time, the last time being four months ago. He was taking no psychiatric medications.

Mental status examination: This man was disheveled, he looked around in paranoid fashion, his affect was inappropriate,he was incoherent and exhibited bizarre gestures. He was disoriented as to person, being unclear who he was and also confbsing me with the Judge. He reported auditory hallucinations with internal preoccupation. He had severe ideas of refwence. He had strong First Rank Symptoms, including thought insertion and broadcast. I asked him a series of typical questions that are used to
determine competency, and it seemed clear he was not competent - for
example, he did not know the difference between a Judge and ackk.

Clinical chart: 1 1 2- % chart fills an entire carton. Over many years
he has spent an inordinate amount of time in SHU, and was considered belligerent, with diagnosesvarying fkom Paranoid Schizophreniato Adjustment Disorder to SchizophreniformPersonality Disorder. By 2000 he was admitted to CNYPC for the eighth time for swallowing razors and other objects. He had been treated in DOCS with various anti-psychotic

medications, including Navane. He had been diagnosed Paranoid Schizophrenia, but also Exhibitionism. He was also diagnosed Paranoid Delusional Disorder. On 11128101, his diagnosis was Depressive Disorder NOS and he was prescribed Zyprexa 20 mg. per day and Seroquel400 mg. twice per day, as well as Zolofi 100 mg./day. A 7/23/03 note fkom Mr. Hilton reflects the clinician feels this prisoner is manipulative, and "He has maintained for some time in SHU without MHU intervention." (This note seems to confirm his report that he has been ignored by OMH staff). But he continues all the while to cycle from SHU to observation and back to SHU, swallowing razors periodically and otherwiseconvincing staff he was a serious suicide risk. A 7/24/03 note by the psychiatrist concludes no mental illness and that this prisoner should stand trial for his law-breaking. Yet the psychiatrist notes bizarre behavior such as wearing a mat as a hat. He was subsequently re-admitted to CNYPC and rekased to Elmira May 9, 2005 (per NY DOCS website).

It is very possible, from history and mental status, that the acts that led to criminal

charges being brought were driven by mental illness, whether or not 13

meets

the criteria for an insanity defense. He receives frequent tickets in SHU. This man is

suffering fiom psychosis and depression, either Paranoid Schizophrenia or

Schizoaffective Disorder, with acute symptoms, including ongoing hallucinations,

delusions and bizarreness. He was declared incompetent in the course of an outside court

case. He is supposedlycurrently in a "competency restoration program," but actually he

has been un-diagnosed, is not being treated, is being denied medications, is being left in

SHU where his condition clearly is poor, and he rarely sees the psychiatrist. Dr.

Langbart, the treating psychiatrist who did a competency evaluation of I IJ". for the

court, testifies that he does not know abouL i TL 's long psychiatric hospitalization

for Schizophrenia during childhood, does not know about his past suicide attempts and

does not know which anti-psychotic medications have proven eff'ective for him (has he

not reviewed the clinical chart nor taken a thorough history?), but his opinion that
B P suffers no Axis I diagnosis and is diagnosed with Antisocial PersonalityDisorder

on Axis XJ would not be affected if he did know about that history (hngbart Deposition,

pp. 86-99).

Research in the social sciences has demonstrated that, in a "total institution" (prison, state psychiatric hospital, large p u p home), when mental health services are inadequate, scarce or difficult to access (for example, where mental health stafiin SHU or observation find they must resort to seeing prisoners at their cell-fionts instead of taking the time to examine them in a private, confidential setting), people may need to resort to extreme measures or behaviors to be "noticed" and get the care they need. In
other words, they suffer fiom psychosis (andlor mania or depression with suicidality) &
they manipulate-it is not a case of eitherior. This unfortunatepattern is especially prevalent in isolated confinement units, where the conditions of confine~nenat re such that
prisoners complain often, and as a result staff can become relatively inured to their

complaints. The problem with the staffs' excessiveconcern about being manipulated is that the harsh conditions of confinement and the lack of a real opportunity for the prisoner to develop a trusting confidentialtherapeutic relationship can lead to repeated suicide attempts and breakdowns in depressed and psychotic prisoners.
f. Methods for Detecting Malingering
There are reliable methods for distinguishing between malingering and bona fide mental illness. These methods are well-known, accepted psychiatric practice. For trained clinicians who perform thorough evaluations, it is relativelyeasy to differentiate between a "mere malingerer" and a prisoner with serious mental Illness. For example, the clinician might ask about the quality of reported hallucinations, and watch for disingenuous responses, defensiveness, or responses that do not seem to fit a h o w n clinical syndrome. The clinician needs to have a layered, complex method. The clinician must assess the match between a person's story and their facial expressions, aEfect, body language, and so forth. The clinician compares the objective mental status examination (what the psychiatrist observes, for example the "internal preoccupation" that often accompanieshallucinations or the pressured speech and flight of ideas that suggest mania) with the subjective history and reportage (what the examinee tells the clinician), and checksto see if there are inconsistencies. For example, people wha suEer from Schizophrenia not only hear voices, they also su&r h m a pervasive thought disorder. It is quite easy for someone to falsely claim they hear voices, and many people who are trying to fake mental illness will make such a claim because they believe that hallucinated voices prove their madness. However, it would be much more difficult even for an accomplished actor to mimic for very long the loose and tangential associations and the bizarreness that are critical parts of the clinical picture of Schizophrenia These signs of "thought disorder" are objectively observed by the clinician doing the examination. No matter how thoroughly a prisoner has studied the signs and symptomsof mental illness, there are noticeable inconsistencies in the way someone intent on faking a mental illness or telling a false story presents the symptoms.
I ask prisoners who may be suffering fiom psychosis whether they experience Schneider's "First Rank Symptoms." These are symptoms that reflect a psychotic failure to distinguish inner from outer reality, or to establish a healthy boundary between self and other. For example, does the prisoner think someone is putting thoughts into his head, or
does he thinkhis thoughts are being broachst to others? Does he believe someone eke is
controllinghis movements, or that his thoughts are controllingthe behaviors of others. The presence of First Rank Symptoms is strong, but not absolute, evidence of psychosis, and should be routinely investigated in the.process of diagnosing.
There are many other ways to assess the reliability of an interviewee. The following are standard assessment methods. Wherever possible, information provided by the interviewee can be corroborated by documents and information fiorn others. The internal consistencyofthe interviewee's story can be evaluated. The story an interviewee

tells in the present can be checked against the story he has told others in the past. The interviewee's intelligencemust be taken into consideration -i.e. a very intelligent person is more capable of reading about a disease or syndrome and mimicking its signs and symptoms, whereas a less intelligent person is likely to make obvious mistakes in the process. The secondary gain (benefit of having more severe symptoms)can be assessed. I become skeptical when I interview a prisoner who has been diagnosed a "malingerer" and yet denies he is mentally disturbed, is quite resistant to mental health treatment, and does not want to be moved to a treatment unit for prisoners with psychiatric disabilities. Where is the secondary gain?
I typically check prisoners' complaints about their environment by touring and observing the environment. The prisoners I interviewed in JW DOCS do not b o w all the others I interviewed. The fact that so many of them gave approximatelymatching answers to questions I asked about practices in the units suggests strong reliability. In general, my mental status examination of prisoners in DOCS tended to be consistent with the symptomsthey reported (e.g. prisoners who reported auditory hallucinations also seemed to me to have flat affect, to be incapable of abstracting and to exhibit a certain degree of thought disorder - and this is a consistent picture of a particular mental illness, Paranoid Schizophrenia). In other words, in cases where I opine that the prisoner suffers from serious mental illness, I found great consistency between prisoners' reports of symptoms and past history (subjective), my mental status examinations (objective), and my review of clinical charts and all peripheral data.
g. PsychologicalAssessment
I have discovered quite a few cases among those I reviewed where the psychologists at the psychiatric hospital, CNYPC, performed psychological assessment (often Hare's Revised Psychopathy Checklist PCLR), on a prisoner who had a diagnosis of serious mental illness, concluding that the prisoner was feigning mental illness or attempting self-harm for secondary gain. The testing psychologist then recommend.ed that the prisoner be put on a Behavior Management Plan because fkther psychiatric treatment was unlikely to be effective. Frequently, the prisoner scores high on the psychopathy checklist and the psychologist will conclude that the prisoner is not credible. What the psychologist does not seem to recognize, however, is that nothing about one's score on the psychopathy checklist establishes or rules out the diagnosis of serious mental illness. And the diagnosis of Antisocial Personality Disorder (ASPD) on
Axis II does not preclude the presence of a serious mental illness on Axis I. Any well-
trained psychologist would continue to assess for serious mental illness. Numerous prisoners I interviewed were un-diagnosed by psychologists at CNYPC, but were, when I examined them and reviewed their clinical records, clearly suffering from serious mental illness.
Psychological Assessment can be a very useful component in the diagnostic process. Richard Rogers provides a thorough review ofthe literature as well as a

practical guide to the assessment of malingering.87 Dr. Rogers is a highly regarded expert in the field, and he provides guidelines for the psychological assessment of malingering.

I find that psychological assessment instruments such as the MMPI-2, while potentially very helpfbl in theory, can be quite misleading in practice. I have reviewed tests administered by correctionalpsychologists who conclude that there is "no Axis I diagnosis'' and the prisoner is "merely malingering," and yet when I review the raw test data I find statements that this profile is consistent with malingering or with conksion secondary to a psychotic thought process. In other words, the clinician couM easily be putting forward a biased conclusion that is not entirelybacked up by the raw data. Psychological assessment for the purpose of uncovering malingering can be quite problematic. Inordinatelyhigh scores on the F or "Fake/Bad" scale of the MMPI-2, for example, might reflect malingering or exaggeration of symptoms, but could just as likely * reflect gross mental disorganization on the part of a very disturbed individual, or even a failure to comprehend the test questions on the part of someone with a brain injury, limited education, or impaired intellectual function. In fact, there is a well-known class bias on the validity scales of psychological test instruments. To rule out these possible n,' fallacies, the test administratormust be skilled in differential diagnosis. The point, however, is if the psychologist who is interpretingthe raw test data thinks in terms of "eitherlof' dichotomies such as "mad" vs. "bad", and has gown excessivelywary of prisoners who try to manipulate staff, then he or she brings a bias to the interpreting of ambiguous test results, and too often concludes the prisoner is "merely malingering."

I have already presented the cases of 4 ,T. and

A- ,cases in

which I strongly believe the psychologists at CNYPC erred in their psychological

asses~rnent,8a~nd the subsequentprescription of strong psychiatric medications (to

prisoners with "no diagnosis on Axis I") or the prisoner's subsequent clinical course

(repeated admissions to observation for suicide attempts or psychotic breakdowns)

disproves the un-diagnosing.

Richard Miraglia, Director of the OMH Bureau of Forensic Services, has testified that Psychopathy is a form of mental illness (Deposition, pp. 237-238), that a high psychopathy score on the Hare Checklist does not indicate whether an inmate has an Axis I diagnosis (p. 238), that inmates with active psychosis should not be administered tests for psychopathy because the results will be inaccurate (p. 243), that testing for psychopathy is not useful in terms of planning suicide intervention and crisis intervention

"Richard Rogers, Clinical Assessment of Malingering and Deception (New York: Guilford, 1997).
AS a psychiatrist, I do not administer psychological assessment instruments. Psychologists perfonn "psychologicaltesting." But this does not mean I have no expertise about psychological assessment instruments or psychological tests. During my entire career I have worked closely with psychologists,and I have often requested "testing" or psychological assessment to help me with the diagnostic process. And it is the psychiatrist's job to examine critically the psychological assessment. After all, even when testing is requested, the psychologist and psychiatrist collaborate in aniving at a diagnosis:

(p. 239), and that it is not appropriate to utilize a test for psychopathy in determining
whether malingering is present (pp. 243-244). Unfortunately the substance of Mr. Miraglia's testimony is not followed in practice by OMH clinicians. Nor has Mr. Miraglia, or any other CNYPC administrator, promulgated a policy to guide the appropriate use of such testing. The inadequacies I have discovered in the psychological assessments I reviewed seem to be a result of this gap in administrative oversight.

After the psychologist at CNYPC writes a long report concluding that there is "No Axis I diagnosis" or that the prisoner is malingering, from then on OMH ciinicians resist diagnosing the mental illness that is clearly presented by that prisoner in subsequent acute breakdowns or crises. This inattention to prisoners' obvious distress further compounds the harm caused by eliminating Axis I diagnoses. Rather than belaboring this point, I will present one more illustrative case, where the diagnosis was downgraded &om Bipolar Disorder with Psychosis to no serious mental illness on Axis I.

&.G.%

(Interviewed twice, once while housed in SHU

at Five Points on 3/13/03, and then briefly while housed in SHU a t

Attica on 9/23/03.)

History: 6-Q.d1 has spent 13 of his 16years of incarceration in SHU.
He told me voices commanded him to do awful things such as to swallow a razor, that the voices get worse when he is in SHU, but then officers give him tickets for swallowingthe razor and he receives punishment of more time in SHU. He said he used to weigh 280 pounds but now weighs only 230, and this was because he is kosher but the staff do not respect his dietary/religious needs. He complained of being stripped naked while in observation in winter, when it was freezing cold. He was at CNYPC three years ago. He complained he was threatened by correctional oficers for talking to me, and that correctional offiiers throw feces at him and put feces in his food.

Mental status examination: This man told me he hears voices and exhibited bizarre facial expressions and clear signs of internal preoccupations that are consistent with current hallucinations. His mannerisms were bizarre, with inappropriate grimaces and sounds. He complained, in obvious delusional fashion, that the correctional officers rape him repeatedly. His thoughts were often tangential, his associations loose. His affect was often inappropriate and disconnected fkom the content of our conversation. He was concrete and incapable of abstraction.
In all these ways, his mental status examination, on two different occasions,
pointed to psychosis, most likelySchizophrenia

Clinical chart: The chart for this prisoner is very thick. He was admitted to CNYPC for the first time in 1986. During another admission, on 7/2/97 his diagnosis was "Bipolar Disorder, Most Recent Episode Mixed, Severe, WPsychotic Features" and Anti-Social Personality Disorder. An OMH Mental StatusReport for Division of Parole of 1/31/97, by Dr. F d , M.D., states: "His hospitalizations are caused by his becoming very psychotic, paranoid, hallucinated and violent. At tiines he was suicidal. He responded well to psychiatric treatment in CNYPC." Medications prescribed include Depakene, 500 mg. bid, Navane, 10mg. bid and Klonopin, 1 mg. bid. An update on 12/17/97during a CNYPC admission notes "He showed a positive response to antipsychotic medications." There were many admissionsto CNYPC and observation; repeatedly, progess notes reflect bizarre and regressed behaviors and that anti-psychotic medications improved his condition, which deteriorated anew once he was returned to.SHU. There is a 10/20/99 admission to CNYPC, Mental Health Level 1,because he smeared feces, set fire to his cell and cut himself. He was taking Prozac 40 mg plus Zyprexa 20 mg., but was assigned a Diagnosis of Borderline Personality Disorder with Adjustment Disorder. A 5/20/02 Psychological Consultationby Dr. John Wilson includes neuropsychological testing that uncovered no abnormality, and reported an IQ test fiom 1995that indicated hctioning at the bottom of "Low
Average7'range. Dr. Wilson continually referred to 6 G 3 )'s suicide
attempts and hallucinations as manipulative and/or fabricated, but then he wrote that in February, 2000, L-'G6 repeatedly banged on his cell door for 36 hours or more, and that he was injected on an emergency basis with the antipsychotic Thorazine. Dr. Wilson repeatedly reported delusional material that this prisoner shared during their two hour interview, but dismissed all of it as if it were merely manipulative. Referring to a neurological examination that was conducted on 4/7/92 for the prisoner's headaches, where no abnormalitywas found, Dr. Wilson concluded that the negative findings "implicitly indicate that (the prisoner's) self-reports are not reliable." Dr. Wilson administered two psychological assessment instruments (tests), the MMPI-2 and the Hare Psychopathy Checklist, and concluded fiom these tests and his interview and review of records that this prisoner suffered only &om polysubstance dependence and severe personality disorder, and no major mental illness on Axis I. In a Behavior Management Plan, Dr. Wilson recommends strongly against any f5.1tur.e
psychiatric hospitalization for =e-s Subsequent to Dr. Wilson's
report and the decision not to re-admit this prisoner to CNYPC in the future, he was still prescribed strong anti-psychotic medications and returned to SKU.

45-e It is impressivethat many clinicians' narrative reports on

- 5 3 progress

notes clearly reflect psychotic symptoms, but these reported symptoms are not consi-t

with the lesser diagnoses applied to the patient after Dr. Wilson did his assessment (they - are consistent with many earlier diagnoses). The medications subsequently prescribed are more appropriate for the psychotic symptoms reported than for the lesser diagnoses. Dr. Wilson continually errs in his clinical logic. For example, consider his opinion that the lack of positive findings on a neurological.exarnination for headaches is proof that this patient's self-reports are unreliable. From neurological examinations I have performed and according to neurologists I have consulted, most reports of headaches lead to negative findings on neurological examination; this does not mean the patient was feigning the pain, rather that there was no tumor or other tissue pathology deteetible. Dr. Wilson's conclusion in this regard is entirely contrary to establishedclinical principles, but it evidences a consistent bias that leads Dr. Wilson to disregard this patient's symptoms and distress. As I pointed out earlier, a high score on the Hare Revised Psychopathy Checklist in no way rules out the presence of serious mental illness.
It is also incorrect for Dr. Wilson to dismiss evidenceof! C.e-6's psychotic
symptoms as mere "self-reports." In fact, there are many assessments by psychiatrists and psychologists in the chart, with diagnoses of serious mental illness, admissions to the inpatient psychiatric hospital, and positive effects of prescribed anti-psychotic and other medications. These are not simply "self-reports" of psychiatric problems; rather, one has to assume that the clinicians recording narrativeprogress notes, making the diagnoses, and prescribing hospitalization and strong medications made objective assessments of
- this prisoner's mental state prior to writing their diagnoses and their orders. In these and
other instances, Dr. Wilson proves he is so certain that 68 3bizarre presentation
confirms malingering with no serious mental illness, that he ignores a much more likely interpretation of the entire clinical picture: EaE 6 suffers from serious mental illness that is made worse when he is placed in SKU, and that his illness, as is predictablewith Schizophrenia and other forms of SMI, has followed a waxing and waning course. I cT b- fk mental illness is so severe that he requires long-term psychiatric hospitalization;
his illness certainly should preclude him from isol&ed confinement. Furthermore, Behavior Management Plans (by OMH policy) should be utilized only when conventional treatment interventionshave failed, but in 5 66 " s case, he has not had the benefit of appropriate treatment, which for him would be long-term psychiatric hospitalization.
Q 69 is a very difficultpatient, and he has refused treatment (often it was a matter of the mental health clinician visiting him at cell-hnt and the prisoner refusing to
talk). His behavior has been obnoxious. Moreover, he has been very manipulative and makes up stories. People with serious mental illness are known to do such things, and they can pose very serious management problems, as this prisoner has obviously done. The result of an overly strenuous and single-minded attempt on Dr. Wilson's part to read all of the history and all psychological tests as evidence of "mere malingering" misses the complexity of this case and the likely co-existence of both very serious and persistent mental illness and obnoxious, manipulative behavior. (Iwill discuss Behavior Management Plans in the next section.)

G. G.Hay found that five of six patients in whom he thought he identified

feigned psychosis eventually developed

Others have pointed out that

the collection of signs and symptoms that are interpreted as malingering today might

actually preview an impendingpsychotic decompensation or suicide in the future. The

consequences of missed diagnoses of serious mental illness and erroneous un-diagnosing

are that prisoners who are prone to break down under the stress of isolated confinement,

and who are prone to acting out and receiving tickets when their psychiatric condition

deteriorates in SHU, are left to endure an essentially indeterminate term in SHU.

The process of un-diagnosis is evidenced in DOCS and OMH studies. For example, CNYPC has conducted two "Special Housing Units Mental Health Needs Studies" @raft 5/17/02 and July 16,2004, hereinafter referred to as the SHU Studies), focusing on the approximately500 SHU cells located at 11 OMH Level I facilities(I inspected ten of the 11). The 2004 study states: "The overall percentage of major
mental illness among SHU inmates has dropped 47% (from Jan., 2002 to March, 2004). ..
This reduction is statistically significant.... The reduction in psychotic disorder and
major mood disorder diagnoses are each statistically significant." A DOCS Memorandum from Program Research Specialist Leslie Kellam to John Culken, Director of Mental Health Services, and others, dated June 24,2003, on the subject of "SHW Placement and OMH Levels," states: "Between 1999 and 2003, the percentage of OMH Level I inmates in regular SHU or Keeplock cells declined over 40 percent, from almost 16percent to nine percent. At the same time, the percentage of these inmates in treatment settings increased Grom one-third to 40 percent."

A decrease of 40% in the number of prisoners sufferingfrom SMI in SHU would be quite impressive, if it reflected a true decrease. The July 16,2004 SHU study goes on to state: "The decrease of Level 1 inmate-patients in SHU with psychotic disorders and major mood disorder indicates that inmate-patients in SKU with psychotic disorders and major mood disorder indicates that inmate-patientswith seriousmental illness are either being diverted from, or transferred out of Sf-iltT." But the study fails to considerthe possibilitythat a significant number of the same prisoners remain in SHU or cycle back to SKU, but in the intervening two years between the two studies they have been undiagnosed. If this were the case, then it would not be true that "inmate-patients with serious mental illness are either being diverted &om,or transfend out of SU[U." In k t , it would mean a significant number are being inappropriatelyun-diagnosed, and that is why the 2004 study concludes there are 40% fewer prisoners with SMI in SHU. In or& to investigate this possibility, I, along with Dr. Carl Fulwiler, requested Plaintiffs counsel to prepare a list of prisoners whose names were included in both the 2802 SHU Study and the 2004 SHU Study, and to list the diagnoses they were assigned in 2002 and 2004. That list is very interesting, and is attached to this report as Appendix F. Twenty two of the prisoners who were in SHU in 2002 and again in 2004, at the times the two

89 G.G.Hay, "FeignedPsychosis - A Review of the Simulationof Mental IMness." British Journal o f Psvchiatrv, 8-10,143 (1983).

studies were done, had their diagnoses changed fiom an Axis I diagnosis that constituted

serious mental illness to an Axis I1 diagnosis that did not, or had their diagnosis changed

fkom an Axis I diagnosis to "no diagnosis." (Other prisoners had their diagnoses changed

fiom an Axis 11disorder to no disorder, or had their mental health needs level changed to

one indicating less need for treatment. For example, k4'

was diagnosed Major

Depressive Disorder, Recurrent, in 2002, and Antisocial Personality Disorder in 2004;

i

was diagnosed Schizophrenia, Paranoid Type in 2002, and Antisocial

Personality Disorder in 2004; C 53

was diagnosed SchizoaRectiveDisorder in

2002, and Antisocial Personality Disorder in 2004; 1 T-T3

was diagnosed Major

Depressive Disorder, Recurrent, in 2002, and "no diagnosis" in 2004; and so forth.)

Major Depressive Disorder, Recunent; Schizophrenia, Recurrent Major Depressive

Disorder, SchizoaffectiveDisorder are all examples of serious mental illnesses that tend

to pursue a waxing and waning course over a lifetime. Thus it is peculiar that someone

who was suffering from Schizophrenia in 2002 would be suffering only fkom AnGsocial

Personality Disorder in 2004. As it turns out, I interviewed seven of the 22 prisoners
who were thus un-diagnosed: . H.bJ , Y - q .I L L % - J eAii-$j

As*- , 1- Q. .and 8 5 ~, C~~ -- 2 ~ : , ~ . & . f l * aI n~d Dare

presented in this report; the other cases are summarized in the appended Case Studies).

My own assessment of the seven individuals of this group of prisoners in SHU was that

all were clearly suffering fiom serious mental illness; this assessment was based on their

history as well as my mental status examinations.

I draw two conclusions fiom this brief review of the SHU Studies: Prisoners with seriousmental illness in SHU are being inappropriatelyun-diagnosed and denied needed mental health services, and the SHU Studies are faulty in that they do not consider this likelihood and thus the conclusion that there has been a 40% reduction in the number of prisoners in SHU who suffer &om SMI is entirely erroneous and misleading.

3. Behavior Management Plans and the Proposed Behavioral Health Units

a. Behavior Management Plans

Policy and Procedure for Behavior Management Plans (the 'BMP~olicy")~st'ates that a Behavior Management Plan in the outpatient setting is indicated when: "1) Active patients have been determined to engage in self-injurious behaviors for secondary gain; 2) It has been determined that their self-injuriousbehaviors are unrelated to signs or symptoms of major mental illness; 3) Traditional forms of mental health intervention, such as phannacotherapy, verbal therapies, and inpatient treatment, have proved ineffective in reducing the propensity to self-harm; andfor 4) It has been determined that there is a substantial risk of reinforcing strategic self-injurious behaviors by providing inpatient treatment."

90 CNYPC Patient Care Services, 8125103, OMHCMT 0079529.

I will comment about these four indications for Behavior Management Plans. Regarding numbers 1 and 2, as I have explained, OMH clinicians are ofien wrong about self-injuriousbehaviors being primarily motivated by secondarygain. OMH clinicians have, in so many cases, incorrectly undiagnosed the patient, and therefore they simply are not in a position to perceive the connection that truly exists between the self-injurious behavior and a serious mental i l k s . Regarding number 3, OMH has not really provided a trial of traditional forms of mental health intervention; rather the patient has likely been in isolated confinement where the conditions have exacerbated the mental illness, has likely been prescribed medications that do not work when the patient is in isolated confmement and is not undergoing other forms of mental health interventionsuch as intensive psychotherapy and psychiatric rehabilitation. Additionally, contacts between OMH and the patient have been mostly at cell-fiont and therefore the confidentiality that is a prerequisite for "traditional forms of mental health intervention'' has not existed. 'Further, the patient's stints in observation have been more punitive than therapeutic. Regarding number 4) in the indications f i r Behavior Management Plans, there is no evidence that any risk exists of "reinforcing strategic self-injurious behavior," because no research has been conducted on prisoners who have had adequate mental health treatment and have not been subjected to the destructive effects of isolated confinement.
Other aspects of the BMP policy are particularly troubling, and, as I will discuss shortly, suggest that the BMPs, as currently conceived and configured, are not only clinically inappropriate and harmll to prisoners, but constitute a violation of clinical and ethical standards. For example, pursuant to the BMP policy, OEAH may advocate with DOCS for additional deprivations beyond those that might otherwise be applied to a prisoner in isolated confinement. These might entail fewer amenities (showers and reading materials) and less out-of-cell time. This contrasts with O m ' s contention that they have been unable to intervene with DOCS when DOCS disciplines a prisoner, except in very limited ways; here, it is OMH itself that is imposing the harsh conditions and deprivations.
OMH has produced a study of the effectivenessof BehaviorManagement ~ l a n s . ~ ' The report begins by asserting: "Empirical evidence revealed that traditional mental health interventions served to increasethe incidentsof self-injury rather than decrease the number of such incidents for this subset of inrnatelpatients." There is no credible
evidence to support this assertion. In fact, of the cases listed where Behavior
Management Plans have been instituted, almost all of the patients have spent long periods in isolated confinement with entirely inadequate mental health treatment, and have been transferred repeatedly to observation where the program is more punitive than
therapeutic. But the OMH report goes on to state that patients on Behavior Management Plans were admitted to CldYPC less often than in the past - ignoring the fact that the
See "Behavior ManagementPlan EffectivenessReport," July,2004,by SharonBarboza-Whitetiead, Chief Psychologist, CNYPC.

BMPs require that the patients not be admitted to CNWC. Thus, it appears likely that when prisoners needed to be hospitalized, they were not. Their admission to observation did not decrease after the plan was initiated. And there does not seem to be a signif~ant decrease in the rate of self-injury after the inception of the plans. The report does show a decrease in the number of incidents reported to the Office of Risk Management after the
plans' inception - but this finding is not discussed, and there are so many variables
involved in terms of which incidents are reported to the OEce of Risk Management, that it is difficult to make any valid conclusions fi-omthat trend. For example, as Superintendent Lord points out, acts of self-ham may go unreported W r d deposition,p. 88).

I encountered a number of prisoners who I believe suffer fiom serious mental illness, and who have been identified by OMH as candidates for Behavior Management
Generally, the individuals I met who have been placed on Behavior Management Plans fit the description Hans Toch provides of the "Disturbed, Disruptive" ~ r i s o n e r ?I~n other words, many of them suffer fi-om serious mental illness and their disruptive andlor assaultive behaviors present staff with very difficult management problems. In the last section (Section VL1.2) I described an unfortunate and enor-ridden process whereby certain disruptive prisoners are un-diagnosed, even though they are suffering fi-om SMI. Often an intermediate step in the process of un-diagnosing and assigning a Behavior Management Plan is the attribution of Psychopathy - and in DOCS and OMH, this attribution usually results fi-om psychological assessment or testing at CNYPC. In the following two examples a high score on the Psychopathy Checklist precedes the prisoner's placement on an inhumane behavior management plan.

--

TS

at Auburn on 10/30/03).

(Interviewed while housed in Keeplock

History: 7 first entered prison in 1990. He had a history of
mental illness prior to incarceration. In 1996 he was given a five year SHU term. He became very depressed and isolated in SHU, he heard voices, he tried to hang himself at Eastern, he was transferred to Green Haven, he could not handle being in SHU and he experienced despair and tried to hang himself again. He was in and out of observation and has received tickets for self-ham. In April, 1999, after attempting suicide several times and cyclingback and forth fiom SHU to observation, he was admitted to CNYPC for six months. He was taking Zyprexa the whole time. At the beginning of his third prison term, his Zyprexa and Prozac were discontinued. He was unable to get OMH to re-initiate medications, and be

92 Including T' 5- , .

,

i

>;: 4 * 8 --ips.+a.n.d i- F.

q

i, ,

4 " i,

9' Toch, Hans & Kenneth Adarns, Acting Out: Maladaptive Behavior inConfiment, Washington,D.C.: American Psychological Association, 2002.

told me he fears he is getting paranoid and deteriorating. He attempted hanging again, and was transferred to observation at Auburn. The mental health staff told him he's not mentally ill and should not have medications.

Mental status examination: There was obvious tardive dyskifpesia (involuntary movements due to brain damage secondary to taking older anti-psychotic medications for a long time) and tics; the prisoner scratched his arm as we talked, was very anxious, made no eye contact for a while and then looked straight into the interviewer's eye in somewhat inappropriate fashion. There was pressured speech and some flight of ideas. There was a thought disorder and some bizarreness, along with credible reports of auditory hallucinations.

Clinical chart: The chart corroboratesthe history T T presented. A
1/12/00 (second) admission note to CNYPC from Green Haven SKU
reflects diagnosis Major Depression with Psychotic Features, a report of command hallucinationsinvolved in suicide attempts since 1996, and medications Prozac 20 mg. per day and Zyprexa 15 mg, per day. During his next prison term, on 10/8/03,he was housed in a SHU-200 and admitted to OMH caseload for a suicide watch. He was then admitted (for the third time) to CNYPC on 12/4/03for a serious suicide attempt. There, he was adjudged not to suffer from a serious mental illness, but to have a high score on Hare's Revised Psychopathy Checklist, by Dr. Michael Guariglia. He was placed on an outpatient Behavior Management Plan, his medications were discontinued, and then he was returned to SHU at Auburn on 12131/03. He immediately evidenced suicidal behaviors, including having a noose around his neck, that were tagged "gestures" by staff. It seems he was denied medications, as per the plan, but was kept in observation because of ongoing suicidal behaviors and statements. The Behavior Management Plan states that if observation is required, amenities in observation will be less than in a SXU cell "so that the SHU environment will be preferable to patient" and that DOCS staff will be alerted that his behaviors are not due to mental illness. Following the inception of the plan, T*T continued to cycle from SHU or Keeplock to Satellite Unit observation for suicidal behaviors, and continued to be denied medications per the Behavior Management Plan. On 4/9/04 his Mental Health Level was 1.

- I

/
1

has a long history of serious mental illness, pre-dating incarceration

and running through three prison terms. His self-hanning and sometimes assaultive

behaviors are related to that mental illness. Yet he has been given tickets for self-

destructive acts, placed in SKU, cycled repeatedly from SHU to observation and back to

SHU, been medicated and then denied medications, removed from the O W caseload,

and generally has been inadequatelytreated fix SMI, leaving him vulnerable to

breakdown, disciplinary problems and transfer to SHU. A Behavior Management Plan was instituted, based on the incorrect notion that his unacceptablebehaviors were willhl bad acts and not due to mental illness. The elements of the plan described in the above case study- including denial of mental health treatment, punitive consignment to observation with reduced amenities, withholding of medications when he is in crisis have caused T, 5 , intense distress and violate basic human rights and basic requirements of clinical practice and professional ethics.94

7p A.

(Interviewed while housed in observation at

Great Meadow on 8/26/03).

History: This man has been in prison since 1990. At the time of our interview, he had been in observation for several days; prior to that he was in SHU after receiving a ticket in ICP. He has been admitted to CNYPC 24 or 25 times, and prior to incarceration he was admitted to Kings County Hospital and other psychiatric facilities on several occasions with a diagnosis of Schizophrenia. He reported that during his last admission to CNYPC, approximately a year ago, after an assessment by Dr. John Wilson, "they said there's nothing wrong with me." He had been hearing voices telling him to do destructive things, but he hasn't heard any for the past couple of months. He feels he did better when he was in ICP. He has been prescribed Depacote, Risperdal, Zyprexa and other mood stabilizers and anti-psychotics. He discontinued his medications in April because
CNYPC does not feel there is anythingwrong with him - i-e.,his pride
pushes him to refkse treatment if they say there's nothing wrong with him. He reported that he listens to radio or t.v. in his cell, paces and sings. He does not read well (he left school in the sixth grade).

Mental status examination: He seemed agitated, with bizarre af$ect and behaviors, including some involuntary tics or compulsive movements such as head shaking. His speech was pressured. He denied auditory hallucinationsbut I observed enough internal preoccupation and bizarre gestures to be very skeptical about that; he clearlyexhibited ideas of
reference and strong First Rank Symptoms (predominantly thought
insertion - signs of psychosis that are very difficult to feign). He
intermittentlystuttered and exhibited slurred speech, and he perseverated on the theme of his innocence. He was very concrete, unable to abstract,
and had inappropriate affect. I observed his SHU cell, and there were many
rolled-up pieces of paper wedged in the windows.

* American Psychiatric Association, "The Principles of Medical Ethics with Annotations Es~eciallv
4th Applicable to ~sychiatry,"1995;Human Rights watch, 111-Equimd: U.S.Prisons and 0 ~ e k k r s
Mental Illness, 2003.

Clinical chart: His larger-than-a-carton thick clinical chart begins with a

12110190 initial assessment reportingprevious psychiatric hospitalizations

and a diagnosis of Schizophrenia,Undifferentiated.His medications have

included strong anti-psychotic and mood stabilizing agents (indicated for

Bipolar Disorder or SchizoaffectiveDisorder) for most of the last twelve
years, and now are Zyprexa 15mg.lday and Depakote 1000mg-/day-an

anti-psychotic agent and a mood stabilizer, respectively. He has been in

and out of CNYPC, observation, and ICP, back to at least 1994, when

progress notes reflect that he could not manage in population but needed

ICP, and other notes reflected that he received tickets and went to SHU,

where his condition deteriorated and he "hung up" and had to go to

CNYPC. At that time (1994), he was recognized to have a very disturbed

presentation, which was diagnosed as organic brain problem with mental

retardation, and his behavior was barely manageable when he was taking

strong psychiatric medications and was provided a structured enviro~ment,

the best being ICP. But then he was sent to SKU, where his condition

deteriorated anew and he was re-admittedto observation and CNYPC.His

admissiondiagnosisto CNYPC on 4/27/97 is Schizophrenia,

Undifferentiated Type with Borderline Intellectual Functioning and ASPD.

By 1999, his diagnosis was Impulse Control Disorder, but there was no

explanation of what became of Schizophrenia, and he was continued on

anti-psychotic and mood stabilizing medications that are indicated in the

treatment of Schizophreniaand not Impulse Control Disorder. He was

repeatedlyplaced on suicide watch in observation. Then, during an

admissionto CNYPC, Dr. John Wilson submitted a 39 page, single-spaced

report of psychological testing at CNYPC on 7/10/02. The test results were
P confitsing. Dr. Wilson found that P. .$ is in the lowest 1%on IQ

tests, IQ in mid- to high-60"s,and has been since childhood. DL Wilson

diagnosed Mental Retardation. He also found organic brain dysfunction

and diagnosed amnestic disorder. But then he found ASPD with possible

differential of Rapid Cycling Bipolar Disorder, but found insufiicient

evidence for the latter. He recommended a Behavior Management Plan and

recommended against future admissions to a psychiatric ward because that

rewards bad behavior. After return to Great Meadow fiom CNYPC,

m9gJda&y,-mi-eed.,icaadtioosnesowf earneaZnytip-rpesxyach2o0timcgs.upffeircideanyt

and Depakote 1500 for the treatment of

active psychosis and a dose of a mood-stabilizer adequate for the control of

a Bipolar Disorder or SchizoaffectiveDisorder - and he was referred to

ICP. He was in ICP &om 9102, and discharged on 5/21/03 for poor

adjustment. He soon was in SHU and cycled to observation while refking

treatment because he believed staff at CNYPC did not believe he suffwed

fiom mental illness. An 8/10/04 update to his Core History noted cv
7P x is not able to read, write or conmntrate. Testing has shown he is

not able to remember more than 2 bits of data at a time. He rnisperceives

many situations, and reacts impulsively." On 8/5/04 he was re-admitted to CNYPC, the stated reason being that he was "disorganized and unpredictable," further: "HE IS ON OUTPATIENT BEHAVIOR MANAGEMENT PLAN. DISORGANIZED, HAS BEEN ACTING OUT, HAS BEEN IN SHU FOR A LONG PERIOD OF TIME YELLING, SCREAMING. HE IS EATING BUT HAS HAD PERIODS WHEN HE WOULDN'T EAT BECAUSE OF THE LOAF DIET." His admission diagnosis was "Psychotic Disorder NOS." By 8/17/04 - less than two
weeks later - he had been discharged &om CNMPC and returned to SHU.
A 9/30/04 Outpatient Termination Note reflected a diagnosis of "none" on Axis I.
7 B x - is clearly suffering from psychosis, likely Schizophrenia, with a mood
disorder, probably a co-occurring organic brain disorder, and Mental Retardation. He has been 'un-diagnosed' by Dr. Wilson at CNYPC after 24+ admissions. But even af'ter he was "un-diagnosed" and precluded by the Behavior Management Plan from future admission to CNYPC, he was prescribed high dosages of anti-psychotic and moodstabilizingmedications. On 8/5/04 he was readmitted to CNYPC; contrary to the Behavior ManagementPlan it seems he was admitted because he was flagrantlypsychotic and "disorganized." Thus, the Behavior Management Plan had delayed his admission to the psychiatric facility, causing unnecessary suffering.
OMH recognizesg5,and it is well known in the mental health professions, that a significant number of prisoners have co-occurring Axis I mental illness and Axis I1 personality disorders. There is some clinical research asserting that traditionalmental health treatment does not work for individuals who score high on Hare's Revised Psychopathy ~heclclist.'~But there is a growing body of literature that exposes the errors in the cctreatment-doesn't-work~a'pproach?7 In fact, with individuals who have co-occurring SMI and Antisocial Personality Disorder, especially those who score high on the Psychopathy Checklist (Psychopathy is not a diagnosis in DSM-IV, but ASPD is), intensive treatment of the symptoms of serious mental illness (psychotic hallucinations and delusions, severe depression, mania and so forth)
95 Menill Rotter, Bruce Way, Michael Steinbacher,Donald Sawyer & Hal Smith, "PersonalityDisorders in
hison: Aren't They All Antisocial?," Psvchiatric Ouarterl~Vo. 73, No. 4, 2002, pp. 337-349;see Miraglia
Deposition, p. 238.
% Gacono, C., Nieberding, R., Owen, A., Rubel, J., & Bodholdt, R. (1997), "Treating conduct disorder, antisocial, and psychopathic personalities," in J. Ashford & B. Sales (Eds.), Treatim adult and iuvenile
offenders with special needs (pp. 99-129). Washington, DC: American Psychological Association.
97 Rice, M., Hams, G., & Connier, C., "'An evaluation of a maximum security therapeutic communityfor
psychopaths and other mentally disordered offenders," Law and Human Behavior, 1992, 16,399-412;
Gacono, C., Nieberding, R., Owen, A., Rubel, J., & Bodholdt, R., 'Treating conduct disorder, antisocial, and psychopathic personalities," In J. Ashford & B. Sales (Eds.), Treating adult and juvenile offenders with
special needs, American Psychological Association, 1997,pp. 99-129.

actually helps individuals take part in treatment and rehabilitation programs, and then they actually are much more treatment-responsive and cooperative than they would be were their serious mental illness not adequately treated.'*

As I explained in the previous section, the serious error of the CNYPC

Psychological Assessments and Behavior Management Plans that I reviewed in the cases
I investigated in DOCS is that the CNYPC psychologists make it an either/or decision-

either the person is a psychopath or there is serious mental illness. Again, this is that

overly simplistic 'triad-or-bad" logic that misses the complexityof the phenomenon. The:

- ~ logic of CNYPC's psychological assessment in the-cases 1have presented ( e

a 3 .rTis

7 p

as well as the case of T R that I presented

earlier) and in many others I reviewed is that a prisoner who is disruptiveand scores high

on Hare's Revised Psychopathy Checklist must not be suffering fi-oma serious mental

illness; rather his or her unacceptable behaviors are reflectionsof willfill disregard for the

feelings of others and other psychopathic traits. Then, the psychologists accept

uncritically and one-sidedly the part of the clinicaVcorrectional literature that expresses

pessimism about treatment prospects with psychopathic personalities, and concludes that

these individuals should not be admitted to treatment programs because: 1. they have no

Axis I diagnosis; and 2. their Axis II diagnosis, i.e. Psychopathy (or the DSM Axis II

Antisocial Personality Disorder) makes them poor candidates for mental health treatment.

When clinicians decide in advance that a certain prisoner, were he to attempt to harm himself o r exhibit frankly psychotic symptoms in the future, is not to be seen by a mental health clinician for a certain period of time, or is not to be admitted to a crisis intervention unit (observation) or a psychiatric hospital (CNYPC), then these clinicians are committing very poor clinical practice that falls well beneath the standard of care in the community, and they are in violation of ethical standards that require the clinician to treat a person who is suffering from
an illness. In other words, they are withholding treatment. It is not a clinicallynor
ethically sound practice to determine in advancethat particular individuals are to be denied certain treatments in the fiture even if they develop signs of an illness that requires that kind of treatment. How can a clinician preclude the kind of open-minded reassessment that should be done when a new crisis arises by ordering that the clinician should not even see the patient for at least a day when the new crisis occurs? In more than a few cases in DOCS, the assumptions underlying Behavior Management Plans were
actually disproved by subsequent events - e.g. someone who was diagnosed "no Axis I
diagnosis" and put on a plan was subsequentlyre-assessed and it was decided the individual was psychotic enough or depressed and suicidal enough to admit him to
CNYPC.

98 Jennifer L. Skeem, John Monahan, and Edward P. Mulvey, "Psychopathy,Treatment Involvement, and SubsequentViolence Among Civil Psychiatric Patients," Law and Human Behavior, Vol. 26, No. 6, December 2002; Salelcin,R., "Psychopathy and therapeutic pessimism: Clinical lore orclinicalreality?," Clinical Psvcholo~R~eview,22,2002,79-112.

It is not permissible to place someone in a treatment setting such as observation in the Satellite Mental Health Unit, and purposely design that form of treatment to be so noxious that the person will not want to go there. Even if one were to give the designers of Behavior Management Plans the benefit of the doubt, and assume that their instructions to make observation more uncomfoaable than a prisoner's SHU cell is motivated by an interest in treating the prisoner's dysfunctional behavior, this is a very ineffective treatment strategy and the conditions it imposes on the prisoner are degrading. Forcing a prisoner to eat cold "loaf' as disciplinebecause he dared to cut himself or try to hang himself falls beneath current standards of human conduct, not to mention standards of professional practice and ethics. Likewise, keeping a patient who has been depressed and suicidal in an observation cell where he is naked except for a gown for weeks at a time, and not admitting him to a psychiatric hospital where he can receive proper treatment, is simply beneath all standards.
b. Proposed Behavioral Health Units (BHU)
The 2004-2005 Executive Budget Forensic Mental Health Initiatives (Plaintiffs Exhibit 238,5/26/04) states:
"OMH is proposing the establishment of two Behavioral Health Units (BHUs), which will serve as an alternative to SHU placement. This program will provide services to inmates with serious mental illness who, due to their level of violence and disciplinary inkactions would typically be housed in SHUs. These are inmates who have displayed a marked inability to conform their behavior to societal or institutional standards of conduct. Short of inpatient commitment to CNYPC, the BHU represents the most intense level of mental health serviws
provided to inmates prone to disciplinaryinfiractions. The major component of
the program is specialized management and treatment, and the program will employ behavioral management and cognitive-behavioral interventions."
I have reviewed the 2005 Draft proposals for Behavioral Health Units, Phase I to encompass 38 beds at Great Meadow and Phase 2 and 3 to encompass 32 beds each at Sullivan. My greatest concern about this development is that the Behavioral Health Units will follow, in philosophy as well as in practice, the wrong direction pursued in the Behavior Management Plans just discussed. OMH urgently needs a well-thought out approach to the "disturbed/disruptive" prisoner. The proposal for the Behavioral Health Units seem to be an attempt to solve this problem, and it contains somegood ideas. It also has some very big flaws built in at the initial stage of planning.
From my review of the proposals, I believe that the BHU is a phase progtam, in which prisoners with serious mental illness and disciplinaryproblems will be rewarded with more amenities and privileges as they demonstrate that they have learned to behave appropriately. The most significant problem with this kind of phase program in a correctional setting is that individuals suffering i%omseriousmental illness tend to get stuck in the lowest phase, or cycle back to the lowest phase after they have reached a

higher phase, because the symptoms of their mental illness prevent them from achieving the required tasks, or get them into disciplinary difliculties that will bump them back to the lowest phase.
In this context, it is a concern that in the documents I reviewed, time fi-arnesare not applied to the various phases. Phase one is the most restrictive phase, and require the prisoner to demonstrate good behavior. This is a set-up for failure in that a prisoner with serious mental illness will likely fail because the very restrictive environment will cause him or her to misbehave or be incapable of achieving what is required to pass on to the next phase. This problem needs to be resolved by lessening the restrictiveness of the setting, offering incremental rewards for small accomplishments, and providing professional staff support to the prisoner with serious mental illness throughout the process. Then, as a limiting factor, there needs to be a tracking and flagging system in place, so that if the phase is designed for thirty days and a prisoner is not able to achieve advancement to the next phase in (to provide an example, 45 days), that failure should trigger an automatic psychiatric assessment and the devising of an individualized treatment plan to help that individual advance to the next phase.
1'0
The disciplinarysystem, as outlined in the proposals, is flawed. A dual disciplinarysystem is envisioned. The subgroup of BKU prisoners who do notcause too serious of a problem will be disciplined by a collaborative team of mental health and security staff within the B m , but the subgroup of BHZl prisoners who cause too much trouble is immediatelyturned over to DOCS to be disciplined. This is going to re-create the kind of dual-track system that exists already: the "good" patient with SMI is welcome in ICP, but the %ad" patient who gets a Tier 3 ticket is ejected b m ICP and has to go to SHU. The kind of dual-track system contained in the BHU proposals is going to lead to transfer for a subgroup of disturbed prisoners from Behavioral Health Units to SKU. Instead, there needs to be a self-contained disciplinaryprocess within the Behavioral Health Units, so that the staff in those units can deal with the entire range of behaviors that set off disciplinary sanctions. In addition, there needs to be a policy that prevents return fiom the BHU to SHU. Once a prisoner begins to take part in the BHtT, he needs to be kept out of SHU.
Finally, the proposals I reviewed do not offer any intensive mental health treatment. I see rehabilitation and education efforts, and various kinds of growth experiences. But if the population is composed of prisoners who suffer h m serious mental illness, there need to be psychiatrists, psychologists, psychotherapy opportunities, and psychiatric rehabilitation programs, and this isjust not visible in the proposals.
4. Prescribing Practices and Record-Keeping
Great advances have been made in psychopharmacology. Lithium, the prototype for a line of "mood-stabilizingyymedications, was made available for routine prescribing in the early 1970s. Pharmacologic treatment for Bipolar Disorder became much more effective, and since then a variety of equivalent "mood-stabilizingyymedications,

including Tegretol, Depacote, and Lamictal, have h o m e available. Pruzac arrived in the late 1980s, and there followed a series of Selective Serotonin Reuptake Inhibitors and other classes of newer antidepressant agents that are more effective than the old-line antidepressants, and much less toxic. And a new generation of "atypical" anti-psychotic medications, beginning with Clozaril in the early 1990s, followed by Zyprexa, Risperdal, Seroquel, Geodon and Abilify, has made the treatment of Schizophreniaand other psychotic conditions much more effective. We are in a new age of psychophannacology,
and it is possible to prescribe relatively safer and more effbctive chemical agents thanthe
ones that were availableprior to the advent of Lithium.
But medications alone are not an adequate treatment for most varieties of mental illness, especiallyif the patient has to spend a significant part of each day in a prison cell. Research shows that medications are most effective when administered concurrentiy with one or another version of psychotherapy or psychiatric rehabilitation. Psychiatric medications are not a substitute for other forms of treatment; rather, they are an effwtive adjunct to other forms of treatment." When medications are prescribed to someone who has little or no opportunity for meaningfbl talk with mental health clinicians, then the medications serve little purpose other than sedation. In my review of clinical charts, I found that there was often no clear rationale documented for the prescribing of psychiatric medications. Medications or their dosages would be changed with no progress note reflecting the clinical strategy of the physicians or psychiatrist ordering the change.
Psychotropic medications can have very serious and potentially toxic or fatal side effects. Periodic blood and urine laboratory tests are required to safely administer many of the psychiatric medications. I did not see appropriateblood tests reflected in the clinical charts. For example, patients being prescribed Lithium, Depacote and other mood-stabilizers need to have regular blood tests to determine if the level is in the therapeutic range, and if it has reached toxicity. In addition, most psychiatric medications require periodic blood tests for toxicity, which means testing liver and kidney function among other things. Mostly these tests were not in the charts I reviewed, or the lab tats were inconsistent or inadequate, placing prisonerstpatients at risk of serious physical harm.
An 8116/02 Memorandum &omZebulon Taintor, a member of the Board of Directors of the New York County Medical Society ,loo to "Hal (Smith?) and Bill" mirrors my concerns here. It is a report of this clinician's findings at Attica Correctional Facility, and states: "Isaw many patients (42 one day) and found, as the OMH Pharmacy and Therapeutics Committee has noted in most facilities, a large number of patients
99 Kupers, Terry. "Medications:Alternative or Adjunct to Psychotherapy?," in Public T k r a ~T~h:e Practice of Psvchotherapvin the Public Mental Health Clinic, Free Press, 1981, pp. 61-79.

receiving Valproic Acid or Divalproex (Depakene, Depakote). In only two patients were
there blood levels in the therapeutic range.. .In most patients the most recent blood levels
were fkom 1999 and 2000, often below the therapeutic range at that time with no dose
change since.. .. I assumed that most of the patients had no therapeutic levels. They
didn't know why they were on the medication and I usually could find no indication in
the chart for using valproic acid.. ... Staff tell me there is only one phlebotomist in the
facility and they had been told psychiatric patient blood would be taken on a 'resources
available' basis.. .." Regarding the fact that notes of non-psychiatric medical treatment
are not in the chart, Mr. Taintor states: "There is a great risk of potentially harmful (drug) interactions with two sets of pk;;icians writing orders without each knowing what the other is doing." He also found some psycho-educational materials for patients on drug side effects, but noted that "there seems to be nothing on the mental illnesses."
Mr. Taintor's memorandum mirrors my findings: Laboratory tests are erratic at best, and often absent from the clinical charts; findings of lab tests that indicate toxicity or an insufficient dosage of medication are not followed up with indicated changes in the medication regimen, and contact between OMH staff and patients is too sporadic and superficial in many cases for effectivepsycho-education about the mental illness and the medications to take place. The failures with respect to laboratorytests result in at least two major problems: the patient is not receiving a high enough dose of the medication to attain therapeutic efficacy, or toxic levels of the medication are not detected and the patient can suffer liver failure and other disastrous side effects.
I noticed in the clinical charts that Clozaril is not prescribed often by OMH
psychiatrists. Clozaril was the first of a line of newer, "atypical" antipsychotic medications that evolved in the 1990swith important therapeutic benefits for severely disturbed patients. Newer medications such as Zyprexa and Risperdal accomplish almost as much, but there are cases where Clozaril might prove more effdive. The problem is that it has some serious, and potentially lethal, side effects if its administrationis not monitored carehlly. For example, one side effect is leukopeniaor a low white blood cell count, which can obstruct immune response and potentially lead to death from infistion. I believe that there are cases in a correctional setting where Clozaril is the medication of
choice. But I am extremefy hesitant to recommend its use in NY DOCS because of the
problems I have discussed in the OMH mental health treatment delivery system. If rigorous monitoring of blood tests is not done, if carehl notes including treatment plans and lab tests are not kept up to date in the charts, and if clinicians do not spend enough time with their patients to foster a healthy therapeutic relationship, then the prescribing of Clozaril can be very dangerous. I will stop short of recommending its prescription in MU DOCS, hoping that the other problems I have described will be ameliorated so that it will eventuallymake sense to recommend the use of Clozaril in very rare cases of psychosis where other anti-psychotic medications are not effective.
Typically a psychiatrist should see the patient who is taking psychiatric medications on a monthly basis or more often, tak to the patient about his condition and

the positive and negative effects of the medications, order the appropriate laboratory tests,
and note in the chart the medications the patient is taking, any changes in the patient's condition, any side effects of the medications, any troubling laboratory results, and then, after completing the above steps, revise or reaffirm the treatment plan, including the rationale for the medications and the non-medication aspects of the patient's treatment plan. If the prisoner is known by past history to suffer from a serious mental illness such as Bipolar Disorder or Schizophrenia, and that prisoner is not taking psychotropic medications for some reason, there still needs to be periodic reassessments by a psychiatrist with the option of commencingpsychophannacologic treatment at an appropriate time.

In too many of the cases I reviewed in NY DOCS, the psychiatrist sees the patient
for a few minutes at cell-front on a very irregular basis; and does not put an adequate note in the clinical chart explaining the treatment plan and the part that is played by the medications. This is an entirely unacceptable practice, and violates all standards of care in the community as well as in corrections, and places prisoners at risk because it involves a lack of adequate monitoring as well as ineffective treatment. Then, in quite a few cases, the clinical notes reflect a changed diagnosis, for example the prisoner who had been diagnosed Schizophrenic is now diagnosed "Adjustment Disorder" or "no diagnosis on Axis I," but the psychiatric medications that would be appropriatefor the Schizophrenic condition are renewed, with no explanationof reasons for gving a strong anti-psychotic or mood-stabilizing medication to someone who is no longer diagnosed with the relevant mental illness.

f2 d4
7115/03.)

(Interviewed while housed at Clinton on

History: E ~4 informed me he had been in observation twice, was at CNYPC in October, 2002, has not been in SHU, and does not get disciplinary tickets. He took psychiatric medications for nine years, but when he arrived at Clinton the psychiatrist discontinued his medications. As soon as the medications were discontinued he became agitated and had trouble sleeping. He sent a written request to the psychiatrist to re-initiate medications and for a long time received no response, but five days prior to our tour she called him in and prescribed a liquid medication for sleep. She did not tell him what the medication was and did not discuss side effects with him. He reported that he has been staying in his cell all the time, seven days a week, he feels depressed most of the time, he does not have the initiative to do anything, does not talk to others, and does not read or write.

Mental status examination: This man was depressed, flat, concrete, exhibited marked psychomotor retardation, presented obvious anhedonia

Clinical chart: There are several diagnoses of SchizoaffectiveDisorder,
depression, and psychosis NOS. When he entered Clinton in 7/03, he was
seen by OMH for "voices and depressed." Throughout his chart there are reports of auditory hallucinations. It seems the psychiatrist at Clinton discontinued his psychiatric medications for no recorded reason, and there is no treatment plan.
Not only is a clinical rationale for medication prescribing absent fiom clinical charts, it is often the case that a patient fails to show up at an appointment to have the medications evaluated and possibly renewed, and then he or she is dropped frorn the OMH caseload for failing the appointment(s). If a prisoner who is known to be suffering from serious mental illness decides to discontinue taking his or her medications for any reason, and the staff do not feel that Medication Over Objection is indicated, it is not an
acceptablepractice to simply discharge that patient from the OMH caseload. In an
institution like a prison, it is the responsibility of the mental health professional staff to follow prisoners known to suffer from serious mental illnes~.'~T' he psychiatrist should continue seeing the individual, even though he or she has chosen not to comply with medications recommended. That way, the psychiatrist can assess the clinical situation on an ongoing basis, and it might turn out, for example, that at a later time the patient's condition deteriorates dramatically and he or she requires emergency assessment and hospitalization. Or, what is more likely, and the more desired outcome is, the fact that the psychiatrist has a relationshipwith the individual makes the individual more likely to trust the psychiatrist and start to ask questions about the medications, eventually deciding to take the medications that are indicated.
Record-keeping, specifically clinical chart notes, are not adequate. I have described the problem in relation to medication prescribing and laboratory tests required to monitor medication prescribing. Clinical chart notes are inconsistent. Treatment plans are often lacking. Changes are made in the treatment regimen, or prisoners are discharged from treatment or frorn a component program such as observation, and there are not sufficient notes in the chart to pennit the reader to understand why the prisoner was discharged, nor what follow-up plan there is.
5. Medication Over Objection
The Rivers v. Katz decision'02requires the state of New York to show, by clear and convincing evidence, that a patient that the state seeks to medicate over objection is incapable of making treatment decisions, and if so, whether medication will benefit the patient, and no less intrusive alternatives to forcing medications exists. (The court
'O' Dr. Donald Sawyertestified that it is the plan of OMH to keep prisoners who have been Mental Health Level 1 on the OMH caseload for the remainder of their term in DOCS,even if they do not comply with
treatment -but this plan is not always active (See Sawyer Deposition,pp. 216-217).
'Ot Rivers v. Katz, 67NY2d 485(1986).

acknowledged that the state's police power justifies forced medications under emergency circumstances, so long as the emergency persists.) The factors involved in the contemporary discussion of involuntary medications in psychiatry are quite complex. On one hand, there is the patient's right to choose to undergo treatment and to be free of unnecessary coercion; on the other hand there is the interest of the social unit (in this case the correctional system) in controlling unacceptable behaviors. Research shows that
where there are adequate mental health services - i.e. in service delivery systems where
clinicians have sufficient time to form a trusting relationship with patients and patients
can look fonvard to seeing the same provider on successive visits - there is relatively
little need for involuntary medication of any kind; on the other hand, where mental health services are reduced substantiallyby budget cuts and staff shortages, the staff are overburdened and are not able to take the time to establish trusting relationships with patients, clinicians more often feel they have to resort to involuntary medications. Such is the case in New York. In California,when the state legislature debated a new law a few years ago that would make it much easier for psychiatrists to order involuntary medications beyond the rare emergency situation, wording was introduced that required counties that wished to enact the new involuntary medication capability to also bolster
their public mental health services - in other words, the logic is that if they first make a
concerted effort to provide adequate services, they will not need to utilize the involuntary medication statute except in very rare and extreme cases.
In response to the Rivers decision, OMH:promulgated regulations which require that the patient be involuntarily committed to a psychiatric hospital before non-emergency medication may be forcibly administered. In addition, there must first be adminimative proceedings and there is a right to a court review, if appealed.'03
OMH now allows for an exception to this rule. There are now "traveling Rivers orders," i.e. court orders for involuntary medication that continue to be in effect afier the patient is transferred from the designated inpatient setting to a Satellite Mental Health Unit, and then to any housing unit in a designated correctional facility. The prison designation seems to depend on the staff in that facility receiving training in the implementation of "traveling Rivers orders." According to Dr. Don Sawyer (Deposition, pp. 474-486), while OMH would prefer that prisoners with traveling Rivers Orders receive involuntary medications only within the Satellite Mental Health Unit or SHU housing with an STP at designated facilities, in fact there are prisoners for whom OMH has traveling Rivers orders who are housed in SHU without STP participation. There is no formal review procedure in place to prevent abuses of the process.
Traveling Rivers orders are very problematic. I have described problem a k r problem in the delivery of mental health treatment to the large population in need within DOCS. A large number of prisoners are relegated to isolated confinement(SHU and Keeplock), mental health services in isolated confinement settings is far from adequate,
103 14 NYCRR Section 27.8.

confidentialityis lacking, crisis intervention in observation cells within the Satellite Mental Health Units is more punitive than therapeutic, and the conditions of confinement
in observation are more harsh even than in SHU, and so forth (as set forth above). I have pointed out major deficiencies in prescribing practices. In my opinion, traveling Rivers
orders would be problematic in any correctional setting -there is good reason why involuntarymedication is required to occur only in inpatient settings or settingswith an
equivalent level of mental health treatment -but in NY DOCS, where the many
deficiencies and abuses I have delineated prevail, permitting traveling Rivers orders will in many cases lead to the warehousing of prisoners in a S W cell, where their hallucinationsand despair will be intensified, and then using force to pull them out of their cell to give them an unwanted injection of medications that might put them to sleep, but will not correct the causes of their psychotic regression and despair.
Thus, this policy of long-term forced medication orders in the outpatient setting, where mental health services are inadequate (as described in my report), means that prisoners are not only denied the mental health treatment their condition requires, they are
4, also subjected to fbrther indignities, including the utilization of physical force in the process of administering the medications. There is risk of physical harm.
6. Staff Training and Collaboration between Mental Health and Security Staff
I had an opportunityto review several training protocols, including training on mental health for SHU staff, training about disciplinaryprocedures followingthe settlement of Anderson, and training in suicide prevention. I have not had an opportunity to thoroughly assess the amount of training that mental health staff and securitysbff actually undergo. Often in a correctional system there are training materials available, and a decision is made by managers in good faith to conduct training for all staff, but then the actual implementation of the training program does not meet desired expectations. For example, the 1995training manual on suicide preventions cautions staffnot to overutilize the notion of malingering and not to relax their guard in preventing suicide risk in prisoners perceived as manipulative, but still staff tend to dismiss reports of suicide ideation on the part of prisoners they consider manipulative. I have seen some other indicationsthat staff training within DOCS and OMH is inadequate. For example, Dr. DeVito testified that there is a need for more training for DOCS staff about mental health issues (DeVito Deposition, p. 51 & p. 131); Dr. Shimkunas testified that the eight-hour suicide training for DOCS staff had not been done for a couple of years, and currently DOCS staff receive only one and a half hours training per year about suicide (Shimkunas
Deposition, p. 200); Richard Miragliatestified that not enough clinicians in O M have
been trained in the Psychopathy Checklist assessment to meet the clinical need (Miraglia
Deposition, p. 233-234). Thus, improvements in the training for both DOCS and OM33
staff are needed, as is recognized by OMH manqgers.

But there is a better method for assessing the adequacy of training, and that is by investigating the actual practices of staff, both security and mental health staff. Throughout this report I have provided evidence of deficient and destructive practices on the part of both DOCS security staff and OMH staff. For example, consider the actual practices I discovered regarding prisoners who present a risk of suicide. There is confinement under harsh conditions in observation, failure to send seriously suicidal
individuals to CNYPC for inpatient treatment, cell-front and non-confidential meetings
between OMH staff and prisoners in observation, poor prescribing practices, a lack of treatment plans in the clinical charts, and a tendency to incorrectly dismiss prisoners' reports of suicidal ideation and intentions as manipulations and malingering.
From these observations, I have come to the conclusion that training in suicide prevention and crisis intervention, for both security and mental health staff, is grossly deficient. In other words, were there adequate training regarding suicide prevention and crisis intervention, better treatment would be afforded prisoners who present a serious risk of suicide, and staff would have a more caring attitude toward prisoners suffering from serious mental illness. Similarly, complaints of emotional pain on the part of prisoners with SMI in isolated confinement are ignored or diminished by both security and OMH staff. This leads me to conclude that training for securitystaff about mental illness and training for OMH staff about the psychological effects of isolated confinement and assessment for malingering are grossly deficient.
In general, I conclude from the deficiencies and unacceptable practices that I have described in this report that there needs to be more and better training for securitystaff about mental illness, its identification and treatment, the extent of past trauma in the lives of prisoners, gender sensitivity, and so forth. And from my investigation of pactices and cases, I have arrived at the conclusion that OMH staff need more and better training about the life experiences of prisoners, the importance of trauma in their lives, the effects of conditions of confinement,the importance of confidentiality, the techniques of clinical assessment of prisoners, the proper format for clinical record-keeping, and psychopharrnacology and prescribing practices. In fact, there is not enough crosstraining, i.e. training of security staff regarding mental health issues and training of OMH staff about security issues.
Similarly, close collaboration between security and mental health staff is essential in a corrections system if prisoners with serious mental illness are to be properly managed and treated. The problems I have pointed out throughout thisreport reflect a lack of adequate collaborationbetween security and mental health staff. The most obvious example is the failure of OMH staff to intervene adequately in disciplinary matters when the behaviors that are to be punished are possibly driven by mental illness. But there are other reflections of poor collaboration. The culture of security is a given in correctional settings. The security staff has the very difficultjob of maintaining order and fostering the smooth operation of the facifity. Of course, mental health staff must collaborate closely with securitys t a i n order to safely engage in treatment while not interferingwith

operations. However, when mental health staff becomes taken over by the cultwe of security to the extent that they forfeit their independent clinical stance, treatment is greatly compromised. When a large proportion of prisoners a~eplagued by serious mental illness and require treatment, a certain degree of tension between security concerns and treatment concerns should be an integral and appropriate part of staff relations. Working through and resolving this kind of tension is a critical ingedient in productive collaboration.

To the extent mental health staff succumb to the culture of security and, for example, over-utilize diagnoses such as malingering or ignore prisoners' reports of emotional pain and despair, the prisoner who suffers fiom mental illness and breaks mles tends to be punished harshly instead of receiving urgently needed treatment. When prisoners with serious mental illness are disruptive, there needs to be a collaborative interventionby security and mental health staff. Where such collaboration is eff'ective, there is much less need for "use of force" and other punishments, and security staff serve to direct mental health staff to cases requiring more intensive intervention.

7. Use of Force on Prisoners with Serious Mental Illness

Many prisoners suffering fiom serious mental illness told me in graphic terms

about having been subjected the use of force by staff. I also had an opportunity to view

videotapes of "take-downs," "cell extractions" and other uses of force. The videotapes I

viewed involve prisoners
11/10/04; pN l( Y 7/25/94; and

ya

5/21/03;

10/26/96, Attica, move to B-North;

T*T* 3

3/5/00.

\/Jk'6/21/03;

y It is quite p M l to watch the 5/21/03 cctake-down"of has been taken to observation, she is being held down on the floor by and stripped naked by several officers using scissors to cut away her clothes. She is screamingand crying the entire time (approximatelyten minutes on the videotape). Mostly the officers hold her face down on the floor and do not talk to her nor reassure her
a until the end of the tape when one says "elax, we'll be out of here in a second." V is also subjected to a strip search in observation. Her clothes are tom off as several officers hold her down on the floor. She is relatively quiet, she wears a "spit mask," they perfonn a cavity search, there is joking in the background and at certain points one or more male officers is present while she is naked.

E

an inmate housed in SHU at Bedford Hills Conectional Facility,

testified that the first time she was brought to observation she did not understand that she

would be subjectto a stripsearch, and the process increased her agitation. She was then

forcibly and brutally stripped and left naked in her observation cell, while male

correctional officers were present. She has observed other prisoners naked in their

observation cells as well. 6 k deposition, pp. 61-65).

I mentioned in my discussion of td A (Section V) that a majority of
women in NY DOCS had been traumatized - physically and sexually abused - prior to
incarceration,and that experiences in prison such as confinement in S W can replicate past traumas or constitute "re-traumatization." Searches by male offiefs can be an extremely traumatic experience for imprisoned women, as many I interviewed told me. The videos confirm their reports. When staff speak in demeaning ways to women, handle them roughly, and violate their boundaries (in the process of a "take down" or search), the women suffer great emotional harm, and when they suffer &om serious mental illness, it is likely the re-traumatization will worsen their illness, their disability, and their prognosis. Greater sensitivity to these issues on the part of staff is urgently needed.

In another video I reviewed, q H

becomes quite emotional when

officers tell him that they are confiscating his address book as "contraband." He screams

and cries, stating that they are taking away his family. He appears increasingly regressed

and paranoid as he gets excited, and an officer tells him to "calm the h c k down," and to

"stop feeling sony for yourself." They take him to observation, forcibly remove his

clothing when he seems unable, and all the while he is becoming increasingly paranoid,

accusing them of poisoning his food and so forth.

p ,who suffered fiom serious mental illness and eventually killed himself

in DOCS, was also shown on video being treated harshly and insulted as he was searched

and transported to observation. K

is forcibly removed tiom his cell after being

"gassed." He is beaten numerous times with a club, even after he is on the floor. He is

treated brutally, and even though he is on the OMH caseload, there does not appear to be

any OMH staff present during the cell extraction, and transfer of this patient to the

hospital. By the end of the videotape he has been stood on his feet; he collapsed, and he

appears to have suffered a seizure. F FbE has been LLgassed("i.e. subjected to an

immobilizinggas), forcibly removed fiom his cell, and is strip s e a ~ h e d(off camera) after

a video-taped interview with a nurse wherein he makes some comments that might reflect

psychiatric illness (e.g. "I always kill my enemies"). The nurse tells him shecannot help

him with his "security-related" problems, and leaves the room. He is put in an

observation cell. Many of the prisoners I interviewed are terrified of the expectable use

of overwhelming force by staff.lo4

When a prisoner who is suffering from mental illness is subjected to the use of force, there are likely to be these predictable ramifications: in all prisoners, an exacerbation of fear and anxiety; in a prisoner prone to paranoia, intensified paranoia; in a prisoner prone to depression and self-harm, an intensification of the depression and increased likelihood of suicide; in a prisoner prone to extreme mood swings, an increase in the extremity of their depressive and manic swings, or in their frequency. Further, in prisoners prone to Posttraumatic Stress Disorder (PTSD) or suffering from PTSD related to prior traumas, a cell extraction or an incident
'" Donald Sawyer testified that, generally, an OMH staff member is not required to be present dming strip
frisks of patients. (See Sawyer Deposition, pp. 197-199.)

involving use of an incapacitating gas, or other use of force, is experienced as a retraumatization and the PTSD becomes more severe and chronic. And in a prisoner suffering fiom severe mental illness who is prone to act out his anxiety and other psychiatric symptoms by resorting to hyper-masculine bravado, there is an exaggeration of that tendency, and this can lead to f d e r use of force by officers.

Many prisoners with serious mental illness in SHU spoke about the use of force

by officers, including the use of immobilizinggas, physical cell extraction and forcible

strip searches. I am not in a position to judge the veracity of every report, nor did I do the

kind of investigation that would be required to assess the necessity of force in each case

or whether the force used was excessive. The point is that prisoners with serious mental

illness are strongly affected by the use of force, but use of force is much more likely to

occur in maximum security prisons, and especially in SHIJ. Thus, the fact that DOCS

,andOMH move prisoners fi-omlower security facilities to maximum security facilities

because the Satellite Units are located in the maximum security facilities, and the fact that

DOCS and OMH consign a disproportionately large number of prisoners with serious

10

mental illness to SHU, means that prisoners suffering from serious mental illness are at greater risk of being on the receiving end of use of force by security staff than needs to be

the case, and that, as I have shown, use of force can be very destructive for them.

8. Post-Release Planning

There is some much needed attention to post-release planning. Some of the substance abuse programs available in DOCS have continuation components for postrelease consumers. And at Sing Sing Correctional Facility I toured the Community Orientations and Re-Entry Program (CORP), a post-release preparedness-training for prisoners with mental illness who are within 90days of the end of their prison term. I toured the CORP program on 5/7/03, and it had just been opened. There were seven prisoners in the program at that time, but the capacity is 31. The July 15,2004"Report on
Outpatient Mental Health Services Provided by CNYPC in NYS Prisons in 2003"by R.
Beer and B. Way reflect the same basic picture: the average number of CORP patients at the end of each month in 2003 was 15. I met with the COW staff, who explained the intensive groups they provide, including anger management, psycho-education about mental illness and its treatment, and medications group. The staff seemed enthusiastic and optimistic about the program's prospects for helping released individuals succeed in the community. The only problems with this encouragingprogram are its small size relative to the large number of prisoners who are released liom DOCS, and the fact that the CORP program occupied a section of the ICP unit. In other words, the beds in the CORP program were from the ICP program, and as I explain elsewhere, more ICP beds are needed.

A very large problem for prisoners suffering from serious mental illness is that they spend a significant length of time in SHU, and then they are released to the community directly from SHU, with no post-release preparation to speak of and no

opportunity to get used to being with people again after the lengthy period of isolated confinement. This is a recipe for disaster. An exampk is G ,R, a prisoner in SIW at Bedford Hills, who was deposed in this case on February 17,2005, while serving a three year sentence in SHU. Her release date was M m h f 4,2005, and at the time of her deposition it appeared she was scheduled to be released to the community
straight out of the Bedford Hills SHU. E,R, who is literate (in contrast to many
other prisoners with mental illness), learned of programs in the communityby reading a Fortune Society newsletter, and tried to follow through, but received much less help from OMH than she needed (and this deficiency is much worse for prisoners with limited reading and writing ability). (See E,R. deposition, pp. 54-59).
VII. How New York's Prisons Compare with National Trends
New York DOCS and OMH pride themselves on offering a N 1 range of mental
health services to individuals confined in NY DOCS. And, indeed, there ~ J Xmany
aspects of the mental health services that deserve praise. For example, as I have reported,
I am impressed by the psychiatric hospital at CMYPC and the ICPs - in spite of ongoing
problems, these are quality programs and should be expanded. CORPS, the pre-release program at Sing Sing, is admirable, even though it is too small to handle the need and it occupied a unit that would otherwise serve as an ICP and thus its development made the
shortage of ICP beds even worse -pre-release programming should be expanded, but this
should occur concurrentlywith the expansion of ICP programming and not at the expense of ICP beds. These components of the mental health services OMH offers to DOCS patients are comparable to some of the best mental health programs in the nation. According to the Bureau of Justice Statistics, 13% of State inmates were receiving mental health therapy and 10%were receiving psychotropic medications in ~ O O O . ' ~ *New York's figures are approximately average.
But there are some areas where NY DOCS and OMH fall well beneath the
standard and precedent being set in other parts of the country. The most glaring example is the large number of prisoners suffering from serious mental illness who spend an inordinately long time in isolated confinement.
New York places a relatively large proportion of its prison population in isolated confinement. Sometimes it is difficult to compare practices across the staks in this regard because the various states report different kinds of figures,some combining administrativesegregationwhile some keep them separate, some counting v q short-
term isolation and some not, etc. But I will make my best effort to accurately reflect
relative population sizes in different states. According to the Corrections Yearbook 2001, between 1994 and 2001 the average percentage of prisoners in segregation and protective
'OS Beck, Alan, Special Report:Mental Health Treatment in State Prisons,2000, U.S. Dept. of Justice,BJS, available at www.ojp.usdoj.gov/bjd.

custody increased fiom 4.5 percent to 6.5 percent.'06 According b a Human fights . Watch report, nationwide, New York's reported 7.8% in segregation(SHU and
Keeplock) is well above the average for the 36 states reportingon the n u m b of prisoners in segregation.Io7California and Texas, two states that pioneered the use of isolated confinement units, house between 3% and 6% of their prison populations in isolated confinement. Washington State, another pioneer in theuse of isolated confinement, houses less than 2% of its prison population in isolated confinement units. In addition, in
comparison to other states, the length of stay for prisoners in NY DOCS SHUs exceeds
that in other states.lo8
Besides subjecting a relatively large proportion of its prison population to isolated
confinement, NY DOCS selectivelyconsigns a relatively large proportion of prisoners
with SMI to isolated confinement. Many states exclude prisoners with serious mental illness fiom long-term isolated confinement. Litigation has led to the exclusion of prisoners with serious mental illness &om long-term isolated confinement in California, Wisconsin, Texas, Connecticut, New Mexico, and Ohio. Illinois DOC, by policy, excludes prisoners with serious mental illness from the isolated confinement unit, Tamms. Even states that do not exclude prisoners with serious mental illness fiom isolated confinement report, on average, that approximately 12% of the prisoners in isolated confinement suffer from serious mental illness. New York DOCS and ONIH report that the proportion of prisoners in SHU and Keeplock suffering fiom serious
mental illness is far above that national average, with as many as 64% of prisoners in SHU in maximum security facilities on the OMH caseload. Remarkably, Harold Smith, Executive Director of CNYPC, testified in his deposition that he did not know that there
were states that exclude prisoners with serious mental illness from isolated conf~nement. (See Smith deposition,pp. 405-406).'09
In some other states, isolated confinement is not designed mainly as punishment, rather it is a time-limited program designed to alter behavior so that prisoners can control themselves and return to general population. I have met with the Mental Health Director of the Departments of Corrections in New Mexico and Connecticut, respectively, and worked out improvementsin their plans to return prisoners to general population. The state of Washington DOC makes clear that the purpose of its isolated confinement units is to help prisoners change their behavior so they can cope better in general population. Tn these states, as well as Wisconsin, if a prisoner does not proceed as expected through the
Io6 Camp, C.G.& Camp, G.M.,Corrections Yearbook 2001: Adult Systems,Connecticut: Criminal Justice
Institute, 2002, p. 38.
107 Human Rights Watch, Ill-E~uivvedU: .S. Prisons and Offenders with Mental Illness, New York: Human
Rights Watch, 2003.
'ol Correctional Association of New York, 'Mental Health in the House of Corrections,"June, 2004. Richard Miraglia, Assistant Commissionerof Forensic S e ~ c efsor OMH, testified that he was aware of
settlementsin a number of other states that exclude prisoners with serious rnental illness fiom isolated confinement. (See Mkaglia deposition, pp. 140-143).

phases of a program where the eventual goal is return to general population, then the mental health staff initiates rigorous mental health assessments to see if symptoms of a mental illness might be causing the prisoner to fail to advance through the phases of the
program. This is a stark contrast to NY DOCS, where prisoners with sesious mental
illness quite routinely accumulate additional disciplinary tickets after they are t r a n s k ~ e d to SHU, and very little is done to correct this unfortunate pattern. In states that design their isolated confinement units to be a time-limited effort to teach prisoners skills they will need to cope in general population or in the communityafter they are released, the guiding idea is that prison is the punishment determined for a crime by the courts while isolated confinement is merely a means to help the prisoner adjust to the prison environment so he or she can safely serve the sentence without disrupting ingtitutional operations. This in contrast to New York DOCS, where punishment in addition to the prison term is the stated aim of SHU and Keeplock ~onfinement."~
Some states are closing their isolated confinement units or converting them to other purposes - Michigan's Ionia Max no longer serves as an isolated confinement facility, and Maryland has announced the state is closing its isolated confinement prison. Virginia had two facilities dedicated to isolated confinement, but that state is converting these facilities to "regular" maximum security prisons, thus reducing the state's isolated confinement capacity by more than 75%.
The routine in isolated confinement cells in NY DOCS is very severe relative to
comparable settings in other states, especiallybecause isolated confinement can stretch into an unlimited time period. (And even in states where routines are less severe, prisoners with serious mental illness are excluded from isolated confinement.) Prisoners are in their cells nearly 24 hours per day, they are not permitted any kind of congregate activities, and they will remain in this type of very restricted and isolated confinement until their SHU term is over or their release date arrives. In contrast, many states are alleviating the extreme isolation and idleness of isolated confinement by incrementally providingprisoners in isolation units with progressively more 01&-of-w11activities, group events and programming. Wisconsin, New Mexico and Connecticut Departments of Corrections have designed phase programs that permit prisoners in isolated confinement
' to earn incrementallymore social interaction and more meaningful programming. In
Florida, with the settlement of Osterback v. ~ o o r e , " the Department of Co11fe;ctions established for prisoners in Closed Custody (isolated confinement) phased release fiom their cells for progressively more hours each day so they could take part in a wide variety of mental health treatment modalities, including group therapy, anger management, substance abuse treatment, psycho-education and so forth. This is in stark contrast to the
situation in NY DOCS, where prisoners in S W spend all of their time alone in a cell and
their mental health treatment is limited to medications and mostly cell-front contact with
"O Multiple OMH staff members testified that SHU is designed to be a punitive setting. (see Key
deposition, p. 187; Devito deposition, pp. 162-163.)
"' US DIST CT SO DIST FLORIDA, MIAMI DIVISfON, CASE NO. 97-2806-CIV; 2001.

OMH staff. Even with the SKU Plan of hprovements (which provide access to two private sessions with a therapist per month and one private session with a psychiatrist), prisoners in SHU spend virtually all of their time alone in a cell. (See Miraglia deposition, p. 125-126).
In terms of suicideprevention, crisis intervention and the use of observationcells, New York DOCS' very punitive approach to suicidal prisoners is much more harsh than the evolving standards in the field require mayes, NCCHC). In Connecticut, there is a strict limit to the time a prisoner can be held in observation at Northern Correctional Institution, an isolated confinement facility, the idea being to either resolve the crisis quickly or transfer the individual whose crisis cannot be resolved quickly enough to the acute psychiatric hospital unit, where more intensive mental health treatment is available. The National Commissionon Correctional H.ealth Care (WCHC) standards on seclusion and restraint include these provisions: "b. In each case, use is authorized by a physician or other qualified health care professional where permitted by law, after reaching the
conclusion that no other less restrictive treatment is appropriate,. ..d. The treatment plan provides for removing patients from restraints or seclusion as soon as possible,... 'When
P clinicallyordered restraint or seclusion is used, it is em loyed for the shortest time
possible in keeping with current community practice."' l2 The long stays in observation cells in O m Satellite Mental Health Units, under very harsh and restrictiveconditions, are well beneath the evolving standards and practices in the correctional mental health field.
Thus, in these ways, NY DOCS falls behind evolving national standards and praktices,
VIII. The Problems are Lon~standinpand Well-Known by Defendants
DOCS and OMH are very aware of all of the problems I have raised in this repod. Since this litigation was initiated, O M .and DOCS have been making limited efforts to correct some of the deficiencies and unacceptable practices that I have identified. For example, as an effort to ameliorate the problem of lack of confidentiality in cell-fi-ont
mental health interviews in isolated confinement units,Dr. Don Sawyer notified OMH
staff that all prisoners in SHU who are on the OMH caseload must be provided a private interview with OMH staff at least twice per month and access to a psychiatrist o w e per month.'I3 This is definitely an improvement over exclusive cell-fiont interviews. However, cell-front interviews continue to be the main form of contact between OMH staff and prisoners for the purpose of 90 day mental health assessments in SHU, for OMH contact with prisoners in Keeplock and prisoners in observation. And even the private
"'National Commission on Correctional Health Care, Correctional Mental Health Care: Standards$c
Guidelinesfor DeliveringServices,Chicago: NCCHC,2003, pp. 143-144.
'I3 Memo of 6/25/03,Sawyerto Unit Chiefs; see also SHZlPlan of Improvement, 4115/05, which
incorporates this requirement.

interviews that have been added to the OMH interventions in S W do not seem to last very long, do not occur frequently enough, and do not necessarily involve the kind of trusting therapeutic interviews that are urgently needed to effectively treat prisoners with serious mental illness. Thus the changed policy does not go nearly far enough in the direction of solvingthe problem I pointed out regarding confidentiality.
There are other new developments that have been initiated since this litigation was initiated, including: prisoners who suffer from SMI and have been designated mental health service level one will remain on the OMH caseload for the remainder of their term.114Pursuant to a prior decree in the Anderson litigation, Case Management Committees have been instituted in an effort to provide more comprehensive mental health care and better staff collaboration; more effort is to be made to acquire past clinical records for prisoners admitted to the OMH caseload at Downstate's Reception unit1"; new rules have been formulated for OMH participation in the disciplinaryprocess since the Anderson settlement; more ICP beds are being requested in budget proposals; a Behavioral Health Unit is proposed; and studies have been conducted of various components of OMH mental health services. All of these changes are steps in the right ' direction, with the exception of proposals for the Behavioral Health Units, which, if effected in accordance with the materials provided for my review, I am aftaid, are likely to replicate the very problems they were designed to ameliorate.'16 But it will be a long time before many of these changes could actually improve services to the current population of prisoners with serious mental illness, if they ever do. And most of the
problems I have identified reflect ingrained staff attitudes - for example, a punitive
approach to suicidal prisoners and insensitivity to their complaints of emotional distress and change of staff attitudes will require robust training and a kind of leadership that OMH and DOCS have not heretofore been able to demonstrate. And consideringthe fact that DOCS and OMH have known for a long time about the longstanding problems I have delineated, and have known about the great harm done to prisoners with serious mental illness, recent efforts on the part of OMH and DOCS to ameliorate the problems have not gone nearly far enough.
Thus, OMH and DOCS are very aware of the high incidence of serious mental illness in the DOCS population, and the fact that the proportion of prisoners with serious mental illness has been rising even as the population has grown dramatically.li7
'I4 See Sawyerdeposition, pp. 216-217; and Memo firomDonald Sawyer to Unit Chiefs, 10116/02.
'I5 OP P&P manual on Internet, Sec. 11, p. 9.
'I6 See my comments about Proposals for Behavioral Health Units in Section VII.I.3. I make all of these commentsregarding the BHUs as a tentative opinion only, since I understandthat I am to have the benefit of Wer discovery once the BHUs are up and m i n g .
"'Hal Smith,Donald A. Sawyer, and Bruce B. Way, 'Qntral Mew Yo& PsychiatricCenter:An Approach
to the Treatment of Co-Occurring Disorders in the New York State Correctional Mental Health System,"

OMH and DOCS have been aware that prisoners are transferred to maximum security prisons solely because they are in need of more intensive mental health treatment.' l8
OMH and DOCS are well aware that mental health treatment programs have not grown apace with the number of prisoners suffering from mental illness in DOCS, and that there are serious deficiencies in staffing, psychiatric serricxs, the number of inpatient beds, the number of slots in ICP and other mental health programs, and the treatment and
illness!'^ housin available for prisoners who are both disruptive and suffer from serious mental According to Dr. Don Sawyer, even though the number of inmates in DOCS receiving outpatient mental health services increasedby approximately 5,000outpatients from 1996to 2000, and expansion of the number of inpatient beds was needed, CNYPC was unable to obtain additional inpatient beds.''' Dr. Bruce Way's studies reflect a need for many additional ICP beds."'
OMH and DOCS are also well aware (and have been for over a decade, if not longer) that prisoners' mental illness drives many of the behaviors that land prisoners with serious mental illness in isolated ~onfinernent.'~~
OMH and DOCS are well aware that prisoners with serious mental illness are vastly overrepresented in isolated conf~nennent.'~~
Behavioral Sciences and the Law, 20: 523-534,2002; CNYPC Governing Body discussion of increased acuity of mental illness,P1. Ex. 461, p. 4); numerous c o d c a t i o n s among OMH administrators about increasing OMH caseload, see 1111/05 testimonyof Richard Miraglia (Miraglia Tr. 185:8-186:7) or 1/23/04 email Beane to Van Heusen, OMHCNY 087962-087963.
1999 Memorandum of Understanding Between OMH and DOCS, p. 2.
'I9 Smith,K.E.,NYS OMH Task Force on the Future of Forensic Services: Report of the Subcommitteeon Prison Mental Health Services, NY:1/31/97. That report noted: 'Wew York has lower per capita inpatient
beds than all other states of comparable or smaller (inmate) populations with the exceptionof New
Jersey.. ..And.. ..The outpatientprogram is becoming less and less able to provide ongoing monitoringand
supportive therapy for an increasingly mentally disabled population," cited in the June, 2004, Correctional Association of New York publication, "Mental Health in the House of Corrections: A Study of Mental Health Care in New York State Priso~~p~.,"11.
'" 5/31/00 Great Meadow SatelliteUnit Meeting Minutes, OMHGM 0010380.
121 10/3/03"Estimates Regarding ICP Bed Expansion," OMHCNY 090163.
I* Deposition transcripts of Selsky,p. 161-162,Lord, 26:4-15,30:5-14; S b i m k u ~1~2,28-12, DeVito
138:12-20, Miraglia 120 - 121; and the 2002 OMH SHU Study.
2002 OMH SHU Study and the 2004 OMH SHU Study, see also Way Deposition, pp. 546-547, and Dr. DeVito's statementin his deposition that someprisoners with mental illness are in SHU for 10 pars or
more, p. 153.

OMH and DOCS are very aware that a very disproportionate number of suicides within DOCS occur in isolated confinement, and in many cases serious risk of suicide goes undetected, as reflected in Dr. Way's studies of suicide and in many reports regarding suicides by the State Commission of Corrections.
OMH and DOCS have long been aware that isolated confinement causes psychiatric damage to prisoners, especiallyprisoners already known to suffer 'from serious mental i 1 l n e ~ s . lH~a~l Smith, Executive Director of CNYPC, wrote to Richard Miaglia on 10114199that "it has been demonstrated that high risk of suicide and serious
psychiatric decompensation are primary factors in managing S W populations" (Pl. Ex. 485). And a 9/25/2000 written communicationliom the NY State Commission of
Correction to DOCS and OMH officials states it "is a well established fact that inmates serving long term sentences in SHUs are likely to decompensate due to extended periods
of isolation and sensory deprivation." (P1 Ex. 95). And a NY State Commission on
Quality of Care in 2003 found that in SHUs, "decompensation, self-harm, suicide are all issues that need to be addres~ed."'~~
OMH and DOCS are well aware that prisoners spend an unacceptably long time in observation cells even though OMH believes prisoners should not spend more than three days there,126that conditions in these cells are very barren and induce a "loss of dignity,"127that observation cells as currently utilized do not constitute adequate mental health treatment for prisoners in crisis.'28
OMH and DOCS are well aware that prisoners suffering from serious mental illness should be transferred to appropriate treatment programs and not left in isolated ~onfinement.'~~
lZ4 In their depositions, Dr. Sawyer, Dr. Shimkunas, and Dr. DeVito all acknowledge that isolated confinementcauses distress and deteriorationin prisoners suffering from serious mental illness. Dr. Don Sawyer, when asked in his deposition"Do you agree that special housing unitsmay cause a patient to get anxious,helpless, hopeless and need a higher level of-care?," responded "Yes, that setting as well" Ipp. 476-477). And Miraglia, in his deposition, states that some prisoners with mental illnesscannot withstand the stress of disciplmaryhousing @. 31).
52/4/03 email, Sawyer to Smith and Way, OMHCNY 091628-091629).
Elaine Lord testified that prisoners spend as long as several months in observation, deposition, p. 152;
P1.Ex. 347; Sawyer depositionpp. 101-102.
Findings of the NY State Commission on Quality of Care for the Mentally Disabled, 2003, OMHCNY
087407.
12/4/03 email, Sawyer to Smith and Way.
'" Elaine Lord deposition, pp. 115-117; Loretta Klein deposition, pp. 184-185.

OMH and DOCS are well aware of the tendency on the part of O M staff to dismiss prisoners' emotional complaints because of excessive concern that they might be
manipulatingor malingering or might suffix only from an "Axis II"diagnosis.'30
A stipulation entered in the &litigation (ordered in 1998, then amended and
ordered in 2000) required that prisoners with severe mental disorders or severe depression were not to be housed in the Attica SKU if they were exhibiting symptoms requiring immediate treatment or evaluation in a mental health setting or were known to be at substantialrisk of serious psychiatric deterioration.I discovered, however, that prisoners that fit this criteria continued to be housed in the Attica SKU.
Thus, even though it is well known by high-ranking officials and clinicians in
OMH and DOCS that the number of prisoners with serious mental illness is growing
rapidly, that mental health services have not grown apace and do not serve the needs of these prisoners, that inadequatelytreated prisoners with serious mental illness are likely to behave in such a way as to get tickets and be sent to isolated confinement, that isolated confinement causes their psychiatric condition to deteriorate and/or kads to suicide in too many cases, that a vastly disproportionate number of the suicidesthat have occurred in DOCS involve prisoners assigned to isolated confinement, that prisoners with serious mental illness are prone to lengthy terms in isolated confinement, that many prisoners with serious mental illness repeatedly cycle from isolated confinement to observation or CNYPC and then back to isolated confinement as their psychiatric condition and
prognosis become worse. Given all of this, one wonders why O m and DOCS do not
correct the deficiencies in mental health care within DOCS and why they continue to actually utilize isolated confinement as a method for managing prisoners with serious mental illness.
IX. Recommendations
1. Mental Health Services in general. Comprehensive mental health services must be provided to all prisoners in need. Adequate mental health treatment requires the availabilityof a trained clinician to develop a trusting relationship with a patient in a setting that permits privacy, where confidentialityis respected so that very personal themes can be explored and worked through. Adequate mental health treatment requires a variety of treatment modalities, includingbut not limited to crisis intervention; psychotropic medications as needed; the availability of a certain number of group activities such as group therapy, psycho-educational groups, facilitated socializationor recreational activities, and psychiatric rehabilitation groups that involve psychoeducational programs, training in the skills of daily living and medication compliance; admission to an acute psychiatric hospital as needed; social work outreachto family members as needed; and after-care planning so that the disturbed individual is not
Dr. Angela Browne report of 81261-27/02 site visit at Bedford Hills,P1 Ex. 11 I; and Dr. Stuart
Grassian's 1999 report about the Attica SHU for the Ew litigationeng v. Gord, Civ. 80-3855,p. 2).

returned to the environment that caused a breakdown but rather is provided with the ongoing care and social supports needed to sustain his mental health. Not all of these modalities need to be available in any particular setting, and not all of them need to be utilized with any particular prisoner. But they need to be available and accessible.
There should be more programs and out-of-cell activities for prisoners with serious mental illness, wherever they are housed. And there should be more congregate activities, suficiently supervised to insure safety. In housing units such as ICP and STP, where the purpose is mental health treatment, all of the out-ofcell activities that comprise an effective acute psychiatric treatment program must be instituted, including milieu meetings, group and individual therapy in a private and confidential setting, psychiatric rehabilitation programs and so forth. Sufficient number of qualified staff must be made available to conduct this programming, as to render effective treatment.
Prisoners with SMI should not be ejected fkom treatment programs on disciplinary grounds.
There should be no double-celling for prisoners with SMI in any location.
2. Exclusion from Isolated Confinement of Prisoners with SMI. Policies and practices need to be changed to exclude prisoners with serious mental illness from isolated confinement of all types. No prisoners with a history of serious mental illness, no prisoner with serious mental illness who is currentlysymptomatic, and no prisoner currently being treated for a serious mental illness should be in isolated confinement (SHU, Keeplock, Administrative Segregation and Protective Custody when protection involves isolation131).
Implementation of this recommendationrequires thorough mental health assessment upon admissions to DOCS, prior to transfer to isolated confinement, and periodically thereafter once the prisoner amves in isolated confinement. An effective ongoing 90 day mental health evaluation should be conducted in a confidential setting, and should be of a duration that permits adequate assessment as well as exploration of possible toxic effects of isolated confinement.
The practice of time-cuts and suspension of SHU terms for mental health reasons must be expanded and made more meaningfU1.
'" In a correctional setting, protective custody is designed to provide safety for a vulnerable prisoner. It is
not apunitive designation. Therefore,prisoners in protective custody should have available all privileges and programs that are available to others in their classification There is no penological objective served by placing them in isolated confinement. They require protection, not isolation and idleness. Yet many
prisoners who are assigned protective custody status within DOCS spend $leu time in isolated confinement. Prisoners with SMT very often require protection. This is why I include this designation in my statements about isolated confinement and its effects on prisoners with SMI.

3. CNYPC. The number of beds availablefor DOCS patients at C W C needs to be increased significantly. Another option is to utilize other psychiatric hospitals
in the community for inpatient treatment of DOCS prisoners on a contractual basis - this
option would help solve the transportation problem when only one inpatient facility in the state serves all the prisons.
The criteria for admissionto CNYPC should be changed so that prisoners who do not meet criteria for civil commitment but require psychiatric hospitalization can be adinitted.
CNYPC Discharge recommendations, such as "transfer to ICP," must be carried out. A lack of bed-space at CNYPC and a lack of bed-space in the recommended 'program should not be a reason for sending the prisoner to a less intensive mental health treatment program than is clinically indicated. For example, if a prisoner is ready to be discharged kom CNYPC but the OMH clinicians recommend that prisoner be transfenred , to an ICP and there is no available bed in an ICP, the prisoner should not be transferred to a general population or SHU unit where the level of mental health care is below what is available in ICP. Rather, the patient should be retained at CNYPC until a bed in the appropriate treatment program opens up. Of course, other recommendations I make will result in more beds being available in ZCP and other treatment programs as well as more beds at CNYPC, so this problem will not be as acute.
4. Crisis Intervention. Regarding suicide prevention and treatment, detection
and prevention need to begin with prisoners' admission to DOCS. Thus, early warning
signs need to be heeded, and past psychiatry history of self-harm needs to be taken as a serious predictor of fiture crises. By beginningearly to think about which prisoners are likely to pose a risk of suicide in the future, DOCS AND OMK staff can work to alleviate some of the stresses that would make suicide more likely. For example, with a male prisoner who has attempted suicide in the past when he felt in danger in a prison, staff can make efforts to make certain he feels safe and therefore does not need to resort to selfdestructive behaviors.
The program in the Mental Health SatelliteUnits should be upgraded and made non-punitive. A significant amount of intensive, confidential, face-to-fitce contact with a mental health worker/psychotherapist must be offixed, the conditions of confinement in observation cells should be improved so that observation is not punitive, mental health staff should have much more input into decisions about searching entering prisoners and the amenities they will be permitted, prisoners who qualify on a security basis must be provided greater amenities and comforts while going through a suicidal crisis, and if a prisoner is in observation for longer than24 hours (or 48 hours over a weekend), then he or she must be transferred to CNYPC where more thorough assessment and more intensive mental health services can be provided. In general, prisoners in the ;crisis unit (observationand dormitories) should receive the quality of treatment and should have the rights and protections that are well-recognized in mental health treatment settings in the

community- e.g., seclusion and restraint must be utilized for the shatest time possible, all less restrictive interventionsmust have been tried prior to consignment of the patient to seclusion or restraint, there must be eequent monitoring by health and mental health
- staff (federal standards require hourly monitoring plus fkequent re-examinations b~
physician who re-writes orders for seclusion and restraint after seeing the patient).
The dormitories in the Satellite Mental Health Units should be utilized blly, thus alleviating some of the problem of bed shortage in mental health treatment programs. Either more of the prisoners who are treated in the Satellite Mental Health Units need to be designated suitable for dormitory dwelling, or the dormitories need to be split into private rooms where patients can be housed.
Suicide risk assessment must be upgraded and standardized. Screening suicide risk assessment should be administered in Reception to all prisoners, and should be administered again to those who are being transferred to isolated confinement and periodically thereafter. A more rigorous version should be administered upon report of suspected risk by security staff and upon admission to observation or CNYPC. The OMH Form 336 ADM (MH) 7/01, "Suggested Guide for Risk Assessment for Suicide in Jails," can be adapted to the prison setting and used as a model for tha:type of information that should be carefully gathered and recorded in the course of suicide risk assessment, but the form should be filled out by a qualified clinician who personally examines the prisoner.
Confinement in an observation cell should not include deprivation of recreation and out-of-cell activities. In fact, to the extent possible, out-ofsell programming and activities should be encouraged and supported.
Admissions to observation should be tracked and reviewed, both as a measure to identify prisoners at risk and as a quality assurance mechanism. Any prisoner who is admitted to observation or CNYPC on multiple occasions should be suspected of suffering from a more serious mental illness than was previously assumed, and should be examined more intensively. C W C is already studying admissionsto observation, and this kind of study is encouraged.
5. Intermediate Care Program (ICP) and Special Needs Unit (SNU). The number of beds in ICP should be greatly expanded, and by a much larger number of beds than is reflected in the CNYPC 2004-2005 plan (which states that 87 ICP beds will be added to the 565 that now exist). The programming should be enriched, as is indicated in the CNYPC plan for ICP.
The number of beds in the SNU program for prisoners with Developmental Disabilities and Mental Retardation needs to be greatly expanded. A rigorous study of the needs of prisoners with co-occuning serious mental illness and Developmental Disabilities/ Mental Retardation should inform this expansion, and the expansion of SMJ capacity should be adequate to provide safety and treatment to all those who need it.

Prisoners should not be discharged %omICP for disciplinary reasons; rather a system for managing behavior problems including mle-violation and assaultiveness should be establishedwithin the ICP.
6. Special Treatment P r o m (STPI and Behavioral Health Unit (BHU). STP inmates should not be housed in the SHU, the time period needs to be specified and needs to be relatively short, the STP program needs to have the explicit aim of moving prisoners with SMI out of isolated confinement, more out-of-cell activities are needed, therapeutic activities need to occupy much more of the day than the current two hours of programming that includes treatment and education, there needs to be a halt to keeping STP inmates housed in the SHU after completion of the STP, and confidentiality n d s to be enforced (i.e. no officers in group sessions). Use of 'Cages" in the group rooms within the STPs should be discontinued, and a more humane method for maintaining security should be established. Smaller groups would lessen the security threat of group treatment in the STPs, and there are other security measwes that can be adopted.
Proposals for BHUs need to be re-designed so that the program is therapeutic rather than punitive, so that there is no harsh entry p b e where prisoners with SMI are likely to get stuck and fail to advance to other phases of the program, so that the disciplinaryprocess stays within the BHU program and does not cycle prisonm to DOCS and isolated confinement, and so that there is more intensive mental health treatment available.
7. Re: Medium SecurityMental Health P r o m s . Mental health services at medium security facilities and other levels of security need to be upgraded so that prisoners in need of more intensive mental health treatment will not as readily be transferred to maximum security facilities where conditions are more harsh and repercussions of disciplinary tickets more severe.
8. Re: Substance Abuse Treatment. Since "Dual Diagnosis" orco-oc4:urxing substance abuse and mental illness, are very prevalent in the DOCS population, and since substance abuse is an Axis I diagnosis in itself,everyprisoner should have a history of substance abuse and substance abuse treatment in the clinical chart. All prisoners in need of substance abuse treatment should have access to comprehensive substance abuse treatment, regardless of housing assignment. This means that even prisoners in isolated confinement should have access to ongoing substance abuse treatment. Substance abuse treatment needs to be administeredby adequatelytrained and certified professional staff. Substance abuse treatment needs to be provided in isolated confinement settings. Cellstudymanuals are not an acceptable fulfillment of this requirement, since many of the prisoners are not literate enough to succeed at cell-study, and the conditions of isolation and idleness interferewith the capacityof many literate prisoners to concentrate and complete assignments. Leaderless 12-step programs such as Alcoholics Anonymous can be part of the comprehensive treatment program, but should not be a substitute for substanceabusetreatment administered by qualified profssional staff.

9. Rehabilitation and Education P r o m s . Vocational, Educational and other general rehabilitation programs need to be upgraded and maintained so that prisoners with SMI will have appropriate health-supporting activities and programs available to them as they engage in mental health treatment. Social interaction is a critical component of mental health treatment, and the availabilityof general rehabilitation and educationalprograms in a correctional setting is the best way to provide the types of constructive social interactions that individuals suffering from serious mental illness need.
10. Record Keeping. Clinical charts must be upgraded significantly. Treatment plans and rationales for all interventions should be clearly stated in the clinical chart. Past psychiatric history, including records from previous psychiatric treatment within DOCS, in jail, and in the community, should be indicated in the chart. Past records should be requested and entered in the chart. Medical history and significant medical intervention, including non-psychiatric medications being prescribed, should be reflected in the mental health chart. History of past traumas should be reflected in the chart. Psychiatric medications and dosages should be clearly listed in the Progress Notes, and all prescribing and changes of medications should be noted and a clear rationale for same be inserted in the chart. Clinicians who examine prisoners on an emergency or elective basis should have access to the clinical chart, including past history and treatment regimens, and should rely on same in doing their assessment. There should be more consistency in the clinical record, for example when a prisoner is discharged from a program such as CNYPC or observation, and recommendations are made as to follow-up treatment, there should be tracking to see if the recommended follow-up treatment has occurred. DOCS and OMH should collaborate on record-keeping, within the constraints of confidentiality. Confidential clinical information should not be available to DOCS staff, but when a prisoner is discharged from a treatment program and re-admitted to a housing unit, and when disciplinarysanctions are determined,both DOCS and OMH should be informed of the movement and the sanctions.
11. Mental Health Screening and the diagnostic~rocess.There needs to be thorough revision and upgrading of the process of diagnosis regarding mental illness, suicide risk, developmental disabilities and mental retardation, neurological conditions such as closed head injuries, and substance abuse. More thorough screening and assessment is needed at every stage of the prisoner's progression through the system. In Reception, all entering prisoners should be examined by qualified O m staff, including face-to-face interviews and mental statusexaminations (currently approximately40% of prisoners in Reception are seen by OMH face-to-face). All prisoners must be thoroughly assessed in Reception for mental illness, suicide potential, Developmental Disabilities, Mental Retardation, Neurological illness and substance abuse. Psychological assessments
should not rely on a few test instruments to rule out SMI; rather a comprehensive review of records, history, mental status and more complete testing should be performed and
taken into consideration in arriving at appropriate diagnoses and treatment plans. The Hare PsychopathyChecklist should not be relied upon to rule out Sh"LI,rather it can play a

part in diagnosing co-occurring personality disorder and in inf&g appropriate treatment options.'32 Periodic and strategic thorough mental health assessments should be carried out with all prisoners prior to transfer to isolated confinementand at 90 day intervals once prisoners are in isolated confinement. AppropriateNeuropsychological Assessment and Neurological examination should be readily available and utilized as clinically indicated. The fact that a prisoner is deemed to be "manipulative," "malingering," or to have "no Axis I diagnosis" at one point in time should not bias subsequent examinations and services - i.e. staff should be aware that individuals can be both manipulative and suffer from SMI, and individuals can exhibit signs of mental illness at one point in time and not at another. Adequate diagnosis requires that the entire clinical picture be considered, including patterns of exacerbationsand remissions.
12. Behavior Management Plans. Behavior Management Plans should not be ,viewedas an alternative to mental health treatment plans, rather they can help delineate a treatment strategy. In other words, if a particular personality disorder is known to reduce the gain from one kind of psychotherapeutic intervention, but another kind of intervention is known to work with this group of patients, then that distinctioncan be delineated in a 4 Behavior Management Plan. For example, for prisoners with Antisocial Personality Disorder that is co-occuning with SMI, a Behavior Management Plan can indicated that a particular form of psychodynamic intervention is not likely to be effective while Behavior Therapy, Cognitive-Behavior Therapy (CBT) or Dialectical Behavior Therapy (DBT) is indicated for this patient. This kind of plan to administer the most effective treatment modality in no way means that adequate treatment targeting the co-occurring SMI can be left out of the plan. And there should be no foreclosure of future contact with mental health providers, nor of admission to a more intensive mental health treatment unit.
13. Removal &om OMH Caseload. Prisoners who have been admitted to CNYPC or observation, and those known to suffer fi-omserious mental illness, should not be removed fiom the OMH caseload, even if they are non-compliant with treatment. If they are in remission and do not desire services, they should be monitored at regular intervals so that any emerging problems and disability can be detected and, within the context of a therapeutic relationship, they can be offered services that staff feel are indicated. Non-compliance with treatment should not be a reason for dischargingpatients with SMI from the OMH caseload. Rather, the non-complying patient must be offered appointmentsat regular intervals, re-assessed by a psychologist and psychiatrist, offered psycho-education about the illness and treatment, and if the prisoner is merely rehsing to take medications he or she should be offered appropriate non-medication fonns of treatment. The recent OMH Outpatient Plan of Improvement mandates that prisoners
- '32 AS discussed in SectionW.I.2, recent clinical research contradictsthe notion that individuals who score
high on the PsychopathyChecklist cannot benefit firompsychotherapyand other mental health treatments in fact, for some in this sub-population, psychotherapy is one of the best ways for staff to reach them, stabilize their co-occuning Axis I disorder, and foster positive change.

who have been on Mental Health Level 1not be removed from the Oh433caseload. This is a positive change, but prisoners who are known to be sugering from serious mental illness, prisoners who have required emergency admission to observation or CWYPC, and prisoners who have exhibited self-ham and suicidal behaviors should also not be removed from the OMH caseload while in DOCS.
14. Discipline. There should be no punishment for behaviors that are clearly driven by psychiatric illness, for example, actions taken by prisoners at the behest of cornrnand hallucinations, or self-destructiveacts (whether they be suicidal in intent or serve some other emotional purpose such as the relief of anxiety) on the part of depressed and suicidal prisoners.
While the settlement agreement in Anderson is being implemented, there needs to be monitoring to see how effectively mental health staff intervene and collaborate in the disciplinaryprocess. Collaborationbetween OMH staff, officers writing tickets, and hearing offtcers needs to be greatly improved.
15. Use of Force.. All incidents of use of force involvingprisoners with SMI should be reviewed by OMH staff as soon as possible. Where possible, OMH staff should be contacted prior to planned use of force and should intervene to see if they can help the prisoner change his or her behavior so that use of force will not be necessary.
16. Monitorin? of DisciplinaryProcedures as an Aide to Screening for SMI. When a prisoner who is not on the 0h4H caseload, or has not been determined to suffer &oma serious mental illness, spends an inordinately long time in isolated confinement, accumulating ever more tickets after being transferred into isolated confinement, this should be interpreted as a possible red flag indicating that psychiatric breakdown is occurring. Similarly, if a prisoner in a phase program (at Southportor Upstate or the proposed BHU), fails to pass through the lower phases of a program or returns to the lower phases after failing to pass a higher phase, then this should be interpreted as presumptive evidence of previously undetected or worsening SMI until proven otherwise, and a thorough mental health assessment should be initiated.
17. Medications. There should be adequate psychiatric examinations and medication monitoring, including appropriate laboratory tests. The psychiatrist must actually examine in a confidential setting the prisoners for whom he or she prescribes, and their meetings should provide an opportunity for substantial discussion about the prisoner's condition and the treatment, including possible side effects of medications and alternative treatments that are available. The psychiatrist must not prescribe via proxy. There should be appropriate notations in chart, including treatment plans explaining rationale for medication prescribing and changes in medication regimens. Appropriate laboratory work should be done, including follow-up interventionswhen blood tests such as Lithium or Depacote levels are abnormal or do not attain a therapeutic range. Patients who suffer from SMI and present extreme behavior problems should be given a trial of the anti-psychotic agent, Clozaril, as indicakd. Medication over Objection should take

place only in a mental health treatment setting. Rivers orders are currently permitted to "travel" to facilitieswith SatelliteMental Health Units; but in those facilities,prisoners requiring "traveling Rivers orders" must be confined in either the Dormitory unit or the ICP.
18. Confidentiality. Cell-fkont interviews should be understood for what they are: brief contacts that serve merely to check on the status of prisoners and arrange a private, confidential meeting. Cell-fiont meetings are no substitute for private, confidential meetings. All substantial talk about psychiatric symptoms, suicide ideation, medications and so forth should occur in a confidentialsetting. In spite of the attention to this issue in the SHU Plan of Improvement, there is a continuing problem of cell-fkont,
non-confidential meetings with O m staff and the meetings between OMH staff and
prisoners in isolated confinement that are occurring in private, confidential settings seem to be quite brief. There needs to be more attention to this problem. Security staff must not be privy to confidential mental health information, and must not be permitted to be in areas (such as the group room in STP) when confidential discussions are occurring.
19. Post-release Planning. Post-release planning needs to be upgraded and expanded. Prisoners must not be precluded fi-ompost-release planning on account of their housing assignment or disciplinary status. Prisoners who are, or have been on the
OMH caseload should be removed from isolated confinement at least six months prior to
being released fkom their prison term, and should participate in an intensive program designed to prepare them for return to the community.
20. Staff training. Much more training is needed for non-mental health staff about mental illness and suicide, and about relating to prisoners with mental illness. Mental health staff need more training about gender and cultural issues, personality disorders and treatment for individuals who have experienced trauma. Sensitivity regarding gender, race, culture and disabilities needs to be enhanced through rigorous training. Moreover, training about security for mental health staff needs to be upgraded. In other words, "cross-training" should be expanded, and topics such as cultural competence, stigma towards people suffering fi-omseriousmental illness, childhood trauma, gender relations and so forth should be included in the enhanced training for both mental health staff and security staff. All staff need to be trained in order to increase sensitivity toward prisoners with mental i l k s , to resist the temptation to dismiss the symptoms of patients who are difficult, who are perceived as manipulative, or who have a personality disorder - after all, many prisoners suffering fkom serious mental illness are difficultin one way or another.
2 1. Staff collaboration. More collaboration is needed between mental health and securitystaff, so that mental health staff does not simply accept security stairs decisions about discipline, housing, etc., but rather discusses and resolves these issues in collaborativefashion. In this collaborativeprocess, significant weight needs to be given to the prisoner's mental health needs so that the resolution is not simply punitive.

Resyectfully submitted,

Index to Appendices

Appendix A Appendix B
Appendix C Appendix D Appendix E
Appendix F
Appendix G

Curriculum Vitae
Litigation in which Dr. Kupm has been involved since 2001
Documents Reviewed
Additional Case SummariesMot Included in the Report
Chart Created by Plaintiffs Counsel Detailing Suicides in New York State Prisons Between 1995 and 2004
Charts Comparing the Data in the 2002 and 2004 SHU Studies Conducted by OMH
Glossary of Acronyms, Psychotropic medications, and OMHIDOCS Officials

APPENDIX A
CURRICULUM VITAE
Terry Allen Kupers, M.D., M.S.P.
Office Address: #8 Wildwood Avenue, Oakland, California94610 Phone Number: 510-654-8333
Currently: Professor, Graduate School of Psychology, The Wright Institute, 2728 Durant Avenue, Berkeley, California 94704 Private Practice of Psychiatry, Oakland Consultant: Progress Foundation, San Francisco
Family: Married to Arlene Shmaeff, Education Director at the Museum of Children's Art (M.O.C.H.A.) in Oalcland; father of three young adult sons
Born: October 14, 1943, Philadelphia, Pennsylvania
Education: B.A., With Distinction, Psychology Major, Stanford University, 1964 M.D.; U.C.L.A. School of Medicine, 1968 M.S.P. (Masters in Social Psychiatry), U.C.L.A., 1974
Training: Intern (Mixed Medicinel Pediatrics/ Surgery), Kmgs CountyHospitaVDownstateMedical
Center, Brooklyn, New York, 1968-1969. Resident in Psychiatry, U.C.L.A. Newpsychiatric Institute, Los Angeles, 1969-1972 Registrar in Psychiatry, Tavistock Institute, London (Elective Year of U.C.L.A. Residency)
1971-1972 Fellow in Social and Community Psychiatry, U.C.L.A. Meuropsychiatric Institute, 1972-1974
License: California, Physicians & Surgeons,#A23440,1968-Present
Certification: American Board of Psychiatry and Neurology (Psychiatry, #13387), 1974Present
Honors: Alpha Omega Alpha, U.C.L.A. School of Medicine, 1968 Distinguished Fellow, American Psychiatric Association; Fellow, American Orthopsychiatric
Association Listed: Who's WhoAmong Human Services Profssionals (199S-j; Who's Whoin California
(I 995-); Who's Who in The UnitedStates (1997-1; 'Who's Who in America (I 9989; International W?lo'sI;aoin Medicine (I995); Who's Who in Medicine and Healthcare (1997-); TheNational Registry of Who'sWho(2000-);Struthmore's

Millenial Edition, Who's Who;American Biographical Institute's ~nkrnationa/ Directory of Distinguished Leadership; Marquis' Who's Who in the World (2004-)
Helen Margulies Mehr Award, Divisionof Public Interest 0C, aliforniaPsychological
Association, Affiliate of American Psychological Association, March 30,2001 Stephen Donaldson Award, Stop Prisoner Rape, 2002 2005 Exemplary Psychiatrist Award, National Alliance for the Mentally Ii1
Clinical Practice: Los Angeles County, SouthEast Mental Health Center, Staff Psychiatrist, 1972-1974 Martin Luther JCmg, Jr. Hospital, Department of Psychiatry, Los Angeles
Staff Psychiatrist and Co-Director, Outpatient Department, 1974-1977 Contra Costa County, Richmond Community Mental Health Center, Staff Psychiatrist and Co-
Director, Partial Hospital, 1977-1981 Private Practice of Psychiatry, Los Angeles and Oakland, 1972 to present
Teaching: Assistant Professor, Department of Psychiatry and Human Behavior, Charles Drew
Postgraduate Medical School, Los Angeles, and Assistant Director, Psychiatry Residency Education, 1974-1977 Professor, Graduate School of Psychology, The Wright Institute, Berkeley, 1981to present Courses Taught at: U.C.L.A. Social Science Extension, California School of Professional Psychology (Los Angeles), Goddard Graduate School (Los Angeles), Antioch-West (Los Angeles), New College G~aduateSchoolof Psychology(San Francisco).
Professional Organizations: American Psychiatric Association (Distinguished Fellow); Northern Califomia Psychiatric
Society; East Bay Psychiatric Association (President, 1998-1999); American Orthopsychiatric Association (Fellow); American Association of Community Psychiatrists; Physicians for Social Responsibility; National Organization for Men Against Sexism; American Academy of Psychiatry and the Law; International Association of Forensic Psychotherapy
Committees and Offices:
Task Force on the Study of Violence, Southern California Psychiatric Society, 1974-1975 Task Force on Psychosurgery, American Orthopsychiatric Association, 1975-1976 California Department of Health Task Force to write "Health Standards for Local Detention
Facilities," 1976-77 Prison/ Forensic Committee, Northern California Psychiatric Society, 1976-1981;1994-
Present Psychiatry Credentials Committee, Alta Bates Medical Center, Berkeley, 1989-1994 (Chair,
Subcommitteeto CredentialLicensed Clinical Social Workers) President, East Bay Chapter of Northern CaliforniaPsychiatric Society, 1998-1999 Co-Chair, Committeeon Persons with Mental nlness Behind Bars of the American Association
of Community Psychiatrists, 1998-2003

Consultant/Staff Trainer: Contra Costa County Mental Health Services; Contra Costa County Merrithew Memorial
Hospital Nursing Service; Bay Area Community Services, Oakland; Progress Foundation, San Francisco; Operation Concern, San Francisco; Marin County Mental Health Services; Berkeley Psychotherapy Institute; Berkeley Mental Health Clinic; Oregon Department of Mental Health, Kaiser Permanente Departmentsof Psychiatry in Oakland, San Rafael, Martinez and Walnut Creek; Human Rights Watch, San Francisco Connectionscollaboration (Jail Psychiatric Services,Court Pre-Trial Diversion, CJCJ and Progress Foundation)
Forensic Psychiatry (partial list): Testimonyin Madrigal v. Ouillisran,U.S. District Court, Los Angeles, regarding informed
consent for surgical sterilization, 1977 Testimony in Rutherford v. Pitchess, Los Angeles Superior Court, regarding conditions and
mental health services in Los Angeles County Jail, 1977 Testimony in Hudler v. D&, San Diego County Superior Court, regarding conditions and
mental health services in San Diego County Jail, 1979 Testimony in Branson v. Winter, Santa Clara County Superior Court, regarding conditions and
mental health services in Santa Clara County Jail, 1981 Testimony in Younnblood v. Gates, Los Angeles Superior Court, regarding conditions and
mental health services in Los Angeles Police Department Jail, 1982 Testimonyin Miller v. Howenstein, Marin CountySuperior Court, regarding conditions and
mental health services in Marin County Jail, 1982 Testimony in Fischer v. Gearv, Santa Clara County Superior Court, regarding conditions and
mental health services in Santa Clara County Women's Detention Facility, 1982 Testimony in Wilson v. Deukmeiian, Marin County Sup Court, regarding conditions and
mental health services at San Quentin Prison, 1983 Testimonyin ToussaintNVricrht/Thompsonv. Enornoto, Federal District Court in San
Francisco, regarding conditions and double-celling in California State Prison security housing units, 1983 Consultant,United States Department of Justice, Civil R i g h Division, regarding conditions and mental health services in Michigan State Prisons, 1983-4 Testimony in Arreguin v. Gates, Federal District Court, Orange County, regarding "Rubber Rooms" in Orange County Jail, 1988 Testimony in Gates v. Deukmeiian, in Federal Court in Sacramento, rsgarding conditions,
quality of mental health services and segregationof inmates with HIV positivity or
AIDS at California Medical Facility at Vacaville, 1989 Testimony in Coleman v. Wilson, Federal Court in Sacramento, regarding the quality of mental
health services in the CaliforniaDepartment of Comtions' statewideprison system, 1993 Testimony in Cain v. Michinan Department of Corrections, Michigan Court of Claims, regarding the effects on prisoners of a proposed policy regardingpossessions, uniforms and classification, 1998 Testimony in Bazetta v. McGinnis, Federal Court in Detroit, regarding visiting policy and restriction of visits for substance abuse infractions, 2000 Testimony in Everson v. Michinan Daartment of Corrections, Federal Court in Detroit, regarding cross-gender staffing in prison housing units,2001

Testimony in Jones 'El v. Litscher, Federal Court in Madison, Wisconsin, regarding confinement of prisoners suffering fi-omsevere mental illness in supermax, 2002
Testimony in Russell v. Johnson, Federal Court in Oxford, Mississippi, regarding conditions of confinement and treatment prisoners with mental illness on Death Row at Parchman, 2003
Hospital Staff: Alta Bates Medical Center, Berkeley
Journal Editorial Positions: Free Associations, Editorial Advisory Board Men and Masculinities, Editorial Advisory Panel Ps~cholowof Men and Masculinitv, Consulting Editor Juvenile Correctional Mental Health Report, Editorial Board Correctional Mental Health Rmort, Contributing Editor
Presentations and Lectures (partial list): "Expert Testimony on Jail and Prison Conditions." American Orthopsychiatric Association
Annual Meeting, San Francisco, March 30, 1988, Panel 137: "How Expert are the Clinical Experts?" "The Termination of Psychotherapy" Psychiatry Department Grand Rounds, MilldPeninsula Hospitals, Burlingame, February 24, 1989 "Big Ideas, and Little Ones" American Psychiatric Association Annual Meeting, San Francisco, April, 1989. "Men in Psychotherapy." Psychiatry Department Grand Rounds, MilWenimula Hospitals, Burlingame, September 29, 1989. "PsychodynamicPrinciples and Residency Training in Psychiatry." The Hilton Head Conference, Hilton Head Island, South Carolina, March 15,1991. Panelist: "The Mentally I11 in Jails and Prisons," California Bar Association Annual Meeting, Annaheim, 1991. "The State of the Sexes: One Man's Viewpoint." The CommonwealthClub of Califomia, San Mateo, March 25, 1992. Keynote Address: "Feminism and the Family." 17th National Conference on Men and Masculinity, Chicago, July 10,1992. Panel Chair and Contributor: "Burnout in Public Mental Health Workers." Annual Meeting of the American Orthopsychiatric Association, 5an Francisco, May 22,1993. Panel Chair and Contributor: "Socioeconomic Class and Mental Illness." Annual Meeting of the American Psychiatric Association, San Francisco, May 26,1993. "PublicMental Health." National Council of Community Mental Health CentersTraining Conference, San Francisco, June 12, 1993. Psychiatry Department Grand Rounds: "Men's Issues in Psychotherapy." Califomia Pacific Medical Center, San Francisco, February 24,1993. "The Effect of the Therapist's Gender on Male Clients in Couples and Family Therapy." Lecture at Center for Psychological Studies, Albany, California, April 15, 1994. "Pathological Arrhythmicity and Other Male Foibles." Psychiatry Department Grand Rounds, Alta Bates Medical Center, June 7, 1993. Roger Owens Memorial Lecture. "Prisons and Mental Illness." Department of Psychiatry, Alta Baks Medical Center, March 6, 1995.

Keynote Address: "Understanding Our Audience: How People Identify with Movements and Organizations." Annual Conference of the Western Labor Communications Association, San Francisco, April 24,1998.
"Men in Groups and Other Intimacies." 44th Annual Group Therapy Symposium, University of California at SanFrancisco, November 6,1998.
"Men in Prison." Keynote, 24th Annual Conference on Men and Masculinity, Pasadena, July 10,1999.
"Trauma and Posttraumatic Stress Disorder in Prisoners" and "Prospects for Mental Health Treatment in Punitive Segregation." Staff Training Sessions at New York State Department of Mental Health, Corrections Division, at Albany, August 23,1999, and at Central New York Psychiatric Institution at Utica, August 24,1999.
"The Mental Health Crisis Behind Bars." Keynote, Missouri Association for Social Welfare Annual Conference, Columbia, Missouri, September 24,1999.
"The Mental Health Crisis Behind Bars." Keynote, Annual Conference of the Association of Community Living Agencies in Mental Health of New York State, Bolton Landing, NY, November 4,1999.
"Racial and Cultural Differences in Perception Regarding the Criminal Justic Population." Statewide Cultural Competence and Mental Health Summit VII, Oakland, CA, December 1, 1999.
"The Criminalization of the Mentally Ill," 19th Annual Edward V. Sparer Symposium, University of Pennsylvania Law School, Philadelphia, April 7,2000.
"Mentally Ill Prisoners." Keynote, California Criminal Justice Consortium Annual
Symposium, San Francisco, June 3,2000.
"Prison MadnessErison Masculinities," address at the Michigan Prisoner Art Exhibit, Ann Arbor, February 16,2001.
'The Mental Health Crisis Behind Bars," Keynote Address, Forensic Mental Health Association of California, Asilornar, March 21,2001.
"Madness & The Forensic Hospital," grand rounds, Napa State Hospital, November 30,2001..
Commencement Address, The Wright Institute Graduate School of Psychology, June 2, 2002. "Mental Illness & Prisons: A Toxic Combination," Keynote Address, Wisconsin Promising Practices Conference, Milwaukee, January 16,2002. "The Buck Stops Here: Why & How to Provide Adequate Services to Clients Active in the Criminal Justice System," Annual Conferenceof the California Association of Social Rehabilitation Agencies, Walnut Creek, California, May 2,2002. "Prison as Trauma: For the Prisoner, the Family and the Whole Community," Keynote Address, annual meeting of the International Association of Forensic Psychotherapy, Dublin, Ireland, May 20,2005.
Books Published: Public Theraux The Practice of Pwchotheravvin the Public Mental Health Clinic. New York:
FreePress/ MacMillan, 1981.
Ending Therav~The Meaning of Termination. New York: New York University Press, 1988. (Editor): Usinn Psvchodvnamic Principles in Public Mental Health. New Directions for
Mental Health Services, vol. 46. San Francisco: Jossey-Bass, 1990. La Conclusione della Terauia: Problemi, metodi, consernenze. Rome: Casa E d i k
Astrolabio, 1992. (trans. of Endine, Therapy.)

Revisioning Men's Lives: Gender, Intimacy and Power. New York: Guilford Publications, 1993. (trans. into Chinese, 2000).
Prison Madness: The Mental Health Crisis Behind Bars and What We Must Do About It. San Francisco: Jossey-BassJWiley, 1999.
(Co-Editor): Prison Masculinities. Philadelphia: Temple University Press, 2001.
Other Publications: "The Depression of TuberculinDelayed Hypersensitivityby Live Attenuated Mumps Virus,"
Journal of Pediatrics, 1970,76,716-721. Editor and Contributor, An Ecolonical Approach to Resident Education in Psychiatry, the
product of an NIMH Grant to the Department of Psychiatry and Human Behavior, Drew Medical School, 1973.
"Contact Between the Bars - A Rationale for Consultation in Prisons," Urban Wealth, Vol. 5,
No. 1, February, 1976. "Schizophrenia and History," Free Associations, No. 5, 1986,79-89.
"The Dual Potential of Brief Psychotherapy," FreeNo. 6,1986, pp. 80-99.
"Big Ideas, and Little Ones," Guest Editorial in Communitv Mental Health Journal, 1990, 26:3,217-220.
"Feminist Men," Tikkun. July/August, 1990. "Pathological Arrhythmicityin Men," Tikkun, MarcWApril, 1991. "The Public Therapist's Buraout and Its Effect on the Chronic Mental Patient." The Psvchiatric
Times, 9,2, Febxuary, 1992. "The State of the Sexes: One Man's Viewpoint," The Commonwealth, 86,16, April, 1992. "SchoolyardFights." In Franiclin Abbott, Ed., Bovhood. Freedom, California: Crossing Pms,
1993; Univeristy of Wisconsin Press, 1998. "Menfriends." Tikkun, MarcWApril, 1993 "Psychotherapy,Neutrality and the Role of Activism." CommunitvMental Health
Journa1,1993. "Review: Treating the Poor by Mathew Dwnont." Community Mental Health Journal,
30(3),1994,309-310. "The Gender of the Therapist and the Male Client's Capacity to Fill Emotional Space." Voices,
30(3), 1994,57-62. "Soft Males and Mama's Boys: A Critique of Bly." In Michael Kimmel, Ed., The Politics of
Manhood: Profeminist Men Remond to the Mythopoetic Men's Movement (And Mvthopoetic Leaders Respond). Philadelphia: Temple University Press, 1995. "GenderBias, Countertransference and Couples Therapy." Journal of Cou~leTs herapy, 1995. "Jail and Prison Rape." TIE-Lines, February, 1995. "The Politics of Psychiatry: Gender and Sexual Preference in DSM-IV." masculinities, 3,2, 1995, reprinted in Mary Roth Walsh, ed,, Women, Men and Gender, Yale University Press, 1997. "What Do Men Want?, review of M. b e l ' s Manhood in America Readings, 10,4,1995. Guest Editor, issue on Men's Issues in Treatment, Psychiatric Annals,2,1, 1996. "Men at Work and Out of Work," Psvchiatric Annals, 2,1,1996. "Trauma and its Sequelae in Male Prisoners." American Journal of Orthops~chiatw6, 6,2, 1996, 189-196.

"Consultation to Residential Psychosocial Rehabilitation Agencies," Community Psychiatric

Practice Section, Community Mental Health Journal, 3, July, 1996.

"Shame and Punishment: Review of James Gilligan's Violence: Our Deadlv Epidemic and its

Causes," ReadingsLSept., 1996.

"Community Mental Health: A Window of Opportunity for Interracial Therapy," Fort/Da,

2,2,1996.

"Men, Prison, and the American Dream," Tikkun, Jan-Feb., 1997.

"Dependency and Counter-Dependencyin Couples," Journal of Couvles T h e m , 7,1,1997,
39-47. Published simultaneouslyin When One Partner is will in^ and the Other is Not,

ed.Barbara Jo Brothers, The Haworth Press, 1997,pp. 39-47.

"Shall We Overcome: Review of Jewelle Taylor Gibbs' Race and Justice." Readings,

December, 1997.

"The SHU Syndrome and Community Mental Health," The Cornrnunitv Psychiatrist, Summer,

1998.

"Review of Jerome Miller's Search and Destroy," Men and Masculinities, 1, 1,July, 1998.

"Will Building More Prisons Take a Bite Out of Crime?," Insidt, Vol. 15,No. 21, June

7, 1999.

"The Mental Health Crisis Behind Bars," Harvard Mental Health Letter, July, 2000.

"Mental Health Police?," Readin~sJ,une, 2000.

"The Men's Movement in the U.S.A.," in Nouvelles Avuroches des Hommes et du

Masculine, ed. Daniel Weizer-Lang, Les Presses Universitaires du Mirail,

Toulouse, France, 2000.

"Symptoms, Meanings and Social Progress," Voices, 36,4,2000.

"Psychotherapywith Men in Prison," in A New Handbook of Counseling & Psvchothera~v

Approaches for Men, eds. Gary Brooks and Glenn Good, Jossey-Bass, 2001.

"A Very Wise Decision by the Montana Supreme Court," Correctional Mental Health Rmort,

5,3,35-36, SeptIOct, 2003.

"?Reviewof William Roller's The Dead are Dancing," Psychiatric Services, 54,11,1660-1661,

2003.

"Foreword," David Jones (ed.): Workina with Dangerous People: The Psychotherapy of Violence,

Oxon, UK: Radcliffe Medical Press Ltd., 2004.

"Malingering in Correctional Settings," Correctional Mental Health Report, 5,6,81-, Marc

,

2004.

"Mental Illness," in Men & Masculinities: A Social, Cultural, and Historical Encvclopedia, Eds.

Michael Kimmel and Amy Aronson, Santa Barbara: ABC Clio, 2004, pp. 537-539.

"Prisons," in Men & Masculinities: A Social, Cultural, and Historical Encyclopedia, Eds. Michael

Kimrnel and Amy Aronson, Santa Barbara: ABC Clio, 2004, pp. 630-633.

"Posttraumatic StressDisorder (PTSD) in Prisoners," in Manacjn~Special Populationsin Jails

and Prisons, ed. Stan Stojkovic, Civic Research Institute, Kingston, NJ, forthcoming

2005.

"Schizophrenia, its Treatment and Prison Adjustment," in man an in^ Special Populationsin Jails and

Prisons, ed. Stan Stojkovic, Civic Research Institute, Kingston, NJ, forthcoming 2005.

"Toxic Masculinity as a Barrier to Mental Health Treatment in Prison," Journal of Clinical

Psycholom, 2005.

APPENDIX B
DEPOSITIONS AND TESTIMONY IN THE PAST FOUR YEARS
Deposition in Snow v. Ukiah, U.S.Dist. Ct., No. Dist. Of Califomia, Case No. C99-3669 TEH, February 2,2001, regarding quality of mental health services in local detention facility
Testimonyin Everson et al.. v. Michi~anDe~artmenot f Corrections, U.S. Dist. Ct., Eastern Dist. Of Michigan, So. Division, No. 0073133, February 16,2001, regarding gender and employment in women's prisons {and deposition)
Testimony in Jones 'El v. Litscher, U.S. Dist. Ct., Western Dist. Of Wisconsin, No. OO-C421-C, September 20,2001, preliminary injunctionregarding confinement of prisoners suffering from severe mental illness in supermaximum prison at Boscobel
Testimony in Robert Charles Comer v. Terry Stewart,U.S. Dist. Ct. for the District of Arizona, No. CV-94-1469-PHX-ROS, post-conviction capital case (and deposition)
Deposition in Westchestw Co. Correction OfficersBenevolent Assoc,, et al. v. C o u .of Westchester. et al., U.S. Dist. Court, New Yo& No. 99 CV 11685 (SHS), May 14,2002, regarding gender and employment in women's local detention facility
Deposition in Groot et al. v. Hudson et al., U.S. Dist. Court, No. Dist. of Mississippi, Eastern Div., No. 1:101CV366-JAD, October 2,2002, regarding possible retaliation and resulting psychological harm in Mississippi Department of Corrections
Testimony in State of Indiana v. Shaka Shalcur, Cause No. 4504-0201-FA-00002, January 29,2003, Crown Point, felony case
Testimony in Russell v. Johnson, Federal Court in Oxford, Mississippi, regarding conditions of confinement and treatment prisoners with mental illness on Death Row at Parchman, February 6,2003
Testimony in Gtoot et al. v. Hudson et al., U.S. Dist. Court, No. Dist. of Mississippi, Eastern Div., No. 1:101CV366-JAD, March 14,2003, re: damages in individual case.
Deposition in Fallcenbure;v. Yolo County3Case No. CIV.S-01-1478 DFL GGH, July 30,2003, regarding jail suicide.
Deposition in Castillo v. Alameida, et al., Case No. C94-2847 MJJ, U.S. Dist. Ct., No. Dist. Cal Oct. 17,2003, regarding gang validation in Calif. Dept. of Corr.
Deposition in Rasho et al vs. IL DOC et al., Case No. 00-528-DRH, U.S. Dist. Ct., So. Dist. Of East St. Louis Div., regarding conditions of confinement and mental health treatment at Tamms Unit.
Testimony in State v. Saucedo, Case No. CC057550, Santa Clara Co. Sup. Ct., California, Oct. 2004, regarding mental state at time of crime
Testimony in Manning v. Dye, Case No. 02 C 0372, U.S. Dist Ct, No Dist IL,, December 10,20
regarding psychiatric sequelae of term on Death Row for individual who was not guilty Testimony in State v. Adam Lowe, Ventura County Superior Court, California, January 28,20C
mental state at time of offense

Deposition in Keith Johnson v. Richard Wathen, et al., No. 7:02CV087-M, US Dist. Ct., No. Dist. Of Texas, Oakland, CA, April 21,2005, regarding effects of sexual abuse in prison

Documents Reviewed by Dr. Terry Kupers

MHPR 202652-0205417; MHPR 0247971-0248599
R 0043687 - 0044353;

9 Bates Ran e
OMHPR 0110937-0110998
I
OMHPR 00076431-0077199
PL 028646 - PL 028897; OMHPR 0006875 - 0007387;
OMHPR 0232343-0234482; OMHPR 0712252-0713137; OMHPR 0729453-0729631 OMHPR 0565 126-0566981; OMHPR 0570244-0571585
, OMHPR 0034921- 0035021;
MHE'R 0577652-0577873 OMHPR 0293648-0293841
h OMHPR 0038402 - 0038584;
OMHPR 0387912-0388061
P OMHPR 0076416-0076430

Bates Range

I

Description

I

MHPR 0281506-0282813; MHPR 0698877-0699236; MHPR 0730830-073 1007
MHPR 0249770-0250290
MHPR 0051425 - 0051698
MHPR 0062440-0062834

MHPR 02872304287543;

Bates Range

. -

OIMHPR 0385720-0386499

OMHPR 0436973-0437959

OMHCNY 049675-04981 1 ;

OMHPR 0523305-0523402;

OMHPR 0523683-0524354;

OMHF'R 0524638-0525666;

OMHPR 0525836-0526427

I MHPR 0572258-0572306,
MHF'R 0578592-0578952

MHPR 0550181-0550463; MHPR 0600184-0600535

Description

MHPR 0259837-0260067

MHF'R 0563657-0564070, MHPR0051818-0051849

OMHPR 0256159-0257769 MHPR 0294549-0294851

MHPR 0295951-0296449 MHPR 0296651-0297039 MHPR 0297238-0297440

MHPR 0515487-0516573; MHPR 0517288-0517802
MHPR 0380874-0381532
MHPR 05366.80-0536893, OMHPR 0552577-0552830
, OMHPR 0047052 - 0047121
MHPR 0585063-0585356;
R 0537390-0537619; R 0537887-0537926;

Description

OMHPR 0535817-0536629;
OMHPR 0543959-0545441
OMHPR 0046995 - 004705 1

MHPR 025770-0257889

OMHPR 0261380-0261454

OMHPR 0645056-0645114

----

0

.- .

MHPR 0013701 - 0013705; MHPR 0013597 - 0013795
MKPR 0029615- 0030634
MHPR 0030948- 0031231

Bates Range

--.

OMPHR 0212865-0214483
P L 008163 - PL 008316;
OMHPR 0015643 - 0016442

OMHPR 0443980-0445308
OMHPR 0032707 - 0033043;
OMHPR 0517803-0519023

OMHPR 0397593-0397668

OMHPR 0547159-0547245,
OMHPR 0585905-0586160
L

no=-riotio--n.

0321316-0323820;
MHPR 0599887-0600183
1 MHPR 0288182-0288383;
MHPR 0594754-0594933 MHPR 0550719-0551531, MHPR 055 1732-0552576, MHPR 0074970-0076054
1
MHPR 0643181-0645008
MHPR 0220508-0220801 MHPR 0221058-0222585

Bates Range
OMHPR 0397094-0397342
O M I P R 0042305 - 0042746 + OMHPR 0042747 - 0043170

-Des- -cription

0261455-0261701;

Bates Range SCOCOO0534-000536

---.

Description

1

- - 3.-

OMHCNY 0059233 -

I

OMHCNY 0059310; SCOC

000571

t

SCOC.OOO655LOOO656, *

1

000723-000726

SCOC 000732-00736

1

SCOC 000758,000777000779

SCOC 00809-000813

1

SCOC 00840-000844

PL 000226 - PL 000240

SCOC 000873-000875 OMH PR 0009936 -

SCOC 001058-001062

U

DMHCNY 0059371 -

j

MHCNY 0059411

1

001086

OMHCNY 0060811-

E

OMHCNY 0060902; SCOC

001761-001765

M H C N Y 060261-060264 C O C 001120-001128
MHCNY 0061252;SCOC
SCOC 001161,001168001 169
PL 000358-PL 000371
SCOC 001659-001663 ?L 000382-PL 000392; SCOC 001198-001199,
SCOC 001360-001362, 00 1404-001409
OMHCNY 0059793 -
OMHCNYOO59886 SCOC 001531-001535, 001766-001774

Bates Range SCOC 001415-001417

Description .Zamora, Jirmnie 98-A-5691
DepositiohTraiiscrtjitji - '
Adams,'~&reen,1128104 Bany, David, 8/17/04 'Bea, Jeffrey 6116/04 Carroll, Takarla 2/17/05 Culkin, John 6/9/04 Devito, Anthony 6115/04 %rdon, Charles 1/20/04 Greene, Gary 2/4/04 Herrmann, Charles 6/30/04 Kellam, Leslie 8/20/04 Key, Nancy 3117/04 Keyser, Sharon 8119/04 Klein, Loretta 3/12/04 Lamy, Frederick 2/25/04 Langbart, Mitchell 10/22/04 Lape, William 3/3/04 Leclaire, Lucien 5/26/04 'Lord, Elaine 2/27/04 Miraglia, Richard 1/11/05 Pace, Adele 8110104

 </s> CSCOF 0008443-0009075
--d.

Bates Range

.. .

-. D-es.criptio*.n- - ---.

----- .

I
I
I
I
t

I
23

. J -*>

Bates Range OMHCNY 0008049
OMHCNY 0008050 -
OMHCNY 0008134
3MHCNY 0008135 -
OMHCNY 0008210
OMHCNY 0008211-
OMHCNY 0008278 OMHCNY 0008279
OMHCNY 0008280 OMHCNY 0008284 OMHCNY 0008285 OMHCNY 0008292
OMHCNY 0008293 -
OMHCNY 0008295 OMHCNY 0008296 OMHCNY 0008298 OMHCNY 0008299 OMHCNY 0008341 OMHCNY 0008342 -

Description Education & Training Department EMSS Medical Services Department of Nursing Dietary Patient Care Services Department of Nursing SatelliteUnit Department of Nursing Nutrition Services Department Department of Nursing/Satellite Unit Department of Nursing/Satellite Unitloutpatient

bMHCNY 0008450 -
OMHCNY 0008455
OMHCNY 0008456 -
OMHCNY 0008477
OMHCNY 0008478 -
OMHCNY 0008672
OMHCNY 0008673 -
OMHCNY 0008686
OMHCNY 0008687 -
OMHCNY 0008838
OMHCNY 0008839 -
OMHCNY 0008909
OMHCNY 0008910 -

'Infection Control 'Department of Nursing Health Information Management Department Uniform Case Record .UniformCase Record Total Quality Management Outpatient Medical Record Manual

Bates Range
OMHCNY 0009043 OMHCNY 0009044 -
OMHCNY 0009101
OMHCNY 0009102 OMHCNY 0009132
OMHCNY 0009133 -
OMHCNY 0009304 OMHCNY 0009305 OMHCNY 0009472 OMHCNY 0009473 OMHCNY 0009711 OMHCNY 0009712OMHCNY 0009869
OMHCNY 0009870 -
OMHCNY 0010033
OMHCNY 0010034 -
OMHCNY 0010122 OMHCNY 0010123 OMHCNY 0010144
OMHCNY 0010145 -

Description Housekeeping Infection Control Housekeeping Human & Fiscal Resources Infection Control Information Center Maintenance Department Introduction Clinical Privileges Department of Nursing

OU Between OMH & Division of Parole

MHCNY 0011826-
MHCNY 0011857 MHCNY 0011858MHCNY 0011899 MHCNY 0011900-

Performance Improvement Plan Pharmacy Formulary

Bates Range
OMHCNY 0012004
OMHCNY 0012005 OMHCNY 0012276
3MHCNY 0012277 OMHCNY 0012326
OMHCNY 0012327 -
3MHCNY 0012353
OMHCNY 0012354 -
OMHCNY 0012450 OMHCNY 0012451 OMHCNY 0012544
OMHCNY 0012545 OMHCNY 0012553 OMHCNY 0012554 OMHCNY 0012601 OMHCNY 0012602 OMRCNY 00 12725
OMHCNY 0012726 -
3MHCNY 0013179
OMHCNY 0013180 -

Description Psychiatric Rehabilitation and Activities Psychology Department Incident Reporting
Risk Management Emergency Management Life Safety Management Fire Prevention Hazardous Materials and Waste Safe Environment 'SecureEnvironment

OMHCNY 0013591 -
OMHCNY 0013604
OMHCNY 0013605 -
OMHCNY 001 3639
ONHCNY 0013640 -

Bedford Hills Clinton Satellite Unit plmira Satellite Unit

Bates Range

Description

OMHCNY 0013685

OMHCNY 0013686 -

Five Points Satellite Unit

OMHCNY 0013743

OMHCNY 0013744-

Midstate Mental Health Unit

OMHCNY 0013777

OMHCNY 0013778 -

Sing Sing Office of Mental Health

OMHCNY 0013823

OMfECNY 0013824 -

Sullivan Correctional Facility

OMHCNY0013851

OMHCNY 0013852 -

Wende Mental Health Satellite

OMHCNY 0013883

OMHCLI 0000273-0000278 Violence Risk Assessment and Prevention

No Bates

CNYPC Outpatient Medical Records Policy &

Procedures Manual

No Bates

CNYPC Outpatient Operations Policy and Procedure

Manual: Transfer Admission Policies

No Bates

CNYPC Outpatient Operations Policy and Procedure

Manual: Referral, Admission, Transfer & Discharge

Policies

No Bates

CNYPC Outpatient Operations Policy and Procedure

Studies, Reports atid-Rrt,ic.les

OMHCNY 108015-108025

.

.

s

,

j

%S

- Draft - DOCS/OMH Mental Health Senrice
Development 1977 200512006 Prepared by N Y S

Department of CorrectionalServices and the NYS

Office of Mental Health

PL 034826-034830

- Steadman, Henry et al: "A Survey of Mental Disability Among State Prison Inmates," Hospital 'and Community Psychiatry, October 1987.

Plaintiffs Exhibit 3 PL 000570-000622

January 31,1997 NYS OMH Task Force on the Future of Forensic Services Report of the Subcommittee on Prison Mental Health Services

OMHCNY 006474000648 18

Risk Management reports on Elmira suicides

PL 000657-000741

2/00 CorrectionalAssociation ofNew York report: Health Care in New York State Prisons

Plaintiffs Exhibit 231

11100 Cornmissioner's Policy Paper on Prison

OMHCNY 020470-020482 OMHCNY 041968-041981

llite Units operated by CNYPC

Bates Range
Plaintiffs Exhibit 77 OMHCNY 043223-043261

Description
I and Traumatized Women in Prison: Avenues of
Systematic CollaborationBetween Mental Health and Correctional Personnel"
9/26/02 draft of report: Mental Health Crisis
ObservationCell and Dormitory Bed Usage in the
MH Satellite Units Operated by CNYPC (Findings
July 2001 - June 2002)

I OMHFPO 0000021

1 9130102 AtticaIFive Points STP Evaluation

I

I OMHCNY 043175-043222 1012/02draft of PreliminaryReport: Attica STP for Mentally I11 Inmates in SHU

OMHCNY 043141-043174

10111/02Preliminary Report: Five Points STP for Mentally I11 Inmates in SHU (Patients entering the STP Program between December 2001 through June 2002

OMHCNY 038344-038383 10131102CNYPC Inpatient Statistical Report: Third Quarter 2002

OMHCNY 038315-038327 1112002CNYPC Inpatient Perception of Care Survey: March 2001, October 2001, April 2002, October 2002

Plaintiffs Exhibit 70

11113102report: "Suicide Risk Factors in New

OMHCNY 043117-043140 York State Prisons"

I Plaintiffs Exhibit 67

11121/02Report: CNYPC "Analysis of Mental

OMHCNY 028600-028611 Health Service Level Designations"

I

--

No Bates

Skeem, Monahan, Mulvey article: "Psychopathy,

Treatment Involvement and Subsequent Violence

Among Civil Psychiatric Patients," December

2002.

OMHCNY 00588070058814

12120/02CNYPC Inpatient Ward Reconfiguration Review

OMHCNY 108180-108196 Report on Outpatient Mental Health Services Provided by CNYPC in NYS Prisons in 2003

OMHCNY 082070-082104 CorrectionsBased Serviceshpatient Operations Annual Report for 2003

Bates Range

Description

OMHCNY 086773-086795 Report on Outpatient Mental Health Services Provided by CNYPC in NYS Prisons in 2003

No Bates

2003 Human Rights Watch Report: Ill-Equipped: U.S. Prisons and Offenders with Mental Illness

OMHCNY 108030-108067

Selected Management Indicators fiom Three Subgroups of OMH Units and Two Individual OMH Units which Provide Mental Health Services to SHU Znmates in NYS Correctional Facilities: January 2003 through January 2005

OMHCNY 028932-028937 1117/03 CNYPC Patient Demographic and Diagnostic Profile: Inpatient & Outpatient (2003)

Plaintiffs Exhibit 79

4/10/03 draft of report: "Transfers to Civil

OMHCNY 043100-043116 Psychiatric Inpatient Servicesfiom a Maximum

Security Forensic Hospital"

Plaintiff's Exhibit 11

4117103 study: CNYPC Review of Intermediate

OMHCNY 043072-043099 Care Program (ICP): (Participants in Program on

9/1/02)

Plaintiffs Exhibit 43

Memo from Leslie Kellam (Program Research

DCSCOF 0006726-0006734 Specialistm)to John Cullcen @ir MH Services),

Doris Ramirez-Romero (Assistant Director MHS)

and Tom Goetz (Senior Attorney) re: SH17

Placement and O M 'Levels dated June 24,2003

Plaintiffs Exhibit 5 Oh4HCNY 042991-043034

7121/03 study: SpecializedTreatment Program (STP) for Mentally I11 Inmates in SHU at Five Points: Interim Evaluation Report (Patients entering the STP Program between December 2001 and May 2003

Plaintiffs Exhibit 75

7/23/03 draft of Interim Report: STP for Mentally

OMHCNY 042943-042990 I11 Inmates in SHU at Attica

Plaintips Exhibit 107 No Bates

10103 Report by the Correctional Association of New York, "'Lockdown: Disciplinary Confinement in New York State Prisons"

OMHCNY 108161-108179

Computed Selected Management Indicators for OMH Level 1 Mental Health Units in NYS
Correctional Facilities: znd3,"' and 4&Quarters of
2004

Bates Range
Plaintiffs Exhibit 359 PL 062682-062769

Description
Correctional Association 2004 Report: "Mental Health In the House of Corrections"

Plaintiffs Exhibit 411 OMHCNY 00803370080380

SHUs in OMH Level 1 CorrectionalFacilities: Mental Health Needs Study, B. Way, July 16,2004

OMHCNY 108005-108014 Review of Intermediate Care Program (ICP)

Participants in Program on 3/1/05 Preliminary

- , . " . i -I ,

Report of Selected Variables Documents Related to O'MH-programs

OMHCNY 026722-034218 Great Meadow and Mental Health Services in SHU

DCSCOF 0006057-0006061 Special Treatment Program - Five Points C.F.

OMHFF'O 00000140000016

Orientation to Five Points STP

Plaintiffs Exhibit 133 OMHFF'O 00000220000027

STP Screening Fonn

OMHCNY 0075661-
0075667; 0079595; 0077225-0077227; 0077220-0077223; 0077210-0077216; 0069873-0069876

Draft: Proposal for Behavior Management at ElIRira CF
BMP List and RCTP Discussion

OMHCNY 075780-075805 John Wilson Assessments

OMHCNY 108068-108094 CNYPC System Overview

OMHCNY 108146

SHU and SHE200 NYS Prisons

OMHCNY 108453

Current Bed Capacities & Planned Expansion

No Bates

CNYPC Outpatient Program Guide (1995)

PL 055167-055209

5/22/98 SHU Manual; "The Marcy Plan" Marcy C.F.

PL 000557-000569

6112/00 Mental Health Services Plan for S3XJ at Attica

Bates Range

Description
6/12/00Plaintiff's Declaration re: Mental Health ServicesPlan for SHU at Attica

Plaintiffs Exhibit 49

6/12/00Mental Health ServicesPlan for Special

DCSCOF 0006044-0006056 Housing Unit Patients at Attica Correctional

Facility

Plaintiffs Exhibit 310 O M H A T T 00010540001084

Specialized Treatment Program
Attica C.F. - 12/20/00- 4/6/01

1117/01Double Occupancy Housing Units

O M H C N Y 043347-043376 2/3/01draft: Mental Health ServicesPlan for Special Housing Unit Patients at Attica Correctional Facility

O M H A T T 00010850001118

Specialized Treatment Program
Attica C.F. - 4/23/01- 7113/01

OMHCNY 0013884-
0013938

5/4/01Policy and Procedure Manual for Attica Satellite Unit

O M H A T T 00011 190001 155

Specialized Treatment Program
Attica C.F. - 7/23/01- 10/19/01

OMHATT 00011560001 184

Specialized Treatment Program
Attica C.F. - 11/5/01- 2/5/02

O M H A T T 00011850001253

Specialized Treatment Program
Attica C.F. - 2/19/02- 5110/02

O M H C N Y 027803-027837 4118/02Mental Health ServicesPlan for Five Points SHU

Plaintiff's Exhibit 9

5121/02Review of the Intermediate Care Program

OMHCNY 043262-043299 at CNYPC

OMHATT 00012540001325

Specialized Treatment Program
Attica C.F. - 5/28/02- 8/26/02

PL 063079-063084

Draft Summary of Prison Visiting Committee Tour of Attica (for 9/17/02& 9/19/02tours)

O M H C N Y 043175-043222 10/2/02Attica SpecialTreatment Program Preliminary Report

OMHCNY 043141-043174 10111/02Five Points Special Treatment Program
Preliminary Report

Bates Range PL 052467-052470

Description
10128102Correctional Association of New York Letter to Five Points Superintendent

OMHCNY 028921-028927
-
Plaintiffs Exhibit 33
OMHCNY 0057521-
0057528
Plaintiffs Exhibit 418 No Bates

12130102 Correctional Association of New York letter to Attica Superintendent 1/03 Intermediate Care Program Plan of Correction
7/03 - 3/04 Bureau of Mental Health Quality
Assurance/Quality Improvement Report

Plaintiffs Exhibit 11

4/17/03 Review of the Intermediate Care

OMHCNY 043072-043099 Participants in 9/1/02

OMHCNY 081790-081833 CNYPC Patient Demographic and Diagnostic

-

Profile (2004)

No bates stamp

Great Meadow BHU Manual, December 16,2004

No bates stamp

Behavioral Health Unit Program Operation Description, 2005

No bates stamp

Sullivan BHU Manual, February 24,2005

.

Letters, ~ern,~rand$>,and'~+ma._,S;i'

OMHCNY 00748190074858

E-mails re: Behavior Management Plans

Plaintiffs Exhibit 399 OMHCNY 0080491

E-mail fkom Sawyer to Unit Chiefs re: Case Management Committees

OMHCNY 108454-108457 Memo from Donald Sawyer to CNYPC Unit Chiefs re: Special Housing Unit Plan of Improvement

Plaintiffs Exhibit 358 OMHCNY 0079526-0079542
Plaintiffs Exhibit 522 OMHCNY 094133

E-mail related to keeping MH Level 1 inmates on caseload:

Plaintiffs Exhibit 523 OMHCNY 094149

Plaintiffs Exhibit 524 OMHCNY 094154

Plaintiffs Exhibit 538

OMHCNY 097199-097231

-

--

--

Bates Range

Description 2/23/99 Letter fi-om Goord to Stone

OMHCNY 00104050010449

7120199 Memorandum of Understanding between the New York State Office of Mental Health and the New York Department of Correctional Services

PL 000653-000654

9/1/99 Letter from Goord to Stone

PL 000653-000654

9/1/99 Letter from Commissioner Good to Commissioner Stone regarding recent meeting on mental health service delivery system in the DOCS

Plaintiffs Exhibit 270

9/24/99 Letter from Smith to Polan re: CNYPC

DCSOF 0010672-0010677 Satellite Units: Residential Crisis Utilization

PL 000655-000656

2/23/00 Letter fiom Commissioner Goord to
Commissioner Stone regarding mental health services to inmates

No bates range

12111/00Letter re: Double OccupancyHousing Units

Plaintiffs Exhibit 551

2/21/01 E-mail from Way to Dorman et al. re:

OMHCNY 093379-093381 Prevalence in Other States - Med Over Objection

OMHCNY 00776400077641

8/1/01 Email &om L. F m g o to multiple people re: Diaeosis

No Bates

5/14/02 e-mail from Kellam re: SKU Population on 1115/02

OMHCNY 034219-034220 5/24/02 E-mail fkom Dan Abreu with attached notes from the special meeting on SKU and ICP

DCSCOF 0014453-0014454 5/31/02 memo to Les Wright fiom Paul Korotkin re: OMH Level 1's in SHU

No Bates

7/18/02 e-mail fiom Kellam re: Reply to OMH Levels in SHU,

No Bates

7/26/02 e-mail from Aziz re: Reply to OMH Levels
in sw,

No Bates OMHCNY 082430
Plaintiffs Exhibit 219

8/9/02 e-mail fi-omKellam re: SHU/OMH
8/16/02 E-mail from Taintor to Smith re: Attica -
Reply e-mail from Peter Russell to Donald Sawyer re:

Bates Range No Bates

:e Placement

Description

No Bates

6/10/03 memo from Kellarn toCulkin et al. re: SHU Placements and OMH Levels;

OMHCNY 043035-043039 6/25/03 Memorandum from Donald Sawyer to CNYCP Unit Chiefs re: SHU Plan of Improvement

Plaintiffs Exhibit 72 OlMHCNY 043035-043039
OMHCNY 090715

6/25/03 Memorandum &om Donald Sawyer to CNYPC Unit Chiefs regarding Special Housing Unit Plan of Improvement
9/15/03 e-mail from Sawyer to unit chiefs - Case
Management Committee Expectations

Plaintiffs Exhibit 555

12/4/03 E-mail from Sawyer to Smith and Way re:

OMHCNY 091628-091629 My notes from the CQC Presentation

OMHCNY 064888-064890 1/24/04 e-mail from Peter Russell to Donald Sawyer re: Behavior Management Proposal

OMHCNY 00648651 0064868

2/2/04 E-mail from P. Russell to C. Antenore et a1 re: Revised SHU Plan of Improvement

Plaintiffs Exhibit 459

2/3/04 e-mail from Sawyer to Way, Smith, &

OMHCNY 089614-0896 15 Miraglia re: Fwd: helplquick

PL 065804

3/4/04 Letter &omN. Loewenstein to H.Smith re:
Robert Houston

Plaintiff's Exhibit 257 OMKGM 0010614

4/2/04 e-mail from A1 Shimhunasto Deborah Kahkejian re: Great Meadow New SKU Study Data

Plaintiff's Exhibit 460

5/18/04 e-mail from Beer to Klingrnan re: SHU

OMHCNY 091069-091070 Caseloads

OMHCNY 087954-087961 7/22/04 E-mail &om D. Van Heusen to R. Miraglia
re: Draft - CNY - Additional Geo. Differential
Request

OMHCNY 097199-097231 10/1/04E-mail from Barboza-Whitehead to

Sawyer, Smith and Lee re: BMP Effectiveness

( I OMHCNY 100612-100614

Study draft
11/22/04e-mail fkom Way to Briney, Petrino and Sawyer re: model for CMCs

OMHCNY 108239-108297 Email from David Barry to
cnopdas@omh.state.ny.us re: BHU Presentation

Bates Range

Description

(Behavioral Health Unit Training Agenda For

Great Meadow B W Draft 4/3/05 attached)

;,,. '~;;;,'~~;~,;;:~.;.:;;:>~~:;~y;;~;;~: > ;#,,,ih;".*g&is;.' .'. ... .",.'..:.. .:;, :::.......:..,.....".......

; . . : : : ,:

: ..

:.. .

. .

.g e,Qt : . ..... .. ;, .,i".. ...... ~..;.,,,..,.,-,.:.:

!.:,.,?:.,;.

.. ,::.,.... ;.,.... .,:;..., .: .., . , , .

OMHCNY 046208-046212; Select CNYPC Ethics Committee'~eetinM~inutes

0462 15

OMHCNY 046 198-046200;

OMHCNY 0003832-

0003834;

OMHCNY 046217-046219;

OMHCNY 046177-046179;

OMHCNY 0003809-

00038 12;

OMHCNY 046125-046127;

OMHCNY 0077551;

OMHCNY 0077124-

0077126

Exhibits 396,397,398

Albion CMC Meeting Minutes

OMHCNY 095760-64
OMHCLI 0000127-35, 218-253,196-197,254-57, 0000146-47,286-294, 261-2,305-06

Select JMC/CMC Meeting Minutes for Clinton, Five Points, and Sing Sing Correctional Facilities

OMHFPO 0000028-31,3455,57-82,0001689-92, 0001457-59,1453-56, 1411-16,1502-05,1544-48, 1320-25, 1368-70,1591-94, 1272-77,1639-46,1738-40, 1828-29, 1868-72,1914-62

OMHSS 0003284-85,345257,3449,3424-25,34063409,3422-23,3410-11, 3420-21,3412-19,3389-92, 331 1-12,3323-24,3321-22, 3313-14,33 19-20,3327-28, 3325-26,3343-44,3335-38, 3347-48,3339-40,333 1-2, 3345-46,3333-34,3342-42,

Bates Range 3329-30,

Description

OMHCNY 95747-50

OMHSS 0003393-96,338588,3383-84,3381-82,337374,3379-80,3371-72,337578,3357-58,3355-56,335960,3351-54,3349-50,336970,3365-68,3363-64,336162,3317-18,3315-16

Plaintiffs Exhibit 26

5/22/02 Satellite Roundtable Meeting Minutes

OMHCNY 034215-034218

OMHCNY 042391-042409 7/29/02 Operations CommitteeMeeting Minutes;
John Wilson's presentation: Overview to CNYPC
Operations CommitteelE3ehavior Management

OMHCNY 032557-032597 8/5/02 Operations Committee Meeting Minutes; 7/26/01 CNYPC Inpatient Statistical Report: Second Quartex 2002

SCOC 001564-001567

SCOC Medical Review Board Meeting Minutes 9/4/03
Other''-;. ; .-- -

DCSCOF 0006414-0006550 Special Housing Unit-Mental Health Training Program

Anderson training video: "Consideration of Mental Impairments in the Inmate DisciplinaryProgram"

No bates range

Enp v. Goord

Rule 41 Voluntary Stipulationof Dismissal Subject to Conditions

Enn v. Goord, Civ 80-3838, Amended Rule 41 Voluntary Stipulation of Dismissal Subject to Conditions

A Hearing Officer's Guide to the Supehtendmt's Hearing

Reed v. Scully, 531N.Y.S. 26 196(1988 N.Y. Sup. Ct.1

Huggins v. Couhlin, 548 N.Y.S. 2d 105(1989

38

Bates Range

Description App. Div. 3d Dept.)
Gittens v. Cou&lin, 541 N.Y.S.2d 718 (1989 N.Y. Sup. Ct.)
m n s v. Coublin, 561 N.Y.S.2d 910 (1 990 N.Y. Ct. of Appeals)

-Notes-on-chatt.sk -otherdeaths.sk
Plaintiff's Second Request filed 4/1/03 Plaintiffs Third Request filed 5/1/03 Plaintiff'sFourth Request filed 6111/03 Plaintiffs Fiflh Request filed 7/18/03 Plaintiffs Sixth Request filed 8/20/03

Bates Range

Description Plaintips Eight Request filed 11/10103

Plaintiffs Ninth Request filed 11/21/03

DAI's First Set of Requests to Admit dated 4/14/05

Plaintiffs Exhibit 256 No Bates

Anderson Training Document: 4/14/04 e-mail fiom A1 Shimkunas to Wurzberger et al. re: OMH Testimony in Tier Hearings (PowerPoint Presentation attached)

DCSCOF 0000387-

Documents related to Suicide Training and Suicide

0000419; 0004272-

Prevention

0004336; 0006082-

0006160; 0006337-

0006355; 0006367-

0006413; 0006440-

0006443; 0006473-

0006494;

OMHCNY 0005777-

0005779; 0007374-

0007396; 0025715-

0025898; 0034410-

0034413;

OMHDS 0000060-0000063;

OMHELM 0000033-

0000035; 0000088;

OMHGM 0000183-

0000184;

OMHMS 0000112-

0000137;

OMKSUL 0000134;

PL 048594-048837

Videotapes

10/26/99

pFk.4,

Strip Frisk

3/5/00

F -FaE

OMH

7/25/94

hg. I&

Hospital 5121103 11/10/4

-fad
Y-i-3;

Observation

:Cell Extraction and
Interview with Removal to
Observation Removal to

Bates Range

5115/01 (audiotape)

Description

T

): Disciplinary Hearing

OMC-TBH0001747-0001885 Log Books: Bedford Hills: SatelliteUnit (10/25/02OMECBH 0001139-0001442 4/1/03)

OMHBH 0002493-0002750

OMHBH 0001443-0001746

OMHBH 0000813-0001002

DAI v. OMH Case Management Order dated 6/23/04

OMHCNY 085617-085620 Documents fiom Defendant's 11/08/04production

OMHCNY 085660-085668

OMHCNY 086678-086701

OIVEICNY 086702-086733

OMHCNY 086734-086747

OMHCNY 086748-086763

OIVEICNY 087555-087577

OMHCNY 087795-087800

No Bates

CV of Richard Miraglia

OMHCNY 089648, 045455-045459,060991060993,045300-045303, 089931-089933, Pls. Ex. 104,090060-090064
Plaintiffs Exhibit 242
OMHGM 00001150000117

Documents related to HARE test
CNYPC - Outpatient Satellite at Great Meadow
Correctional Facility

OMHCNY 0066743

Documents re: Traveling Rivers' Orders

OMHCNY 0066741-2

OMHCNY 0077284-85

I

OMHCNY 0077291-2

1

OMHCNY 0078832-3

Bates Range

Description

OMHCNY 0077304-5

I 1 OMHCNY 108450-108452 SHU Mental Health Statistical Tables

I

Plaintiffs Exhibit 568

' Obtaining Prior Mental Health Records for Patients

OMHCNY 0060985-
0060990

admitted to Service at Downstate Correctional Facility

I OMHCNY 027050-027072 1 9118/02 Quality of Life Instrument

1

IPlaintiffs Exhibit 238 No Bates Plaintzfs Exhibit 220

2004-05 Executive Budget Forensic Mental Health Initiatives
I
3/8/04 Final SCOC Report: David Estime

No Bates

OMHCNY 036787-036801 Letter &omDr. Goyal, M.D.,Dir. Medical Services to Dr. Menon, Clinical Director re: Docs Medical

045206

Buscerna re: Anthony Burton Iavestigation

OMHCNY 044654-044690 CNYPC Medical Staff Meeting

OMHCNY 044691-044703 Statewide Medical Staff Meeting Beeche's

Conference Center OMHCNY 044725-044726 Central New York Psychiatric Center

1

I

I Incident Review committee Meeting.

I

OMHCNY 046750-

Incident Review Report of Q b

OMHCNY 044727-044730 Central New York Psychiatric ~ k t eInr cident

Review Committee Meeting,

OMHSS 0000088

Letter &omJurgen Karker, to Unit Chiefs, Level 1

Facilities re: Follow up of Patients discharged from

RCTP to SKU

OMHSS 0000092

E-mail from Bradigan to Devito, et al. re: Change

I
OMHCNY 025976
I

1 Breakdown of No Show/Callouts-Mental Health
Month of April 2000
1/26/00 Letter from Smith to Miraglia re: CNYPC
I Overtime Expenditures
42

Bates Range

Description

OMHCNY 047045

Memo from Buscema to Physicians et al. re:

PCM's on Patients Discharged from CNYPC &

Returning to a SHU Environment

OMHCNY 044770-

CNYPC Incident Reporting Policy and Procedure

Manual re: Filing of Criminal Charges Against a

Patient

OMHCNY 0010405-

Memorandum of Understanding Between the New

001 0449

York State Office of Mental Health and the New

York State Department of Correctional Services,

OMHBH 0003636-0003643 Bedford Hills Evaluation, Bedford Hills Satellite

Unit Evaluation of Operating Systems

DCSCOF 0006044-0006056 MH Services Plan for SHU Patients at Attica,

61 1 2/00

OMHGM 0000158-

Great Meadow Satellite Unit Principal DSM IV

0000 160

Diagnoses

DCSCOF 0005732-0005733 Justification for the Need for Additional Nurses at

Level 2 Facilities

OMHCNY 053410-053419 CNYPC Performance Improvement

Proposal, Callout Compliance Rate

DCSCOF 005734-0005735 Memo to M. Prisco from C. Frater re: OMH

inmates on Psychiatric medications

OMHCNY 026023-026024 7/20/00Letter from R.Miraglia to A. Holmes RE:

Forensic Overtime

OMHCNY 047164-047172 8/00IRC Meetings

OMHCNY 056580-056584 Performance Improvement Forum Meeting 8/16/00

OMHCNY 053389-053391 CNYPC Outpatient Performance Improvement

Projects (2000),(Updated 9/19/00)

OMHCNY 056826-056836 CNYPC Outpatient Performance Improvement

Cover Sheet

OMHCNY 047116-047118 TRC Meeting 11115/00

OMHCNY 056568-056571 Performance Improvement Committee Meeting

1 1116/00

OMHSS 0002733-0002740 12/5/00Memo from Bord to Adanas re: J C M O

Mock Survey

OMHCNY 053303-053309 CNYPC Outpatient Performance Improvement

Projects (2000)(Updated 12111/00)

OMHCNY 053443-053447 12/13/00Memo b m Lauve to Performance

Improvement Committee Members re: Performance

Improvement Committee Meeting Minutes

11/16/00

Bates Range

I

Description

1 OMHCNY 056502-056509 Performance Improvement Forum Committee

Meeting

OMHCNY 047102-047107 IRC Meeting 12113/00

OMHSS 0000178

12/21/00Memo fiom Boyd to Perilli re: SHU

Training Feedback

OMHGM 0000013-

Memo fiom Greasley to Shimkunas re: Justification

0000015

for Sixth Nurse

OMHCNY 043347-043376 Draft, Mental Health Services Plan for Special

Housing Unit Patients at Attica Correctional

Facility Submittedby the NYS Office of Mental

Health and the NYS DOCS

OMHSS 0002775-0002781 Letter fiom Roland Cote to Doris Ramirez-Romero,

re: Sing Sing ICP Monthly Report

OMHBH 0000165

Letter &om Michelle A. Petrino Unit Chief OMH

I to Capt. Ballte and Capt. Gladding re: SHU/PMH
Training

I OMHCNY 030773-030839 1 CNYPC Environment of Care Performance

I

I I 1 OMHBH 0000159-0000164 SHU Rounds Schedule-2001

OMHBH 0000158

Memo fkom Sheryl L. Salaris to Michelle Petrino

re: Langley Stipulation

OMHCNY 056868-056884 CNYPC Performance Improvement Proposal

Coversheet: ~m~rovemeonft Patient ~ s c o rRt ates

OMHCNY 056860-056867 CNYPC Performance Improvement Proposal
I Coversheet: Reducing Redivison of Patient Transfers to RCTP

OMHCNY 0568850569191; OMHGM 0000130-0000131

I CNYPC Performance Improvement Proposal Callout Compliance Rate; 5/7/01 memo &om

I

I Shimkunas to Duncan re: Continuationof

I

Restricted Diet in Observation Cells

OMHCNY 056535-056538 Performance Improvement Forum Committee

OMHCNY 047703-047706 Psychological Autopsy of. A .Se
(died 5/14/01)
OMHCNY 056820-056825

OMHGM 0000149

I OMHCNY 047720-047729

Levels in SHU
Memo f?om Hemnam to Smith,. Farago, Sawyer,
& Buscema, re: Psychological Autopsy Report -
Patient E Fa

Bates Range

Description

OMHCNY 043334-043339 Clinton Satellite and Catchment Evaluation of

Operating Systems

OMHCNY 045180-045185; Memo from Spriggs to Herrmann re: Shane

Maxwell, attaching Root Cause Analysis & Action

Plan in Response to Sentinel Event

OMHCNY 043340-043346 Memo fiom Sawyer to Smith re: Clinton Satellite

Unit Visit Reports and Recommendations

OMHCNY 047681-047683 MorbidityMortalityReview CommitteeMeeting

Minutes

OMHCNY 041968-041981 Draft: Mental Health ObservationCell Usage in the

Mental Health SatelliteUnits Operated by Central

New York Psychiatric Center Report July-

December 2001

OMHCNY 047751-047760 Documents re: death of 3 L,

including

Incident Review Committee Meeting Minutes, e-

mails, and Report of Special Investigation

OMHGM 0000016

E-mail from Shimkunas to Smith re: Operational

OMHCNY 090350

Probf ems

Re SHU

OMHGM 0000154

E-mail h m A1 Shimkunasto Donald Sawyer re:

SHU Follow-UP

OMHCNY 054353-054371 Draft Quality Assurance Review of Suicidesin

New York State Correctional Facilities

OMHCNY 027803-027837 Memorandum from Sawyer to Miraglia et al. re:

STP Program Description - 5 Points Correctional

Facility

OMHCNY 034140-034153 Memo fiom Herrmann to Miraglia, re: CNYPC

Quarterly Incident Statistic Report

OMHSS 0002758-0002761 Message from Superintendent, Sing Sing

CorrectionalFacility to David Boyd re: SHU

Committee

OMHGM 0000152-

E-mail ikom Shimkunas to Sawyer et al. re: Great

0000153

Meadow Observation Overflow Reduction

OMHCNY 056471-056477 Performance Improvement Forum Committee

Meeting Minutes

OMHCNY 034215-034218 Satellite Roundtable Meeting

OMHSS 0002756-0002757 E-mail from Culkin to Boyd re: Reply to Sing Sing

SKU

OMHCNY 047742-047744 Letter from Henman.to Farago re: Incident

InvestigationRecommendation(s) re: death of
G

Bates Range

Description

I

OMHSS 0002754-0002755 E-mail from Spriggsto CN Unit Chiefs re: SHU

I

I I Private Interview Letter, Monitoring Form and

Progress Note

OMHCNY 047730-

Morbidity/MortalityReview CommitteeMeeting

0047733

OMHGM 0000148

Memo from Shimkunas, to OMH Clinicians on

SHU Rounds re: 24 Hour Screenings

OMHSS 0002763-0002771 Special Housing Unit Multi-Agency Review

Committee on Inmates with Active Mental Health

Cases

OMHCNY 056451-056460 Performance Improvement F o m Committee

Meeting

OMHCNY 043223-043261 Mental Health Crisis Observation Cell and

Dormitory Bed Usage in the Mental Health

Satellite Units Operated by CNYPC July 2001 -

June 2002 Draft

OMHGM 0000146

E-mail from Shimkunas to Privett re: SHU

ContactsfOperations

OMHCNY 043175-043222 Attica Special Treatment Program (STP) for

Mentally Ill Inmates in Special Housing Units,

Preliminary Report Patients entering the STP

Program Between November 2001 and May 2002

(Draft)

OMHSS 0000142-0000143 E-mail from Mahoneyto ICP Coordinatorsre:

Fwd: DOCS ICP Budgets

OMHCNY 043141-043174 Five Points SpecialTreatment Program (STP) for

Mentally Ill Inmates in Special Housing Units

Preliminary Report Patients entering the STP

Program between December 2001through June

2002

OMHCNY 053494-053497 CNYPC Outpatient Performance Improvement

Projects (2002), (Updated 10125102)

OMHSS 0000101 OMHSS 0002762

1 Email h m Leclaire to Wilhem et al. re: OBS Cell

Dischar"ge Procedure

J

E-mail from Key to Fischer and Kikendall re: FtU

1118 Meeting

@\ :

APPENDIX D

NEW YORK DOCS INTERVIEWS OF 183 PRISONERS

by Terry A. Kupers, M.D., M.s.P.'

Elmira Correctional Institution - 3111/03

/ *

+- \-\ ,

" *J -

>-,

- L- *-i

cIL_
* 1"
_-hr

r>

Southport - 3/12/03

a

c

4

Five Points Correctional Institution - 3/13/03

5+ .

! Z y*\v<8c*<++>,

' The list of prisoners interviewedby me is complete. However, the case studiesthat follow in this
Appendix C include only those cases that are not included in the foregoing Report.

Clinton Correctional Facility -7/15- 7/16/03

\ s

- L & _ _

L- * ".

-- ,%
. I& 1

! - # < &K 2 2

2
Upstate Correctional Facility - 7/17-7/18/03

Sullivan Correctional Institution - 5/5/03

*
Lizd+ i""

9 - \

Ti + < t - n r 2

Bedford Hills Correctional Institutional - 5/6/03

Sing Sing - 517 -5/8/03

kt-"-

- i
t-

*> j r - -

,?

% -

-*asv

3 -3 I

Great Meadow - 8/26 - 8/27/03
2; #:" -
: ~;,"i b" *-.;*

Wende Correctional Institution -9/22/03 and 9/25/03

Attica Correctional Institution-9/23/03

k; ,t

"- -- -

Lr

v:" # - - - t " t,

Albion Correctional Institution - 9/24/03

L

-

2$ - *I * . - t d${*l,CtXI+-24

Auburn Correctional Institute - 10/29/03-10/30/03

*

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"
\ *+

--" srP

i il sin.

Elmira Correctional Institution - 3/11/03

72.pn2

(Interviewed while housed in RCTP).

Mr. I.p-&.who had previously been in ICP, cannot remember how old he is, is
disoriented to place and conhed about person, and cannot remember when he came to prison. His conversation is confbsed and he talks nonsense. There is bizarreness and strange affect. Th&e are lapses in his train of thought. He says that the medications he takes do not work. He tells me he has tried to hang himself at CNYPC. He is cmently awaiting transfer to CNYPC. He is too incoherent to give a history. This man is acutely psychotic and probably suffers fi-oman organic brain disorder as well, His clinical chart fills a carton. He has a long history of Schizophreniawith command hallucinations. He was admitted to public psychiatric hospitals several times prior to incarceration. There was significant drug use, including possible effects of illicit drugs during commitment offenses. He began this bit in 1998, being sent from Downstate Reception to CNYPC, but he has been repeatedly admitted to CNYPC since 1987(prior bit?). He has been very suicidal, including cutting his neck, arms, genitals, etc. He is consistently noted to be agitated with flight of ideas, severe thought disorder and hallucinations and delusions. He is repeatedly admitted to CNYPC, diagnosis Undifferentiated Schizophrenia He is prescribed a cocktail of anti-psychotic, mood stabilizing and antidepressant medications, with minor tranquilizers and sleep aides thrown into the mix. He becomes non-compliant with medications, decompensatesandor becomes suicidal, and returns to CNYPC. ICP
is probably the best place for him within DOCS when he is relatively stable and can be
out of a hospital.

Example of: Acute psychosis in RCTP Treatment in ICP for SMI

C &3a,L

(Interviewed while housed in RCTP).

L arrived from the Southport SKU six days before our interview. He had been in SHU for two months on account of an incident at Auburn (he says he refused DNA testing). He entered prison in 1989. He tells me he attempted suicide by
overdosing on medications, and he really wants to die -he is intent on ax;complishing
suicide. He has been prescribed psychiatric medications since 1996 or 1997,but is not currently taking any. On mental status examinationhe is ckarly depressed, cries as we talk, and exhibits psychomotor retardation with a sense of hopelessness and helplessness. He says he paces incessantly in his cell, does not dream any more, and that his depression is made much worse when he is in SHU. He is bothered by the fact that all the prisoners
in the SKU seem angry. The fact that nobody visits him, and he is serving a 22 year b life prison term, increasehis depression and despair. He says he is on the 0MH caseload, but does not take medications. He complains that he is viewed as assaultive, even though he has not had tickets during 15 years in prison.

Example of: Severe depression worse in SHU Southport SHU w SMI

"ft-4 -

(Interviewed while housed in RCTP).

has been in prison for four years and tells me he is slated for release in November. He transferred to observation &om SHU. He has never been to CNYPC, but this is his second time in RCTP at Ehnira, and he was also in the Mental Health Unit at Five Points twice and twice at Sing Sing. He takes antidepressant medications because of "stress." He says he goes to the crisis unit because he is beaten by staffin the SHU. He avers agitation and insomnia, and says he repeatedly cuts himself in order "to get away from abuse by the COs." He says he was beaten by officers after trying to hang himself. He has asked for protection which has been refused. He claims officers are constantly retaliating against him. He claims other prisoners in SHU throw fmes at him. On mental status examination he seems to have ideas of reference, but is otherwise coherent with intact thinking, orientation and relating. He had a psychiatric history prior to incarceration, including seeing a psychiatrist because of family problems and then trying to shoot himself in the head prior to incarceration. His clinical chart includes a 3/20103 Admission to CNYPC, for self-destructivebehavior, seen as non-psychotic impulse control problem. A 1998 admission to Bellevue psychiatric ward is noted. At other times, hallucinations are noted. There is a 1012102admission note to observation
with a diagnosis of Impulse-Control Disorder & MH Level 1. On 10/23/02his
medications include Remeron 30 mg, Trazadone 100mg. and Trilafon (an anti-psychotic agent) 4 mg. b i d . Previously he had been prescribed Risperdal and Seroquel (both antipsychotic agents) and Zoloft. On 4/15/03 he is placed on a "Behavior Plan" in SHU. In May, 2003, several notes report his wish to go to ICP. In other words, this man spends significant amount of time in SHU, becomes suicidal or self-destructive, and cycles to observation. He is prescribed antidepressant and anti-psychotic medications. His report of hallucinationsis questioned. He is also reported to have a seizure disorder.

Example of: Severe depression, worse in SHU Cycle to observation & back to SHU Also un-diagnosed at CNYPC

PI&,

(Interviewed while housed in SHU).

""$ A, has been in prison for eight years. He is interviewed while in SHU,
where he has been for four months. Just prior to our interview he learned a disciplinary hearing decision was reversed because there was no consideration given to his mental health status, and now there will be a new hearing. He says he has had "mental problems" all of his life, and is currently taking Zyprexa, 5 or 10 mg. per day. He has been at CNYPC. He complains about the NIKU, "any time you have a mental problem you get stripped and searched." About SHU: "The mental health staff come around the

SHU, but merely talk to you through your food slot." He reports he has been hearing voices his whole life, and with the right medications "I can deal with it." He complains that other prisoners in the SHU suEer from mental illness to such an extent that they bang on their doors, or scream, or otherwise cause a nearly constant commotion. He complains that the officers "hold onto your food and play with you." He gets headaches, and the voices get louder, when he is alone in a cell in SHU. He gets desperate to get out because "it's upsetting to be cut off fiom the world." He gets paranoid in SHU. "Officers control mail and everything, and when they cut off the radio, you don't know what's going on." When the officers come by and ask him how his food tasted, he wonies that they are putting somethingin it. Officersdo not respond when a prisoner calls them. On the swing shift, the officers come around only two times in eight hours. He loses sleep in SHU, and that makes his mental illness worse. He is unable to concentrate, and cannot read as well as usual - which depresses him. An officer walks around with the nurse who passes out medications, and that officer "messes with people." The night prior to our interview he paced in his cell for four or five hours. While he told the police he'd done more drugs, he actually only smoked marijuana. He finished tenth grade, and never received a GED in prison because he has spent so much time in the box. He has received 50 tickets in DOCS, most of them involving command hallucinations telling him to do the illegal acts, usually fighting. He reports he has told mental health staff about that, but they ignore him, so he has stopped telling them. And Dr. Fontana has told him that "if you pull this psychotic routine again we're going to strip you down." When he was in observation, he smeared and threw excrement in response to voices telling him to do so. On mental status exam there is flatness, concreteness,history of
hallucinations and delusions, and very strong First Rank Symptoms. In other words, this
man, by history and mental status examination, suffers fiom active psychosis, and needs to be removed from SHU and placed in a mental health treatment setting such as ICP.

Example of: Actively psychotic in SHU Condition much worse in SHU Disciplinary infractions secondary to SMI

$"a 0 -

(Interviewed while housed in SHU).

14 6 had been in SKU since August of 2002. He had a history of severe anxiety and was prescribed Elavil and Valium in the community prior to incarceration. He says he has been to CNYPC five times since e n t e ~pgrison in 1980. He has repeatedly tried to kill himself and has been in observation on multiple occasions. Being in a SHU cell causes him to become much more anxious; in SHU, he chews his fingernails, cannot sleep except with the medications he is prescribed, cleans his cell three or more times per day, thinks a lot about killing himself but is dissuaded by thoughts of how tenible it is to be in observation, and sees the "doctor'" once a month. His clinical chart reflects he has been in prison this term since Feb., 1997, and had an
admission to CNYPC in 1997. He came in as a MH Level 2, and has been changed to 1.
He carries a diagnosis of Psychotic Disorder NOS, Cocaine abuse and ASPD, with a

GAF of 40 on 3/22/99. In a 1987 admission note to CNYPC a long history of selfmutilation and swallowing foreign objects is noted, and he is diagnosed Adjustment Dis w mixed features and ASPD. An 8/10/89admissions note to CNYPC states: "Highly suicidal. He is experiencing auditory hallucinationswhich are telling him to kill himself. Believes other inmates are plotting to kill him. Spanish speaking only and illiterate. Highly agitated. Unable to differentiatereality from command hallucinations. Danger to Himself and Others; Dx: Atypical Psychosis." His chart reflects multiple suicide attempts, assaultiveness, and his.3197 admission to CNYPC was for cutting himself with a razor and then swallowing it. This was his fourth admission to CNYPC, but first during the present prison term. While he was not cooperative with treatment, the staff at CNYPC felt he harmed hi~nselifn response to command hallucinations. He has been on and offthe O M caseload, he is prescribed Elavil at his request, he is not cooperative with treatment, he goes in and out of SHU and in and out of observation (i.e. he cycles between SHU and observation); he seems to be suffering from intermittent psychotic episodes with multiple suicide attempts. He has also been prescribed Trilafon (an antipsychotic medication), Depacote (mood stabilizer), Benadryl, Zoloft, Thorazine, Vistaril and others. He has also been diagnosed Impulse Control Disorder. During a 5/7/03 fifth admission to CNYPC it is noted that he sexually assaulted a fennale MH worker in SHCT (likely exposing himself, and he seems to have a proclivity to doing that), he is assaultive, and some questions are raised about the authenticity of his claims about auditory hallucinations. His discharge summary (927103) diagnoses Impulse Control Disorder with Schizoaffectivecrossed off the list of diagnoses. He was in restraints, in observation, and on a SPF 1Behavior Management Plan in the hospital. He was discharged back to SHU because the treatment team decided he was neither psychotic nor
suicidal any longer - but they note that the psychiatrist at the SHU reported bizarre
behavior and thought process.

In summary, this prisoner is intermittentlypsychotic and self-harming, carries many bona fide diagnoses, but s also a management problem and is currently in SHU. Clearly his being in the SHU makes his mental illness flare up, and then he cycles to observation andlor CNYPC. At CNYPC, when he exhibits bad behavior, staff begin to think he is feigning psychosis. However, the psychosis seems to be real and ongoing, based on history, chart review and my mental status examination.

Example of: Psychosis and Depression in SHU SHU worsens symptoms Undiagnosed by CNYPC Cycle from SHU to observation with suicide attempts

@ N,

(Interviewed while housed in SHU).

o N. had been in the SHU for one year when he was interviewed. He
describes feeling very lonely and isolated in SKU, where he "goes into" himself, has
nothing to do and gets bored, and then gets into trouble with neighbors or officers. He is

being treated for psychosis with Risperdal and Zyprexa. On mental status examination he exhibits loose associations,inappropriate and labile affect, he makes non-sense sounds, and is obviously internallypreoccupied with auditoryhallucinations. He exhibits clear
First Rank Symptoms, including the belief that people are controlling him and getting him to believe certain things. In other words, he is quite obviously actively psychotic at
the time of our i n t e ~ e w .He complains of an inabilityto concentrate, and though he earned a GED in prison, he is unable to read in his cell in SHU, and this makes him distressed. He does not feel that the mental health staff take him or his problems seriously. He sees a psychiatrist once a month in an office.

A review of

\

clinical chart reflects that he was in SHUs at various

&titutions since approximately October, 2001. His diagnosis on 3/29/01 was Depressive

Disorder NOS, and on 1/30/02 it was Psychotic Disorder NOS. He has been at MH Level

2,3 or 4 except he became a 1 on 6/20/02. A ScreeningIAdrnissionNote in Groveland

,CF notes bizarre behavior. A Core History on 4/8/01 notes auditoryhallucinationsand

setting fire to his cell, and a history of psychiatric care prior to incarceration and

polysubstance abuse. He was in RCTP fiom 11/19/02until 12/13/02, for threatening

behavior and medication non-compliance (Rx Paxil40 mgjday). A 5/17/02 review of ' treatment plan notes PlMS Level 1, "obsessional mind, tangential & circumstantial

thought process, and he may need MH Level 1 services in future." A 9/26/00 progress

note reflects a trial of Risperdal2 mg. bid., for Psychotic Dis NOS. On 11/24/01 he is
in SHU, tossing property out of cell, which initiates a call for a psychiatric evaluation -

he is noted to have messy cell and poor hygiene, but Dr. Abid Darr, M.D., sees him and

diagnoses substance abuse but no psychosis nor depression; on 1/30/02 Dr. Darr decides

his diagnosis is PsychoticDis NOS, WO Schlz, but he is still in SHU and refixsing meds.

A 4/5/02 notes a one month trial in double cell at Upstate, which was a failure because he

should not be double-celled, and he is transferred from Upstate to Southport SHU. At

Southporthe remains at PIMS Level 1 (it is very likelyhe cannot progress because of his

serious mental illness). He writes psychotic-appearing notes to judges and others, He

continues to refuse medications, and continues to be confined in SHU. On 7/11/02 he is

prescribed Zyprexa 10mg./day plus Paxil20. He continues in SHU, is on and off .

medications, outpatient "supportive.therapy" is provided, mostly at cell-bnt. On

11/20/02he is in observation on medications. He is still in observation on 12/1/02. He is

sometimes diagnosed "no diagnosis, ASPD on Axis I[,he is given Mental Health Level

6 on many screenings in SHU, and then on 7/8/03, during his first admission to CMlPC

for paranoid delusions and decompensation, his Diagnosis is definitely Psychotic

DisorderNOS and he is prescribed Seroquel800mg. Per day, Trileptal, 600 mg. Per day,

Clonidine .2 mg bid., and Risperdal2 mg. Per day. In other words, this admission

disproves previous assertions he does not sufTer fiom an Axis I serious mental illness,

and his decompensation into an acute and severe psychotic state in SHU requires very

high doses of anti-psychotic and antidepressant medications. At CNYPC he is noted to

have a possible history of psychiatric treatment for severe mental illness from childhood;

it is noted he has been frequently diagnosedPsychosisNOS within DOCS, has been

prescribed several anti-psychotic meds including injections during years in DOC, and that

he has deteriorated in SHU and has been a compliance problem.

In summary, this man suffers intermittently from psychosis and depression, remains in SHU with occasional trips to observation where he remains for weeks, is inconsistentlyprescribed antidepressant and anti-psychoticmedications because he does
.not comply,'is not sent to CNYPC and is never accused of malingering. Outpatient
therapy in SKU mostly consists of monthly cell-front or ofice visits.

Example of: Severe psychosis in SHU SHU worsens psychosis Un-diagnosis, on psych meds, subsequent breakdown disproves Cycles from SHU to observation & CNYPC and back to SHU Sent to Upstateldouble cell in spite of SMI

C E

(Interviewed while housed in SHU).

o E has been in prison for four years. He has been in SHU ever since he
came through Downstate Reception. He says he has ''poor communication7'with SHU staff, and gets tickets. He is psychotic and takes Zyprexa. Prior to incarceration, he had been admitted to Bellevue's psychiatric ward two or three times, had been in the state psychiatric hospital and had been homeless. He is seen by Dr. Fontana monthly, at cellfront. He explains that because the officers plot against him, he does not take showers. He also talks to himself out loud and he tells me that the staff think he's crazy. On mental status examination, his affect is very flat, he gives off an odor from not bathing, and he talks about voices but prefers not to call them voices. He seems internally preoccupied with First Rank Symptoms and ideas of refaence. I asked him if the voices have anything to do with his receiving tickets, and he said, "If they don't respect me, there's trouble." He was in the STP at Attica and liked the group therapy. He was discharged for outstanding charges, involving unhygienic acts. He has received tickets for self-harm. He complains he cannot get to see the doctor, he gets angry about the refusal of mental health staff to seehim, and he either talks to himself or hams himself. He says he has been to observation quite a lot, but doesn't feel he needs to go to Marcy.

This prisoner's clinical chart confirms pre-incarceration multiple psychiatric hospitalizations, and a diagnosis of Schizo-Affective DisorderIBipolar Type in 1999. He studied up until the fifth grade level and cannot read or write. Early 0M.H clinical notes diagnose PTSD. He has been in SHU most of the time he has served in prison. He is confined in S W and periodically found to have hygiene problems with a foul smell emanating from his cell. He was in Attica STP in 6/00. Around that time he had no Axis I diagnosis, and an Axis I1 disorder. He was admitted to CNYPC for the .first time on
3/20/03, for an overdose of Naproxen (a non-steroidal anti-inflammatory agent). He was also prescribed Vistaril and Zoloft. At CNYPC, Dr. Wilson did a Hare Psychopathy checklist evaluation and diagnosed ASPD. He was admitted to RCTP on 4/4/02 for
"decompensation.. .pt. Collecting shit in cell has not showered X 1month, yelling out.
Admitted to RCTP on 12111102"decompensating, voices, rapid speech, poor hygiene,
hearing voices." Again on 7/1/03, he was admitted to RCTP for poor hygiene, paranoid,

fighting. Multiple SHU MH screens at cell-hnt note he is unhygienic, paranoid, rehses to tallc, etc. Yet his diagnosis is sometimes either none on Axis I or Depressive Disorder without psychotic features. On 5/7/03he was diagnosed Major Depressive Disorder without psychotic features. In Sept., 2003, there is a diagnosis of Adjustment Disorder with Depressed mood. His medications are mostly antidepressants,but on 11/23/02he was prescribed Zyprexa, 5 rnh., Celexa and Trazadone; in April, 2003, he is prescribed Seroquel50 mg. at bedtime; and in May, 2003, he is prescribed Thorazine 50 mg. at bedtime. He is also periodicallyprescribed antidepressants. Many notes in his chart reflect psychosis andlor severely regressed depression - e.g. frequent mention of paranoid ideas, self-destructive, unkempt, unhygienic, lethargic. In summary, this man has spent much of his prison time in SHU, has been repeatedly suicidal and has been to CNYPC once and observation in the RCTP many times, each time returning to SHU. There is very strongevidence of intermittent psychosis, both in my mental status examination and in the narrative chart notes even when psychosis is not diagnosed, and there is the prescription of anti-psychoticmedications along with antidepressants; however, since a psychological assessment in April, 2003 found only ASPD, his diagnosis has been downgraded and he has continued to cycle between observation and SHU.
Example of: Psychosis in SKU Disciplinary problems probably related to SMI
Un-diagnosed @ CNYPC by Dr. Wilson per Hare Test
Subsequent obvious psychotic episode(s) Given antidepressant and anti-psychotic meds with no dx Cycles from SKU to CNYPC & observation and back to SHU

Southport 3/12/03

I? 0-

(Interviewed by Drs. Kupers & Fulwiler & Betsy

Sterling while housed in SHU).

Fa

told us he has a pre-incarceration history - hospitalization at

Elmhurst Hospital in Queens - and his diagnosisis Schizophrenia He says he sees

things that are not there. He was in Protective Custody at Aubum, but got into trouble

with an officer and was sent to SHU. He says he isolates himself at Southport for fear his

anger will break out and he will get into more trouble. He admits to feeling paranoid, and

says that he also isolateshimself to protect himself fiom enemies. He thinkshis

confinement at Southport is "a test," and his explanation of the test moves on to a

discussion of voices. He believes "they are trying to inject me with HTV through their

TB test." He has made suicide attempts by slashing his wrists in prison. He sees the

psychiatrist, but does not trust him. He is prescribed Atarax, Benadryl and Sinequan. He

talks about the voices being from Satan. The voices try to manipulate him, and command

him to do things or tell him someone is going to hurt him. He gets angry or depressed in response to the voices. He stays up nights reading the Bible.
This prisoner's clinical chart contains a psychiatric evaluation in jail noting no MH problem, an admission diagnosis by OMH of Adj. Dis at 18 upon admission to DOCS. After a few weeks in GP, a social worker notes on 9/29/87 some psychoticsounding symptoms about strange thoughts, notes that he is vague and evasive, and says he will follow him. On 1/6/98malingering is noted. He is screened but not admitted to MHU on 1/6/99. His MH Level goes from a 6 on 2/7/00 to a 4 on 3/14/00 and a 3 on
4/5/00, all at Southport. Besides ASPD, he has an Axis II Diagnosis of Mental
Retardation on 3119/00. There is a diagnosis of Depressive Disorder on 4/1/00. He is admitted to the OMH caseload 4/26/00, having spent most of his prison time in S W . He is assigned to outpatient treatment with monthly treatment plans as of late 01, early 02 he is viewed as stable, PIMS Level ID. A 4/9/01 note reflects 'Yangential and unfocused." On 5/1/02, treatment plan review notes "He is generally cooperativewith MH therapy sessions. He does, however, typically discuss issues that have no relevance
to NZIl and emotional hctioning. In the past, he has exhibited suspicious thought
process, but in recent months not. He is currently not Rx'd psychotropic medications."
A 7/26/02 review notes: "still somewhat grandiose and tangential in thought process.. ..
"sewices are limited due to restrictions of SHU." 7/02 - 10102 prescription of Zyprexa, Depacote. On 10125102,"He has refused to comply with recommended medication trial of Zyprexa and Depakote. From 1998 through 2000 there are a series of handwritten notes in chart from F.C. or another name, Ar-Rashid Al-Akbar, with clearly regressed, psychotic content. In summary, this chart is consistent with my mental status exam.
Diagnoses vary, including Adjustment Disorder with Mixed Features, Depression NOS
and Personality Disorder. By 1/24/03, notes reflect OMH opinion he is not suffering from mental illness but merely seeks transfer out of Southport SHU. There are other OMH notes implying malingering, but then on 8/17/02, a psychiatrist's progress note states: 'Son-stop talk, disconnected, tangential, pseudo intellectual presentations, looseness of associations,psychomotor hyperactivity, grandiose." Impressionis Narcissism with Grandiose Delusions, and medications prescribed include Zyprexa and Depakote. (Zyprexa 10mg. and Depakote 1000mg were discontinued 10/12/02because
of non-compliance.) A 3/19/03 progress note by Bill Vertoske, a Psy XI who does not
believe he suffers from SMI, notes his reaction to our interview on 3/12/03, "He began session by telling us that we were 'in trouble' following his interview with clinical experts last week per current lawsuit." This man is chronically psychotic, sometimes coherent and sometimes not, receives outpatient treatment in SKU with no admissions to
CNYPC, and is intermittently declared not to be suffering from SMI, and then treated as
if psychotic.

Example of: First episode of psychosis after entering DOCS as a late teenager Psychosis in SHU Inadequate treatment False ascription of malingering

ki b!

(Interviewed while housed in SHU).

n.-r N has been in SKU since 1988 (at Clinton, Attica, and now for five months at Southport). He has been to CNYPC four times between 1991 and 2001. He is a 9 i t t e d to the psychiatric hospital because the voices he hears get out of control and command him to harm himself, often by banging his head against the wall. He states: "I've been in the SHU too long, to be honest with you, because I have mental health problems and instead of giving me mental health treatment they give me tickets." Most , of his tickets,he reports, are for hurting himself. He has a history of psychiatric hospitalization in Hawaii in 1987, prior to his incarceration. He describes severe depression, including psychomotor retardation and vegetative signs. His last ticket was six months ago, and he has a sentence in "the box'' until 2009. He also receives tickets
' for fighting, and he says that his depression causes him to fight - i.e., he cannot control
his anger when he is depressed. He takes Haldol, Elavil and Benadryl. He says OMH
does not help him because of the fights he has been in - one occurred while he was at
CNYPC. He cannot read or write. He says, "I be bugging out in my cell, I talk to myself, I make up things, I listen to radio, I think a lot about bad things, I hear voices at night, I get depressed, I pace, sometimes for hours, I feel like the walls are closing in on me, I get really nervous and Ijump out of bed." He has been rejected for admission to the STP. On his clinical chart there is a diagnosis of Major Depression with Psychotic Features during an admission to CNYPC in October, 1998, and again in December, 2002, and a note documenting the hoarding of feces during an admission to RCTP on 9/27/99. He seems to have entered DOCS around 1990, with violent assaults on his record. He had seen a psychiatrist for five years as a child and he was prescribed psych. medications, although he didn't know which ones. His diagnosis in 1990was Adjustment Disorder, but since approximately 1996, it has been Major Depressive Disorder with Psychotic Features. He is both very assaultive and repeatedly self-harming, with multiple cuts on his own body. He has been prescribed Haldol and Cogentin, at other times Zoloft and Risperdal. His thick chart contains notes about banging his head on bars to the point of bleeding, many stays in observation when he did not eat or acted inappropriately,etc.

Example of: Psychosis/depression in SHU Inadequate treatment Describes mental problems leading to tickets and time in SHU

p ?A5

(Interviewed while housed in SHU).

& has been in prison for six years of a 25 to 50 years prison tenn. He has been at Southport for two months, but in SHU since 2001, and he will be released fiom SHU in 2004. At Five Points he was on the O m caseload, but he says he did not want to take psychiatric medications, so he was sent to Southport. He has been told he suffers from Bipolar Disorder. He knows he gets very depressed. He was on Depacote, but did not want to take it because of side effects. He has not attempted suicide. He says there are no mental health services at Southport. He cannot explain why he is currently in SKU. He had a lot of problems with a bunkie while he was at Upstate. When he was in population, he did fine. He was investigated for gang affiliation while at Five Points. He tells me he leans toward the Egyption culture, maybe the race. He found Clinton to be a much worse SHU than Southport, and Clinton a rougher prison. He does not go to the recreation area; he says "they won't let me because my hair is too long." He seems depressed on mental status, with psychomotor retardation and a sense of hopelessness. He says he does not want to take medications "on principle."

Example of:
SMI in SHU - he reports Bipolar Dx
Not on treatment - discontinued because of non-compliance

A, Q

(Interviewed while housed in SHU).

A

has been in prison for five years, and he has been in SHU for four

years. He says he gets out of SHU next month. He believes the officers mess with the

food. At Upstate they put a bigger guy in the cell with him. There were no witnesses

(my assumption is that violence occurred - he doesn't want to talk about it). In October,

2002, he was on a 1-to-1 watch, but usually, when he asks for mental health help, none is

forthcoming. He requested STP at Five Points, but was refised because they said he does

not have enough box time. He believes his tickets are usually on account of his mental

illness. He cannot handle the stress when he is double-bunked. He gets very depressed

in SHU. In September, 2002, there was a family tragedy (he lost his father and a child),

and then he wrote a suicide letter himself. He complains that nobody from OMH came to

see him. He feels he needs someone to talk to. He sees "the psych" once a month for 15

minutes. He is depressed most of the time, "down on myself'; his only pleasure is in

hearing good things about his children. He has been taking psychiatric medications since

he left Reception. On mental status examination he is very depressed with obvious

internal preoccupations.

Mr. R.A.'s clinical chart documents a diagnosis of Psychotic Disorder NOS on
9/25/01. There was a suicide attempt on 12/28/01. There was an admission to CNYPC from Five Points SHU - observation in MayIJune, 2002, for depression and suicide
ideation with auditory hallucinations, Diagnosis Psychotic Dis NOS or Depressive Dis
NOS, Rx Zyprexa 20 mg-/day,Lamictal100 bid., Prozac 20 mg. upon admission. A
6/5/02 Trauma Screening Form reflects molestation by priest at age 13, and reported
death of twin brother -but interviewer felt he was fabricating "some facts." At CNYPC
staff notes malingering, vs. "seeing things," "hearing things." Mother's story conflicted with his. Discharged with Diagnosis Dysthymic Disorder, with suggestion his hallucinations are not authentic. A 7/23/02 Core Outpt. Eval. suggests malingering, and he is in SHU at Five Points. A 7/1/02 progress note in observation at Five Points, after he has been there for ten days due to ''concerns regarding lethality," states he feels better and does not want to return to CNYPC. On 7/8/02 he is told he does not qualify for STP because it's for inmates with 'severe and persistent mental illness.' He is seen cellside in
SHU every two weeks for a while. He is changed to a MH Level 2 on 8/26/02 so that he
can be double-bunked. He was on no psych meds after discharge from CNYPC (DIG order on 6/25/02) and is discharged from OMH services on 8/26/02. A 9/24/02 Outpatient ScreeningNote reflects that his father, sister and daughter were killed in a fme in No. Carolina. He was re-admitted to OMH, caseload with a diagnosis of Acute Stress Disorder, no meds. On 9/30/02 he was re-admitted to observation at Elmira on 1-to-1
watch, Bx Vistaril 100mg. b.i.d. He remains in observationthrough 10/7/02, then
returned to SHU at Southport. He expresses wish to work on sexual abuse issues and complains that nobody from MH listens to him. He was seen every couple of months for FU, and in 90 day MH screens in SHU. On 1/7/03, a Treatment Plan Review notes no medications, PlMS Level 11, no self-harm, soon to be released from SHU. In summary, this young man with no prior psychiatric history is in SHU for a lengthy term, suffers depressive and psychotic symptoms, is admitted to CNYPC, where it is then decided he does not need psych services, and then returned to observation and suicide watch. He had prescriptions for Zyprexa and antidepressant, but later, in observation, he is given Vistaril. He is taken off and put back on the OMH caseload. Obviously, he experiences great difficulty managing in the SHU.

Problem: SMI in SHU Un-diagnosis Discontinue because OMfI believes malingering

-5 \[

(Interviewed while housed in SHU).

a,4 believes that the Attorney General is manipulating his mind and getting
him into trouble. He sees an OMH therapist but takes no medications. He was at ICP at Attica in 1993-1994. He is Hepatitis C positive and believeshe got the disease from the
food. On mental status he exhibits loose associations and quite obvious delusional
material. He also exhibitsintense anxiety and pressured speech. He is acutely delusional

and quite disturbed. He claims he is repeatedly assaulted by staff because he does not back out of his cell correctly. He is obviously actively psychotic.
Example of: Psychosis in SHU Not adequately treated

Five Points Correctional Institution - 3/13/03

B-$

(interviewed while housed in observation).

f is seen in observation, where he was transferred from SHU. He has been in prison for 16 years. He is taking medications for hypertension, has had strokes, and has had triple bypass surgery. He calls the medical unit, "Walsh" (the regional medical unit, where he was probably on Keeplock) a 'Weath Unit," and says you only go there to die. He has been in the box for five months, and being thus confined has made him very depressed. When asked why he is in observation, he responds "they are playing with my food." When the therapist, Ms. Miller, came to see him at cell-front, he threatened to harm himself. On mental status examination, this man is quite depressed with psychomotor retardation and an intense sense of hopelessness. He reports uncontrollable anger and paranoia, feels bitter, cries quite a lot and experiences lethargy. His clinical chart is consistent with the history he presents. He has been at Walsh, and on 8/21/01 was transferred from there to the RMU and on to Five Points OMH Satellite Unit. He is diagnosed Mood Disorder Due to Gen'l Medical Condition, Alcohol Dependence, Impulse Control Disorder (he has many tickets, some for assaults), Personality Disorder and medical conditions including Asthma, Hypertenscion, Seizures, etc. He has a pre-incarceration psychiatric history, a weekend admission to Bellevue at 16 or 17, but he was involved with substance abuse at the time. There is a history of sexual abuse from childhood. Meds included Risperdal 1mg. per day on 9/28/01 plus assorted medications for physical ailments, including Atenolo175 mg. b i d . and Dilantic 200 ing. b i d . On 1/17/02he was taking Seroquel200 mg. per day. He has been admitted to Satellite Mental Health on at least four occasions for suicide prevention, and has been followed as an outpatient by OMH with monthly contact while in SHU, but he has not been admitted to CNYPC. At Five Points, on 1131/02, upon admission to SatelliteUnit for suicide risk, it is noted he wants to be retxuned to RMU (Reg'l Medical Unit) and has difficultyhaving a younger cell mate in a SHU setting. He evidently yells on the SHU gallery, bangs on his cell door, etc. He explains it is an attempt to have himself transferred to a RMU where his medical conditions can be treated.

Example of: Depression and likely psychosis in SHU Severe medical condition Deteriorates in SHU

7,C ,

(Interviewed while housed in observation).

6 has been in prison for many years. He jumped fiom a 4th floor at age
20 -he says he sincerelybelieved he could fly. Between prison terms in approximately
1996, he was civilly committed to Mid-Hudson, where a fight occurred and he reports he "killed a roommate." He re-entered DOCS in 1997, and he says, he is considered , mentally ill and dangerous. He has been to CNYPC, where he was told (following a psychological assessment by Dr. Wilson) that there's nothing wrong with him, "it's a behavior problem." He complains the staffthreaten him. He has been in observation for 56 days. He received his clothes and letters a few days prior to our interview, but before that he was stripped and lacked amenities. When asked if he suffers &oma mental illness, he reports he has been depressed since age 15 or 16. He attempted suicide at 15 or 16 and was admitted to a psychiatric hospital (Marcy a s civil commit?) There he was I , charged with assaulting a staff member in 1989. He says he gets depressed a lot, he will not admit to hearing voices, but "something" tells him "to do certain things." He was admitted to Mid-Hudson three times on civil commitments or court-related evaluations. In 1988 he attempted to hang himself in jail and was admitted to CNWC for a competency evaluation. He remembers he had been on street drugs,was very paranoid, and the jail officers thought he was a threat to the jail. He thinks the officersmess with him and hold back his meals. He has set cell fires within DOCS. He has tried to hang himself and he has cut his wrists. He claims he did not brush his teeth for 30 days in observation because he had no tooth brush nor paste. He has never been in SHU. He was in ICP and did well at Wende. He has been prescribed Thorazine, Stelazine, Seroquel (400 mg. twice a day) and Depacote (1000 mg.). The anti-psychotics did help him calm down, and Depacote helped stabilize his moods. He has tried Prozac, but became agitated. He says his only interviews with mental health staff occur at cell-hnt. He has received tickets for threatening st* but these incidents only occur after his medications are discontinued. He wants to be prescribed the medications. On mental status he seems
depressed with an edge of agitation. He has ideas of reference, believing th& the C.0.s
mess with him and refuse to give him his meals. He has "thoughts" (his euphemism for auditory hallucinations) that he believes are really people trying to make him do things. He describes a feeling that he is going crazy, "my brain feels like it's blowing up." He reports that when he feels like threatening people, he punches himself in the face instead, or bangs his head against the wall. He complains of severe anhedonia.

6 thick clinical chart fills two cartons. There is corroboration of much of the history he presents. He has spent most of his adult life in a mental hospital or behind bars. He is serving a life sentence. A car accident in 1976led to a seizure disorder. During his first DOC bit, around 1995, he cut himself repeatedly and had to be hospitalized. He cycled to Observation quite a lot, was prescribed high dosages of mood-

stabilizing medications and anti-seizure meds. He soon was treated with anti-psychotics a s well, and intermittentlywith antidepressants. He continued recycling to Observation, CNYPC and back to GP or Keeplock. He was convicted of killing a roommate at MidHudson Psych. Center on 7/30/98 by choking. He is consistently noted to get agitated, engage in "para-suicidal behaviory'and represent a grave danger of assault as well as self-
harm. He is usually MH Level I when in Observation or CNYPC.He was functioning
well in ICP in October, 2001, with diagnosis Adjustment Dis w Depressed Mood, and a combination of mood-stabilizing, antidepressant and anti-psychotic medications. During a 9118101 admission to 5-Points OMH Satellite his diagnosiswas Organic Mood Disorder, Mixed, with Vistaril and Thorazine prescribed. During his 43rd admission to CNYPC in August, 2001, he complained of agitation and auditory hallucinations commanding him to kill others. He was prescribed Seroquel800 mg. per day, Risperdal6 mg. per day, Remeron 45 mg. before bedtime, Vistaril300 mg. per day and Phenobarb 60 mg. b i d . On 10/01/01his diagnosis was Intermittent Explosive Disorder with ASPD and Seizure Disorder. He was discharged to Wende ICP, but he had homicidal feelings towards a reputed child molester and had to be sent back to CNYPC. An 11/21/01report
of Neuropsych. Testing by two Binghampton University students found that p E has
deficiencies in multiple realms, including intellectual functioning, memory, and selfharming behaviors. He was admitted to CNYPC for the 47th time on 3/1/02, with diagnoses Impulse Control Dis. NOS and ASPD, because he tried to hang himself after acting "agitated." He was found on the floor with a noose around his neck and had to be sent to the medical hospital. He was prescribed Remeron 30 mg., Depacote 2,000 mg., Seroqeul600 mg. and phenobarb 90 mg. at time of admission. He was noted to calm down and act appropriately at CNYPC, except he got into disputes with other inmates and had to be placed on a SPL I because he was suicidal. He was intermittently placed in side rooms or in 5-point restraints, often for agitation, and was given injectionsof neuroleptics on an emergency basis several times. He was noted to suffer seizures, for which medications were prescribed. Upon dischargeon 3/15/02, he is calm, but is "guarded and suspicious." He is seen as goal-directed and manipulative, with ASPD and Borderline Character Disorder. He is prescribed Depacote 1,000 mg. b i d . and Phenobarb 90 mg. b i d . On 9/13/02 he was re-admitted to CNYPC because he made a serious suicide attempt by hanging and was cyanotic, plus he was banging his head. A '"Behavior Plan for "$Be, " is dated 1/09/03. In it, a PCLR score of 40 (out of 40) is noted, it is noted he has spent nearly 50% of his time in DOC as a psychiatric inpatient, and a series of consequences are outlined. He will not be re-admitted to
CNYPC (too much secondary gain and no benefit), he will be placed in observation with minimal amenities (two mats and a smock) and a 1-on-1 DOC watch when he is selfdestructiveor assaultive, There will be a weekly teleconference about him with CNYPC
and 5-Point treatment teams, each time he acts out he will be made to participate in a "careful behavioral chain analysis, he will be subject to usual DOC disciplinary procedures, he will be medicated symptomatically, he will be praised for good behavior, when he demonstrates appropriatebehavior for five days he will be given fhrther amenities, a job possibility will be sought when he is on good behavior, and he will not be admitted to ICP or STP (for which he is ineligible), but since he cannot be in GP he will be sent to AdministrativeProtective Custody with constant video sw.eillance. It is
20

anticipated he will display a protracted increase in self-injuriousbehaviors, termed an "extinction burst," after this plan is instituted. This behavior plan is supportedby a 11118/02, 112page PsychologicalAssessment by Dr. John S . Wilson, in which 6 6
history is summarized; he is given no Axis I diagnosis but Axis TI diagnoses include
ASPD (psychopath), narcissistic and sadistic personality disorder, and it is noted he does not even meet the criteria for Borderline Personality Disorder, but his instability of mood make psychotropic medications likely helpful, etc.
Subsequent to the Behavior Management Plan (1/9/03): He was in Five Points OMH Satellite Unit from 1115/03 until at least 4/14/03. There are daily, brief typed notes
while he is in observation with gown, blankets, no mattress -notes mostly comment
about whether he is eating. Clearly he gets no recreation. He is treated with Haldol or Seroquel to "help with his temper." His medications are discontinued because he does not suffer from mental illness. He has a JMC (Joint Management Committee). Dr.
Wilson comes to visit from CNYPC and alters the management plan; 9 Ca gets his
"greens" (clothes?) back in late February, but not fill amenities. He is given CBT daily for fifteen minutes, but seems uncooperative -notes reflect he does not wish to participate in skill-building, etc. Given.&I1amenities, but in observationcell, on 3-12/03. Comrntinicates re sex with other P in RCTP by writing in a novel and passing it to the other. Notes go through 4114/03, he is still on 1-to-1observation in RCTP, still in smock and mats, still threatening suicide with very limited amenities. By 5/14/03 he remains in observation, is on loaf for throwing milk, and is on random 15 minute checks instead of 1-on-1. He is not on medications, but is requesting them. He intermittentlyrefbses to eat for significant periods of time. By 6/2/03, he has had a hearing for two tier 3 tickets (includingthrowing milk at CO while in observation), and is given six months SIW time, which he will serve in the STPUnit, but he will not be in STP programming. He was
placed on A2 Unit,and told staff he liked SHU better than observation, and enjoyedrec as well as keeping food in his cell. A few weeks later he was given a razor. He had additional hearings and was given more SHU time. He adjusted well to SHU until he
"cut up" on 7111/03,and was sent to outside hospital where 60 stitcheswere done on his
arm,and then he was returned to 140-1 observationin RCTP. His behavior deteriorated,
he smeared feces and rubbed feces in his wound and picked at sutures. He was placed on
loaf, and again began rehsing to eat. As of 7/22/03 he is in RCTP,non-cooperating with CBT, on a self-harm hunger strike, and on 140-1 watch and video monitoring, with
limited amenities. Notes continuethrough 7130103 that describehow he is still in observation on 1-to-1, but he is eating.
Example of: Probable atypical SMI, with depression'
Most of time spent in isolation, SHU or observation
Self-destructive over entire lifetime Un-diagnosed and put on Behav Mgmnt Plan Remains on anti-psychotic & mood stabilizing meds even after un-diagnosed Spends very long time in observation w no amenities

Probably regresses in SHU Many, many admissions to CNYPC

T y

(Interviewed while housed in STP).

This is T, Y"s third prison term. He has been in STP since Dec. 5, and he
has been in S W since 2001. He likes STP better than SHU because there are more opportunities to talk to staff. He likes group therapy and the movies that are shown. Two weeks prior to our interview he had an incident in which he blacked out and felt his mind was not right, but the COs who took him to the infinnaryjoked about his situation. He was 16 when he was involved in "the riot" at Southport, and feels the staff never lets him forget that. He is taking Prozac, Risperdal and Seroquel, and feels the medications slow his speeding mind and help him sleep. Still, he keeps believing they are poisoning his food. He has a very difficult time in SHU, the noise bothers him, he cannot q ~ ehtis racing mind. The last of several times he was at CNYPC was last November, after staff discontinued his medicationsbecause they found pills in his cell that did not belong to him. He hears voices commanding him to cut himself. When he cuts his wrists the officers disrespect him, he is taken to observation where there is no mattress and no sink and he is stripped and his voices get worse. He has heard voices since childhood, but never as bad as when he is in SHU. He was shot in the lungs as a teen, and attempted suicide as a teen, and was taking psychiatric medications prior to corning to prison. He abused substances. He has "panic attacks" in the SHU. He believes the COs harass him as "get back" because of the 1991"not." He complains the COs beat him for no reason. His symptoms and history are very credible, and he suffers fiom psychosis with or without a mood disorder.

The clinical chart for this prisoner reflects M H Level 1 since January, 2003, at
least four admissions to CNYPC since 1998, and that he has been diagnosed Schizophrenic, disorganized type, and has been observed to have bizarre, sometimes catatonicbehavior. He was transferred h m Auburn SHU to CNUPC on 11/16/01,was clearly psychotic and regressed with a Dx. of Schizophrenia, and back to Auburn SHU at discharge on 4/18/02. He was treated with anti-psychoticmedications, including Seroquel250mg. per day, and was noted to be very regressed. Previous admissions to
CNYPC included self-ham, once by hanging. A 12/5/02 CNYPC discharge summary notes a recommendation that Prisoner M.M. go to STP, and that reco~nmendationwas
followed. This very disturbed man with Schizophrenia decompensates intermittently, but he is also assaultive and draws long SHU terms - there is no evidence on the clinical
chart that MH staff intervene with hearing officers. He receives many tickets which
result in increased time in SHU, and the dates of the tickets are interspersed between admissions to CNYPC. Time in SHU worsens his psychosis. STP is an improvement, but he should not be returned to SHU and needs a longterm treatment setting such as ICP.

Example of: Severe psychosis, Schizophrenia, in SEW Symptoms worse in SHU

Cycling from SHU to CNYPC and observation & back to SHU
Tickets related to mental illness
Recent transfer to STP- concern re future return to SHU

Sullivan Correctional Institution - 5/5/03

7.pa3

(Interviewed while housed in the Satellite Unit).

p.p 3 had been at Fishkill until one year earlier, when he was transferred
to the MH Satellite Unit ICP. There he took prescribed psychotropic medications (the

, anti-psychotic Zyprexa) and managed adequately until mid-April, 2003, when he stopped taking his medications. His behavior regressed, and he began to threaten others and

became agitated and disorganized. He was about to be transfmed to CNYPC when we

met. On mental status exam, 9,B,

was agitated, with pressured speech and loose

' associations, and spoke passionately in a sometimes delusional manner, while at other

times seeminglucid and concerned about very real dangers facinghim in the prison

environment. He told us he has never been to SKU, and feels that he has generally been

,I, treated alright by OMH. It is noted that p,9,;%" was admitted to psychiatric
hospitals prior to incarceration, he entered prison in 1994, and he is noted to have been

suffering from Paranoid Schizoprenia since early adulthood. He has been admitted to

CNYPC on multiple occasions (approx four times), usually due to non-compliance with

prescribed anti-psychotic medications (Risperdal, Zyprexa).

Prisoner

8B ~ C

(Interviewed while housed in observation).

B,B C was transferred &om nearby Woodburn CorrectionalInstitution to the
SatelliteMH Unit because he told an officer he wanted to hurt himself. He stateshe is Bipolar and takes Depacote, Benadryl, Risperdal, Zoloft and Haldol. He has been hearing voices since 1999. He was hospitalized on a psychiatric ward at Bonsequors Hospital psychiatric unit prior to incarceration. He sees a psychotherapist at Woodburn, but feels it isn't really treatment because his therapist sees him only for a few minutes at a time and really does not wish to talk to him about anything. He stays to himself most of the h e , and has a job as a porter. He has been in the ASAT drug treatmentprogram and the ART anger management program. In observation he wears only a Ferguson gown
and has only a Ferguson blanket and thin mattress in the cell with him. He has been in
observation for approximately a week, and being here has made him even more depressed because there is nothing to do. He finished the ninth grade. He has never been in keeplock nor SHU. He feels that Woodbume is a "prettyOK place." On mental status examinationhe seems oriented in all spheres, his affect is flat with some depressed mood and occasional internal preoccupation linked to inappropriatelaughter. Review of his
chart corroborates his history and is ~onsistenwt ith mental status today. He had psychiatric treatment prior to incarceration; he made a serious suicide attempt in 1994, he
is serving one and a half to three and a half years, and he has not been to CNYPC. He
was transferred fkom Woodboume to Sullivan MHU on 4/29/03because of suicidal

ideation and plan. His Diagnoses include Bipolar Disorder and Paranoid Schizophrenia, and he is prescribed Risperdal6mg./ day, Haldol 5 mg. pm, Depacote 1,000 mg, and Zoloft. He is MH Level 1. His history includes many suicide attemptswhile incarcerated. Later progress notes reflect diagnoses Par. Schiz and Bipolar, and he is treated with anti-psychotic and mood-stabilizing medications.

Example of: Prisoner with SMI in Medium, no SHU time Transfer to Max MHU when he decompensates Kept in observation for a week without admit to CNYPC Observation has harsh conditions

T, Pij

(Interviewed while housed in SHU).

"B W . has been in prison for seven years on this bit, and had a prior bit of
six years. He is mentally ill, HW+, and has a serious dmg problem. He has been in and out of SHU since 1998, mostly related to drug use within prison. He is not assaultive, but he has been in the same cell in SHU for two years, with seven months remaining of his SHU term. He would like to be transferred to Keeplock where he might serve out his SHU term while being able to attend drug treatment. He describes very severe depression, great trouble getting up in the morning and getting started with his day, a strong need to isolate himself even within the SHU context, and suicidal thoughts. He has been at CNYPC three times. He is proud of earning a "violence certificate" at Marcy. In SHU he is unable to concentrate and read, he has panic attacks, and the depression is much worse. He sees the psychiatrist approximately once a month at cell-front, but never has a private, confidential interview and does not really talk to the mental health staff when they make rounds at cell-fiont. He has been to the Mental Health Unit (observation)several times, the last time in December, 2002. On mental status he appears earnest but depressed. There is psychomotor retardation, a sense of hopelessness and low self-esteem. He says he is not currently suicidal because he has a plan to get himself placed in keeplock so he can be in drug treatment (he has not been in drug treatment except for a brief time in an NA program) and maybe earn his parole. His clinical chart corroborates his history. He was admitted to CNYPC in Aug. 2001 and again in August 2002. His diagnoses include Major Depressive Disorder with Psychotic Features, Psychosis NOS and Dysthyrnic Disorder. He has had many admissions to observation for suicidal behaviors, including hanging up and cutting himself. His emotional symptoms are clearly worse when he is in SHU. A 6/6/01 Admission Note to CNYPC gives reason for admission: " T H was referred due to regressed and unpredictable behavior. He was eating his own feces and was experiencing command hallucinations. He attempted to hang up in SHSJ and had o be cut down." His medications have included Thorazine 150 mg. h.s., Wellbutrin, Vistaril. Clearly this man suffers fiom serious mental illness, a severe mood disorder and psychosis, and he decompensates and becomes suicidal repeatedly while in SHU. He cycles from SHU to
RCTP and CNYPC and back to SHU, he has a substance abuse problem and using drugs gets him sent to SHU and also worsens his mental illness. Yet he remains in SHU. He

needs to be removed and placed in a treatment setting such as ICP, and he needs concurrent substance abuse treatment.

Example of: Depression with psychosis in SHU for substance infractions Dual Diagnosis with SubstanceAbuse and SMI Unable to get drug treatment because he is in SHU for drug offenses Cycles from SHU to observation and CNYPC and back to SHU Deterioration in SHU

Prisoner

Cis hs

(Interviewed while housed in SHU).

smiles readily and says innocently "some of my disciplinaryproblems are because of my mental illness." He receives many tier 3 tickets because he writes threatening letters. The letter-writingis entirely compulsive, he explains, and he does not really think about it and he cannot stop himself. I asked if the compulsion to write threatening letterswas related to mounting anxiety or anger, and he seemed reassured that he was being understood. I asked about earlier obsessive and compulsive symptoms and he averred washing his hands hundreds of times per day at age 13. He began making
threateningphone callsin his mid-teens, and that became a habit, He saw a psychiatrist in the communitywho prescribed Zoloft 150mg./day to help him cut down on the
compulsive behavior. He was in the ICP, but two weeks ago he was charged with
assaulting an officer-his first overtly assaultive charge although there have been many
threats and threatening letters. He explains that he did not actually assault anyone. He is very hard of heaxing, and did not hear an order to move back while being escorted and in handcuffs. He stepped back and lost his balance, and evidently bumped into an officer. He was accused of kicking the officer, was thrown against a wall and beaten. Since he has been in SHU the past two weeks he has felt much more anxious and has trouble controllinghis "cussing." He also gets very depressed. He has not been admitted to CNYPC, but he does intermittentlyfeel hopeless and suicidal. He cannot concentratein SHU, cannot read, and has great difficulty sleeping. On mental status he appears quite sad in spite of his smiling, seems quite sincere, describes compulsions that include the writing of threatening letters, clearly has no intention of harming anyone, and seems perplexed about how he has gotten himself in the jam he is in and what he might do to get out of it. In other words, he seems quite innocent in multiple senses of that word.

The clinical chart for prisoner QGhconfirmtshe history he presents. He has not
been admitted to CNPTPC. He entered Downstate Reception a MH Level 2 on 3/1/99, and his MH Level was changed to 1at Sullivan on 10/21/02. His Dx is Obsessive-
CompulsiveDisorder and Eepressive Disorder. He had one psychiatric hospital stayin the community, court-ordered for evaluation at time of trial. He was sentenced fbr 'bomb threats." He has been prescribed Zoloft by OMH, and is described as a "shy, coy, childlikemale who gets angry and makes false statements." (5/8/00). He has been seen by outpatient OMH staff, and has spent much time in SHU. There are no notations re OMH staff discussing his mental illness with any hearing officer, except on 2/22/99 a

Fz. note refers to referral to MH from

for second opinion - possibly regarding a

hearing? There are many outpatient Progress Notes, mostly noting OK adjustment when

he is in S W (and seen at cell-front). He is sometimes in Protective Custody. He is

prescribed 150 mg. Zoloft per day, plus Vistaril and occasional other medications.

Nobody writes that they suspect malingering or doubt his diagnosis, until social worker

David Privett writes on 11/20/03,that compulsion to write threatening letters occurs

when angry, and therefore he doubts the diagnosis of OCD - this is an erroneous

conclusion, since a compulsive symptom is likely to be worsened by anger or anxiety.

Notes continue through 4/04. A psychiatric evaluation on 2/18/04 contains a diagnosis of
Depressive Disorder + R/OOCD, and Zoloft 200 mg./day +Buspar & Vistaril is

continued. He is seen cell-side frequently, and every two weeks by a therapist, cell-side

or in a private room.

Example of:
SMI in SHU
Rule-breaking (threats) driven by SMI (OCD + Depression)
More disturbed in SHU

c CrT.

(Interviewed while housed in SHU).

&.. T' has been in prison for five years and has been in the SHU for one year. Before that he was in IPC (involuntary protective custody) because staff were afraid there would be retaliation against him for talking to investigators in a case involving the rape of his sister, where the perpetrator is also behind bars. He is depressed, and he cuts himself frequently. Last Thanksgivinghe swallowed 40 or 50 pills in a suicide attempt. He receives disciplinaryreports (tickets) when he tells the mental health staff on their rounds in SHU that he is contemplating suicide. He believes the officers are poisoning his food. He was seeing a psychiatrist in the community prior to incarceration,and taking Thorazine and Elavil. He is currently prescribed Zoloft. He has never been removed fiom his cell to see the mental health staff, rather he sees them at cell-fiont when they make rounds. When he was taken to observation following his suicide attempt last Thanksgiving, he ate his own feces because he very much wanted to die. He received a ticket for that behavior. He reports that being in SKU makes his depression much worse, and makes it impossible for him to get help fiom mental health staff. Currentlyhe wants to die and is contemplating suicide. He feels hopeless about getting help from mental health while in SHU. He is overtly depressed, agitated, and anxious, and exhibits pressured speech and flight of ideas. His clinical chart includes diagnoses of no
diagnosis, anxiety, depression, psychosis NOS and psychopathy, but also corroborates his
story about repeated admissions to observation for suicidal behavior. A 7/21/03 inpatient
CNYPC ScreeningIAdmissionNote has the diagnosis Psychotic Disorder NOS and
ASPD, notes hallucinations and delusions as well as suicidal, mentions paranoia, and
gives him a GAF of 25, with 60 the highest in the last year. He had been in observation
at RCTP for a suicide attempt, The 7/21/03 core history notes no pre-incarceration history of psychiatric treatment. A Psychological Evaluation Notes psychopathy on the
PCL-R.Psychologist John Pelkey recommends: "Any acts of self-harm or involvement

in para-suicidal activity should be viewed as entirely manipulative in nature." A Behavioral Management Plan is recommended. He is placed on SPLI Level 1. He was discharged from CNYPC on 8/12/03, on no medications. But on 8/07/03, he had been taking Risperdal3 mg. per day and Zolofi 100mg. per day.

Example of: Severe Depression in SHU Cell-front only treatment Cycling from SHU to observation and CNYPC and back to SHU Un-diagnosis Remains on psychiatric medications after undiagnosed

2,A,

(Interviewed while housed in SNU),

A has been in prison since 1987and has been in the Special Needs Unit at
Sullivan for the past year. He has been in ICP programs as well as General Population at several different institutions. He takes psychiatric medications, and reports that if he does not take the medications he will certainly hear voices commanding him to kill himself. He has not attempted suicide for several years, but earlier he was admitted to CNYPC. He is a h i d of being sent to observation in the MHU because he had a very traumatic experience there. The last time he was there there was blood all over the cell he was placed in, and spiders and other bugs under the mattress and along the walls. KSOnv, *004Z~'& f" you. He spent a month there, naked except a thin gown. He gets tickets when he admits to being suicidal. Currently he is on Keeplock status for arguing with an officer while being transported to court. He has learned to read and write in prison, and now has a job. He has had multiple suicide attempts, including attempts to swallow batteries and razors. He has been called a malingerer in the past, but currently feels he is doing OK if he takes his medications. His clinical chart corroborates the history he presents. He has been admitted to CNYPC several times over many years. He is diagnosed Major Depression, Recurrent, with ASPD. Other notes include Psychotic 'Features, and command hallucinations are noted repeatedly, especially as involved in
suicidal threats and behaviors that lead to re-admission to CNYPC. He has spent time at
Meryl Cooper. He is prescribed relatively high dosages of anti-psychotic medications. Other medications at various times include Seroquel, Depacote, Neurontin, Rerneron, Sinequan and various minor tranquilizers. Interestingly, in 1991, he was viewed as suffering from SMI, but his medications were minor tranquilizers, then antidepressants were added, and by 1994or 1995, he was being prescnied anti-psychotic medications. One wonders if the stresses and traumas of prison life worsened his depressive condition and caused the psychotic features. There seems to be no disagreement that he suffers from serious mental illness and low intellectualhctioning, even if IQ reported is 87, and there are notes about him not being appropriate for SHU.

Example of: Psychosis/Depression and Mental Retardation

Spent a month naked in observation Viewed as not appropriate for SHU

L : V:,

(interviewed while housed in ICP).

L. V who speaks slowly, has been in ICP at Sullivan for a year. He has
been in ICP, SHU, and observation at several institutions. He has been to CNYPC 19 times altogether, during his three prison terms. He reports he hears voices and gets very depressed. The last time he was discharged from CNY'PC it was recommended he go to ICP. He has received tickets for assaulting an officer. He likes the ICP at Sullivan, and
feels he is treated OIL His clinical chart corroborates his history. He was admitted to
ICP on 8/9/02, was diagnosed Bipolar Disorder, and was prescribed Depakene 1000 mg. bid., Risperdal3 mg. bid., and Zoloft 100 mg. His chart reflects a history of long-term serious mental illness from early adulthood with prominent auditory hallucinations, as well as a record of criminal behavior and assaultiveness. He becomes withdrawn, disheveled, suicidal, mute, smears his cell with feces when he stops taking his medication. He can also become assaultive, and has a long criminalrecord and many disciplinariesin DOCS. This man is in ICP, which is appropriate. He needs long-term mental health care and is obviously incapable of programming in GP and should never be in SHU. There are notes reflecting old head injuries/ organicbrain disorder, and he did have some psych assessment in the mid-19907s,or a partial work-up. He seems to be erroneously diagnosed as Bipolar alone -he clearly becomes psychotic (some notes
reflect psychosis, e.g. Admission/Screeningform dated 8/9/00 - others do not mention
psychosis) and is taking anti-psychotic medications as well as a mood stabilizer and antidepressant. Clearly, his condition worsened in SHU, and there is a question whether
the ticketed behaviors that landed him in SMJ might have been driven by mental illness. As of progress note dated 8/27/03, he remains in ICP, is prescribed Risperdal, Zolofi, Benadryl and Depacote, is working as a porter and waiting to be admitted to RSAT.

Example of: Psychosis and Depression in ICP Wrong diagnosis on chart: leave out psychosis But prescribed anti-psychotic medications

E. P

(Interviewed while housed in ICP).

E

is in the eighth year of his first prison term. He has been in ICP for

one week, and prior to that he spent 45 days double-celled in general population, even

though he is Mental Health Level 1. He has never been in SHU,but he has been in

Keeplock and he has been in "a strip cell" (observation) many times. He has been

suicidal on many occasions. He explains that if he does not take his medicationshe gets

frustrated and "harigs up." He hears voices. Because he has Hepatitis C, he does not

want to take an antidepressant. So he takes Risperdal, which helps "a little." He keeps

his frequent suicidal thoughts to himself because he is terrified he might be sent to a strip

cell again. His mental status reflects depression with a bizarre edge to his presentation,

suggesting the possible presence of delusional thinking that is being kept under wraps. His chart includes a September, 2000 admission to CNYPC and multiple diagnoses, including Delusional Disorder, PTSD with Depressive Disorder, Paranoid Personality Disorder, and Adjustment Disorder. In 12/00he was transferred from Great Meadow to Wende because of security concerns, and evidently he has problems getting along with other prisoners, and is victimized. He seems under-diagnosed, being admitted to C f u i C for paranoid delusions while still being diagnosed Adjustment Disorder or Mood Disorder. He is prescribed Risperdal, and his chart corroborates his history. On 4/3/03 he was MH Level 1.

Example of: a SM, probable psychosis, in ICP
Under-diagnosis Double celled in GP in spite of SMI , Rough time in observation

F*

(Interviewed while housed in Keeplock).

81,

X f, has been in prison since he was 16. He is currently on Keeplock in

General Population at Sullivan. He was transferred to Sullivan in February. He has been

at CNYPC nine times, mostly because he becomes suicidal when he is severely
depressed. He says they keep him only a short time because he arrives from SHU-if he

were arriving fkom GP, he believes they would keep him at CNYPC for a longer period.

He also cannot control his terqer when he is depressed, and gets tickets for assault. He

is a h i d to tell staff how he feels because they will throw him in a strip cell, where "you

are naked and cold and nobody talks to you." He says he was in observation at Clinton

for 67 days in 2001. There is no other treatment besides a strip cell, so it is overused. He

has been in SHU, where he gets very depressed and has even more trouble controlling his

anger. The officers in SHU treat him badly, and he is always afraid he will get additional

tickets. He has received seven tickets for self-destructive behaviors, and several resulted

in SHU tams. In SHU, contacts with mental health are not confidentialbecause they
occur at cell-front - and therefore he will not talk to the mental health staff in SHU, even

though he becomes very depressed and strugglesbecause he cannot control the anger that

mounts when he is in SHU.

Prisoner 1q>'s clinical chart is consistentwith the history he presented. He was at CNYPC fiom 9/25/02 to 10122and again fkom 10131/02 through 2/12/03, when he was
transferred to Sullivan. He is noted to have a diagnosis of Adjustment Disorder .With Mixed Disturbance of Conduct, despite the fact that notes reflect multiple suicide
attempts, hearing voices, a diagnosis in 12/98upon admission to CNYPC for the third
time of SchizoaffectiveDisorder, and during a prior admission to CNYPC, he was
diagnosed Bipolar Disorder, Manic type. In a 10/31/02 Core History at CNYPC,'The
patient was transferred to this facilitybecause he hears voices. He stated he wanted to kill himself. He did display psychomotorretardation. He was very depressed. He was sleeping and eating poorly." Again, during his seventh admission to CNYPC, he

"presented in a dysphoric state, stating that he wanted to be reunited wihis deceased
grandmother.. .." In mid-2000, upon discharge from another CNYPC hospitalization, he
started refusing medications, and for this reason was rejected from the ICP program that
had been recomrnended. He has also been diagnosed Mallory Weiss Syndrome, and in
7/21/00, it is noted that this condition causes him no current problems. In spite of a Dx of
Adjustment Disorder, he was prescribed Zyprexa 10mg. b.i.d. dn Paxil20 mg. b i d . from Feb. through May, 2003. And on a CNYPC face sheet of 2/12/03, the "Primary" diagnosis is Bipolar Disorder, Manic Type. There are many self-hamrlsuicideincidents, many stays in observation at multiple institutions, and quite a lot of time in SHU and/or Keeplock. A 3/10/03 progress note (after he was returned to SHU at Sullivan following a
stint in observation from 2113 through 2/18/03 to serve a three-month SHU term): "...
F3related that the medication is, in fact, fine. He hasn't felt depressed, or heard voices, just feels anxious about being in SHU another couple of months. He was
reassured regarding this. He will be followed up, as usual - Dr. Kathpalia, M.D." He has
intermittentlybeen cooperative and then refbsed to see or talk to IvlH staff or to take medications. He has attempted to harm himself while in observation on several occasions, and he has presented very big management problems, especially when he is in SHU or on Keep-lock. In summary, this prisoner is severely depressed and likely suffering from a severe Axis I mood disorder, most likely Bipolar Disorder with intermittentpsychosis, acts out, often with self-harmingbehaviors, is not very cooperative in treatment, has been admitted to CNYPC on at least seven occasions and has spent a large amount of time in observation. Meanwhile, he is often underdiagnosed as an Adjustment Disorder even while being prescribed strong doses of anti-psychotic and antidepressant medications. He is in Keeplock in GP now, but has spent a lot of time in SHU for behaviors that are possibly linked to his mental illness, e.g. self-destructive acts.

Example of: SWdepression, currently in ICP, was in SHU Tickets for self-harm Naked and cold in observation for two months @ Clinton Long time in SHU with cycling to observation and CNYPC and back to SHU
Bedford Hills Correctional Institutional - 5/6/03

EsEs

(Interviewed while housed in observation).

E,E. G tias been in prison since 1992, and was in the ICP since it opened in
2000. She reports she has cut herself many times, and shows many scars. She began a long series of suicide attemptsbyjumping off the third floor of the old hospital after losing an appeal in 1993or 1994. She says '%hey say you get therapy in ICP, but you don't." She has been to SHU one time. She describes an incident in February, 2002, when she refused to sit in the BOSS chair and they "took me down." Officers cut off all of her clothes. She is currently on Keeplock status. It is very cold in observation. She banged her head on the metal of her cell for an hour and no staffcame to see what was

going on. Her therapist comes by in the morning and talks to her at cell-fiont, and her psychiatrist sees her only at cell-Eont as well. There is no recreation for women in
observation. She is never seen in an office while in observation. She feels there is no treatment going on, especially in observation but even in ICP, and people "don't get to talk about their mental health problems.'' She was at CNYPC in 1990 for an evaluation for court, and since being in DOCS, she has been there 18 or 19 times. She currently takes Prozac, 60 mg. per day, and Seroquel600 mg. per day. She does not think she is
psychotic. When she gets a ticket, she believes Oh4H is consulted by the hearing officer. Her clinical chart fills over half of a carton. There are many admissions to RCTP and
CNYPC, she is recurrently suicidal and assaultive and is placed on behavior management, SPL 1, e.g. on 11/30/02 at CNYPC. Diagnoses include Dysthymia, Impulse Control Disorder, ASPD. She is fi-equentlyself-injurious, cutting, banging head, setting fire to cell, hanging up. She is fi-equentlyin restraints. Her 19th admission to
CNYPC was 7/02 - 12/02. She suffers fiom hyperthyroidism. She has been prescribed
Depacote, Haldol, Klonopin, Vistaril, In 7/03, two months after our interview, she made
another suicide attempt by hanging, was not damaged physically, and was re-admitted to CNYPC. In summary,this prisoner presents a very complex and diEcult clinical picture. She is diagnosed Borderline Character Disorder, there is self-injurious and acting out behavior, she is repeatedly hospitalized, she is not cooperative with medications. She suffers from hyperthyroidism. One wonders about the presence of psychosis or mood disorder with psychotic features. But ICP, where she has been for years, is probably the best treatment environment for her.

Example of: SMI in ICP w cycling to observation & CMYPC Harsh treatment in observation

bd C,

(Interviewed while housed in observation).

C had been transferred fi-om SHU to observation and had been in SHU (osr on Keeplock status) since July. Prior to that, she had been in ICP because, she reports, she is "Bipolar and explosive." She has been admitted to CNYPC, she has had episodes of fighting, she has tried to stab herself and she has trashed her cell. It was after another prisoner, X died, that she tried to strangleherself and was admitted to CNYPC. She is prescribed Seroquel and Trazadone, and has been prescribed Depacote in the past. She claims she was ''beaten" by COs on the way to observation. Shehas a two year old daughter, and says she came to prison while in a post-partum depression, as a parole violator. She has been 'kecycling" between SHU and observation. She was abused as a child and suffers from flashbacks, but now her flashbacks include scenes of being beaten by officers. A month prior to our interview she tried burning hefselfwhile in an observation cell, and was sent back to SHU. She has a very hard time in SHU, it is very loud, and she has traumatic memories of her friend dying there. She gets depressed and cries a lot while in SHU. She would like to go to the ICP. She suffm &om asthma as well as panic attacks. In SHU, she is unable to concentrate, and,for example, finds herself reading the same paragraph over and over again without any comprehension.

past, she had been prescribed Depacote. She was admitted to RCTP on 11/11/03with stab marks on her ann and complaints about COs, and on 11/13/03 she was discharged back to ICP from the donn. A 3/3/04 progress note reflects testimony given for disciplinaryhearing. In summary, this woman is very disruptive and chronically selfharming. She is given various diagnoses, is prescribed anti-psychotic and antidepressant medications (previously mood-stabilizing), and cycles between SHU, observation and CNYPC. She has also been in ICP without noticeable improvement in disruptive pattern.

Example of: SMI (likely Bipolar) in SHU Cycle to observation Deteriorate in SHU Complaint of poor therapy in ICP

8-8C .

(Interviewed while housed in SHU).

8B.C has been in prison since 1998, and will be leaving in September. She
says she has an anger problem, she gets depressed but she is not suicidal, and she takes Seroquel to help her sleep. She is sent to observation when her anger gets out of control. She has witnessed other women being beaten in observation. She feels there is something wrong with the security staff in observation, and they like to beat women. She is unable to read in SMJ because of the incessant noise. She has never been to CNYPC, but she has been in a substance abuse treatment program. Her clinical chart corroborates her history. She had history of psychiatric treatment for a mental disorder that involved

hallucinationsprior to incarceration. From Jan. through June, 2003, there are weekly progress notes about contact in SHU. Her dx is deferred, or she is diagnosed conduct
disorder or impulse control disorder. She is prescribed Seroquel for "insomnia," 200 mg.
twice per day as of 1/29/03-with no good rationalenor report of efficacy(what logic is
there in taking a sleeping pill twice a day?) Notes are poor, with no adequate medication rationale. She is occasionally sent to observation complaining of self-harm ideation. On 8/12/03, she was discharged £romthe OMH caseload. In summary, this young woman is not adequately diagnosed, but she is given relativelyhigh dosages of the anti-psychotic Seroquel, and cycles between SEW and observation.

Example of: Depression in SHU . Complaints of harsh SIIU conditions Mental functioning diminished in SHU Cycles to observation and then back to SHU Discharge from the OMH caseload

'%%Ty ss

(Interviewed while housed in SHU).

F~f, y, has been in prison for four years and expects to be released in 2007.
She is currently prescribed Seroquel, 1,000 mg. per day, and Vistaril. She has been at CNYPC at least twice. She has been involved in altercations. She experiences
hallucinations and delusions when she is enraged and involved in altercations. But she receives tickets, mentions to the hearing officer that she is a mental patient, and she claims no consideration is given to her mental health status. She has lost 60 pounds from not eating in SKU at Albion. In SHU at Albion the psychologist is always in a rush and talks to her briefly at cell-front. When she arrived at Bedford Hills she was placed in observation for nine days. She relates that she has been paranoid and hearing voices since she was 15, at which time she began taking psychiatric medications. In SHU she has problems with her memory and concentration. She gets disoriented and agitated and
the voices bother her - she thinks there is someone outside of her cell "messing with me."
She believes people are listening to her and watching her, and that there is a camera in her cell. She had a period of two years in GP at Albion without a ticket. She has
attempted suicideby cutting her arms. She had previously been sent to CNYPC because
of an overdose. Now her therapist sees her in an office. She stays in her cell for weeks
or months because she is too paranoid to leave it. She is frightened by what she considers abuse by officers of women in observation. It hasn't happened to her, but she is terrified that it will. She watches cell extractions in observation and is homfied. She thinks the
SHU and observation at Albion are much worse than at Bedford. Her clinical chart describes violent tics, paranoia and visual hallucinations involving seeing people in the
walls. She was admitted to CNYPC for the first time on 7/25/02, to be discharged on
10/17/02. She had been in St. John's psychiatric hospital prior to incarceration. Her clinical chart is consistent with the history she provides. In Feb., 2003, she was in CNYPC inpatient and on SPLI observation, periodically in restraints, acting belligerent. She is prescribed anti-psychotic medications as she reports, and in the past she has taken

Haldol, Seroquel, Zyprexa and others. She is noted to be recurrently very suicidal, to experience hallucinations, but when admitted to CNYPC she is agitated,oppositional and belligerent. Diagnosis is Paranoid Schizophrenia or Psychosis NOS. A 1/6/03 Update of her inpatient core history notes her being convicted in court of assault on another prisoner at Albion and being given additional years on her current sentence, to be eligible for release in 2007 instead of 2004. Third admission to CNYPC is 8/1/03through 9/16/03. She is both psychotic and disruptive, noted to be assaultive, she also threatens to "hang up," and is considered a suicide risk. On 11/24/03she is at CNYPC, fourth admission, on SPL 1, and disruptive. On 12/4/03,news arrived at CNYPC that her brother had died. Soon afier, she seems to have calmed down, was grieving, and could be advanced to SPL 2. She was discharged to Bedford Hills, first to OMK Unit and then back to SHU. She is consistently diagnosed Schizophrenia and remains on anti-psychoticmedications. She needs to be removed &om S W and transferred to a long-term mental health setting such as ICP.

Example of: Psychosis (Par. Schiz.) in SHU Does poorly in SHU ,I, Cell-front interviews Outside criminal case Cycles to observation/CNYPC & back to SHU

E,E,T,

(Interviewed while housed in SHU).

G

has been in prison for 11 years. She is seen in S W , where she has

spent over four years. Before that she was in general population. She states she was half

way through a doctoral program prior to entering prison. On mental status examination

she exhibits pressured speech, agitation, some anger and difficultyputting many

sentencestogether into a coherent line of thought. She is taking no medications and is

not receiving mental health help; she saysbecause there is no confidentiality. She says

the isolation in SHU is devastating, there are no programs, and staff tell her that if she

goes on a visit she will be strip-searched and the time will be counted against recreation.

She says she is on involuntary protective custody because other prisoners threaten her,

but she does not want PC. She complains that DOCS does not make it safe for her in

general population. She says she sleeps all the time in SHU, is depressed, finds herself

cursing a lot, and suffers panic episodes. Her clinical chart discusses agoraphobia and

anxiety, with an admission to RCTP on 2/6/02. She has another admission to RCTP in Jan., 2004. OMH notes go back to 1993, reflect anxiety, depression, agoraphobia, etc. -

fears re safety in GP -but no dx, no meds, and she is sent from RCTP to SHU when

doing SHU time, with talk of PC but no protection initiated.

Example of: Depression in SHU Cycles to observation and back to SHU Harsh treatment in SHU

e.

(Interviewed while housed in SHU).

has been in prison since July, 2002, was seen in SHU, where she has been since August, 2002. She has received between 30 and 60 tickets. She says she is very frightened, and is on her way to observation where she has been before. She has tried to hurt herself in the past, but says she is merely strippednaked and kept in an observation cell where she receives no mental health treatment. She claims she cannot control her tendency to talk loudly, but raising her voice in SHU results in more tickets. She describes a vicious cycle where she loses control of her voice in SHU, talks loudly, and then gets more tickets which mean more time in SKU. She is not taking psychiatric medications presently, and had a side effect of hair loss. She would like to be in group psychotherapy. She reports she was beaten in observation and believes this happened because she was unwilling to "get naked in front of men." She has been to observation four or five times. She has been in observation for 16 days, and has never been at Marcy, nor in ICP. She received Social Security disability (SSI) when she was on the street because of mental illness and mental retardation. She was in Special Education all of her life. She has two sons and a daughter who come to visit her.

Example of: SMI in SHU Dysfunctional in SKU Shouts, leads to more tickets Cycles to observation and back to SHU Rough treatment in observation

R ,?.

(Interviewed while housed in SHU).

P has been in prison since 1994. She had been diagnosed ManicDepressive prior to entering prison, and she is currentlyprescribed Seroquel800 mg. per day. She states it is the wrong medicine, "but they won't change it." She is also prescribed Tegretol and Paxil. She has been to observation four times, each time because of self-destructive behavior. She says nobody comes to see her after she expresses suicidal intentions, and then she tries to cut herself or hang herself. She never did anything like that on the streets. She was in ICP for seven or eight months. She describes "the worst abuse" as being beaten while being taken to observation. She also claims she is beaten while in observation. She sees a therapist each week and a psychiatrist every two or three months, but both see her for only a few minutes. She tells me she gets tickets for trying to harm herself. She is short and muscular and masculineappearing. Her 15 inch thick clinical chart includes record of three or four admissions to CNYPC w diagnosis Schizophrenia. Shehas a pre-incarceration record of multiple

psychiatric hospitalizations with diagnoses including Bipolar. Her meds at Bedford Hills included Seroquel, Klonopin, Paxil and Haldol. She also takes seizure meds and has had a seizure work-up, includingbrain imaging. Her third admissionto CNYPC was on 3/17/00 for Depression with command hallucinations and suicide intention. By 7l10101
she was admitted to CNYPC for the fifth time, diagnosis Major Depressive Disorder,
Borderline Personality Disorder and Seizure Disorder. She took a large combo of meds, including the above plus Thorazine, She underwent some Dialectical Behavior Therapy (DBT). Suicide continues to be the issue, plus disruptive behavior triggering 5-point restraints, pm anti-psychoticinjections, etc. Chart through 8/01, continues to be hostile, danger to self, and require meds cocktail plus intermittent restraints. This woman obviously suffers from SMI, there are notes in chart about her exaggerating some symptoms, but she is consistently diagnosed Maj. Depressive Disorder, often with Psychotic Features, and she is given a cocktail of anti-psychotic,mood-stabilizing and antidepressant medications. She should not be in SKU, but needs long-term mental health treatment such as ICP.

Example of: SMI (Bipolar or Schizophrenia) in SHU Cycles to observation and CNYPC and back to SHU Functions poorly in SHU

G?EZ

(Interviewed while housed in ICP).

6 Z has been in prison since 1996. She was admitted to CNYPC once, six months ago. She says "there's abuse - the COs push you to your limit where you have to hurt yourself." She was admitted to ICP after returning from Marcy. She complains that observation is very cold. She reports that she received a ticket for cutting her neck. She is very depressed. She suffers from memory problems. On mental status examination, it is clear this woman is depressed but also has impaired orientation and memory and below average intelligence. She is prone to suicidality if upset. She does
not have any family. She has not received a GED. She is prescribed Prozac, 60 mg. per day, and Trazadone, 100 mg. at bedtime. She has been sent to SHU once because she rehsed to take her medications. The mental health staff arranged to get her out of SHU. She likes her therapist, who sees her for a half hour every Thursday. Her clinical chart is
consistent with the history she reports. Her Diagnosis is Depressive Disorder NOS. She
is prescribed Prozac 60 mg. per day. She was at CNYPC in October, 2002. She was also in observation at CNYPC in 9/03 and10103 for suicidal crisis.

Example of: SMI (Depression) in ICP Removed from SHU per OMH staff

14 b&

(Interviewed while housed in ICP).

H.aB"-

in DOCS for 90 days on a parole violation. She served a year in

2001-2002. She is in ICP after spending 30 days in the mental health satellite. She says

she suffers from OCD (obsessive compulsive disorder) and PTSD (posttraumatic stress

disorder). She had been in SKU at Albion and had a very rough time there, feeling she

was hassled by the COs. She is prescribed Sinequan, Luvox, Paxil and Klonopin. She

has suffered from mental illness since childhood. She was in psychiatric hospitals at bast

three times prior to entering DOCS. The diagnosis that sent her to the hospital was

Depression. She has made several suicide attempts. She has five sons and a daughter,

but does not want her children to visit her in prison. She complains that the COs at

Albion are mean and brutally beat women prisoners. Her clinical chart is consistent with

the history she presents. She is diagnosedPTSD with substance abuse and possible

Borderline PersonalityDisorder on 2/27/03. Medications include Seroquel800 mg.,

Paxil40 mg. and Luvox 200 mg (quite strong dosages of two antidepressantsplus an
atypical anti-psychotic agent - an unusual medication regimen for PTSD alone.) She is

in ICP, and there are notes about past sexual abuse, suicide attempts, paranoia and

disorganized thinking. She had earlier been diagnosed OCD. Notes do reflect her having

emotional difficulties, and earlier abuse with PTSD is reflected often and related to

current emotional crises. It doe: seem, from chart review, that this prisoner would react

strongly to being roughly handled by male officers.

Example of: History of trauma PTSD & OCD in ICP Medications unusual for diagnoses

5 Gjn

(Interviewed while housed in ICP).

came into DOCS in 1995. She has been in ICP for five years. She has been in observation, Keeplock, and now she is in ICP step-up. She overdosed on Klonopin on 9/13/02. She is now prescribed Seroquel and ZoloPt. She sufferspanic attacks and insomnia She likes the therapist she sees monthly for 15or 20 minutes,but is upset with her psychiatrist because the doctor won't talk to her about the son who was killed a year ago, She has been admitted to CNYPC once. She had many psychiatric hospitalizations in the community for Dissociative Disorder and Depression with suicidality. She gets restless legs from the Seroquel. She says that since she has been in prison she has wanted to die. She has never been in SKU. She has done a lot of time in Keeplock. When she becomes depressed she starts thinking about killing herself. She has lost a lot of weight. She is currently depressed, is losing weight and is unable to sleep, and in this state she stays to herself and does not take showers. It was my

impression that she might be taking too much Seroquel, and this could be contributing to her depression. In her clinical chart there are diagnoses of Borderline Personality Disorder and Histrionic Personality disorder with polysubstance abuse. She had a preincarceration mental health record of treatment for Dissociative Disorder and Major Depressive Disorder. She made suicide attempts and was sent to observation. She was admitted to CNYPC on 1/30/02, suicidal, precipitating event being the death of her son. She is prescribed a combo of mood stabilizer (Depacote), antidepressant (Paxil) and antipsychotic (Seroquel &/or Zyprexa).

Exa Depression & DissociativeDisorder in ICP

Sing Sing - 517 -5/8/03

L*Lek -

(Interviewed while house

6,d,K has been in prison for 11 years. He was released last May and
remained in the community for five months until his parole was violated in 10103. He has been in observation for two days because he wanted to kill himself. He has a long history of Depression in prison. He was in CNYPC in 1999. He has served quite a bit of time in SKU, but at one point the 0MH staff at Sullivan gave him a time-cut, and he was in general population at Sing Sing prior to transfer to observation. He tells me that in observation one does not see the staff very often nor for very long, and then only at cellfront. He is not taking medications, and does not see OMH staff outside of observation. He says that while he is in observationhe rekses to come out of his cell to talk to mental health staff because he is frightened. He had been in ICP. He complains that COs treat all "mental health guys" as if they are a threat. He has done a lot of time in SHU, and definitely his depression gets much worse in SHU. He also experiences panic attacks in SHU, and becomes fi-ightened that he will never get out. Just prior to this observation he had been giving away all of his possessions and preparing to h himself. He feels better now that he is safe in observation, but he feels that he needs one-
on-one psychotherapyso he can talk to someone about his feelings - and he definitely
does not get that in observation. He feels he should be in a Medium Security facility, and if he were in Medium he would not be so depressed On his mental health chart, he is noted to be a Mental Health Level 6 in January, 2003, then a 3 in April, 2003, and a 1
now. This in spite of many admissions to CNYPC noted. In other words, this prisoner
suffers from chronic serious depression, and is sometimes treated at CNYPC or observation, but then is essentially discontinued from treatment until the next time his depression leads to a suicide crisis, usually in SHU.

Example of: SMI (Depression) in observation Has spent much time in SHU, with worsening Depression Multiple admissions to observation and CNYPC Dropped from treatment between acute exacerbations

c,6

terviewed while housed in SHU).

Cs@.- is clearly suffering fiom a chronic psychotic condition. He exhibits a
tremor (possibly related to psychiatric medications), he is anxious and very anxious to please, and he exhibits pressured speech. He has been admitted to psychiatric hospitals in , the community six times, and has had ten prison terms. This is his third SKU term, and it began in February, 2003. He received a ticket for breaking the no-smoking rule and then getting into a fight with a CO about it. He was previously prescribed Haldol, 10mg. per day (in spite of likely tardive dyskinesia), Cogentin, and Zyprexa 1 112mg. per day; but on this bit he is not taking psychiatric medications even though medications were offered
to him. He hears voices tellinghim "I'm the Creator, I'm God." He does not try to harm
himself. The only contact he has with mental health staffis that the psychiatrist comes to I, see him briefly at cell-front "once in a while." A nurse brings his medications (but he
said he does not take psych meds - he reports a head injury in the Marines in the early
80's, and that he takes medications for that all the time). He has been admitted to CNYPC several times while in DOCS. He had a questionable competency examinationdetails unclear. He was in ICP at Attica and liked that program. On mental status exam he exhibits very strong First Rank Symptoms. This man suffers fiom chronic Paranoid Schizophrenia and is housed in SHU following assault on an officer. His medication status is unclear h m his history. He does not claim command hallucinationswere involved in the assault. His clinical chart is consistent with this history. His diagnosis is Paranoid Schizophrenia, he is not very treatment-compliant He has been medicated with Haldol, Zyprexa, etc. He is left for long periods in SHU with little if any treatment, always considered SMI, but minimally assessedltreated A Treatment Plan of 10/21/03 reflects he is in ICP and has been for a month, but is aggressive and on Keeplock. Notes reflect that he remains in ICP, is intermittentlynot motivated or fails appointments, but takes his medications (combo of Zyprexa, Haldol and Cogentin), through April, 2004, when chart ends.

Example of: Prisoner with SMI (Schizophrenia) who spends much time in SHU Multiple admissions to observation and CNYPC Not very compliant with treatment Eventually transferred to ICP, where he does better

3%4,

(Interviewed while housed in SHU).

3-A has been in prison since December, 2001, after serving extensivejail
time. He is seen in the SHU at Sing Sing on 5/7/03,his first term in SHU, where he has

been since Dec. 26,2002. His ticket was for being agitated and making noise. He says he was hearing voices at the time, the voices "were telling me lies, telling me to protect myself." He did not raise his mental illness as a defense at the time of the hearing, and he reports that as fax as he knows OMH did not report to the hearing officer that he suffers Erom mental illness (there is no note in his clinical chart reflecting a report to the hearing officer). He says he is Bipolar and Schizophrenic, and he is not proud of it. At the time of the incident that led to his SKU term he was taking only an antidepressant (actually Depacote, a mood stabilizer), whkh did not help with the voices. He believes he is someone besides himself. Prior to incarceration he was hospitalized on a psychi ward at Metropolitan Hospital. He finds himself crying when in general Because he complained he was womed about that symptom, he was trans Fishkill to Sing Sing so that he could receive mental health treatment. In the process, he was reclassified fiom Medium to Maximum merely to receive mental health services. But then, soon after entering the max facility, he received a ticket that led to a SHU term. He is currentlyprescribed Depacote, 1,000mg. per day, Zyprexa, 20 mg. per day, and Atarax for sleep. He feels the medications help, and he is calmer when taking them. He only sees mental health staff when they tow the SHU, and only at cell-front for a few minutes. Once every four months he is taken to an office to talk to mental health staM. When mental health staff query him at cell-fkont, he does not tell them anything because he does not want to be overheard by others. He gets depressed and agitated in SHU. He tries to read and pass his one year term without getting into more trouble. He was offered STP and refused. He has gained ten to 20 pounds since December. He did not appeal his ticket within the 30 day deadline because he is shy and afraid of stigma if he admits he suffers Erom mental illness. His chart is consistent with this history. He is diagnosed Bipolar Disorder. It is noted that he had a pre-incarceration history of psych hospital admissions. He has been in observation for self-ham. Notes fkom rounds in SHU are consistent with his report he won't talk about his problems during cell-fkont interviews. He was admitted to CNYPC in 7/03. He is prescribed anti-psychotic (Haldol, Seroquel, Zyprexa at different times) and mood-stabilizing Oepakote) medications. He was admitted to the re-entry program in 9/03 and was still there in 11/03, when the chart I reviewed ends. In summary, this mostly well-behaved man with chronic serious mental illness trashed his cell at the behest of command hallucinations and served a one-year
S W term for that.

Example of: Prisoner with SMI (Bipolar with Psychotic Features) who spends much time in SHU SHU makes mental illness worse Command hallucinations involved in behaviors that led to ticket No known participation by OMH in hearing Cell-front interviews in SHU preclude real understanding of his emotional pain

w xg

(Interviewed while housed in A Block).

W X , has been in prison since 1990. He was taking Zyprexa and Haldol,
but the medications were discontinued two and a half months ago. He hears voices,

calling his name and accusing him of robbery. He has been at CNYPC ten times. He sees 0Mf-I staff regularly. He has not been in SHU at Sing Sing, but was in SHU at
Auburn in 1999 and then at SoutbPort in March, 2002. He had a four month ticket at SouthPort for telling a CO to "shut up" at the behest of voices. He was prescfibed Lithium and Mellaril at the time, and he believes OMH was not involved in his hearing. He has migraines that date to a car accident when he was three years old. He also has scars on his forehead fiom the accident. He was in observation a few months ago because he was hearing "tapes" (voices). He has been at ICP at Sing Sing. On mental status exam, this man exhibits very loose associations, tangential thinking, pressured speech, bizarreness and flat affect. He says he is afbid for his life and that "they poison the water and food." He has severe First Rank Symptoms. When he is in SHU the voices become louder and he experiencesmore serious First Rank Symptoms. He used illicit drugs as a teenager. This man suffers fiom chronic psychosis and is currently functioning adequatelyon medications in population. He is prone to tickets for behaviors that are fostered by command hallucinations, and the time he has spent in SHU has made his psychosis much worse. His clinical chart corroborates the history he presented. His diagnosisis Schizoaffective/Bipolar Disorder. He has been admitted to CNYPC on multiple occasions, has been in and out of SHU, is prescribed anti-psychotic (e.g. Zyprexa) and mood stabilizingmepacote) medications, and is generally a disruptiveand very disturbed individualwho has remained in treatment with OMH throughout his period of incarceration.

Example of: Prisonerwith SMI (SchizoaffediveDisorder) in GP currently Has spent time in SHU with worsening condition OMH is not involved in disciplinary process Multiple admissiolls to CNYPC Currently doing well in treatment & GP
Prisoner. E E qb -. (Interviewed while housed in Keep-lock).

E

says he has been in prison for 23 years on a second tenn, 15-to-life.

He is currently in Keep-lock on a 90 day term on A-Block at Sing Sing, and he was in

SHU a few times in 2000. He does not feel he has a mental illness. He is not taking

medications, He complains of being denied proper medical care for Hepatitis B & C, and

he believes he is unable to get to see the doctor. He has not been to CNYPC, and is not

on medications though the doctor wants him to take antidepressants. He believes they are

using a gamma ray device on him,and the mental health staffknow about the device.

They place something in his rectum which gives him a vibrator effect. They selected him

to oppress in this way because of 'The Blue wall of silence." Staff are able to hear all of

his private thoughts. He has been in SHU, and it was temble,

The clinical chart reflects he was at CNYPC, admitted for belligerence and agitation and mood fluctuation, discharged 8/27/01. because he refused to give a history, refbed treatment, and wanted to be discharged. He has been to RCTP, and he is a MH

41

Level 1. He is diagnosed Delusional Disorder and ASPD, and refuses meds. No psych history prior to 2001 per sister's report, in chart, but when delusions identified in 2001 by MH, it seems they were already established and fixed. A 1991mental health evaluation when he was admitted to Sl3.Jstates he had no mental health problems.

This prisoner obviously suffers from Paranoid Delusional Disorder and is in Maximum GP, being seen by MH but not taking any psychiatric medications. & as on 2/13/03, he is reported in a Treatment Plan Review to be paranoid, delusional and to have
poor reality-testing; why does mental health staff not intervene to prevent his being placed on Keep-lock?

Example of: Prisoner with SMI (Paranoid Delusional Disorder) on Keeplock in GP Has been in SHU Non-compliant with mental health treatment

Prisoner - 6 -G33L.*

(Interviewed while housed in A Block).

G 6 , has been in prison since 1991on his third term. He is housed in A Block at Sing Sing and is seeing a mental health clinician for counseling. He has been
admitted to CNYPC four times and has been in observation very many times, for as long as two weeks at a time. He denies being suicidal. He believes he suffered a first breakdown in 1995while in "the Box" (SHU) at Southport. He has been returned to "the Box" on several occasions after being discharged fiom CNYPC. The longest stint he served in SHU was one year. The first time he went to SHU he was "out of control" at Attica and was not able to get to see the mental health staff. Someone from mental health came to his cell front to "chat," but he did not consider this to be treatment. He suffers fiom mood swings, thought he was Jesus Christ on one occasion when he was transferred to CNYPC, but does not remember whether he hears voices when he is acutely disturbed. He has been offered ICP, but refwed because he had a job he wanted to keep. He does not take psychiatric medications at present, by his choice. He is single and his mother visits approximately every two weeks. On mental status exam, this man has a severe stare, is very concrete, there is some bizarreness and one senses he is internally preoccupied with hallucinated voices but does not admit to same, and while he does not aver hallucinations nor delusions, seems to be suffering from a chronic serious mental illness.

G E Z a clinical chart essentially confirms the history he reported, except that
more severe mental illness, with hallucinations, delusions and assaultivenessin response to command hallucinationsare noted during admissionsto CNYPC. He has been admitted to CNYPC on four occasions. He was at MH Level 6 through June, 1996, and has mostly been at Level 1 since. He is diagnosed Bipolar Disorder with Manic episodes. He has been prescribed Haldol and Depacote. The chart does note that he attempted to hang himself in 1996because of command hallucinations. He tends not to cooperate with treatment, and it is noted that he can become combative or assaultive, sometimes

with no warning. He seems to have had an acute exacerbation of mental illness in midJune, 2002, when he was preoccupied with sexual ruminations and inappropriately touched a female officer. He was sent to observation and then put on Keep-lock. His medication dosages were increased, but he intermittentlyrefused to take them. He was considered for transfer to CNYPC but not actually transferred. He was kept in observation for well over two weeks with daily notes about his intermittent psychotic behavior. He seems to have suffered an acute psychotic/manic episode that was managed by keeping him in observation and increasing Haldol and Depacote to 15 mg. and 1,000 mg per day, respectively. He was released from observation to serve time in Keep-lock for behaviors that seem very related to his psychotic/manic condition. Notes for the latter part of 2002 and 2003 reflect monthly meetings with a clinician.

Example of: Prisoner with SMI (Bipolar with Psychosis) in GP with no medications History of SHU confinement and multiple admissions CNYPC Spent weeks in observation during acute psychotic episode Refused ICP because he wanted to keep his job

p. ?a

(Interviewed while housed in ICP).

has been in ICP for one year. He has been in prison since 1988. He was in SHJJ once, at Wende, for pointing a finger at a hearing officer. He often feels depressed and wants to kill himself, though not presently. He has been in observation a couple of times. He is prescribed Depacote, Seroquel and Cogentin. He stopped his medications one week ago because of side effects. He hears voices related to Jesus and biblical ideas, and he believes God talks directlyto him. He was sent to Bellevue psychiatry fiom Rikers Island once because he would not talk. He likes ICP because he feels safe. He gets very upset when placed in segregation, both in SHU and in observation. In observation it's worse because there is no recreation. He has been admitted to CMYPC five times, and once was given forced medications. He felt very suicidal when in the Box, and heard louder voices. The very thick (a carton) clinical chart is consistent with his history. He is diagnosed SchizoaffectiveDisorder and prescribed anti-psychotic and mood stabilizingmedications. He decompensates when he non-complies with medications. In summary,this man suffers fiom chronic serious mental illness and is doing OK in ICP and on medications.

Example of: SMI (psychosis) in ICP, doing OK History of SHU term and multiple admissions CNYPC

F-P4

(Interviewed while housed in General Population).

has been in prison for five years and had three prior bits. He is in general population. He has been in observation and in SHU once, never in ICP. In SHU, he claims "they hmass you, they treat you like a murderer." He says he became very

paranoid in the Box, whereas in population he had merely been frightened. He is prescribed Seroquel, Buspar, Benadryl and possibly Neurontin. He says his medications make him sleep, so he takes them at night. When he has a breakdown, he cuts himself. He describes a pressure building up in him that makes him cut. He was transferred to Marcy in 1999, and then released, without any preparation nor arrangements for mental health care. He did not receive mental health care in the community, and he became paranoid. He had a history of mental problems and mental health treatment prior to incarceration. He describes hallucinations and delusions beginning in the mid-go's, worse in prison and even worse in SHU. He describes out of body experiences. He relates delusional material about a "black hole" he went through. At one point he was screaming in his cell in SHU, officers took him to observation where he spent two weeks, then he was sent to CNYPC and placed in 5-point restraints. He also cut himself in SHU. He was in ICP in May through August, 2002. He liked it, and does not know why he was discharged. He also had drug treatment while at Coxsackie facility. When "the power gets too strong, I feel like cutting myself." He would like to go to ICP, because he is afraid he is around too many evil people. On mental status examination, this man exhibits inappropriate affect, a very stark glare, bizarreness and loose associations, and pervasive delusional thinking. He also describes depression and frequent self-harm .I, impulses. This man's thick (two volumes) clinical chart reveals he was in ICP and doing well in 2002. He has been in and out of observation and transferred between SHU and observation, for example on 8/6/02. He is diagnosed Paranoid Schizophrenia. He has been prescribed Haldol and Zyprexa and so forth. He was returned to GP from ICP, and expressed concerns that were discussed by his OMH therapist. In other words, his chart corroborates the story he presented, is known by OMH to suffer from Schizophrenia, has been in treatment including medications and ICP, and has been in SHU and cycled between SHU and observation.

Example of: SMI (Paranoid Schizophrenia) in GP, doing OK on meds with outpatient treatment Spent time in SHU with worsening mental illness (paranoia) and multiple admissions to observation and CNYPC Has done well in ICP

Prisoner Custody).

ysp

(Interviewed while housed in Protective

,p,0 was in SHU for seven months and complains of being in cuffs all the
time and being beaten by C.0.s. He was sent to P.C. because he'd been beaten in GP. He complains he is depressed, and reports he is prescribed antidepressant medications. In P.C. he remains in his cell all day, idle, and this makes him very nervous. He gets out of
his cell from 5 P.M.to 9 P.M. and eats with other prisoners. He does recreation in a tiny
"yard" with one other prisoner. He is illiterate, and has never been to school. He sees "the psych" on rounds daily at cell-f2ont. He avers hearing voices intermittently, not on the day of our interview. He has limited English. He has been in observation 20 times,
where he remains naked, and sleeps on the floor. He is taken there whenever he "hangs

up." It is fieezing in observation, and he always feels humiliated by the experience. He confides that his tickets often occur when he is hearing voices telling him to do what he eventually is ticketed for.
The clinical chart confirms the history this prisoner presented, but documents much more seriousmental illness, includingpsychotic episodes. He was t r a n s f e d to Sing Sing fiom Downstate and has not been at CNYPC during this term, but was admitted to CNYPC in 1996 during another term. He canies a diagnosis of Psychosis
NOS,but was discharged fiom CNYPC after three weeks with no Axis I diagnosis except
polysubstance abuse, but with prescribed meds including Depakote 1,000 mg./day, Klonopin 2 mg./day, Prolixin 20 mg./day and Cogentin. He had received psychiatric treatment, inpatient and outpatient, in Puerto Rico prior to incarceration. He was a polysubstance abuser. He has been prescribed Neurontin and Zyprexa Auditory hallucinations, delusions and "serious impairment in judgment'' are noted, he has been suicidal in the past, he cooperates with verbal therapybut intermittentlyrefises medications. On 11/13/02he was overheard by a CO talking about suicide, seen by mental health that day and two more times when he denied suicidality, until on 12/28/02, he was admitted to observation for danger of self-harm. He reported command hallucinations telling him to kill himself, but on 12/30 a clinician opined he might be manipulating. He was also requesting P.C. and not wanting to go back to GP for fear of being cut by another prisoner. He made a few superficial cuts on himself in the next f m days. He is seen three times by the treatment team. On 1/7/03, still in observation, he denies he heard voices. He is discharged around 1/10/03. On 1/16/03he is seen in ER, nervous (note unclear), referred to P.S.U. He was returned to observation where he cut himself again and was noted to bang on the plexiglass. He was given intramuscular medications. Though his cuttinghelf-harm continues, he was discharged Grom observation, then re-admitted on 1/22 for cutting that staff noted was ""manipulative,"and finally he was sent to PC. On 1/31/03he is noted to be hearing voices telling him to hann himself and he is re-admitted to an observation '"strip cell." He then goes in and out of observation, with comments about "manipulating" interspersed with prescription of
and raising dosages of Zyprexa andlor Haldol for "hallucinations." Seen by OMH
fkequently, but mostly at cell-fiont in PC when he is not in observation. His diagnosis remains psychosis with depression in various places in chart. This depressed and likely chronicallypsychotic prisoner is also manipulative, frequentlysuicidal and some of the suicide attempts are related to his seeking PC status. But even after being transferred to PC he continues to self-harm. He is prescribed meds, spends a lot of time stripped in
observation, and is not sent to CNYPC during this term.

Example of: SMI (Psychosis and Depression), in Protective Custody Spent time in SHU Long periods in observation Considered manipulative, un-diagnosed Re-diagnosed and medications continued Seems both manipulative and suffering from SMI

L-s8

(Interviewed while housed in ICP).

g

,who is serving a life sentence, tells me he does not take his

medications, has disturbing involuntary movements, is schizoid and does not want to talk

to anyone, and does not want to talk to me. His thick clinical chart reflects five CNYPC

admissions, a diagnosis of Undifferentiated Schizophrenia with substance abuse. A

4130198 note while he was at CNYPC reflects rehsal to communicate,refbsal to

cooperate and refusal to 1eave.hiscell. A 11/01discharge note from CNYPC warns about

involuntary movements and intolerance for neuroleptic medications. He is described as

very schizoid, denying problems. He deteriorated in general population. He was

prescribed crushed Zyprexa and Ativan in 9/98. He has been admitted to CNYPC at

least five times, decompensated.

Example of: Prisoner with SMI (Schizophrenia) in ICP Non-compliant Cannot function in GP, needs to remain in ICP

kk-

(Interviewed while housed in ICP).

'I-\G%. has been at Sing Sing for two years, this is his sixth or seventh bid. He
has never been in SHU and never been admitted to CNYPC. He has been to observation two or three times, the last time was a year ago when he got upset at a CO. He has
received a ticket for screaming, which was dismissed. He has been taking psychiatric medications since age ten, and he has been hearing voices since ate 18. He is prescribed Prolixin, and has a tremor that is better when he relaxes. He feels ICP is OK, but a lot of the prisoners sleep all day. He would like more programs in ICP. On mental status this man suffers from obvious tardive dyskinesia, and displays flat affect and concreteness. His very thick clinical chart corroboratesthe history he presents. His diagnosis is Schizophrenia, Undiff. Type or Paranoid type. He has been on Prolixin by injection for 13 years. In summary, he is suffering from chronic Schizophrenia and is coping
adequatelyin ICP, though he complains of the lack of programs and he suffers &om tardive dyskinesia. I do not understand why he remains on a neuroleptic with tardive
dyskinesia - he should be prescribed an atypical anti-psychotic, and since Risperdal is
now available as long-acting intramuscularpreparation, he should be tried on oral meds
or his parenteral medications should be changed.

Example of: SMI (Schizophrenia) in ICP No SHU term Has tardive dyskinesia, yet still on neuroleptic

l4-3, (Interviewed while housed in ICP or CORP).

H

has been in prison for 36 years. He had been in psychiatric hospitals

prior to incarceration, including Mattawan, Mid-Hudson and Creedmoor. He has a court

order for treatment over objection. He does not wish to be interviewed. A review of his

chart discloses that he was in CNYPC in 1992, and has been switched more than once

from a Mental Health Level 1to a Level 6. He has been in ICP since 1993with a

diagnosis of Paranoid Schizophrenia. A report of a 1974 psych evaluation reflects that he

is "very psychotic, Paranoid Schizophrenia, and uncooperative." He is prescribed Haldol

and Cogentin and goes to recreation, but he resists group therapy. In other words, this

man suffers from chronic Schizophrenia and has been in ICP for many years.

Example of: SMI (Schizophrenia) in ICP Switched from MH Level 1 to 6 and back repeatedly

o-L** ..-

(Interviewed while housed in ICP).

G . L, has been in prison for 18 years. He has never been in SHU, and has been admitted to CNYPC twice in 1988 and 1991. He is prescribed Vistaril and Trazadone, and in the past was prescribed Sinequan and Prozac. He says his problem is recurring depression, and when he is depressed, he hears voices. He has not been to observation for years. He thinks ICP is "OK," and he attends groups. He hished the eighth grade in school, and has worked at a gas station. On mental status this man exhibits a bizarre stare, is flat and concrete, and appearance, affect and thought process are consistent with chronic Schizophrenia in remission on medications. His four inch clinical chart corroborates his history, his diagnosis is Chronic Undifferentiated Schizophrenia, he has been in ICP -previously he'd been denied ICP admission because of disciplinaryproblems.

Example of: SMI (Schizophrenia) in ICP No SHU term

Rk-3*

(Interviewed while housed in ICP).

k,d has been in prison over ten years, and in ICP for two months. Before
that he was in population -he has not been in SHU at Sing Sing. He did two SHU terms at Auburn, 15 months and six months, and while in SHU he was sent to observation. He had a serious drug problem on the streets, and drug abuse resulted in his returning to prison five months after his first bit ended. He went through drug treatment at
47

Greenhaven Prison. He has a history of mental illness since age 18,with a diagnosisof Paranoid Schizophrenia. He says that "prison breaks you." He does not like to be in population because other prisoners victimize those with mental illness. He used to get into argumentswith COs, and tells of being beaten by COs in 1995,but now he "uses my head" and stays out of trouble. He works in welding He has not had visits for ten years
- he explains he does not want the officers to get at his family. He likes the ICP at Sing
Sing better than the one at Auburn, because you get out of your cell more, there are televisions on the block, and there are tables where he can play checkers. He is currently prescribed Seroquel, 200 mg. twice per day, and Cogentin. He feels the officers do not pick on him as much in ICP, and he feels he is in fairly good shape right now. On mental status, he exhibits loose associations, flat affect, reports hallucinations and seems concrete. A review of his chart discloses three or four admissions to CNYPC between
1995 and August, 2000 - October, 2001. He suffers from auditory hallucinations and
becomes assaultive with officers when he does not take his medications. He was
transferred from CNYPC straight to the Auburn SHU in 1996. HEhad been on the psych.
Ward at Kings County Hospital at 18, he was subsequently admitted to a couple of more hospitals in the community, usually with psychotic symptoms linked to assaultiveness. There are incidents where he refbed to take his medications, became assaultive in DOCS, and had to be admitted to CNYPC. His fifth admission to CNYPC lasted for 415 days, fiom August, 2000 through October, 2001. In summary, this man suffers fiom chronic Schizophreniaand is currently stable on Seroquel in ICP.

Example of: SMI (Schizophrenia) in ICP Had been in SHU, with negative effects, and multiple admissions to CNYPC

V*L
Population).

(Interviewed while housed in B Block General

. v. L has spent 22 years in prison. He had been in ICP for one year three
years prior. He has been at CNYPC nine times, mostly for depression and not communicating. He says he halts his medications and withdraws, and that is when he is transferred to CNYPC. He was in SHU for nine months in 1987, but did not go to CNYPC &om there. In SHU, he withdraws and gets depressed, or he gets into fights. He is currently prescribed Prolixin and Prozac and sees a mental health worker every two weeks. He complains of being abused by other prisoners because he is mentally ill. He has an AA degree in business. He has been in observation 15times, the last two years ago. He merely sleeps all day in observation. He has no complaints about the treatment he received there. His mental status reflects flat affect, concreteness and a credible history for chronic Schizophrenia with no active signs. This prisoner's very thick (an entire carton) chart reflects a diagnosis of chronic undiffaentiated Schizophrenia,is prescribed Prolixin, and has been admitted to CNWC on many occasions, usually when non-compliant with medications. Typically, he becomes withdrawn, his hygiene deteriorates, and he is found to be hallucinating and irrational. He is diagnosed Schizophrenia,has spent little time in SNU, and seems to be managing in GP.

Example of: SM.I (Schizophrenia) in GP, doing OK with treatment Has been in SHU, CNYPC and ICP

k.x,

(Interviewed while housed in ICP).

' k has been in ICP for five years, and in prison for 17 years. He was in
SHU once in 1993. He has been admitted to CNYPC six times, and is currently taking anti-psychotic medications. He had a homble time in the Box, became very nervous and could not relax and suffered a mental breakdown under the stress. He does not like the side effects of his medications, but takes them in order to stay in control of his ''bugging out." He thinksthe ICP is OK, but he hates observation, where "they don't treat you like a person." His chart corroborateshis history. His Dx is Par. Schiz., he periodically noncomplies with medications and becomes delusional with disorganized behavior and thinking and needs to be admitted to inpatient, he is prescribed Risperdal4 mg. per day plus Haldol Decanoate.

Example of: SMI (Schizophrenia), in ICP, doing OK No SHU since 1993, but did poorly there at that time Finds observation traumatic

E,G J -

(Interviewed while housed in CORP).

G is in the CORP program, being in prison for a parole violation and getting ready for release very soon. He has a long history of substance abuse. He does not like the side effects of psychiatric medications, so he refuses to take them and the staff do not force him. He is not in mental health treatment. On mental status, there are loose associations, flat affect and concreteness suggestiveof chronic Schizophrenia. A review of this man's chart reveals a diagnosis of Paranoid Schizophrenia, many admissions to CNYPC, Mental Health Level 1, and fiequent refusal of treatment and
medications.

Example of: SMI (Schizophrenia), in CORP program preparing for discharge Not in mental health treatment Actively psychotic, but doing OK

L bL b

(Interviewed while housed in ICP).

L C has been in prison over thee and a half years, did all of his time in Sing Sing, is currently in ICP, and is soon to be released. This is his third bit. He was in
SHU eight months ago, and came to ICP fiom the Box. He had no money, he was
borrowing cigarettes, he told a CO that he wanted to go to PC, he had a razor, and then
found himself in the Box (in observationon the way? - he's not sure). He is prescribed
Depacote, 2,000 mg-per day, Risperdal, one piH in the evening, and Cogentin. He likes

the groups in ICP. He had no psychiatric history prior to incarceration. He does not get any visits, his mother does not know how to get to the prison. He remains in ICP, does not go to see the doctor, and is afraid of guys he owes money. He has done some drug treatment in ICP. Being in SHU is extremely traumatic for him because there are "gangsters in there" who threaten him. He perseverates about cigarettes and owing money, and he is very frightened of population yard. He says he is Bipolar, meaning "I swing on people," he goes on to report he "acts dumb, gets 'crazy,' and gets paranoid."
He also gets depressed and he hears voices - the television or other people talking to him
when nobody is there. He says his mental illness gets much worse in SHU and in observation. And when he is in SHU or PC mental health staff talk to him only at cellfront. Mental Status exam reflects borderline or low intelligence, smiling that is sometimes inappropriate, expresses guilt about killing a worm while fishing, stares and halts the conversation reflecting thought blocking and psychotic autism, and there is concreteness and psychomotor retardation. He had been at CNYPC for a few months prior to coming to ICP. He says that PC is the same as SEFU, except in PC prisoners can watch more television and eat together. His clinical chart is consistent with the history he presents. His dx is Schizoaffective,previously Schizophrenia. He is prescribed antipsychotic and mood-stabilizing meds (including, at various times, Haldol, Risperdal, Depacote, etc.) He has been on Haldol Decanoate because compliance has been a problem. This man suffers ffom chronic serious mental illness, is relatively stable in ICP but probably needs PC if he is not in ICP.

Example of: SMI (Schizoaffective or Schizophrenia) in ICP Has been in SHU and not done well there Finds PC same as SHU

6 fL

(Interviewed while housed in ICP).

c 0 A has been in prison for 15 years, for committinghis first felony. He
had been a merchant seaman. He has syphilis and TB. He has been in ICP since
November, 2002, and was in Five Points ICP before that. He has been in ICP for his entire term. He has large memory and cognitive problems, and cannot fimction without help. He takes medications, some psychiatric but he does not remember which ones, and he takes medication for Vertigo. He feels other prisoners take advantage of him, and he
has had a few fights. He cannot function in general population - there is too much going
on, and too much victimization. He spends his time reading. His out date is August, 2003, and he plans to get a room in a residence for merchant marines. He has been in SKU twice. He used to hear voices, but no longer. He was at CNYPC once, in 1993 or 1994. On mental status this man is pleasant and talkative, but there are obvious cognitive deficits and large memory gaps with noticeable confusion. His clinical chart is consistent
with the history he presents. He carries a diagnosis Dementia NOS. He has been tried on
anti-psychotic medications, and on various antidepressants. He is obviously incapacitated by organic brain disorder, with intermittent psychosis. He seems to manage in ICP.

Example of: Demential Organic Brain Syndrome in ICP Intermittent psychosis
Clinton Correctional Institution - 7115-7116103
A, CL speaks very little English, and this interviewer speaks a little Spanish,
so this was a brief interview. He has been in prison for most of 25 years. He is currently serving time for a new commitment for violent crimes. He has a life sentence. He has a history of depression, and his chart reflects OMH treatment duing the 1990s. He was discontinued from the OMH caseload in June, 1999. His clinical record contains reports
of depressive episodes in Jan. and again in Oct, 1999, while he was in SKU - depressed,
not eating, mute, sent to RCTP or PSU at Great Meadow for crisis, sent to CNYPC and was refised admission, on and off antidepressants, returned to SHU each time, discharged from OMH caseload with diagnoses Adjustment Disorder With Depressed Features or Depression NOS.
Example of: Significant Depression Discharge from OMH caseload Spends much time in SHU
*kbH has been in prison for three and a half years. He is currently in
KeepLock in ICP andlor PC. In April, 2003,he ingested 1600mg. Seroquel as a suicide
attempt, and a few days later assaulted an officer. He was sent to CNYPC and while there barricaded himself in a room. At CNYPC he was diagnosed 'no mental illness"
and his medications were discontinued. It was then that he bamcaded himself. He has spent much time in SHU, has received tickets for self-mutilation, and has been to , CNYPC twice. When he is in the Box, the voices he hears get worse, has the paranoid idea that the officers are out to get him, gets tenified, and is driven to cut himself. His
concentration is poor in the Box,and his voices and suicide ideation become much worse.
Then he gets tickets for self-harm. He becomes confused and disoriented as to place and time, and there are no newspapers to help him orient himself. He has been hearing voices since the age of 15, and he has been prescribed Depacote in the past. He does not see anyone fiom mental health at Clinton. On mental health status he stares intensely, is concrete and flat, and presents credible history of auditory hallucinations. Two months prior to our interview he was diagnosed no mental health problem and his medications were discontinued at CNYPC. He is supposed to see mental health s m e v e r y other month, but it does not happen. He wants mental health treatment, and is on Level 1. His mother died when he was six, his father "gave me away," he grew up in group homes and he went to the ninth grade in school. He has not earned a GED. He began cutting

himself in group homes. He has cut himself quite a lot while in SHU, and has scars on his arms and legs. He reports that "cutting" relieves his anxiety, he gets a rush, and then he feels better. His clinical chart is consistent with his history. His diagnosis on 8/16/00 is SchizophrenicDisorder, a core history lists diagnosis Schizoaffective Disorder; he has been admitted to CNYPC twice since beginning this term in August, 2000, the last in September, 2002. He was prescribed Seroquel200 mg. h-s. and Paxil20 mg./day through 2001. He still was prescribed these medications (actually 300 mg. Seroquel) in SHU at Midstate as of 5/21/02. Through 4/9/03, he still carried an Axis I diagnosis and was receiving medications and outpatient treatment at Elmira, and cycled several times to observation for suicidal thoughts and/or behaviors.
Example of: SMI in SHU Cuts/self-harm and receives tickets for that Un-diagnosis and discharge from OMH Deterioration in SHU Tickets in SHU related to deterioration, more time in SHU

e L,e,.. has been doing 17 years on a parole violation. He has been in and out
of SHU since 1994, and in the Box for a year on this sentence. When he is in the Box he receives more tickets than when he is elsewhere in the prison. He has not been to CNYPC. He has been to observation three or four times, usually when he threatens suicide. He does not feel that staff take seriously prisoners' suicidal thoughts. He has not taken psychiatric medications, and had no prior psychiatric history when he first went to SHU. Mental health contact is limited to cell-front interviews. On mental status this man seems inappropriate, for example smiling at the wrong time. His thought process is delusional, especially when he begins talking about female attorneys. He attempted suicide in KeepLock nine months ago; he says he did so because he told a CO he was having trouble and nobody did anything. The psychiatrist, Dr. Menendez, does not do rounds in SHU. A review of this man's clinical chart reveals a 12/12/01nursing
assessment recommending referral to CNYPC for self-harm statements, and a treatment
recommendation: "Transfer to OBS for psych. Eval., stabilize and return to SHU."

Example of: SRlI (psychosis) in SHU Deterioration and more tickets in SHU No real mental health treatment
Cycling from SHU to observation, less often to CNYPC

y*N b

(Interviewed while housed in General Population).

7,N began his fifth prison term on 1/14/03. He was admitted to Bellevue
psych ward prior to incarcerations. He rates the mental health care very low, and says

51

that the psychiatrist, Dr. Menendez, is no help at all. He sees the psychiatrist every two months. He is prescribed Haldol, but it causes tenible side effects. Mental status examination reveals pressured and tangential speech, no eye contact, bizane grimaces and lack of logical thinking. His clinical chart reflects a diagnosis of Schizophrenia and Mental Retardationwith a GAF of 35. He has been in CNYPC and ICP. He insists that I read an affidavit he has prepared describing the abusive way he has been treated, and in the affidavit his thought process is clearly delusional, fragmented, incoherent and bizarre. In other words, this man is actively psychotic while in general population and taking
medications. His thick chart contains diagnoses of Psychosis NOS and Schizophrenia,
Undifferentiated. He has a WAIS IQ 111scale of 65. He is prescribed Depakene, Haldol and Artane. Bellevue admission at 16is noted. Prior Rx Seroquel1200mg. per day, Prolixin, Depakene 2000 mg. per day, another time he is on Haldol Decanoate 200 mg. per month, and so forth. He is admitted to observation or CNYPC after non-complying with meds and decompensating. He is given a lot of time in Keeplock. He is seen every two months by the psychiatrist and is followed by a case manager.

Example of: SMI (Schizophrenia) in GP Spends time in Keeplock

E.E,c,~

untemewed while housed in SHU).

E,E,C had been prescribed Zyprexa and diagnosed Bipolar Disorder until the previous April, when his diagnosis was downgraded to no diagnosis and the medications were stoped. He caught an outside case five months prior to our visit. He had a psychiatric history, including hospitalization, prior to incarceration. On mental status exam this man laughs inappropriately, has very disturbed memory and concentration, exhibits internal preoccupation, and demonstrates very loose associations. He is incoherent. He tells me he is a poet, and gets fan mail from Tupac (who is deceased). He rocks in his seat, probably self-stimulating. When asked if he is sad for missing his mother, he laughs energeticallyin total contrast to how he says he is feeling. Michael is his therapist, and visits with him only at cell-front. In summary, tbis occupant of SHU is
floridly psychotic and not receiving OMH treatment. His diagnosis has been changed to
"no diagnosis." His clinical chart reflects the process of 'b-diagnosing." He had been diagnosed SchizoMective Disorder, and more recently "no diagnosis." History of psychiatric hospitalizationat 15noted in chart. Most SHU screening evaluations are skimpy and contain almost no information about signs and symptoms. In June, 2000, he
tried to climb through the ceiling from the bathroom in the visiting room, but fell through the ceiling. It was noted he was acting in a bizarre fashion, but Dr. Langbart felt there
was no mental health problem. A 10/01 screen reflects emotional problems and
recommends fUrtherevaluation, and then a 10118/01 RCTP note reflects no mental health needs - he had been sent to observation for evaluation. But on 10118/01 he is prescribed
Zyprexa 10mg. Per day, Lithium 900 mg., and emergency Haldol. 3/8/02 and 9/02 AdmIScreening forms diagnose Bipolar Disorder I, most recent episode Manic, with ASPD. This man is clearly suffering &om SMl, but is retained in SHU without adequate

mental health treatment. His lack of cooperation is an issue, but on quite a few occasions notes in his chart reflect serious mental illness. He needs a thorough psychiatric assessment and it is likely that if he were placed in a treatment setting he would be more likely compliant with the treatment he urgently needs.

Example of: Active psychosis in SHU Un-diagnosis and no mental health treatment Continues on medications Deteriorates in SHU

Eh%-

(Interviewed while housed in SHU).

G,%,'has been in SKU for a year, and in prison for five years. He has
another 11 months of SHU to do. He reports "they say I'm Schizoaffective." He stopped taking his medications five days prior to our interview, and reports he feels "speedy." He was sent to SHU for possessing a pipe, which he says he needed "to get an undercover (agent) prisoner." He says that in November of 2002, he was moved h m SHU to APPU, which he describes as a high-profile protective custody unit. The officers told 'b him that he's a dead man because it's a KKK unit. Fearing for his safety, he came out of his cell with a pipe, and that's when he was transferred back to SHU. He says he wrote notes at the time threatening "to take them down if I go." He has been at CNYPC twice during this prison term, on one of those admissions he was told he is Paranoid Schizophrenic. The last time he was at CNYPC for two months, and then returned to S W . He has been a problem drinker for many years. He tells me both that the killed his wife in 2000 while arresting him, and that months later she was thrown in front of a train, and he does not recognize a contradictionbetween these two stories. He is prescribed Geodon 80 mg. per day, Trazadone 100mg. at night, and Vistarill50 mg.per day. In the past, at Clinton, he has been given involuntary injections of Haldol. He talks to Mike, the therapist, at cell-front in SHU, and sees Dr. Menendez every other month. He works on being able to control himself, and he believes he should be sent to Sullivan to the Special Needs Unit. He does not think he can survive in general population because he has enemies. He has made suicide attempts. He womes about the medications because they slow him down and if he is released from segregation, he will not be able to take care of himself. On mental status exam there is some pressured speech, and agitation. His clinical chart is consistent with the history he presents. He was admitted to CNYPC twice in 2002 for a couple of months each time. On 4/24/03 he was prescribed Vistaril75 mg. bid., Geodon 80 mg. p.m., and Trazadone 100mg. h.s. He has a pre-incarcerationhistory of psychiatric hospital admissions, and at least three admissions to CNYPC in the 1990's. On 7/6/02 he is in observation and it is noted he has tried to "hang up" three times in the past year. There are many notes throughout his chart about pressured speech and grandiosity. There are discussions about whether he is
delusional, claiming elaborateplots against him, or he is merely sufferingfrom Axis II
problems. He is sent to observation for suicide threat on several occasions. On 4/24/02, a nursing progress note reflects " Ek%was found by the night shift in the SHU to have a

sheet around his neck. He told me that 'the FBI and some other people planned to have the Black people kill him when he left the SHU.' He planned to 'kill himself before they do it to me."' He was placed on a 1:1 watch in the SHU that night. There are many other notes reflecting possibly delusional ideas. Other medications have been prescribed, including phenothiazines. This man is clearly delusional and psychotic, and is suffering in silence in SHU while OMH tries to make up their minds whether he has an Axis I diagnosis. His mental condition is deterioratingin SHU.

Example of: SMI (probably Schizoaffective) in SHU Cycle to observation, CNYPC, and then back to SHU + Protection issues intertwined with delusions

Yt TsI<-

(Interviewed while housed in D Block SHU).

7sPK reports he was seen by Dr. Menendez on 1/2/03 and involuntarily
injected w t h Haldol because he was "acting violently." He charges racism, noting that prisoners are regularly beaten when taken to observation, this occurs more often if the 1, prisoner is Black, and there are no Black officersnor Black mental health nor nursing staff. He describes in detail being carried to observation and having his clothing cut off. He was last in observationin January. He has not been admitted to CNYPC, though he says he was there "for a few hours" (for an evaluation?). He is in SHU on a 90-day ticket, and spends his time playing chess, reading the Koran and working out - trying to sustain his sanity. On mental status exam, this man wears glasses and has a beard; he is dressed in a red shirt, exhibits insistence verging on pressured speech, seems intense, obsessive and oppositional, does not aver hallucinations and is not certain whether he suffers from a mental illness, but he is certainhe is "not normal." He appears to have ideas of reference and asks attorney Sarah Ken if she is a stenographer. He says he feels pressure, he is isolated and lonely, and he feels depressed a significant amount of the time. He believes his depression is worse because he cannot contact his family and feels abandoned. He says he will not seek mental health treatment for his depressionbecause of the awful experiencehe had in observation. His thin clinical chart contains mention of history of paranoia and flat or depressed affect plus treatment by CNYPC during a previous bit, but screenings this bit are repeatedly unremarkable and recommend no mh services. A 10119/90 observation note reflects "laughing, crying, screaming, throwing things." He intermittently is seen by OMH, and notes reflect some paranoia, phobia, and repeatedly depression, but no mental health services either wanted or felt by staff to be needed. An 11131/01AdmissionIScreening Fonn contains diagnosis Mood Disorder . NOS. Mental Health Level is 4,3, or, but on 1/2/01, it is 1. He has been in and out of "the box," and OMH repeatedly is ambivalent about his mental state and need for
treatment -they recognize "agitation" or "depression" or "'phobia." He has been to
observation severaltimes, but he is soon discharged from treatment and receives no psychiatric medications. An example is a 1/23/97Outpatient Screening!Admission note, which states: "appearance: distrustful, suspicious; Emotion: angry, volatile, inappropriate affect, smiling when expressing anger; Speech: pressured, circumstantial; thought:

paranoid, grandiose, entitled. No hallucinations; Insight: impaired by his agitation." He is diagnosed Psychosis NOS with ASPD, and he is placed on Special Watch. He spent several days in RCTP, and was prescribed Prozac and minor tranquilizers. Other notes reflect no mh problem, and diagnose Conduct Disorder. Then he spends more time in SHU, as at time of our interview. In summary, this man seems moderately disturbed with an atypical clinical picture. He is paranoid and does not want mental health services. He likely suffers significant mental illness and disability alone in a SHU cell.

SMI (atypical psychosis) in SHU Reports rough treatment when taken to observation Under-diagnosed Involuntary Medication on urgent basis while in SHU

N 0-

(Interviewed while housed in D Block SHU).

N , 0 received SSI disability on psychiatric grounds since 1986, and
entered CDC in 1994(he may meanjail -he has a 95 ID No.) He was prescribed Mellaril, Haldol, Cogentin and Valium prior to incarceration, he was admitted to the psych. ward at Kings County Hospital, and he suffered fiom EPS (extrapyramidal syndrome, a Parkinson-like neurological problem caused by phenothiazines), but he has not been in mental health treatment in DOCS. He spent six months in the Box at Upstate, and he did 30 days Keeplock at Clinton. He has not been to observation and has not been admitted to CNYPC. He has only a few disciplinary tickets, and the ones that resulted in his SHU term had to do with refusing to program. He has attempted suicide by overdose twice, once at age 24 and once at Kings County Hospital. He reports he heard voices telling him to jump out of the window. This is his first prison term. He took hallucinogenic drugs prior to incarceration. OMH does not see him. He currently feels anxious and suffers from insomnia He has not found mental health treatment helphl in other settings, so he has not participated nor requested it. On mental status, his flat affect, concreteness and akinesia, along with his history, suggest chronic Schizophrenia. His thin clinical chart contains no diagnosis, but OMH screening on 8/1/95 notes history of sevetal inpatient hospitalizations and SSI disability. SHU mh evals contain almost no info, and he has not been on OMH caseload. He appears to suffer from SMI, and is being ignored while he remains in SHU.

Example of: SMI (probably chronic Schizophrenia) in SHU Missed on screening, no mental health services

62%

(Interviewed while housed in observation).

O.S. was seen in observationwhile awaiting transportation to CNYPC
where he is being admitted. He reports having mental health problems since 1982. He
was in ICP prior to observation. On mental status exam he exhibit. pressured speech. He spent 15 months in SHU at Attica prior to being transferred to ICP at Clinton in 2001.

On mental status exam he seems to have ideas of reference and is somewhat agitated. His clinical chart is consistent with the history he presents. He has a long history of serious psychiatric illness and the prescription of anti-psychotic medications. He is diagnosed SchizoaffectiveDisorder or BipolarDisorder, and prescribed Depacote, Haldol (oral and I.M.), Zyprexa, Klonopin. He was admitted to CNWC multiple times in the
late 1990's. Yet he was given a long SKU term. In June, 2001 he was tried in STP
without success, and then he was referred to ICP in 7/01.

Example of: SMI (Schizoaffective or Bipolar) was in SHU for a long time Eventually transfer to ICP Current acute episode, in Observ awaiting CNYPC transfer
a,-I=-(In$ terviewed while housed in Meryl Cooper program).
d,T i has been in the Meryl Coopper program for one year. He has been in
prison for four years, his first term. He is prescribed Depacote and Zyprexa, and has been seeing Dr. Melendez and taking medications for over a year. He had been on and off medicationshis whole life prior to incarceration. He applied to be in Meryl Cooper, but now feels the program is not for him. On mental status exam he has scars on his forehead, a shaved head, tatooes on his forearm. His speech is slow and deliberate and his affect is flat. He admits to poor memory and slowed learning. He went to the ninth grade in Special Education. He used drugs as a teen. He had head injuries growing up and describes himself as 'Wutzy." He went through a plate glass window in 1998,but has no memory of the event. He was admitted to CNYPC from jail because he smashed his head against the wall in a suicide attempt. He finds the Meryl Cooper program too difficult for him, with his limited cognitiveability, and he cannot progress with the phases of the program. He sees the therapist, Mike, and has requested a transfer out. He came here from a medium security facility, Oneida His clinical chart contains the diagnosis Depressive Disorder, in 6/02 he was prescribed Paxil and Zyprexa. He is Mental Health Level 3. In 6/03 he was on Depakote. The chart does not reflect limited intelligence, nor head injury, nor problems with phase progression due to intellectual functioning. This man seems to suffer from a combination of closed head injury with organic disorder, limited intelligence and a functional mental illness.

Example of:
SMI, MR & Organic Disorder in Meryl Cooper program
Has special needs Cannot progress in phase program due to intellectual deficit

Prisoner

ew
"$"\

(Interviewed while housed in APPU).

F,FIV, entered DOCS in April, 2001 for the first time. He is housed in the
APPU per his request, for protection. He had been assaulted by another prisoner at
Auburn. He tells me he suffers from an anxiety disorder as well as hypertension, asthma,

57

and heart problems. He complains that the medical care is quite poor, and this increases his anxiety. He describes "panic attacks" where his heart rate speeds up and he feels palpitations. He is prescribed an antidepressant. He became very anxious when he was in a "strip cell" (observation) at Auburn CI for three days. He reports brief sessions with Dr. Melendez, the psychiatrist, and occasional talks with therapist, Keith. This prisoner's chart confirms he entered the DOC on 4/9/01. He had little in the way of prior psychiatric history. He has been rated Mental Health Level 3 much of the time, with one 4 in May, 2001 at Attica. There is a diagnosis Major Depressive Disorder, Recurrent and Moderate on Admission Screening (6/1/01). He was admitted to the OMH Satellite Unit on 9/24/01 after threatening self-harm. He has been prescribed Prozac 20 mg/day (7/12/01), Zoloft 150mg./day, Effexor 150 mg. b i d . There are notes in his chart about coronary artery disease, hypertension, diabetes, degenerativejoint disease and other medical conditions. He was admitted to the APPU on 6/10/03. He seems to be compliant with treatment and to have little if any disciplinaryproblems once he is in a safe setting.

Example of: SML (Major Depressive DisorderIAnxiety w medical conditions) in APPU Requires protection, does OK in protection Poor medical care increases anxiety

%.& vi

(Interviewed while housed in General Population).

cannot remember his DIN number. He thinks he is prescribed Zyprexa, 20 mg., Cogentin, 1 mg. and Trazadone, 100 mg. He exhibits obvious tardive dyskinesia. He seems intellectually impaired, and shares that he was in Special Education. He feels the mental health treatment is OK. He had an auto accident that caused damage to his brain. He was on SSI in the community. He hears voices say mean things to him, they used to tell him to kill himself. Sometimes he cries and falls apart, obsessing about the loss of his parents. He is on the list to go to RSAP drug program, but he has been on the list since he arrived at this prison and they are very backed up. He gets into trouble for talking to himself in the hallway. He does not get tickets, but he is scared he will. He has been at Clinton for three months, and has an extensivepsychiatric history with admissionsto many hospitals. His clinical chart contains a diagnosis of Schizophrenia, Paranoid type. On 1/10/03he was admitted to R@rP and then to CNTSPC (only admission) with a Mental Health Level 1. He is prescribed Zyprexa, 20 mg., Cogentin, Trazadone 100mg. and Seroquel 100mg. OMH treatment plan is to see him two to three times per month for ten to 15 minutes, continue medications and encourage to take part in programs. He is coping in max GP with OMH outpatient treatment.

Example of:

SMI (Schizophrenia) in Max GP

Organic Brain Disorder

Coping in GP with medications and outpatient mental health care

a *- e 1 %

(Interviewed while housed in SHU or Keeplock status).

Z,Thhas been in prison for 14years,and came to Clinton in 2002. He is in
SHU (or Keeplock status) for assault on an officer, and has a seven month SHU tenn. He has asthma, which he says gets much worse in segregation, and he is afraid he cannot get adequate medical care in segregation. He has been treated by OMH since 1992 for Bipolar Disorder, and is now prescribed Seroquel250mg..per day. He says nobody in segregation is prescribed Depacote or any other mood stabilizer. He womes a lot and gets very depressed. He does not hear voices, has not been admitted to CNYPC nor to observation. He earned a GED in prison and was never on SSI on the street. He says he has traumatic stress disorder, which they call Schizophrenia He has been in the RSAP drug treatment program, and needs to take it again but there is a long wait to get in. On mental status exam, this man is very intense with a flat stare, there are tangential thoughts and bizarreness consistent with Schizophrenia. I suspect he experiences delusions and hallucinations, in spite of his denials. His chart is consistent with his history. He had pre-incarceration psychiatric admissions for Schizophrenia, at least three times at Bellevue. He was homeless on the streets. His diagnosis is Schizophrenia, Paranoid type. He is prescribed anti-psychotic meds, most recently Seroquel400 mg. per day. He is not admitted to CNYPC but has been in observation several times, usually for decompensation after non-complying with treatment. He is periodically dropped from
OMH caseload due to refusal - this may be related to his losing control and getting
tickets.

Example of:
SMI (Schizophrenia) in SHU
Not treated adequately
Asthma worse in SHU
Upstate Correctional Facility -7/17 - 7/18/03

KB2*

, (Interviewed while housed in SHU).

K,2a has been in prison for 12years. He has been in SHU since 1993,
and at Upstate for three months. He explains he gets in trouble with COs. When he was at Southport, attorneys fiom PLS tried to arrange for him to have a neurological examination, but that never happened. He has a history of lead poisoning as a child; he dropped out of school in the tenth grade. He says he thinks he has memory problems because he fell a lot as a kid. He became depressed and tried to hurt himself at Southport. He does not hear voices; he has not been at CNYPC. He was in observation a few times at Attica and Clinton. When he throws at staff, he loses control and doesn't know what

he is doing. Being in the Box causes him to get angry and lose control. He feels if he had received mental health treatment when he first came to prison he would not have gotten tickets. He cannot control his temper, and the problem is much worse when he is in segregation. He is single-celled at Upstate and sees mental health. He sees the psychiatrist only rarely, and was told last time he asked to see him that he would have to wait three weeks. He stopped his medications a few days ago, because they caused nausea and he had to go to the hospital, but then they started the medications again. He tries to study in his cell but has limited ability. He saw the telemedicine doctor once. He has been ticket-fkee for a while because he reads the Bible. His mom visits him once per month from NYC. On.mental status, he seems intellectually impaired, very sweet, smiles inappropriately, has slurred speech, seems childish. He clearly suffss from Developmental Disability along with mental illness and a probable organic brain disorder, and he needs a protective environment such as the S W or possibly an ICP.

On his clinical chart, there are diagnoses of Bipolar Disorder and Impulse Control problems in Oct, 2001. A 9/12/02 note re Neuropsych testing, in SHU, reflects his refusal to take tests and no more attempts will be made to test him. A history of head trauma is noted. He is prescribed Neurontin since 4/1/03 (1200 mg./day), Depacote, Remeron, Zyprexa and Benadryl. His Mental Health Level was changed from 6 to 3 on 7111/01, and then to 2 on 8/15/01 at Shawangunk CF, "due to increasing impulsivity and refusing to communicate with staff." On 10/10/01 his diagnosis was changed from Impulse Control Disorder to "Bipolar Disorder NOS with suspected Organicity." But on 6/13/02 he is transferred to Elmira SHU as a Mental Health Level 1,and on 3111/003he
is transfened to Upstate as a M H Level 3(?) A 12/19/01treatment plan review at Elmira ( S W states he 'has continued to make threats, openly masturbate in the presence of
female staff Patient also has a history of head trauma and may warrant
neuropsycholgical testing as soon as can be arranged....He states 'I have 2 personalities.
I get aggressive with something evil'." The neuropsychological testing did not happen because he refused, he continues to be seenby OMH at cell-front. It is noted that he has sustained head traumas, and then the treatment plan review states: "Rehabilitation and Social Supports are minimal due to SHU status." But then, instead of doing something about that, e.g. moving him to ICP or even STP (he is rehsed fiom STP at Five Points, reasons unclear), he is sent to Upstate where there are even less services - and his Mental Health Level is changed to 3 (without any evidence of improvement in his mental state.)

Example of: SMI and Mental Retardation and Organicity in SHU Inadequately diagnosed Mental Health level changed as he is transferred to Upstate Deteriorates in SHU

C ,C ,f,

(Interviewed while housed in SHU).

L-cY. entered Upstate in 2000 and is single-celled. He feels "this place is OK except the COs mess with me and I lose my temper." He sees Mr. Kim, the mental health

worker, once a month for five to ten minutes in a room, and then sees the psychiatrist via telemedicine once every one to three months. He does not sleep well; the COs mess with him and then he loses his temper. He gets a lot of tickets, becomes suicidal, and has been sent to observation at Upstate. He believes the COs tell other prisoners to beat him up, and they do. He has substance abuse problems. He is prescribed Paxil, 40 mg. Per day, plus Trazadone 200 mg. hs and 100mg. in the A.M. He is depressed and cries all day when he is not sleeping-but he sleeps a lot in the daytime. He does not read because he cannot concentrate. He was in Special Education in school but dropped out in the ninth grade. He has been having cognitive and memory problems since a serious car accident at age 37. He does not hear voices, but he is very depressed; he has sleep apnea, feels hopeless, criticizes himself a lot, and berates himself. He has been to observation at Upstate four or five times, and was sent to observation at Clinton for seven days without receiving any real treatment. He was considered developmentally disabled (MR) and was on SSI for psychiatricreasons prior to incarceration. He has also been admitted to psychiatric hospitals in the community, usually for serious suicidal acts. He says he loses control when he gets angry, and he gets angry a lot in segregation. He has not had drug treatment. He thinks he needs to be in a mental hospital. His clinical chart corroborates .his history. He is given the diagnosis Depressive Disorder. On 4/18/01, his medications 'I, were Paxil40 mg-/dayand Sinequan 100mg. h.s. There is very little mention of DD or Mental Retardation in his chart, though he is noted to be obese, disheveled, and having a
diEcult time coping. He has several stays in observation at RCTP,and cycles to SHU or
Keeplock. Some notes reflect the opinionthat he suffers firomno SMI, yet he remains on medications and continues to cycle to observation. Other notes clearly identify depression. This man has a drug abuse problem which remains untreated, he suffers from DD/MR as well as an Organic Brain Syndrome secondary to closed head injuries, and he suffers a bctional serious mental illness (DepressiveDisorder). Still he is at an institution that does not offer mental health treatment at the level of intensity required for his SMI and other conditions.

Example of: SMI (severe Depression) with DDIMR at Upstate Anger grows and is out of control, leading to more tickets Cycles to observation and back to SHU Inadequate treatment, sometimes downgraded diagnosis Should not be at Upstate because of Mental Health Need

fa3

(Interviewed while housed in SRU).

$3 ( has been in prison since 1988this bit, or for a total of 25 years as an
adult. He has had a couple of strokes and limps. He came to Upstate in April, and has a 150day SHU term. He is single-celled because of a violent felony. He has two college degrees. On mental status exam it is obvious he has serious memory problems. He has never been admitted to CNYPC but has been in observation at Upstate. He has taken medications for depression, suicidality, hallucinations and diabetes-but he cannot remember which medications. He sees things. He believes mental health staff see him as

6 1

depressed and suicidal, with hallucinations. He feels confused about things, possibly because of the strokes. He sees a dead person in his cell, and talks to him. He feels the staff at Upstate are very mean, and beat the prisoners. He cannot get a wheelchair, though he believes he needs one. He is prescribed Sinequanvia telemedicine, and sees the therapist only occasionally. He was reksed admission to STP when he was at Five Points. He believes that time in the Box causes his anger to mount and then he gets more tickets.

Example of: Combined SMI (Depression, possible psychosis) and MedicaYStroke Condition In SHU at Upstate Inadequate treatment, inadequate disability rehab and support

&a?

*

(Interviewed while housed in SHU).

f who wears a neck brace, has been in prison for 16 years and in SKU off and on for six years. He describesmental health care within the DOCS as "garbage." He has taken medication for delusions in the past -Zyprexa -but not now because he rehses to take it. He has been admitted to CNYPC three times between 1996 and 1997, and was sent to observation numerous times at Cornstock. He exhibits delusional thinking about a sinus condition, and he believes "they think I'm suicidal because I complain about my sinuses." He says the brace on his neck resulted fiom an assault by officers in 1998. He is single-celled. He is bringing a lawsuit because "they say I'm delusional when it's really a physical problem." On mental status exam, this man does seem bizarre and delusional; he perseverates about his sinus condition in a delusional
fashion - but he does not want mental health treatment. Still, this is no reason to
discharge a clearly psychotic individual fkom the OMH caseload and send him to an institution where he cannot receive mental health attention. His clinical chart is
consistent with the history he presents. In 1997,1998, he was admitted to CNYPC with
Delusional Disorder, with no known psychiatric history prior to incarceration. He was discharged from CNYPC with diagnosis Adjustment Disorder and no meds. He has been seen by OMH off and on since, but no consistenttreatment, and he spends time in SHU. In other words, he is suffering serious mental illness alone in his cell and is not receiving adequate mental health care.

Example of: SMI (Delusional Disorder) in SHU At Upstate, where there are insufficient mh services Discharged from OMH caseload for non-compliance Cycled from to observation, CNYPC (in past)

d,L-.

(Interviewed while housed in SHU).

w,L . has been in prison for three years, and in SHU for 22 months, nine of
them at Upstate. He has been treated for depression throughout his prison tenure. He

complains about officers' insensitivity - e.g., after he was placed in a cell with a prisoner he could not get along with, they got into a fight, and then the officers beat him up and gave him a ticket. He cannot read in SHU because he is unable to focus and concentrate, so he lays on his bunk most of his waking hours, looking at the ceiling and having too low energy to do anything else. He withdraws, isolates himself, cries a lot, and many
days does not even get out of his bunk. He has not been admitted to CNYPC and has not
been in observation. He is prescribed Zoloft and Benadryl. He had attended college and worked prior to incarceration. His mother is a CO at Rikers Island. His girlfiend comes to visit him. This man suEers from Major Depressive Disorder and is taking antidepressants. His chart contains a diagnosis of Depression NOS, and admission to OMH OP services on 9/20/02. Progress notes reflect stress due to a sense it is unfair that he is incarcerated, and sadness about separation fkom family and his child. He is offered relaxation techniques, etc.

Example of: SMI (Depression) in SHU, at Upstate where mh services are lacking
Deteriorates, worse depression, in SHU

M. E,

(Interviewed while housed in SHU).

& E is doing one to three and is hoping for release in September. He .$,
says he was a police officer. He is prescribed Paxil and a tranquilizer; he was taking Neurontin and Seroquel when he entered jail. He has ten tickets for smoking and complains there is no place to smoke. He says he never sleeps, until he "crashes" from exhaustion. He stopped taking psychiatric medications at Downstate. He has much anxiety and a history of hearing voices. He also experiences depressive spells and severe mood swings. He receives mental health care via telemedicine, which he likes. He gets agitated in the Box. From 1992 until he came into prison he was prescribed Paxil, Neurontin, Seroquel and Effexor. He has seen the mental health staff at Upstate twice in the four months he has been here. He was on methadone for many years, but does not have a drug problem in prison. On mental status exam this man is obviously in a manic episode, and with his history he is suffering fiom Bipolar Disorder. His clinical chart reflects repeated admissions and discharges fi-om OMH caseload,but in 10/03he was
prescribed Paxil pm (sic?! - this is definitely the wrong treatment for someone with
Bipolar Disorder, since it tends to precipitate a manic episode) for "Anxiety DisorderfPanicattacks." OMH does not question credibilityof symptoms, but underdiagnoses as Anxiety and treats with Paxil while at Upstate. This man needs to be on psychiatric medications and needs to be transferred to a more intensive treatment setting.
By history, his agitation is worse in the Box.

Example of: SMI Wipolar Disorder in manic phase) in SHU at Upstate Currently in Manic episode, not discovered by OMH Not receiving assessment and treatment he needs

5.k4#

(Interviewed while housed in SHU).

S 4 has been in prison (jail?) since 1993, and has been at Upstate for
three years. He says the officers abuse the prisoners here, write tickets, and tamper with your food. He sees the mental health counselor through the food slot of his cell door. He
has been forced to take medications on account of his aggression. He was admitted to CNYPC three times in the late 1980's. He does not like being double-celled because there is no privacy. He does not have a behavior problem when he is not in segregation, but in seg he cannot control his anger and he gets into cell fights. He is in the Box for smoking pot; he has no prior SHU time. But he has received between seven and nine tickets since coming to this box, one for refusing to move, one for fighting, etc. "You get tickets because you feel oppressed and you're forced to do things against nature. That takes you out of your comfort zone, then they put another prisoner in your cell and he comes at your fkom a different place - I can't deal with all the pressures." He feels the COs abuse their authcrity. "Anger builds, you go into emotional overload." He has a lot of trouble getting along with cell-mates. He has learned to cope. Sometimes he gets into trouble with a cell-mate because he does not want to go into personal stuff with him. He is proud of himself for maintaininghis sanity throughout this ordeal. On mental status examination he is angry but coherent; his history is credible.

Example of: Not in mental health treatment currently History of admission to CNYPC three times in the 1980s Anger builds up in SHU

A ,o

. (Interviewed while housed in Keeplock).

A 6, 1 has been in DOCS since May, 2001, on his second bit. He had a five
year prior term. He has been at Upstate for two months, having transferred from Southport SHU. He does not know why he was sent here. He believes it might have to do with his attempting suicide, which was triggered by retaliation against him by staff who thought his family was making threats. He knows his food is being tampered with because he has an ulcer. He believes his SHU time has expired and he is on Keeplock(?) He made a suicide attempt prior to his hearing. He has made two significant suicide attempts in prison. He has a life sentence, but he is evidently appealing, and he claims staff threw away his legal mail. His first suicide attempt was by OD at Wende; he was stripped in observation for a week and received no treatment except group interviews by mental health staff with COs present. He asked to be returned to his cell because he felt he was not getting treated. He feels he is suffering a lot being cooped up at Upstate. For example, he is no longer doing SHU time, and he should be having privileges restored

while he is on Keeplock-but he isn't because he is here -he does not get visits, and he
should. There is no mental health care here -it's ajoke. He had no prior psychiatric
history, he has never been admitted to CNYPC. He thinks he is depressed and suicidal, and it's related to having his chances of reversing his conviction unfairly ruined. He feels
like he is treated like a beast here. His symptoms include sadness, crying, self-
castigation,psychomotor retardation, no motivation to do anything- e.g. he has started
but not finished many letters - and he gets angry easily. He is single-celled because of his sentence. This man is depressed and not receiving adequatemental health care. He is single-celled,but he needs out-of-cell programming. He says he is on Keeplock status, so he should have more privileges. His chart contains the diagnosis Depressive Disorder and Adjustment Disorder with Mixed Features, several stints in observation, sometimes lengthy, a 9/4/03 note reflecting phone call fi-om grandmother telling staff she'd received a letter where he says he is going to kill himself. He is sent to observation. He cycles firom observationto SKU and back to observation. As of 1104,his Vistaril was discontinued and he was prescribed Remeron 30 mg-/day.

Example of: SMI (depression) in SHU ' Confusion r e SHU vs. Keeplock term Depression aggravated by segregation Cycling from SIFU to observation and back to SHTJ

c -g*

(Interviewed while housed in SEW).

entered prison in 1983, and came to Upstate in March,2003. He
has been in a wheelchair for 12 years with a TI0 spinal lesion and paraplegia-he carries
a bag. He was in PC at Greenhaven Hospital in 1992when, he thinks, he had Guillian Barre or a tick bite. He was convicted of a sex crime, and he has been attacked in prison many times. He has not been well protected, even when in PC, and he was attacked men
in his wheelchair at Greenhaven-his neck was cut. He received a six month sentenceto
SHU because he refused to program in PC because he felt unsafe. He later refused double-bunk for the same reason, and was given another ticket. He is in a single cell at
Upstate, and is not receivingmental health care. He has not been admitted to CNYPC,
but he was in observation a few times for suicidal acts early in his prison term. His thin clinical chart corroborateshis history. He is given no psych diagnosis, and had been
prescribed sleeping pills years earlier. This man is talkative, wheelchair-bound, and not
suffering fkom SMI although he does experience a lot of pain and suffering.

Example of: Disabled (wheelchair) in SHU Protection issues lead to tickets No known SMI, but seems depressed due to cirumstances

5% 6ib

'.(Interviewed while housed in SHU).

has been in prison since 2000 and at Upstate since 9111/02. He tells me in a tearful, angry tone that he has no significant mental health treatment history, but he has been in a suicide cell three times in May. "The COs stand there and humiliate you, they take their anger out on you, it's the only place in the prison where there's no video camera. They turn the water off, I tried to hang up using ripped up pieces of my (Ferguson) gown, I did it to get water, I was desperate to get water!" And he adds that the CO came to see him when he was in observation and told him not to be surprised if all his property was destroyed when he got back to his cell. He had 33 tickets in May. He says, almost incoherently, that he went to the suicide cell three times because he was trying to get their attention in order to fix his wrong reputation. He is HIV+, is supposed to be taking a medication cocktail, but they don't give it to him and they say he is refusing to take it. He did refuse one time, but states that he wants to take it regularly. On mental status exam he is agitated, almost desperate in his attempts to be understood, he is markedly depressed and crying during the interview to the point of incoherence. He gets anxious and agitated when he is in the Box, the COs harass him, and he then gets desperate and tries to kill himself, He has received 40 tickets while in the Box. He has a SHU term that lasts until 2011, during which time he will not be permitted commissary and won't be able to use the phone. He believes officers are afiaid of him because he is
HIV+ and he is angry. He feels the COs blame him whenever other prisoners bang on
their doors and make noise. He says he is a "'paranoid person." He believes he was fiamed whenever he was alleged to have committed unhygienic acts. He seems earnest in his attempts to kill himself. He has been asking for four months to receive psychiatric medications, but they do not give him any. They say he refused psychiatric medications, he says that is not true. He is serving 25 years to life. In his clinical chart, he is admitted to CNYPC on 4/24/03 with diagnosis deferred. Depression is noted on 2/21/01. On 11/30/2000he is seen by mental health cell-side and complains angrily about having to share a cell. On 1111/01he is prescribed Trazadone 100mg. B i d . for depression, and on 1/13/01, mild mood disorder is noted at Five Points. SKU mental health evaluations often contain long notes, e.g. describing suicide ideation, trips to observation and cell-
front conversations with mental health staff. This very emotional, labile man with HZV
seems in a vicious cycle of acceleratingbehaviors that result in tickets and more negative attention. He is agitated and depressed, he does require psychiatric attention and is not getting much except for cell-fiont interviews, yet on notes &omthose interviews, OMH staff do see that he is having emotional problems.

Example of: SMI (Depression) in SHU Deterioration in SHU

Tickets - many -related to SMI
mv+
Not getting treatment that is urgently needed

w?r

. (Interviewed while housed in SHU).

F F $"" ,has been in prison for eight years and has four more years to serve.
He has be& at upstate for 15 months and is on Level 3. He is prescribed Paxil, 20 mg. per day, plus a sleeping pill for the severe insomniahe experienceswhen he is in the Box. He gets anxious and claustrophobic in the Box; he feels his heart racing and sometimes
hears voices, gets fiantic thinking he cannot breathe. He states that his panic puts him in
closer contact with oflficers and he hears chains rattling and thinks they are going to beat him, so he gets more anxious. The psychiatrist is giving him Paxil for precisely this problem. He never had anxiety nor panic in GP. In the Box he cannot concentrate, he has to read things over and over again in order to comprehend them. He says he is a spiritual person (he wears dreads that are woven around his head and he has a beard), but others think he is crazy because of his spiritual ideas. He was beaten by a cellmate, and he asked the cellmate if he was satisfied. He has visits, but not by his two children who are on Long Island. He sees the psychiatrist via telemedicine, once every three months
for approximatelyeight minutes. He did the drug program, MAT, for six months -but
found it not very helpll. His clinical chart contains diagnoses GeneralizedAnxiety Disorder and Adjustment Disorder with mixed Depressed/Anxious mood. A 10/3/02 Treatment Plan contains a Problem List that includes anxiety, mild depression, paranoia and physical/sexual abuse victim. He is seen as an outpatient, mostly cell-fiont, in SHTJ,
and prescribed Paxil and Vistaril. In sutnmary, this depressed young man with panic
disorder and severe insomnia is helped slightlyby Paxil, but basically is very symptomatic and dysfunctional when he is in the Box.

Example of: SMI (depression) in SHU
Many symptoms and marked deterioration in SHU

N,"B.-

(interviewed while housed in SHU).

has been in prison for three years and has been at Upstate for two weeks following a ticket for assault on an officer. He was implicated in a riot at Auburn
6/14/03,and was given six -sevenmonths in the Box. He says, "This box is extreme,
you don't have socks, the food is horrible, the portions are small, there's a lot of mental abuse, the staff play games with the food, they don't give you things you're supposed to get, there's name-calling and racial slurs, you're double-celled." He has no psychiatric history, has not been to CNYPC, is not on medications. He says he cannot sleep here,
and he's up for several days. He has a son, looks forward to going home; he was in print shop and on the waiting list of ASAP, but is not any longer. He is afiaid he will start to
bkcome aggressivetoward others as others have become here. He says there's a lot of

depression in the box. He's seen a lot of guys go off on their bunkies or hang up. The staff is slow to respond. This man does not suffer fiom a serious mental illness.

Example of: No SMI, in SHU Symptoms of SHU confinement

R.N,

(Interviewed while housed in SHU).

This 21 year old man had a three year term and is currently in prison on parole violation. He has been at Upstate for 90 days for a dirty urine. He needs a single cell because he is on the OMH caseload. He was at a Medium security prison, Mt. McGregor. He is seeing OMH because he gets claustrophobia and depression. He is not taking medication. He wants to see the psychiatrist and take medications, but he has been waiting a month on the list for telemedicine. He sees Dr. Kemp once a month in a room, but worries they are on camera. He is a h i d that they'll retaliate against him for talking to us. All of his tickets have been for dirty urines. He was sent to prison at 16 for a drugrelated robbery. He has been in ASAP, but didn't complete it. He has been depressed since he was eight years old. His parents fought a lot. He received a GED in prison and
(',
reads a lot, even in the Box. He has made many suicide attempts, he overdosed at ten or 11. He has never been to observation, nor to CNYPC, nor to a hospital on the outside. He thinks a lot about suicide, and feels very depressed being in the Box. He hopes to leave prison in 83 days and return to his family in Baltimore. This man is depressed, and is in prison and in the Box for turning in dirty urine.

Example of: SMI (Depression) & substance abuse (Dual Diagnosis) in SHU
Depression worse in the Box

T*a ,

(Interviewed while housed in SHU).

Q nas been in prison since 1995, and had a prior bit going back to 1991. He has spent the majority of his prison time in the Box. I ask why and he says "It's the stress level, I lose my temper, I like staying to myself, I get into hassles with other prisoners." He does not have problems with the staff. He did a 26 day hunger strike at Comstock & Great Meadow because he believed they were messing with his food. He has had no tickets since November. He was on Zoloft for six or seven months by telemedicine, and liked it, but they discontinued it four months ago to see how he'd do. He says he needs something to help him relax, and he has sleep problems. He can go
four days without sleeping. He does not heat voices, but he thinks he is "crazy." He has
"bad nerves," his hands shake, he is jumpy and he can't sleep. Prior to incarceration, he was admitted to St. Lukes/Roosevelt Hospital psychiatry ward because he was psychotic for a couple of months after doing Angel Dust. He has a long psychiatric history, and has been behind bars off and on since age 15. He tried to hang up at Rikers Island in 1990, but he has not been to observation nor to CNYPC while in DOCS. He is more depressed

than ever now; he lost his mother in 2000 and his aunts and grandmother in recent years. He has not had a visit in four years. He has not received a GED, and has not been in a
drug treatment program in prison. He talks to P 4" in a room for six or seven
minutes at a time, but has not done that in months. He has a cellmate, and has been involved in three cellie fights. Having a cellmate makes his depression worse. He does not think P 3 is sincere. He thinks he needs psychiatric medications. He does not know anything about any 90 day evaluations. On his clinical chart he is diagnosed Adjustment Disorder (9/12/02), and then Depression (10102), but on 5118/01 he is
terminated from OMH caseload. On 12/31/02he is diagnosed Depressive Disorder NOS and is Mental Health Level 4. His SKU mental health evaluations seem superficial, sometimes reporting no depression, for example, even though by history and progress
a notes he is depressed at approximately the same time. Notes reflect mild to moderate
depression, and he is seen at his cell-fiont and given in-cell course work by OMH. He is
prescribed Zoloft for a diagnosis of Depression in Sept. and Oct., 2002, and is noted to be in psychotherapy related to the death of his mother. This man is clearly depressed, with a history of likely substance-inducedpsychosis prior to incarceration. He needs a single
cell and mental health treatment -not available at Upstate.

"' Example of: SMI (Depression, some psychosis) in SHU at Upstate Inadequate treatment Cell-front meetings with OMH Screening mental health evaluations shoddy

Z ,K .

. (Interviewed while housed in SHU).

Z,K , has been in prison for three years, and at Upstate since April, 2003.
He has a 1 113to 4 year sentence, but he "gets hit" at the Board for insubordination. He is OK with having a cellmate. He has been in the Box for so long that he is not focused. He had a "don't care" adolescent focus when he came to prison. He has not been to CNYPC, has not been to observation, and only sees mental health if there is a family problem. He has not had any visits since being at Upstate. He has knee problems and wants medical attention, but staff say there is nothing wrong with his knee.

Example of: No known SMI in SKU

asR,

, (Interviewed while housed in SHU).

O ff has been in prison four years on his second bit. He came to Upstate in June, 2002. He is seeing mental health staffbecause he hears voices and is suicidal. He says he needs Prolixin and Cogentin. He has been prescribed Navane, Haldol and other medications in the past. He was admitted to several psychiatric hospitals prior to incarceration, including G Building (Psych) at Kings County Hospital with a diagnosis Major Depressive Disorder. When he stopped taking his psychiatric medications, he got

69

tickets. He succeeded at staying ticket-fiee at Clinton for 19 months, and then got into a fight, got cut, and received a ticket. He is depressed because he is afraid he will die in prison. He tries to get the staff to give him medications to keep him focused. On mental status exam he is very sad with psychomotor retardation. He is currently on Mental
Health Level 2, but will be switched to Level 3. He also has black outs and gets ragehl -
the psychiatrist at Comstock says he needs a CAT scan. He is always sad, he lays in his cell and tries to sleep, he does not talk to anyone, he tries to avoid officets so he can stay out of trouble. He does not receive visits &om his family. He was hearing voices until 2001. In SHU he has memory lapses and he goes into rages for no apparent reason. He is fkightened by the rage that builds up when he is in segregation, for no real reason. He had a competency exam prior to trial. This man has had multiple head injuries as a child and used Angel Dust on the street. He has a long history of auditory hallucinations, memory lapses and rage episodes. His clinical chart contains a recent diagnosis of Adjustment Disorder with mixed features. Pre-incarceration psychiatric hospitalizations are noted. He was in observation at Clinton on 8/3/01 for ''bizarre behavior and S/S of depression." He was sent back to his SHU cell. A n older Screening form, 10/8/99, has diagnosis Schizophrenia,Undifferentiated, at Clinton, and he was MH Level 2 and was prescribed Zyprexa up to 15mg. per day. Mostly he is h4H Level 3 to 6 . He often tells mental health staff who visit him at cell-fkont that he is not having any problems, but one suspects denial. In summary, there is serious mental illness (not Adjustment Disorder) plus organic brain pathology, yet he is not being evaluated, he is not in treatment, and he is in an institution that lacks adequate mental health services for his level of pathology and dysfunction.

Example of: SMI (Depression, Psychosis) at Upstate Cannot control growing rage in seg Inadequate Mental Health Treatment Downgraded diagnosis Cycling from SHU to observation and back to SHU

c-a*

Great Meadow - 8/26 - 8/27/03
, (Interviewed while housed in observation).

has been in prison for seven years on this bit, and seems to have been homeless/living in a SRO hotel prior to that. He has been admitted to CNYPC twice, and prior to incarceration spent six months at St. Lawrence Psychiatric Hospital. He does not know why he is in observation; he knows he was getting c o n b e d and aggravated a lot and staff said he was not making sense. He has been in observation for several days and thinks he is being prescribed Zyprexa. On mental status exam he seems confused and incoherent with bizarre gestures and flat affect. He is relatively unresponsive to questions and thinking is tangential if not chaotic. He seems to be trying very hard to organize his thoughts, but with little success. He says he has trouble finding words. He was in GP, and says he gets along OK in GP. Prior to transfer to observation he was

seeing the psychiatrist once per month for up to 15 minutes in an office. He reports being suicidal in the past. He spent 30 days in the Box last year, and had a very rough time there. He has been admitted to CNYPC, evidently on more than one occasion, for six or nine days at a time. This man is clearly in a confbsional state, most likely an acute psychotic episode but an acute brain disorder must be ruled out. He has spent several days in observation and has not recompensated. He reports he is being given antipsychotic medications. In his clinical chart there is a diagnosis of Schizotypal Personality Disorder on 8/21/03. This is clearly a wrong diagnosis, one that is not true to the acute psychotic state I find him in now, and this is clearly not his first episode. His Treatment Plan of 9/16/03 states: "History of hospitalization, tends to become isolated with deterioration in personal hygiene while exhibiting bizarre behaviors." He had been managed in GP with occasional OMH intervention prior to the admission to observation during which I encountered him. But a note in his chart for the day after my interview, 8/27/03, reflects he is in the dorm, coherent and not confused. A day or two later he is returned to GP. He is sometimes on medication, Zyprexa 15mg. per day, and som he requests discontinuingit and is reported to do well, with minimal s e ~ c e sH. e was to be released soon after I saw him. He most likely suffers from chronic Schizophrenia, though the chart contains many lesser diagnoses, he does not cause trouble, he is sent to CNYPC or RCTP when he starts talking to himself, hitting himself and body odor accu~~lulatesI.think his symptoms are downplayed and he's someone who suffers in silence while being mostly ignored.

Example of: SMI (probably Schizophrenia) in GP with OMH outpatient treatment Under-diagnosed/psychosisdownplayed but evident Ongoing OMH treatment not intensive enough, given severity of condition

T ,6 ,

(Interviewed while housed in observation).

.has been in prison for two years and has one more to serve. He has
been in observation for several days, having been transferred from Coxsackie where he was hearing voices commandinghim to cut himself. He has been hearing voices for four years. He was alreadyprescribed Zyprexa, but they increased his dosage. He also takes Paxil andlor Remeron. In observationhe is seen only at cell-fiont for a few minutes, but today he was taken to an office, he thinks it was because we were corning. He has not been admitted to CNYPC. He believes they will send him back to Medium security at Green, but he fears that without more intensivehelp he will again become selfdestructive. His daughter died recently, he was informed by letter, and this weighs on him. He has a lot of trouble managing in GP. He has been having depression and mental problems since 1992. He hears his father's voice when he is depressed, telling him to "get it over with" (i.e. suicide). He cut his neck three weeks ago, and has made multiple suicide attempts. He was in observation one other time, and says the mental health staff does not like to send anyone to CNYPC. He does not receive tickets for cutting himself. He assures us he is not manipulative, but truly earnest about killing himself. In summary, this man suffers fiom a Major Depressive Disorder, recurrent, with psychotic features

(credible command hallucinations ordering him to kill himself), and has been seriously depressed for four years, worse since his daughter's demise one month ago. He requires residential mental health treatment such as CNYPC or ICP, but he is certain he will be returned to GP at Green.

Example of: SMI (Major Depressive Disorder) in GP in Medium Security Facility Sent to observation at GM for acute psychotic decompensation and suicide crisis Needs more intensive ongoing treatment

L,&"

(Interviewed while housed in dorm of RCTP).

aa fi- had been in GP at Great Meadow and was told that his hygiene was
poor and he needed to see the psychiatrist. He has been told they want him to stay and go to ICP. He is taking Zyprexa now, but was not at Great Meadow. He spent three months at CNYPC, returning to Great Meadow in January, 2003. He tells staff he does not want to take psychiatric medications. He has been admitted to CNYPC seven times; he would like to return to GP but believes they plan to send him to ICP. He was in the Box for three or four months at Attica. He has been seen by OMH since 1990. After he rehsed meds, OMH continues to see him and convince him to take meds, then his hygiene deteriorates and they send him to the mental health unit. He isolates himself. On mental status, his affect is flat, and he is very concrete. He seems to suffer from psychosis which is in partial remission after a recent decompensation.

Example of: SMI (chronic psychosis) in GP at GM Decornpensated and sent to RCTP Plan transfer to ICP Has done time in SHU

..- -
bi -I

(Interviewed while housed in SITU).

b e 3 has been in prison since 1994, and in SHU for seven years with many
tickets accumulated in SHU. He does not know what the charges are; he believes they may be sexual, he feels the actions in question are not intentional but rather result &om "tension." He has never been admitted to CNYPC. He has been in observation three or four times, but cannot remember when the last time was. He has taken psychiatric medications in the past, but not since he has been at this institution. He does see a mental health worker on a weekly basis in an office. He has not been in ICP. He reports that his emotional symptoms are much worse in the Box; he has nightmares and cannot control himself so he gets more tickets. He has a lot of trouble concentrating, repeatedly thinks of hurting himself, cannot control his mounting anger, and though he likes to read, he finds he cannot concentrate and finish reading anything. He believes that his mental illness causes dyscontrol of his anger, he consequently gets more tickets, and he has no hope of getting out of SKU prior to his release date in 2012. He writes sexual letters in

response to command hallucinations, and that is why he receives tickets. On mental status examination he describes credible auditory hallucinations including command
hallucinations that often lead directlyto tickets, complains of "fi-~strationa~nd~problems sleeping. His affect is inappropriatewith smiling at inappropriate times and his thinking
is disorganized but he tries to be responsive. He exhibits very strong First Rank
Symptoms and his memory is grossly impaired. He repeatedly looks suspiciously around the visiting room. He went to the 1lth grade in school, and his mother and sister visit him in prison. His chart is six inches thick In it, he is diagnosed Impulse Control Dis. And ASPD and Paraphilia NOS. But on 6/10/97, he was given a diagnosis of Psychotic Disorder NOS. At that time, he was noted to be "seeing things, People came out of space
ship,. ..being hyperverbal with bizarre acts, not aggressive.. .." His Mental Health Level
was 1 on 11/8/01, and he was at CCF MH Unit for a crisis. He is repeatedly admitted to MH outpatient and then discharged, and noted to be uncooperative in treatment. In 11/01 he was noted to smear feces in SHU, and not to learn fkommental health treatment nor fiom punishment. By 12/11/97his treatment plan included "Pt. Will not utilize false reports of hallucination and delusionsto cope with stress of SHLT..." In other words, he was considered "Bad" and not "Mad" fkom that date onward, even though continual SHU confinementwas causing serious psychiatric problems. A 2/8/02 Progress Note is typical for his chart. He was transferred fkom Clinton SHU to Observation for flooding the range, breaking up his cell and threatening to hurt himself. He reported command hallucinations preceding his bad behaviors. He is discharged back to SHU on 2/14. He is repeatedly observed for suicidal behavior, continues to get tickets in SHU, continues to "throw" and be placed behind Lexsan, makes inappropriate sexual statements and threats, and continues to be seen periodically by OMH staff at cell-front with a negative mental
status reported - interspersed with notes about voices, suicidal, etc. He is intermittently
prescribed Benadryl and minor tranquilizers or Trazadone. He is usually a MH Level 6. This man suffers from serious mental illness, likely psychosis, and his command hallucinations inform acts that repeatedly lead to tickets, but since this does not seem to be taken into serious consideration by staff and hearing officers, and he is mainly seen by OMH at cell-hnt and denies symptoms, he keeps accruing more time in SHU, mostly for sexual offenses that seem compulsive in nature, where his symptoms are aggravated. He is under-diagnosed, and his severe disability based on SMI ("Mad") is missed while his unacceptable behaviors are deemed 'Bad" and reacted to with fixher tickets and more time in SW, which, cyclically, worsens his mental dysfunction. He has never been treated in a mental health unit such as ICP, has never been admitted to CNYPC, and he deserves treatment and removal fkom SHU on account of unrelenting severe psychiatric problems.

Example of: SMI (chronic psychosis with acute exacerbations) in SHU Under-diagnosed Not admitted to CNYPC because he is considered "Bad" Inadequate treatment Hallucinates alone in cell, gets tickets in SHU, condition worsens

fl.0- -

(Interviewed while housed in General Population).

M-0 has been incarcerated for eight years on his second bit. He was
admitted to CNYPC from Auburn once in 1999when voices commanded him to throw excrement. The doctor had taken him off of his psychiatric medications, and he believes that's why he heard the voices he hadn't heard since being in jail. He had been on Depacote and Risperdal for six days at the time I interviewed him, but he said the voices have not disappeared. He links his voices in time with his violent outbursts. He has not
received tickets recently, but has spent approximatelythree years in the Box for actionsspitting at an officer, flooding his cell -which he was commandedby voices to do. He
believes that all three times he was charged with assaults on staff he was not taking his
medications. He sees the psychiatrist once a month for ten minutes in an office. He has
been to observation approximatelynine times, usually for three or four days. His father
died; he has no visitors. On mental status exam he seems a little silly and grandiose; he has tangential thoughts, exhibits ideas of reference, and has a fixed delusion about the government doing brain surgery on him. He says he wants people to think he is normal.
He set fires and busted up his cell during his previous term. He says he used his time in the Box to meditate and study Black history. He has been essentially free of disciplinary
tickets for two years, the two years he has not been in SHU - he thinks he learned about
consequences of acts. He had a drug problem, and has been in RSAT, but feels the program did him little good. In summary, this man suffexs from psychosis in partial remission on medications in GP. His chart reflects a history of fire setting. He began receiving mental health treatment in prison in 1996. He was transferred from SHU to CNYPC in 1999, diagnosed Delusional Disorder, and discharged back to SHU. He has been diagnosed Schizophrenic, in a Treatment Plan Review on 1/10/03,there is Dx Paranoid Schizophreniaand he receives outpatient care in GP at Great Meadows. He is prescribed anti-psychotic and mood stabilizing medications.

Example of:

SMI (Schizophrenia) in GP with OMH outpatient treatment

Spent much time in SHU

Condition worse in SHU

Tickets driven by voices, SMI, often when not taking medications

- e&@-

- 1. (Interviewed while housed in C Unit of General

Popuiation).

. g. B-# has been in prison since.I991(including jail?). He was refared to
OMH because he believes his food is being poisoned by the DOC, which he is certain of because of the shortness of breath, pain and altered states of consciousness he experiences. ''They have something that puts you to sleep, and when you wake up you
don't know what time it is.. .. They do this to people they think might be a leader of the
, future." He thinks the DOC would rather view a prisoner as mentally ill than deal with this problem. He has spent 11months in SHU for two different tickets. He currentlyhas
ajob as tier-tender. On his very thin clinical chart it is noted that he believes his food is poisoned. There is no diagnosis, no meds prescribed, and he fails appointmentswith ' mental health staff. There is a "Screeaing/Admission Note" for 1/7/93, indicating a
suicidal gesture, he did not want to talk, no treatment and no follow-up. This man does
suffer fiom a serious mental illness, likely Paranoid Delusional Disorder but must R/O
Schizophrenia-but he does not receive mental health treatment and there is no diagnosis
in his chart.

Example of: SMI (Delusional Disorder vs. Schizophrenia) in GP Has done time in SHU Assessment and Treatment inadequate He does not cause trouble

b bq*

(Interviewed while housed in SHU).

~4 burned himself in response to command hallucinations telling him, to
do so; this happened while he was not in treatment. He is prescribed Zyprexa, but his psychiatric medications have been given irregularly because he sometimes is non-
compliant. He was admitted to observation on 1/28/03. He has many tickets for self-
harm and destructionof property -he reports they are all on account of command
hallucinations. He had been admitted to Bellevue Hospital psychiatric ward prior to incarceration. He has been in SHU or Keeplock since October, 2002. His clinical chart
reveals that in 2001 he was admitted fiom Elmira to CNYPC (4/6/01 - 5/4/01) and
discharged to Clinton. His diagnoses include Adjustment Disorder and Impulse Control
Disorder and mild Mental Retardation, but notes reflect a history of psychiatric problems prior to incarceration with prescription of Ritalin for 1 112 years and Thorazine circa 1995. A 4111/01 Inpatient Core Evaluation at CNYPC resulted h m self-destructive acts
and threats, he was diagnosed Adjustment Disorder and prescribed Sinequan 50 mg./day.

75

In Feb., 2002, he is prescribed Zyprexa 10 mg. and Paxil20 mg./day. He is rejected for ICP in May, 2002, for lack of motivation. A 6/9/02 note reflects depression and suicide intent by hanging. Many other admissions to observation for self-destructive behavior are noted. 4/25/03 Rx of Zyprexa 10mg. b i d . plus Paxi120 mg./day. Mental status is consistent with psychosis in partial remission, and there is some question of a low intelligence. This man seems quite disturbed, has a history of serious mental illness, and is repeatedly cycled from SHU to observation and prescribed anti-psychotic and antidepressant medications, yet OMH views his problems as behavioral rather than linked with serious mental illness. It is quite clear that his behavior problems are exacerbated by SHU confinement; he needs to be transferred to a mental health setting such as CNIlPC or P C , thoroughly assessed, and given a trial of therapeutic rather than punitive confinement to see if his psychiatric problems and behavioral problems can be diminished.
Example of: SMI (psychosis, poorly assessed) in SHU Cycle from SHU to observation and back to SHU Under-diagnosed, un-diagnosed at CNYPC Remains on anti-psychotic medications Needs more thorough assessment and treatment
This 34 year old Latino man has been in prison for eight years, mostly in Keeplock and SHU. He feels he is set up repeatedly for tickets. He believes he gets tickets for refusing to cooperate with mental health treatment. He was in a doublecelled SHU and did poorly. When he is in SHU he cannot control his anger, and he tries very hard to stay out of trouble but often fails. He suffers fi-omhyperthyroidism, he thinks because of his food being poisoned. He exhibits a delusional system that involves the officers moving him out of a double-cell Upstate situation and giving him a mental illness diagnosis. He says he was beaten while being transported to Great Meadow on 3117103. The psychiatrist at Great Meadows, Dr. Faruki, wants him to take fairly large doses of the medications. He has been assaulted by cell-mates, for example at Upstate. He says he is diagnosed Paranoid Schizophrenia,and his mental status examinationis consistent with that diagnosis. He shares delusions about being tortured with heat to the extent his body is burned. He exhibits thought disorder and first rank symptoms consistentwith Schizophrenia. He denies he suffers fiom a mental illness, and gives that as the reason he is not admitted to ICP. He is behind a shield now, but cannot fully explain how that happens. He also worries that the radiation he is receiving will causeburns on his penis.
In his clinical chart, he is given a diagnosis of fUOPsychotic Disorder by history on 8/18/03, and he is MH Level 2. On 3117/03 & 8118/03 he has a diagnosis of Psychotic
Disorder due to gen'l medical condition and on 4117101 there is a diagnosis of
Bereavement. He is sent to SHU in March, 2002. His MH Level in Upstate SHU
beginning in December, 2002, is six each month until it is changed to 3 on 3/17/03 (and he is involved in a fight on this date), to 2 on 3/21/03. He was admitted to O M '

caseload on 3/17/03 and discharged on 7/2/03. A Core Evaluation on 5/29/03 notes "Has verbalized in letters and verbally that he has been monitored through a virtual reality system which emits low grade radiation damaging his body." Further, "poor adjustment to the prison system. Is mistrusthl and suspicious of the correctional system. May benefit from medication therapy but he refuses to accept that his delusions are not real. Need help to accept they are not real." Hyperthyroidism is noted. Delusions are again noted by nursing on 10/1/03, and he is determined to be "functional in general population." Severalnotes reflect his refusing mental health treatment in mid-2003. SHU mental health evaluation of 8118/03 notes delusions. He is seen cell-side in SHU through Sept, 2003, and refuses treatment. On 1Of 1/03he is in observation for refusing his thyroid medication. He is angry and uncooperative, and delusions are noted. In
summary, this man is clearly suffering from delusions, is diagnosed psychotic by OMH,
is uncooperative with treatment, and is left in SKU, where he decompensates and goes to observation at least twice and back to S W , and then goes to CNYPC.

Example of: SMI (Paranoid Delusional Disorder or Schizophrenia)in SHU Under-diagnosed while narrative notes document delusions Screening in SHU misses severity of illness
Cycles from SlMJ to observation and back-to SHU
Non-compliant with treatment, and discharged while delusional

d-MS -

. (Interviewed while housed in SHU).

M has been in prison since 1996, and has been in SKU for a long time. In SHU, he admits to sensingthe walls closing in on him,cannot concentrate, gets angry and the anger becomes uncontrollable, leading to tickets that lengthen his time in SHU. He cannot relax and he cannot sleep in SHU, which makes his mental condition worse. He sleeps two hours at a time, and then he is up again and the lack of sleep makes his mental illness worse. He does not go to recreation because he is afiaid of being "hassled"
by guards or having his cell searched. He is very depressed and is hearing voices -
symptomsthat have been with him since 1999. In March,2003, he was admitted to CNYPC afker setting fire to his cell. He says he did it because he was feeling frustrated and unable to control the hatred that builds up in him when he is in SHU. He was sent back to the Box (SHU) from Marcy. He overdosed on Tylenol, among other things, but the Tylenol O.D. was immediately after he was released back to SHU from CNYPC. He says it cannot be that he manipulates to get out of Box, because he actually dislikes time at CNYPC more than SHU. On mental status exam he exhibits flat and depressed afSect, psychomotor retardation, and reports very credible auditory hallucinations. He halted taking medications because he had been promised programs that were not forthcoming. He hears the voice of a girlfriend who died in 1994. He also hears almost continuous
self-deprecating voices. He has been to the tenth grade, and there is a question of his being deported to South America when he is released. In his clinical chart, he is diagnosed Adjustment Disorder on 9/28/02, he is MH Level 4 on 9111/02; 3 on 9/28/02; 2 on 10111/02; and 1 on 5/14/03. On 5/16/03 he is admitted to CNYPCwith the diagnosis

Major Depression, Recurrent, after setting fire to his cell and overdosing on Tylenol in
SHU. He was prescribed Paxil, 20 - 30 mg. per day & Trazadone 50 mg. He was
discharged back to SHU on 6/11/03. He has had various diagnoses, including Maj. Depr. Dis, Recurrent, ASPD, Adjustment Disorder and no diagnosis -but never malingering.
He has taken a series of antidepressants,including Wellbutrin, Prozac and others, and he is monitored in SHU by O M . In summary, this man is clearly suffering from a psychotic disorder that includes depression, that is inconsistently treated and only goes
into partial remission. His diagnosis does not include psychosis, but a 5/16/03
Screening/Admission Note & Psych Eva1 after he set fire to cell reports: "thought
processes 10% coherent, 90% illogical, disorganized, influenced by violent idea of self-
destructive behavior.. ..He has started to hear voices in the prison, but relates them to his
belief in Voodoo." His GAF was 30. He has at least two CNYPC admissions and was sent back to SHU each time, the last in April, 2004, and his diagnosis remains Maj Depr
Disorder, Recurrent - in spite of notes reflecting clear psychosis during episodes of self-
destructive behavior. This man is intermittently very disturbed with SMJ and should not be in SHU.

Example of: SMI (Depression with Psychosis) in SHU Under-diagnosed or un-diagnosed Cycles from SHU to Observation, CNYPC and back to SHU Treatment Inadequate Narrative notes reflect greater psychopathology

ads

(Interviewed while housed in SHU).

6 S- has been in SHU for four years and will only be released i?om SHU in
2009. He has been in prison since 1998 on his third bit. He complains about being constantly sweiled because he is a "special case," and indeed, during our interview, a C.O.was glaring at him through the window of the door. He says he is being forced to "smell stuff," and "my life is being publicized to the people of New York, I even heard my name on the radio." He says being in SHU makes him nervous and he talks to himself. He has a shield over his cell door. He claims SKU attacks one's sanity: there is no privacy, and because he cannot read and because he cannot concentrate in SKU, there is nothing to do. He believes he is being singled out, watched, and set up by staff. He believes the officers mess with his food. On mental status, he is very intense and angry,
exhibits pressured speech with obvious ideas of reference and First Rank Symptoms, and
he has an obvious neurological problem involving involuntary movements. When I ask him about the involuntary movements he says they began in SHU. He has been on the anti-psychotic medication Seroquel, but he is not aware of ever being prescribed phenothiazines (which can cause involuntarymovements). He has not been admitted to CNYPC. He was in observation at Auburn for one day. He does not see OMH except when they make rounds at cell-fiont. He would like to go to STP. He does not go to recreation. Steve Martin was told by another prisoner that this prisoner is the most disturbed prisoner in the SHU, and has "gassed" other prisoners, His clinical chart
,
78

contains diagnoses of Delusional Disorder and Psychotic Disorder NOS, yet he is repeatedlyMenta1Health Level 6 except when in acute crisis (7101 and 7/02), when he becomes Level 1 or 2. He is admitted to observation on several occasions, and then back to SHU. He is prescribed Seroquel, but is often non-complying with meds. He was in STP in July, 2001, at Attica This man is clearly psychotic, probably Delusional Disorder but must rule out Schizophrenia He also has a neurological problem that warrants study. He has a long SHU term, has been diagnosed psychotic and delusions are repeatedly noted by OMH staff, and cycles to observation. In other words, he is known by OMH to be psychotic, is warehoused in SKU with intermittent medications and little but cell-front intervention. He has been in ICP. He should not be in SHU because his condition deteriorates in isolated confinement; he needs to be in a residential treatment setting such as ICP.

Example of: SMI (DelusionalDisorder or Schizophrenia) in SHU Cycles from SHU to observation and back to SHU Under-diagnosed Narrative notes re delusions, not reflected in diagnosis Very inadequate treatment Went to STP, return to SHU

y y

(Interviewed while housed in SHU).

"I Y has been in prison for seven years on this, his second bit. He has been in SHU for five years. He has been hearing voices for quite some time, and attniutes his rule breaking to command hallucinations. On Aug. 21,2002, he cut his wrists because the voices commanded him to do it. He has attempted suicide by cutting, has a history of not eating, and has lost weight (down fkom 275 to 190). He is currently on "loaf." One cutting incident occurred after an officer gave him a razor. He has been to observation many times, the last time was for cutting an artery. He says that being in the Box makes him think of killing himself all the tirne. He shows me multiple scarson his forearms. He has asked to be in ICP but is told he needs to be in SHU because of his large size. He was admitted to CNYPC in 1998and diagnosed psychotic. He is prescribed Seroquel, but states it does not really help with the voices, which he still hears. He admits to feeling paranoid, for example fearing they are recording our conversation and that someone will do something bad to him. He gets depressed and hears selfdeprecating voices. All of his psychiatric symptoms get worse in the Box. He sees the psychiatrist once a month for fiveminutes. He has been to observationmany times. He has set fires a few times, each time in response to command hallucinations. He gets black outs, and has had an MRI. On mental status, he is earnest, depressed affect, and displays some memory lapses. This man is clearlypsychotic and depressed, and his serious mental illness is made worse by SHU confinement. Clearly his tickets result from behaviors commanded by voices.

His clinical chart fills a file carton. He has at least four admissions to CNYPC
5/14/98 - 6110198; 3/9/99- 6/16/99; 12/28/00- 3/13/01; 4/25/02- 5/31/02. At one point
he was discharged from CNYPC after being admitted for slashing an artery in a suicide
attempt, and it was recommended that he not be returned to SHU - yet he was returned to
SKU. His diagnosis is Psychotic Disorder NOS on 1/21/98& 6/16/99; Major Depressive Disorder on 6/16/99 & 3/20/01 (the latter with psychotic features). An update of his rnh record on 3/17/99states that he has a long SHU term and "Essentially we might as well say that he is going to be in S W the remainder of this incarceration." He is repeatedly suicidal, hears voices, is assaultive, sexually indecent and otherwise disruptive. When he was admitted to the mental health unit at Five Points on 12/27/00"He was actively psychotic, violent, and suicidal. He was banging his head against the wall but received no injuries. He wanted to die and stated if someone tried to stop him he would hurt them. He did hit a corrections officer in the head when the oEcer tried to stop him." There are conflicting notes about psychiatric history prior to incarceration, some saying he was hospitalized and on medications. IQ tests at age 14 and on admission to DOCS register an IQ around 71. Records show he has been prescribed Thorazine, Risperdal, Haldol, Sinequan, Seroquel, Paxil, Benadryl, Zoloft, Trazadone, Zyprexa, Klonopin, Cogentin (per update 4/29/02). A Behavior Management Plan, SPL 1, was ordered during J, admission to CNYPC in May, 2002, when he was self-destructivewith razors and had a deep cut on his arm. In May, 2002, afier psychological testing at CNYPC (61510' 2 by Dr. Wilson), his diagnosis was changed to ''No Diagnosis" on Axis I and ASPD on Axis 11, and a Behavior Management Plan was designed, including the directive that he was not to be seen by his therapist for at least 24 hours after self-injurious behavior so he won't injure himself to gain attention. He is returned to SHU at Great Meadows. A Special Mental Health Status report by psychiatrist, Dr. Byung Kim, on 8131/02notes psychiatric history pre-dating incarceration, auditory hallucinations, diagnosis was Psychotic DisorderNOS with prescription of Seroquel400mg./day. On 1/13/03he is admitted to observation because of "psychotic symptoms, talking to himself, responding to internal stimuli." He scratched his arm and required a cell extraction. On 5/23/03 his Seroquel was raised to 300 mg. per day. On 9130103, his diagnosis was "No Diagnosis" on Axis I
and ASPD on Axis 11, and Behavior Mgmnt Plan was still being followed in SHU - and
he was once more transferred to observation. Through 2/04, he continues to be seen cellfkont in SKU, assigned "no diagnoses," continues not to improve with treatment while in SKU on anti-psychotic medications, intermittently smears feces, sets cell on fire, and attempts to kill himself, by acts that are now branded ccpseudo-suicidal." Even though he is given "no diagnosis," progress notes continue to evidence psychosis with hallucinations,depression and suicidal intent and actions. He continues to cycle to observation and back to SHU, even though he is no longer admitted to CNYPC. For
example, a note of 5/8/02 at CNYPC states: "Debriefedwith i Y !after incident last
night in which he assaulted staff and required restraint 1 Y Y said he was hearing the voice of his deceased grandmother (whom he never has seen). She was telling him to do
things.. .. He also said he sees blood dripping fiom the faces of his two dorm mates at
night and it scares him.. .." He continues to be given tickets for incidents that occur
while psychotic symptoms including cornmand hallucinations are reported in the progress notes.
80

Example of: SMI (Psychosis, probably Schizophrenia) in SHU Deteriorates in SHU Cycles from SHU to Observation & CNYPC Tickets related to command hallucinations No known consideration of mental illness in disciplinary process Un-diagnosed at CNMCContinued on anti-psychotic medications, continued psychotic symptoms Continued on strong doses anti-psychotic medications
0 fl has been in prison for nine years and in SHU for 43 months. He
believes he is considered a security threat. He does not get tickets -his last was in 1999.
He says they write reviews of SHU prisoners, but they don't interview you. He says that officers taunt prisoners with mental illness and drive them offthe deep end; some do it for amusement. He spends his time reading and doing legal cases. He denies emotional
problems. His chart corroborateswhat he says. There are very superficialperiodic
mental health screens, obviously done at cell-fi-ont. He has no report of mental health problems in his chart, and he is Mental Health Level 6.
Example of:
Long-term SRU,no known SMI
has been in prison for 23 years and will be released in 2007. He has been in SHU for 14 years because of a riot that occurred in 1991. He is comfortablein SHU because he says he was being picked on and beaten up in GP. He sees Ms. Kim twice a month in the mental health unit office. He is prescribed Zyprexa, 15 mg-/day, and it cuts down on the voices he hears. He has been admitted to CNYPC four times, and has been to observation a dozen times for suicide attempts driven by command hallucinations. He has had no tickets for two years. He goes to recreation and exercises. He says they have begun giving tickets to prisoners who refuse to go to see the mental health staff, and if you refuse your medications three times they discontinue the treatment. He spent six months at CNYPC, where "theydo not lock you up," and liked it there. 'Dr. Fasuld refuses to send you to CNYPC when you are disturbed; instead he has you locked up in an observation cell in the middle of winter with the window open, telling you he's punishing you so you'll go back to your cell." He spends his day reading and writing, exercising, and laying in his bunk. On mental status exam he has flat affect, he is earnest and coherent. His history is credible and he exhibits no current delusions. His clinical chart is consistentwith his history. He had psychiatrictreatment as a child and cut himself in a suicide attempt in 1975. He is considered a leader of the 1991riot, and he is considered assaultive and self-hanning. In 1991he was diagnosed Adjustment Disorder, but prescribed Haldol5 mg. b i d . Over the intervening years he has had many

long admissions to observation for suicide risk, has been prescribed Thorazine 100 mg. to 300 mg. per day as well as various antidepressants, and has been considered assaultive. His diagnosis has varied, from Psychosis NOS to Adjustment Disorder with disturbance of conduct and ASPD. In 1998,he was diagnosed Schizophrenia,Paranoid Type. His fifth admission to CNYPC occurred in 7/98, for attempted hanging, diagnosis Paranoid Schizophreniaand prescribed anti-psychotic medications. I found no mention of STP in the chart I reviewed. This man suffers from a serious and persistent mental illness and is taking anti-psychotic medications during long-term SHU confinement. He needs to be in a treatment setting such as ICP.

Example of: SMI (Psychosis, Schizophrenia) in SHU Cycles from SHU to observation, CNYPC Tickets related to command hallucinations Un-diagnosed, but continue anti-psychotic medications

00 41

. (Interviewed while housed in ICP).

0-A, has been in prison for 19 years. He has been in ICP for a year. He
eats in GP mess hall, or, if he feels paranoid, he is fed in his cell. He reports that mental health staff do not help if you get a ticket, and you will probably be sent to SHU. He has been admitted to CNYPC 18 or 19 times, when he has heard voices and felt paranoid and depressed. He thinks SKU is like observation; both are awfbl. He has been hearing voices since the age of 13, and had pre-incarcerationadmissionsto psychiatric hospitals. He has been in observation for up to a month, and has only talked to mental health at cellfiont when there. This man obviously suffers fkom a severe and persistent mental illness, most likely Schizophrenia, and he is taking medications while being confined in ICP. A review of his chart reveals 20 admissions to CNYPC, a murder conviction at age 16, a history of closed head injury with possible organic brain syndrome, prescription of Depacote and Prolixin, a stay in ICP, and a note that he is not cooperativewith mental health treatment.

Example of: SMI (Schizophrenia) in ICP Many trips to observation & CNYPC Long stints in observation, poor treatment Cell-front interviews

5*X.

. (Interviewed while housed in ICP).

x-Y,a has been in prison since 1992,and has been in ICP for six months.
Prior to that he was in GP. He is prescribed Zyprexa and Paxil. He still hears voices and gets depressed, but he is better when he takes the medications. He has been admitted to CNYPC seven times, sometimes when he was self-destructive, sometimes when he was too aggressive. He does very poorly in SKU, where he has been twice, for up to six

months (at Attica). From the Attica SKU he was transferred twice to CNYPC and back to SHU, and also cycled to and fi-om observation. He tends to go to CNYPC when he becomes paranoid and stops eating. Once he was in observation for 19 days, he explains "they don't like sending guys to Marcy so they keep us in observation." He says if you get a ticket in ICP, they kick you out. "In GP, guys make fhof you." This man obviously suffers fiom severe and persistent mental illness, most likely Schizophrenia, and is doing OK on medications at ICP. Previously he cycled between Attica SHU and CNYPC and observation.

Example of: SMI (Schizophrenia) in ICP Had been in SHU, cycled from SHU to observation & C N W C and back to SHU

r-li .
Population).

. (Interviewed while housed in Keeplock General

, u ;C"er
,J

has been in prison for 12years, and is cwently on Keeplock status in

GP. He has been to CNYPC many times, mostly for depression and being suicidal. He

has tried to starve himself and has lost a lot of weight in the past. In 2001 he was in

observationat Clinton for three months, and Dr. Melendez said she would keep him there

forever if he didn't eat. He has had psychiatric problems since the age of seven. He is

Jamaican and faces deportation when he is released. This man seems credibly severely

depressed and is prone to suicide,but it seems he is held in observation for very long

periods, even while losing a lot of weight. Review of his chart reveals four CNYPC

admissions, often for suicide, with diagnosis of Adjustment Disorder with Mixed or

Anxious or Depressed Moods, Depression, Anxiety Disorder and Malingering. He also is

alleged to make lewd gestures or expose himself on occasion to female staff. In 9198 he

had been to CNYPC and was in a depression group. On 10126199he was noted to be

depressed with rigid & constricted thought patterns and chronic suicide ideation..

Medications as of 10126199included Zoloft 100mg., Neurontin 900 mg. bid., and

Vistaril 100mg. He continued to become seriously suicidal (he was once found hanging

"secretively?' and had to be cut down), is given a diagnosis of Adjustment Disorder and

antidepressant medications. At other times he is diagnosed Depression NOS and

prescribed stronger medications. For example, in June, 2000, he was taking Depacote

1,500 mg. per day and Zoloft 200 mg. per day. Between admissionsto CNYPC he is

usually MH Level 6, and he spends a lot of time in SHU because of misbehavior. In Jan.,

2001, he was put on a behavioral plan. In June, 2001, he was re-admitted to CNYPC

with a diagnosis Depressive Disorder NOS, after again threatening suicide. This man is

clearly chronically depressed and suicidal, and has been diagnosed and treated for that

condition, including multiple admissions to observation and CNYPC and the prescription

of strongpsych medications. He is also disruptive and manipuIative. Too often staff

ignore his bona fide depression because of his manipulativeness, and his emotional

symptoms are thus relatively downplayed. In other words, he is repeatedly given a

diagnosis of malingerlno diagnosis, but then becomes disturbed and self-destructive and

cycles into treatment. Clearly he suffers fiom Major Depressive Disorder, Recurrent, and is un-diagnosed during remissions.

Example of: SMI in SHU (currently Keeplock in GP) Long stays in observation Severe Major Depressive Disorder, recurrent Under-diagnosed as Adjustment Disorder Medicated as if severe mood disorder Un-diagnosed during relative remissions, and mental health level upgraded

- 83-* l-4.-

(Interviewed while housed in SHU).

- r refises mental health treatment and stays in his SHU cell all the time. He has spent his entire term in the Box. He says "I am feeling out of control right now." He thinks he is being treated better than usual right now because of our visit. He has not been to ICP. His psychiatric problems are made much worse by confinement in SHU. He feels the cell walls close in on him. He is unable to focus enough to read, and he cannot concentrate. This man is frankly paranoid, his anger is barely under control; he is self-destructive, and all of these problems are aggravated by his confinement in SHU. Steve Martin saw him and became concerned about his risk of suicide. He is too paranoid to seek mental health treatment, but he does have self-destructive inclinations. SHU is obviously aggravatinghis paranoia and self-destructiveurges.

Example of: SMI (Paranoia, Depression) in SHU Refuses to seek mental health treatment
Deterioration in SHU -
Caught in Bind: Does not trust OMH, severely disturbed, not treated
Wende Correctional Institution - 9/22/03 and 9/25/03

hi V*

(Interviewed while housed in ICP).

A 3 , has been in prison for ten years. He suffers fiom mental illness and
low intellectual function. He was in the SMJ, was transferred to SHU for ten months, then was transferred (with the help of PLS attorneys & a time cut) to ICP in September, 2002, and remains in ICP -where he says he does well. He believes the charges that led to his SHU term were fabricated by a C.O. who did not like him. He did very poorly in school and is not literate. He had head trauma with brain damage at age nine or ten. He is prescribed Vistaril and Zolofi. He has spent a lot of time in SHU. He did not do well
in SKU, and experiencedhallucinations -he saw faces of ladies, no voices -he was very
anxious and afiaid of self-harm, suffered palpitations and headaches, he was paranoid that people were playing tricks on him, when he is behind Lexsan (he was fiom 1995 through 1997)he cannot breathe and gets even more anxious. He believes the guards messed with his food while he was in SHU, talks to himself and stays up all night. He
84

went to observation several times &omSHU, but never to CNYPC. He set fire to his cell on more than one occasion -he reports that he was feeling desperate because the food was so bad, and he could not controlhis impulse to set his shirt on fire. He bangs his head as a desperate way to get help for his other emotional problems. On mental staas examination, this man is oriented but grossly deficient in cognitive and memory h c t i o n s . He cannot do serial 7's, and with serial 3's he cannot understand the notion of "take away" or subtract. He has a misshaped head and many scars. He seems depressed, vulnerable, and has low IQ. This man is very depressed, suffers cognitive impairment fiom DD or head injury or both, and is very vulnerable in prison. He has severe psychiatric sequelae when he is housed in SHU.

Example of: S M (Depression, R/O psychosis) and Mental Retardation in SHU Condition deteriorates in SIW , Transfer to ICP, finally, and does better

fl-44

. (Interviewed while housed in observation).

(I,

- !4 I& was transferred to observation fiom an 5-200 unit at Collins

Correctional Institution a few days ago, where he is on Keeplock status. He has been in

prison five years, with three priors. He is to parole in January. He has never been to

CNYPC, but this is his third admission to observation. He tried to hang himself with a

sheet. He had been depressed and irritable, and then they made him share his cell, which

frightened him that he mightjump on his cellie. He says there are cell-fights daily in the

S-200. He says he was given Keeplock because a shank was found in his light, but it was

there before he entered the cell. He says that in observation there are dailyrounds at cell-

h n t and meetings with the team in a separate room. He feels staff do not pay attention

to the needs of prisoners in observation, and he had to scream for 15 minutes to get water.

He has been taking Seroquel for five months on account of the voices. On mental status

examinationhe is wearing a gown. He exhibits moderately depressed affect and a

credible history of command hallucinations telling him to cut himself. He hears other

voices, telling him he is bad, he does not belong, etc. He does not think OMH intervenes

when prisoners on the caseload get tickets. He does not know if he will receive a ticket

for hanging up. His clinical chart contains a diagnosis of Adjustment Disorder with

Depressed Mood on 3/21/03. Mental Health staff seem to feel he manipulates for fear of

going to GP. But he is prescribed Seroquel200mg. per day as of 12/15/03, and

hallucinations are noted periodically in his chart in spite of continuingdiagnosis of

Adjustment Disorder. On 1/30/03he was returned to the Orleans5-200 after 2 days in

the RCTP. On 3/14/03 he was returned to RCTP. This man with depression and

psychosis, Rx Seroquel, is in observation because living with a cellmate in S-200 is

unbearable for him, and his symptoms include command hallucinations and he is

prescribed an atypical anti-psychotic. A chart note reflects Dr. Langbart discontinuing

Seroquel in Feb., 2004. He cycles fkom S W to observationand then back to SKU, and

the MH staff repeatedly underdiagnose him.

Example of: SMI (Depression with Psychosis) in SHUIS-200 Problems with cellmate Un-diagnosed o r under-diagnosed Still, strong anti-psychotic and antidepressant medications prescribed

y a

. (Interviewed while housed in RCTP dorm).

is in the RCTP dorm, has never been in SHU, was in the RMU in Cocksackie and before that in GP. He came off a 30 day hunger strike at Great Meadows which he did because "they poisoned the food." He is in RCTP because he swallowed a spring and some paper clips. He says he would kill himself if they send him back to GP at Wende. He claims the officers are all family at Wende, and they are hard on nonblacks. He had been in psychiatric hospitals prior to incarceration, including Dorothea Dix during trial to determine competency and mental state. He has been prescribed Lithium and Thorazine in the past, but is currently on no psychiatric medications. He hears voices commanding him to take his own life. He has spent up to a month in observation while on a hunger strike. On mental status he exhibits flat affect, concreteness and a picture consistent with chronic Schizophreniaor Borderline (severe) Character Disorder with Psychosis and Depression. He was adrnitted to Dorothea Dix Hospital in Raleigh, North Carolina, in 1989 for depression, and was prescribed Thorazine. A 3/12/04 discharge summary from Erie County Medical Center (admission to medical ward) notes malnutrition fiom a hunger strike while at Wende. He remained there for three days and was transferred back to Wende with a nasogastric tube in place on 3/12/04. It is noted that this hunger strike commenced January 4,2004. A DOCSlOMH treatment Progress Note for 3/24/03 contains a diagnosis of Antisocial Personality Disorder, no medications given, and a treatment plan opines that he is using mental health contacts at; a manipulation. As a management plan, he will be seen only once per week on Tuesdays, there will be weekly stafTmeetings about him, and the goal will be for him to maintain his weight and hydration. A 1/15/04discharge s m a r y h m Erie County Medical Center notes admission following overdose/ suicide attempt while on a hunger strike. History includes several prior suicide attempts, by ingestion of razors, toxic substances, etc. He reported to staff there that he had been raped by staff and beaten at Wende, and was terrified of going back there. History given to physician included prescription of Lithium and Thorazine as recently as 1999in DOCS, but he has not taken them since "because they don't give them to me." Psychiatric signs included "Onpsychiatric exam,while talking to the patient, would reveal that he is depressed, he does have suicidal ideations, anhedonia, insomnia, appetite derangements and is tearful." Discharge Diagnosis: "1. Depression, with suicidal attempts, 2. Seinure Disorder, 3. Drug abuse, 4. Attempted Overdose." At the same time, there is a note that says the psychiatric consultant felt that there was no psychiatric problem, but the patient required one-on-one observation for suicidality(??) There was no follow-up to the complaint of rape, and the only ethics committee discussion that occurred seems to have involved his
competence-it was decided he was competent. A June 26,2002 R M U Nurse
Practitioner Monthly Note at Coxsackie RMU reflects that he has claimed to have been

raped by two COs at Clinton, that he is diagnosed with seizure disorder as well as a history of depression, suicide attempts and malingering. On 6/30/04he was discharged from RMU and moved to "the Box" because he refused to go to A Block where he had had trouble with officers. From the Box he was sent to the MHU for swallowing a fork, and then back to the Box. He also has been on Keeplock for a substantial period of time. This man suffers fiom chronic and persistent mental illness, possibly Schizophreniabut at least severe Borderline Character Disorder and Depression with recurrent psychotic decompensations, and is temfied of GP at certain institutions. He is repeatedly diagnosed ASPD, on little evidence and with little formulation on the chart except he is manipulative. He definitely suffers fiom a more severe mental illness. He probably does do hunger strikes to gain a transfer when he is terrified, but he is also very depressed and starves himself nearly to the point of death. He is repeatedly sent to observation, never to CNYPC inpatient. He needs a somewhat protected, and more therapeutic setting; ICP would be a good placement.

Example of: SMI (Depression, must rule out psychosis) in GP Not in SHU, Medium Security Cycles from GP to observation or CNYPC Considered manipulative only by OMH

% @=

(Interviewed while housed in ICP on Keeplock).

iJ (J has been in prison for seven years. He is in ICP on Keeplock because of a dispute with another prisoner. He had been in ICP at Sing Sing. He describes his tendency to give things away, and then get mad at another prisoner for not reciprocating. He has been admitted to CNYPC several times. He was in SHU for two years around 1996,and vowed never to return. He is prescribed Zoloft,but in the past took Lithium and Haldol. He was diverted from corrections to Mid-Hudson in 1995,where he remained for a year. On mental status, this man is clearly disturbed and bizarre, he exhibits flat affect, very idiosyncratic language, neologisms, some incoherence, tangentialthinking and loose associations. He is likely suffering from chronic Schizophrenia or a related disorder, and is managing on medications in ICP. His clinical chart is consistent with his history. He is diagnosed SchizoaffectiveDisorder with
substance abuse and ASPD. He was admitted to CNYPC on 1/28/03, with that diagnosis
and meds Geodon 80 mg. bid., Tegretol400 mg. b.i.d., Neurontin 800 mg. b.i.d. and Vistaril 150mgjday. He evidently is admitted to CNYPC when he is manic, expresses flight of ideas, and becomes belligerent. He manages OK in ICP when he takes his medications. He has been in restraints when out of control, and has been considered for medication over objection.

Example of: SMI (Schizoaffective) in ICP, has spent two years in SHU Actively psychotic now
--FS. ,.(Interviewed while housed in SKU).
"- 5 seen while in Wende SHU by Terry Kupers and Steve Martin on
9/22/03,is not onthe OMH caseload. He has been in S W for a month and a half. He has been in other SKUs. He was sent to SHU from GP at Wende because of an alleged fight. He reports they have been "moving guys with mental illness out of SHU in preparation for our tour." He says most guys with mental illness miss recreation because you have to stand up fully dressed and yell out when the officer comes by, and they cannot do that. Similarly, prisoners with SMI miss chow, showers, etc. He says the COs treat guys with mental illness the same as they treat the others - and that's the problem, they should treat them differently. Being in SHU makes him angry. His thick clinical chart contains no mental health diagnosis; there is a note in which he requests to see psych to get sleeping meds for insomnia--no medications are noted, and there seems to be no psychiatric treatment.

Example of: Untreated prisoner in SHU Need for mental health services not pursued Describes victimization of prisoners with SMI

x - N.

, (Interviewed while housd in SHU).

X

has been in prison for 11years and is seen in SHIJ where he has been

for the past five months, and for much of his time in prison. He is depressed and sleeps

excessively. He has attempted suicide by swallowing a battery. He has been to

observation for depression and risk of self-harm. He finds the time in observation a

welcome break to the constant noise of SHU. He is prescribed Prozac and Vistaril and is

on the honor block side of the SKU. He has not seen the psychiatrist since entering SHU.

He has asthma and is very nervous that the poor medical response he sees when prisoners

have heart attacks means that he will not get the care he needs. He says that mental

health staff only recently began making rounds in the SHU -he thinks a suicide at

Greenhaven was the reason they started doing rounds. In SHU, his depression gets much

worse, he gets very lonely, there are no activities, he feels the walls are closing in on him,

he gets paranoid he'll be charged with something he did not do. He says that prisoners

with §MI in SHU make a lot of noise and keep the others up all night. He thinks he has

problems sleeping because of all the noise, especially fiom prisoners who are 'behind

glass" (Lexsan). He reports that most SHU prisoners miss recreation most of the time

because they go by unannounced and you have to be standing, dressed, etc, Prisoners

also miss meals and showers for the same reason, especially those with mental illness.
On his side of the SHU, guys help each other - on the other, non-honor block side, they

aren't as helpfbl and that's where a lot of guys with mental illness are placed. His chart

corroborates his history, he is diagnosed Adjustment Disorder w Depressed Mood, he has been to observation several times for self-harm, not to CNYPC.

Example of: Depression in SKU, goes to observation for self-harm threat Afraid because medical condition (Asthma) not treated Receiving little or no mental health treatment

"1 m u

(Jnterviewed while housed in SHU).

8-4 M

cuffed in fiont with a waist chain, appears angry and delusional,

even as he denies any mental health problems. He has been in S H J since March, 1999.

He was in Southport b r n Jan., 1992,through March, 1999. When asked why he is in

SHU for such a long time, he says '?hey have questions about my behavior." He says he

stays to himself, does not talk to prisoners in neighboring cells, rarely goes to recreation,

takes showers "now and then," and has eight or nine tickets, mostly for contraband such

as a CD. He theorizes that Sen. McCain7sbrother has been plotting to keep him in SHU

this long, and says of course he's angry. He does not take any psych. meds and says he

does not need any. He seems delusional and in denial. His thin clinical chart contains

diagnoses of Psychotic Disorder NOS on 2/26/99, and Schizophrenia in partial remission

on 5/5/03. On 6/9/03 his diagnosis was changed to Schizoaffective Disorder. There are

notes reflecting disorganized behavior and thought disorder throughout OMH notes from

2001. He was admitted to W C in 1988with diagnosis of psychosis, not since. He

was transferred to ICP at Wende 6/5/03. So this man was known to OMEI as suffering

&om serious mental illness, i.e. psychosis, and yet he was left to spend years in SHU until

his condition became so obviously deteriorated that he was transferred to ICP only after I

saw him in SHU.

Example of: SMI in SHU for years Moved to ICP just before my tour Not compliant with treatment Inadequately assessed, but known by OMH to be Schizoaffective
. (Interviewed while housed in SHXJ).

S C has been in prison for seven years and he has been in SHU for 14 months. He has a ticket for fighting with another prisoner. He has received five tickets while in SKU for reasons he claims are minor, such as complaining about denial of legal visits. In GP he rarely received tickets, maybe a tier 1 or 2. He explainsthe fact he receives more fiequent tickets in SHU as a consequence of %ey keep you in a box here." He says they refbse to give him a form to appeal tickets. He was admitted to CNTSPC once, but was told he was too violent to remain in Mental Health treatment. He was at CNYPC once, three months ago, and was prescribed Benadryl and Seroquel (twice per day). Then they stopped the medications while he was in observation at Clinton. He was

in observation for two weeks in July, 2002, after they "gassed his cell," they say because he refused to cuff up. They did an extraction without giving him a chance to agree to exit,,and mental health was not contacted. He was given a ticket for that incident, but it was later thrown out. He was also beat up while in Keeplock because "I wanted to talk." He was naked with no gown and no clothes for two weeks in observation, and nobody came to talk to him. He threatened to "hang up." He was also in observation at Clinton one other time. He hears voices and becomes very depressed. The medications they gave him in observation helped. The voices and depression are much worse in SHXJ, and his suicidal ideation mounts. He sees Dr. Kravitz on rounds in SHU, but he does not talk about much because "I don't like to put my business out in front of my cell." He experienced command hallucinations telling him to kill himself, and that was the reason he was admitted to CNYPC. He has been hearing voices since the age of 13, command hallucinations telling him to do bad things and hurt people. He abused drugs and alcohol prior to incarceration. He earned a GED in 2000. He reads, but not in SKU because he is unable to concentrate or focus. All of his symptoms are much worse in SKU. On mental status examination, he exhibits flat affect, and reports hallucinations and depressed affect. There are ideas of reference, he is disoriented as to date, he is articulate, but he cannot abstract and seems confused about what is going on. He definitely suffers from SMI, I likely Major Depressive Disorder with Psychotic features. In his clinical chart, there are diagnoses SchizoaffectiveDisorder (Bipolar Type), Delusional Disorder, and ASPD. While at CNYPC (5129103 - 9110103), Psychological Assessment (6123103) was done by John Pelkey. Results include psychosis, probably Schizophrenia, and mixed personality problems including significant authority problems and ASPD. An ICP setting is recommended, but prognosis is guarded. He was actually returned to SHU, and by 5111104he remained in SHU with the diagnosis Schizoaffective Disorder, medication, Zyprexa 15 mg. bid., actively hallucinating and delusional. This man continues to be activelypsychotic in SHU, and should be transferred to an appropriatetreatment setting such as ICP.

Example of: Active psychosis in SHU Under-treated Cell-front interviews

P.d -

(Interviewed while housed in SHU).

d f a has been in prison for 12 years and SHU for 26 months. He was
admitted to C'NYPC last month, from observation after he tried to overdose and hang himself. He received a ticket for self-harm, which was dismissed. He has received six tickets in DOC, all for self-ham. He is senring 25-to-life for an escape attempt in 2002. He reports very depressed moods alternating with '%ighs," for which he is prescribed Depacote, and recently Risperdal. He is also prescribed Celexa His emotional
symptoms become worse in SHU because nobody talks to him He claims a C.O. tells him that he's suicidal, and "Why don't you just do it?" He says the C.0.s treat prisoners
with mental illness worse, in part because the C.0.s think the prisoners are faking. He

hears derogatory voices when he is depressed. Many of his suicide attempts are ordered by command hallucinations. He says it is very cold in observation, and they give you a mat and a gown. Team meetings with prisoners in observation last only a few minutes. He is unable to concentrate and read in SW. He gets more paranoid in SHU, and feels the C.0.s also treat him in a mean fashion because of an assault on an officer that occurred during his escape attempt. He paces in his cell quite a lot, and talks to himself. He had a history of serious mental illness prior to incarceration. On mental status, he
smiles and is coherent, he credibly reports wide mood swings and severe depression with
command hallucinations. He is soft-spoken and has a sense of humor. He seems to suffer from a Bipolar Disorder, and is currently in mid-cycle.
In addition, to reviewing this prisoner's inpatient mental health records fiom CNYPC, and his entire outpatient mental health chart for the period of his incarceration fiom 1994until the present, I have reviewed the following documents: the court decision in his case; Facility Reports regarding the July 29,2001 incident; the transcript of the initial hearing; his disciplinaryhistory; a 5/12/92 evaluation report by substance abuse counselor Christopher Taylor, a letter from the prisoner dated 2/14/99 to Auburn Memorial Hospital; and an Auburn Memorial Hospital report dated 2/4/99. He suffered an extremely abusive childhood, the loss of his mother at age nine, and placement in multiple foster homes, group homes and so forth. There were many traumas. He has a long criminal record, with previous prison terms. He also has a long record of polysubstance abuse with multiple attempts at rehabilitation. And he has a long history of serious mental illness.
A 5/12/92 assessmentby chemical dependency counselor in the community, ChristopherTaylor, notes "occasional depression, mood swings, and anger control problems." Mi. Taylor notes that he has experienced "auditory hallucinations" and "blackout spells," and has undergone psychotherapy and has been prescribed psychotropic medications. This prisoner's history of mental illness is also noted in a
10/5/95NY DOCS outpatientmental health progress note. That note indicatesthat his
mental illness includes "chronic depression with serious potential for suicide, physical and sexual abuse as child, has taken Mellaril and Elavil, on Prozac 20 mg-/day, Atarax 75 mg./day, has a drug and alcohol history."
He has been seen by outpatient mental health providers within the NY DOCS
almost continuouslysince the beginning of his current term in 1994. He has been prescribed antidepressants and anti-anxiety medications for most of that period, along
with occasional anti-psychoticmedications. Diagnoses while in the custody of the M I
DOCS have included Depression (alternatively Dysthymic Disorder), anxiety disorder, polysubstance abuse, antisocial personality disorder, borderline personality disorder, Major Depression with Psychotic Features, and Adjustment Disorder. For long periods he was seen in outpatient psychotherapy monthly or every three weeks, for sessions lasting a minimum of 30 minutes. On several occasions he was admitted to the RTCP for suicide attempts or crises interventions. In early 1998his psychotropicmedications were discontinued for a short time. However, in March, 1998, there is this note by psychiatrist

Dr. Kathleen Nelson: "depressed mood, decreased sleep, crying spells, decreased energy and overwhelming sadness. Restart Prozac 20 mg., Vistaril50 mg." A 4/29/98 progress note assigns the diagnosis of Major Depression, moderate, recurrent," and the dose of Prozac is doubled to 40 mg., while the dose of Vistaril is increased to 100 mg. In the ensuing months Atarax and Sinequan are prescribed in addition to the other medications.
On 2/4/99 this prisoner is transferred to the Auburn Memorial Hospital because of an overdose of his prescribed medications, presumably a suicide attempt. And on 2/5/99, he is admitted to the RCTP At that time he is noted to be, "agitated and anxious." Once again on 4/30/99 "threats of self-harm"are noted, he is observed to be agitated with "ruminations of hopelessness and inadequacy and significant risk of self-harm." Inappropriate affect - smiling - is noted on several dates. On 6/9/99 he is re-admitted to the hospital after cuttinghis arm,and there is the first mention in his chart of manipulation, to wit: "Clearly this inmate is manipulating for his environment." He is moved into and out of the hospital and RCTP until 6111/99,when he is transferred to honor housing on another cellblock. He continues to receive psychotherapy and to be prescribed Prozac 40 mg./day. Eventually, Prozac is increased even further, to 60 mg. per day. After attempting "to hang-up" at Wende Correctional Facility, (it was also noted that he was refusing to eat and was mute and catatonic), he was admitted as a psychiatric inpatient to CE$YPC on August 10,2001 with a diagnosis of "Major Depressive Disorder". He made a suicide attempt while in the hospital on 8/19/01.
This prisoner was involuntarily committed to CNYPC by the Supreme Court, County of Oneida, as a mentally ill inmate on 9/20/01, on the recommendation of two psychiatrists who found him mentally ill and suicidal. At the time he was admitted he was being prescribed Prozac 60 mg-/day, Atarax 200 mg./day and Risperdal2 mg./day. He was noted to have many symptoms of Posttraumatic Stress Disorder (PTSD), including flashbacks, insomnia, agitation and social isolation. While he was an inpatient at CNYPC, Psychologist John Wilson, Ph.D., administered a number of psychological assessment instruments, and concluded that this prisoner was bctioning at a borderline level of personality development, that he suffered fkom some gender confusion and sexual identity difficulties, that he utilizes the primitive defense mechanisms of splitting, projection, projective identification and omnipotent control, and that he "will show faultyjudgment and reality testing when angry or enraged. Dr. Wilson opined that he was dishonest, that he was malingering, and that treatment would be very difficult. Meanwhile, while he was in the psychiatric hospital, he was taking Risperdal2 mg. twice per day as well as Seroquel 100mg. or 200 mg. per day, plus Celexa 20 mg. per day and some minor tranquilizers. He was discharged from CNYPC on October 4,2001, with the Diagnoses "Major Depressive Disorder, With Psychotic Features, Polysubstance Dependence, and Antisocial Personality Disorder with Borderline Traits." His discharge notes mention that the hallucinations and delusions he had been suffering, had diminished or were absent by the time of discharge. After discharge fkom CNYPC, he returned to the SHU at Wende, and was given the medications Celexa, 20 mg. per day, and Vistaril, 250 mg. at night. Diagnoses on his outpatient chart matched those on the Discharge Summary fkom CNYPC. On 1119101, Sinequan 150 mg. was added to his

medications. He was noted to be complainingof depression, insomnia, and visual hallucinations. On 11/09/01he is diagnosed on outpatient progress notes with Major Depressive Disorder with Psychotic Features.
A disciplinaryhearing co~nmencedon October 10,2001. It appears fiom the transcript, that this prisoner may have been incompetent to represent himself at that proceeding. As part of the proceeding the hearing officer heard confidential testimony from mental health staff regarding this prisoner's mental condition. According to the Memorandum Decision, dated 11/14/02, the hearing officer asked the mental health employee 'We has stated that he doesn't recall any of this incident. Would that (be) part of the psychiatric disorder?" The witness responded: "No, it doesn't appear to be. Central New Yorlc Psych. Center's report is that they are under the impressionthat he is malingering and that he is not experiencingthese symptomshe verbally reports, he didn't experience any psychotic episode." As a result of the hearing, this prisoner was punished with ten years in isolated confinement.
I reviewed this prisoner's file and gave a report to the hearing officer that included these points:
1. This prisoner has a lifetime history of serious mental illness, with relatively intensive treatment, including psychotherapy and fairly strong dosages of psychotropic medications since at least 1995 and throughout his current term of incarceration.
2. There is evidence that he experienced "blackouts" dating back to at least 1992 (prior to this term of incarceration), as noted in a chemical dependency assessment done in 1992.
3. There is no mention of manipulation or malingering in the charts I reviewed until 6/9/99.
4. The dosages of antidepressant medication (Prozac, 60 mg. per day -where the
standard dosage is 20 mg. per day) and anti-anxiety medication (Vistaril as high as 250 mg. per day), plus the additional prescription of Sinequan, an antidepressant with tranquilizing effects, at 300 mg. per day - all of these unusually high dosages of psychotropic medications indicate that clinical sstaff believed that he has been suffering from a severe and bona fide mental illness throughout his incarceration.
5. While Dr. John Wilson discusses malingering in his report of psychological
assessment (9/25/01) during this prisoner's inpatient admission to CNYPC,his
report also reflects that he diagnosed very severe forms of mental illness. Dr. Wilson also diagnosed severe character pathology, difficulty in regard to reality testing, severe regression and reliance on primitive defense mechanisms such as splitting, projection and projective identification.

During the same admission to CNYPC, two psychiatrists declared that this prisoner's mental illness qualified him for civil commitment and several psychiatrists prescribed anti-psychotic medication at relatively strong dosages (Risperdal, 4 mg. per day), supplemented with two anti-depressants (Celexa and Sinequan) and a relatively strong dosage of an anti-anxiety agent (Vistaril).
The combination of these dosages of three categories of psychotropic medications constitutes a relatively strong psychiatiic medication regimen.
Other than Dr. Wilson's isolated report, there is no mention of malingering in this prisoner's Inpatient chart.
Even after Dr. Wilson's report was in the chart, the psychiatrist's diagnosis upon discharge &om CNYPC was Major Depressive Disorder with Psychotic Features; and that same diagnosis, Major Depressive Disorder with Psychotic Features, appears on the outpatient progress notes following this prisoner's transfer back to the SHU at Wende. There is no mention of the possibility of malingering in either place.
Psychiatric medications were prescribed after he was returned to the SHU at Wende.
While a psychological assessment, such as that done by Dr. Wilson, is useful in determining the full extent of a prisoner's psychological problems, the fact that one psychologist determines malingering, among other forms of psychopathology, is present, does not negate all the other diagnoses and treatments at the hands of various other professional clinicians.
In fact, the long record of diagnoses and treatment at the hands of many clinicians makes it extremely unlikely that this prisoner is "merely malingering." He might manipulate to some extent and on some occasions - many individuals suffering from serious mental illness do so, especially where mental health services are in
short supply -but it would be extraordinarilyunusual for a manipulative person
with no serious mental illness to fool a large number of clinicians over many years - and to continue to fool them so that they would diagnosis severe depression with psychotic features where there is no mental illness.
Similarly, it would be extraordinarilyunusual for a large number of clinicians to continueto prescribe psychiatric medicationseven after a psychologist makes the diagnosis of malingering' if there were no mental illness
The more likely explanation of Dr. Wilson's findings are that this prisoner suffas from bona fide serious mental illness and presents a complex clinical picture. Dr. Wilson focused on one aspect of that complex clinicalpicture while other clinicians decided it was more important to focus on the depression, anxiety and psychosis that were making this prisoner so dyshctional.

15. It is quite possible that this prisoner's complex psychiatric disorder played a significant part in his actions on July 29,2001.

16. It is quite possible that his psychiatric difficulties contributed significantlyto his rule-violating and violent acts on those occasions, or that his mental state was impaired to the extent that he was incapable of forming the requisite intent.

17. It is quite likely that the reason this man has had to be prescribed such high dosages of psychotropic medications is that the long stints he has spent in isolated confinement have intensified his anxiety and rage and caused psychiatric breakdown, which the mental health staff have been trying to control by increasing medication dosages.

As of Dr. Shimkunas' deposition on 6/3/04, this prisoner was in SHU at Wende, approved for STP, and had been waiting months to be admitted to that program.

Example of: SMI in SHU Deteriorating Condition in SIXU Cycles fromSHU to observation & CNYPC and then back to SHU SMX involved in disciplinary infraction Long wait to be admitted to STP

EL F-

(Interviewed while housed in SHU).

G F2 has been in SHU a very short time. He takes medications for
Depression and voices. He has cuts on his wrists, and reports he has been in psychiatric hospitals six times because of command hallucinations. Command hallucinations tell him to cut himself, and then he receives a ticket and is sent to the box. He is lethargicin his SHU cell, and sits and reads the Bible. He seems to be suffering from Major Depressive Disorder, Recurrent, with psychosis and multiple suicide attempts. He has been prescribed Haldol and Thorazine, but he thinks he now receives ZoloR and Seroquel. Medications usually help make him feel better when he is in any o t k situation,but in S W they do not help at all. He would like to go to STP, but he says "Nobodyhelps me." His clinical chart contains an 11/26/02 diagnosis Depressive
Disorder NOS & Psychotic Disorder NOS. He sometimesrefuses medications, or is
prescribed Haldol, ZoloR, etc.

Example of: SMI (Depression with Psychosis) in SHU Self-harm in response to Command Hallucinations Tickets for self-harm Inadequate treatment, given severity of condition

E. E.

(Interviewed while housed in observation).

G N has many scars from cuts on his face, some recent. He is seen while
in observation, where he has been for two days. He had been in GP, but has been on Keeplock since June. He tears fixtures and lights in his cell and then cuts his face. He also sets fires. He had a long psychiatric history prior to incarceration, fiom age nine, including many admissions to the Bellevue psychiatric ward. He was declared incompetent to stand trial at one time and sent to Mid-Hudson psychiatric unit,where he was restrained on a bed and injected with involuntarymedications. He was in ICP until last January, when he left to re-enter GP. He is prescribed Zyprexa, Lithium and Trazadone, and says the medications help him. He is called out of his cell to see a mental health worker every two weeks. He likes to cause trouble for guards. He does not remember his commitment offense. He says he suffers black outs, and can be violent. He was abused as a child in a home with much alc~hoalbuse. He gets into rages and then has black outs and memory loss for the incident. He says he does not know why he does the violent things he does, he is "not afraid to die" (on fkrther questioning he admits he thinks he is already dead). He tells me he is going home soon. He says he used to hear voices, but does not experience hallucinations when he takes his medications. His clinical chart contains a 2/7/02 diagnosis of Psychotic Disorder NOS and an 11/13/03 diagnosis of Bipolar Disorder, Hypomanic recent episode. He is also diagnosed Impulse Control Disorder, PTSD, polysubstance abuse, ASPD & Borderline Personality Disorder. A history of serious mental illness fiom childhood is noted, he is prescribed Zyprexa 5 mg. And Depakene 1500 mg. on 11/21/02, but interestinglyon that date no diagnosis of psychosis or Bipolar is entered. He has been in ICP and 5iP, and in May, 2002 he was in GP with a diagnosis Psychotic Disorder NOS and prescription of Zyprexa 15mg. and Depakote 1500 mg. In other words, the clinical chart corroborates his history, he suffers &om SMI and it is worse in SHU. He should not be in SHU.

Example of: SMI (Schizoaffective vs. Bipolar) in SHU Deteriorates in SHU
Cycles from SHU to observation & CNYPC and back to SHU

2 3-

. (Interviewed while housed in observation).

s is seen in a Ferguson gown and is in observationat Wende Correctional Institution. He has been in prison for six years. He came from the Southport SHU, where he has been for three years. He has received eight tickets, most while in SHU. He believes that in SHU, the COs have nothing to do, so they harass the

prisoners and then write tickets. He complains of being starved by staff while in observation, and he says he has a lawsuit about staff beating him while he was in observation. He dropped out of school in the 1lth grade. He was sent to observation two days ago, when he told a socialworker he would kill himself if they kept him. at Wende.
He is prescribed Zolofi and Depacote - staff feel he has an&erproblems. He is very
concerned that if sent back to Southport, where COs have a grudge against him and there is no mental health service, he will kill himself by hanging up. I alerted the psychologist, Dr. Tony Devito, at Wende about this concern, which I believe is credible. He has not been admitted to CNYPC. He has been in observation three or four times, each time returning to SHU upon discharge. In September, 2002, he was in observation for 14 days, half at Upstate and half at Clinton. He wants to be in the satelliteunit, but staff keep sending him to a SHU where there are no mental health services. He is not certain if he hears "voices," he knows he talks to himself quite a lot in SHU. He also suffers fkom "shaking," worse in SHU, especially when it's cold. He avers some ideas of reference in SHU, for example if he hears a whistle he thinks they are whistling at him. On mental status exam he is intense, scared and depressed. His eyes are directed downward. There are some vague ideas of reference but no clear hallucinationsnor delusions. His clinical chart contains many OMH admission sheets with diagnoses deferred or blank, on 9/16/02 he is given a diagnosis of Impulse Control Disorder with ASPD and a GAF current 55, best inyear 55, at which time he was again being screened by CNYPC for suicide risk. It is noted he has substance abuse problems, and no sexual trauma He repeatedly cycled between Upstate (single cell) and observation at Wende or Clinton when he becomes suicidal. But he is not diagnosed except Conduct Dis and ASPD until 10103 (after we see him), when he is moved to Southport, Level 2, and prescribed Zoloft, Trazadone, and later Depacote; and by 1/04,he is prescribed Depacote
and Vistaril and preparing for release &om prison. In summary, this man with sigmficant
mood disorder had been housed at Upstate where there was not adequate mental health level of care, and cycled many times to observation at Wende or Clinton before being transferred to a facility, Southport, where he could finally be prescribed antidepressant and mood stabilizingmedications. Prior to that time, he was viewed as manipulativeby staff, who kept returninghim to Upstate where he would become suicidal anew and have to cycle to observation.
Example of: SMI (Depression) in SHU at Southport Inadequate mental health services Cycles from SHU to observation and CNYPC and back to Southport SEW Under-diagnosed
This interview was very brief because he speaks no English. His chart reflects he was in RCTP with a Diagnosis of Schizo-Affective Disorder on 8/6/02; he was returned to SHU fkomRCTP on 6/14/02, and he has multiple CNYPC admissions with diagnosis Schizo-Affective Disorder. Old chart has diagnosis Schizophrenia, Undifferentiated

Type, prescription of Haidol, and pre-incarceration psychiatric hospital admissions. A
6119/02 Outpatient Core Evaluation summarizes: "The patient has a history of six admissions to CNYPC; the most recent hospitalizationwas fiom 10112/99 to 11/10/99. All adrnissions were due to poor medication compliance, which resulted in
decompensation. During these periods of decompensation, the patient becomes grandiose, paranoid, agitated, verbally abusive and can be dangerous to himself or
others.. .. Recently he is alleged to have assaulted an officer and was placed in SHU for one year. He is refusing medications and feels he can do well without it.. .." The note
goes on to say he cannot have rehabilitationbecause there is none in SMJ, he is not currently psychotic by mental status, and he agrees to request medications as needed. In other words, he suffers fiom SMI and repeatedly cycles from SHU to CNYPC and back to SHU. There is no notation to suggest that OMH participated in the disciplinary hearing process when he was consigned to SHU. From then on he was seen on SHU rounds only, and intermittentlyprescribed Risperdal2 mg. twice per day, sometimes refbsing medications, as reflected in progess note of 3/5/03. His diagnosis remained Schizohrenia,Undifferentiated. This mans suffers from Schizophreniaand spends long periods in SHU, where he periodically decompensates. He should be removed from SHU and placed in a treatment program such as ICP.

Example of: SMI (Schizophrenia)in SHU Deteriorates in SHU Cycles from SHU to observation and CNYPC and then back to SRU Not followed closely, & likely is psychotic much of time in SHU without detection

,

p (Interviewed while housed in B Block, Company 99).

@

has been in prison since 1998. There was much disagreement about

his competenceto stand trial, and many psychiatric evaluations. He has a long history of

serious mental illness and psychiatric medications. He was in ICP in Sing Sing for seven

or e i e t months, and graduated to GP. After being discharged %om ICP, he tried to kill

himself twice. He became paranoid after halting his psychiatric medications at Eastern

Corr. Inst. He has not been to SHU and has no tickets. He went to CNYPC in 1986or

1987 because of self-harm. He exhibits tardive dyskinesia, he avers hearing voices, he is

receiving mental health treatment but feels it does not help. On mental status exam he is

disoriented as to time, affect is flat, he speaks rapidly and is unable to abstract. He

describes the "strip cell" where you are naked and it's cold. He believes they are

"messing with my food" on B Block. He is Jewish and wears a yamulka, and he takes

psychiatric medications. He is on B Block, Company 99, where there are a lot of

prisoners with mental illness. This man presents a clear picture of chronic Schizophrenia;

he exhibits tardive dyskinesia, is in GP, Company 99, and is receiving mental health

treatment.

Example of: Chronic Schizophrenia on Company 99, GP, in outpatient treatment

F X

(Interviewed while housed in B Block, 99 Company).

X has been in prison for 13 years of a 22-to-life term for murder. He is
housed on B Block, 99 Company-he reports that 13or 14of the 16prisoners on that
company suffer from serious mental illness. He has been at Wende since 1998. He expresses complaints about COs; for example they say "If you don't like it, then go cut up." He had a long psychiatric history prior to incarceration. He complains that the COs
breach his confidentialityby talking about him with each other. He is not receiving
mental health treatment presently, and states that mental health staff do not intervene with oflicers or hearing officers if prisoners with SMI get tickets. He has been to CMlPC nine times, and has been to SHU only once on this bit. He does not tell mental health staff how he is feeling because he is afraid they'll throw him in a strip cell. He does not like ICP because "there are no programs over there." He shows us scars on his forearms from previous cutting episodes. He is a h i d of groups/crowds, and gets paranoid around others. He suffers from severe depression and hears voices. He is visited by his wife and daughter and feels supported. He was in Special Education until the tenth grade. He was always "hyper" as a child. His chart contains diagnoses of Adjustment Disorder and Depressive Disorder NOS with Borderline Intellectual Functioning. Multiple CNYPC admissions for self-injurious behavior that occurs when depressed. On 5/5/03 a diagnosis of Bipolar I1was recorded. Medications include Zyprexa 20 mg./day &d Lamictal, 300 mg./day. He seems to do well with outpatient support on these medications in Company
99.

Example of: Chronic SMI, probably Schizophrenia, possible MR, in GP, Company 99 Receives outpatient OMH treatment Many admissions to observation and CNYPC
Attica Correctional Institution -9/23/03

b'

(Interviewed while housed in SHU).

has been in prison two or three years this bit, and did four years previously. He has been in SHU for one year because he fought with another prisoner, and then in SKU he threw a bottle of pills at a nurse and received a longer SHU term. He
finds himself yelling at staff, and then he gets more tickets - all because of the pressures
of the SHU. He has been in mental health treatment since 1984, with a diagnosis of Bipolar Disorder. He was taking medications, including Risperdal and Artane. When he was a teenager in California he was admitted to Napa State Hospital and Langley Porter psychiatric unit. When he does not take medications such as Risperdal, he cannot sleep and he gets agitated and paranoid. He shows many fresh cuts on his arm, and says when he does not hear from home he gets paranoid and cuts himself. He has Hepatitis C. He

denies being suicidal, but cuts to see blood. He has been to observation two or three times, and admitted to CNYPC two or three times. He would like to be in STP. He says he cuts himself to avoid hurting someone else, and he feels better after cutting. He typically sees mental health staff for five minutes at cell front. He gets anxious and cries when in SHU, and he feels suicidal. Interferon makes him too depressed. He is behind lexsan, and hears his neighbors screaming a lot. On mental status exam he exhibits an intense and bizarre stare. He thinks the COs harass prisoners with mental illness. He does not go to yard for fear of run-ins with COs. He says mental health staff merely say "hi" as they do rounds, and don't talk to prisoners with mental illness in SHU. And they do not intervene when a prisoner with SMI gets a ticket. His clinical chart is consistent with the history he presents. From 1992 his diagnosis has shifted &om Impulse Control
Disorder to Adjustment Disorder or Axis TI problem. But notes reflect anxiety and
depression when in isolation. In May, 2002, he was prescribed Risperdal, and on 4/30/03 he was prescribed Seroquel400mg. A 7/23/03 Treatment Plan Review notes a diagnosis of Mood Disorder NOS. He has been prescribed Vistaril and Sinequan in the past, but at other times Tnlafon, Haldol and Prolixin (anti-psychotics). A 2/1/04 review notes he is ticket-free, but he manipulates to get the medcations he wants. Medications in this period include an antidepressant (Paxil or Wellbutrin) and Atarax (minor tranquilizer). He has received other tranquilizers in the past. The diagnosis Mood Disorder NOS continues through late 2083. Rut clearly there are also psychotic features or psychosis, and this is not noted in the chart even though symptoms of paranoia and thought disorder are cited and anti-psychotic medications are prescribed. This man clearly suffers from chronic psychosis and depression, and deterioratesin SHU where he is now. He also cycles to observation, CNYPC and back to SHU. He needs to be out of isolation and in a treatment setting such as ICP.
Example of: SMI (Depression, Psychosis) in SHU Deteriorates in SHU
Cycles fromSRU to obewation & CNYPC
Under-diagnosed
(Interviewed while housed in SHU).
has been in prison for three years this tenn. He was sentenced to Willard (low security drug program), he threw a tray and was sent to Five Point SHU, where he got in a fight and was eventually sent to Attica SKU. He was admitted to CNYPC for 30 days so that his psychiatric medications could be regulated. He now takes
Depokene, Neurontin and Seroquel. On June 13th he was discharged from CNYPC to
the Attica SHU, and had a fight on the bus which earned him a longer SHU term. He definitely feels that his mental illness causes him to get into fights. He wears sunglasses at night to disguise himself so that the people observing him will not recognize him. He has been in STP before, and likes it. He was sent to observation last night because he tried to hang up. He had a psychotic episode at Five Points, replete with hallucinations. He was told he could go to ICP, but they never let him go. When they did a telemedicine

conference, he requested candy and pizza. His medications are discontinued periodically and his condition becomes wope. When he got his last ticket for fighting, the hearing officer did talk to mental health, but that didn't help. He says he is manic, and that is why he cannot control his temper. The pattern is that when he becomes psychotic he gets
into trouble. He has been to observation at various institutions, and to CNYPC once.
He's angry because he feels he should be out of SHLT, but he got a bogus ticket. He did not go to his hearing. He believes he should be in ICP. When he is in a less pressured setting, he slows down and can control his temper. He has cut himself and tried hanging up. He says he wants to die. He also burned himself on the stomach in response to
command hallucinations -the voice of God told him to sacrificehimself for God's sins.
He received his GED at 17, and has a drug problem. He started drug treatment in DOCS, but never finished. On mental status exam he displays pressured speech, agitation, bizarre and intense facies, flight of ideas, and inability to slow down when asked, and ideas of reference. He says he cannot sleep without medications. His clinical chart is
consistentwith the history he presents. An admission note for 5 Points MHU has
diagnosis Schizoaffective Disorder. His progress notes at 5 Points and Attica reflect outpatienttreatment and MHU treatment for mood disorder and hallucinations. He was
admitted to RCTP on 5/2/03 for waving a blade, threatening self and others. He had to be
'I' taken down and sent to RCTP. On 5/15/03 he was admitted to CNYPC for the first time. He was felt to be manic. He was placed on SPLl behavior treatment plan that lasted h m admission until 5/25/03. He was on SPLl again in early June, and was discharged from CNYPC on 6/12/03. He was taking Depakene 750 mg. b i d . and Seroquel4W mg. bid., but his primary diagnosiswas Adjustment Disorder with additional Dx Intermittent ExplosiveDis., SchizoaflFectiveDisorder, ASPD and substance dependence. While he was placed on "Behavior Management Restrictive Intervention Monitoring Form'' and monitored or restrained while at CNYPC, there was no psych testing and no Behavior Management Plan (in the chart) that would follow him upon his return to SHU. There was a recommendation at CNYPC that he go to STP. Medications include Zyprexa, Risperdal, Mellaril, Depacote, Neurontin, etc., at different times. He is basically seen cell-fkont in SHU and medicated, with ongoing notes about command hallucinations and bizarreness, and he is repeatedly sent to RCTP for fi-ankpsychosis and danger of harm to self or others, all at the behest of command hallucinations. In summary,this man is severely disturbed, likely diagnosis Bipolar Disorder with Psychotic Features (or R/O Schizoaffective),is not adequatelymedicated and should not be in S W . His mental illness definitely a o m s his misbehavior. He should be in ICP or equivalent treatment setting.

Example of: SMI (Schizoaffective) in SHU Deteriorates in SHU Tickets driven by SMI Cycles from SHU to observation & CNYPC and then back to SHU Inadequately treated Recommended for STP but not sent there

F-F T r" F - 3 -

(Interviewed while housed in SHU). has been in prison 15 months this term. He had left prison in

2000 but returned on a parole violation. He is depressed and anxious, but says he cannot

get mental health treatment because he is not psychotic. He has a tenible time in SHW,

where there is constant bangi~~yge,lling, and he cannot escape the noise. He gets

anxious, and he thinks he gets into fights in order to escape the anxiety. He has asked for

mental health treatment, but all they do is talk to him through his cell door. He claims

that prisoners with serious mental illness are abused in SHU - if you do anything wrong,

they put you on loaf. He has been put on loaf erroneously. On mental status exam, this

man is coherent and not psychotic, but he is clearly depressed and anxious. His chart

contains reference to depression, diagnosis Adjustment Disorder with Depressed Mood,

no meds, little contact, ME3 Level 6.

Example of: SMI (Depression) in SHU Not receiving OMH treatment Depression worse in SHU Under-diagnosed, mental health level inaccurate

b.7

(Interviewed while housed in SHU).

b "T ,serving a life sentence, has been in prison for nine years and in SHU
since May 20. He has spent three years in SHU altogether. In SHU, for the least problem, the whole gallery starts banging on their plexi-glass. He is prescribed Trazadone for depression. He mostly sits in his cell and talks to himself. He took a murder bit for his uncle. The first seven years he was in prison he didn't care about anything, and was very angry. When he set fireto his cell he was s a t to SHU. At 18 years, he tried to shoot himself through the mouth. He lost part of his brain and the &ont of his skull (scars and misshaped skull obvious). He has seizures. He has tried to kill himself by OD twice in prison. He goes to a strip cell for approximately nine days, then back to SHU. He tells me he beat the arson charge - it was suicide. He was in ICP for a year at Clinton. He is depressed and psychotic, he tells me. ICP was a good place for him. He fears he cannot survive in GP. He tries to read, but cannot concentrate. His clinical chart is consistent with the history he presents. His diagnosis is Impulse Dyscontrol Disorder with anger and self-harming behaviors, a history of serious suicide
is noted, he has a pre-incarceration history of psychiatric admissions for suicide attempts.

He transferred from Southport to Attica 12/2/02. He was prescribed Zolofi 100 mg./day. He had been prescribed Haldol and Cogentin in 1996, and later, Seroquel. He has also been diagnosed Dysthymic Disorder, Psychosis NOS and PTSD. He had a trial of ICP in 6/02. He was in STP in 9/03. In summary, this man has a severe head injury with frontal lobe loss and resulting organic impairment, he is impulsive, self-destructive, depressed and possibly suffers from psychosis. He needs to be in a protected mental health treatment setting such as the ICP.
Example of: SM[ (Depression, Organic Brain Syndrome) in SHU Had done well in ICP Cycles from §NU to observation and CNYPC and then back to SHU

Albion Correctional Institution - 9/24/03

, v.8-

(Interviewed while housed in SHU).

111

8 ) - has been in prison for seven years. She was paroled in Feb., 2003,

and then violated & returned in July. She will be released in November. She had been

housed in SKU for five months at the time of our meeting. She has received 70 tickets

during her tenn, and had spent time in SHUpreviously. She has a long psychiatric

history, beginning with an inpatient stay at Jaccoby Hospital at age nine years, when she

was prescribed antidepressant and anti-psychoticmedications. Her mother was an

alcoholic. She was in Special Education. She has been hearing "voices" since age nine.

She received a ticket today, she says it was written by an officer who regularly "sets

women up for bogus tickets." She reports that prisoners suffering from mental illness are

treated badly. She reports that while she was being brought to the room where we

interviewed her, the officer told her to tell us that she was not hearing voices, that she

does not want to kill herself, and that she is being treated well in the SKU. She also

complains that the oflicers in the SHU think it is f b n y that she takes psychiatric

medications. She complains of frequent flashbacks to rapes that occurred around the age

of ten. On mental status, she is very depressed with psychomotor retardation and

describes a consistent picture of Major Depressive Disorder with Psychotic features. She

explains there is a marked intensificationof her depression when she is placed in SHU,

with even more severe depression as the time in the SKU lengthens. She cries as she tells

us that she feels more and more like "nobody cares" when she is left alone in the SHU.

Her depression worsens. She reports that in the S W she feels "very claustrophobic," she

hears the voices of people calling to her, she feels the walls are closing in on her, she gets

very confbsed and cannot concentrate, and she has a very difficult time controlling the

rage that grows within her. She complainsboth that male officers can and do watch her

undress and go to the bathroom, and yet when she needs help and calls out, nobody

responds to her requests. She describes the "strip frisk" that occurs when she is taken to

observation, and reports on an incident a few months ago when she resisted the attempt to

strip her because she was feeling very paranoid and unsafe, and "they jumped me." A

woman C.O. cut her clothes off while male C.0.s were in the room, and she complained about this. She has been taken to observation four times, all four times from the SHU, and after she spent several days to a week in observation she was returned to the SHU. She was not transferred to CNYPC nor the MHU at Bedford Hills on any of these occasions, however she had been at Bedford Hills earlier. In her chart there are notes from Bedford fills, she has been diagnosed with Depression and Posttraumatic Stress Disorder, a long history of serious mental illness and psychiatric hospitalizationprior to incarceration is noted, and she has been presctibed Seroquel (anti-psychotic), 500 mg. per day, and Paxil (antidepressant), 60 mg. per day for the period July through October, 2003. She has also been prescribed Risperdal and other medications. A 12/12/02 RN's Progress Note of a private interview while prisoner is in SHU: "She also reports having t panic attacks. Pt. Upset because the Lt. lied about her. She says he grabbed her by her hair. She says she froze up and had a flashback. Pt. Reports that she feels pressure building up and at times feels like she wants to die. Pt. asking for a medication evaluation. Discussed procedure for getting a cross gender pat frisk exemption." A 5/21/03 Progress Note states: "Pt. tearful. Felt she was treated unfairly during transfer to OBSO. 'I hurt myself. I hit my head as they were bringing me into the cell."'

Example of: SMI (Depression, possible psychosis) in SHU Deteriorates in SHU Past trauma history Traumatized by searches, move to observation Cycles from SHU to observation and then back to SHU

& PI

(Interviewed while housed in SHU).

B* rJ has been in prison for three years, convicted of cashing a bad check,
and has been in SHU at Albion since July 17 for a ticket that she says was given to her by an officer who she had cussed only after he had cussed at her. She thinks she has spent more time in SHU than in General Population. She reports a beating she received at the hands of officers on September 26,2001, which resulted in head trauma. On another occasion, she was ordered by an officer to walk to the Administration Building one evening. She felt she was unable to do so because her legs were hurting and she was afiaid to walk that far at night. An officer and a Sergeant came to her cubicle to get her, and demanded that she give them her identification. By mistake, she picked up a picture of her daughter and gave it to them. They got angry at her because she failed to produce her identification. She became angry and asked for her daughter's picture back. She believes that officersgive her tickets in retaliation for her lawsuits. She has pulled her hair out since childhood, and reports she received on ticket for trying to color her hair to disguise the hair-pulling. She reports that immediately after being released from SHU she feels disoriented, scared and confused in General Population. She says she suffers from bcnerves,"she becomes confusedwhen she is housed in SHU, and she hears the voice of her baby crying. She had been admitted to a psychiatric hospital in the community prior to incarceration because she was depressed, tried to hann herself, and

was experiencing auditory hallucinations. In SHU she "hears things," for example she wakes and finds herself answering out loud an imaginaryvoice. Or she sees shadows running around in her cell. She is prescribed Haldol, Cogentin and Vistaril. She reports that if one is suffering from a mental illness in the SHU, "the officers laugh at you, make jokes about you, and Mite you tickets more ofien." She received six tickets while in SHU, the one for trying to color her hair, another for arguing with another prisoner on the yard, etc. She believes time in SHU has destructive effects on her mental state. She becomes scared, lonely and sad, and worries that they (officers) will do somethingto her "stuff." She receives visits fi-om her mother and children, ages 13, 15 and 17. On mental status, thiswoman exhibits very depressed affect, psychomotor retardation, low selfesteem, and hopelessness about her future. She takes psychiatricmedications some of the time and not at other times. She started taking the anti-psychoticmedication, Haldol, once again a week prior to our meeting. She notices that when she is not taking her medicationsshe is easily provoked and gets into arguments with officers. When asked if the hearing officer takes her mental illness into account, she says they say they do not care about her mental illness. She describes episodes when she gets confhsed and dysfunctional, and then something goes wrong between her and an officer and she is given a ticket. Her clinical chart contains diagnoses of Trichotillomania (compulsive hair-pulling) and Depressive Disorder, with earlier (February, 2003) entries mentioning Bipolar Disorder and Panic Disorder. She is prescribed Haldol (including Haldol decanoate, 50 mg. per month, plus p-o.), Prozac (40 mg.), Trazadone (200 mg.) and Cogentin. There are notes about pre-incarceration domestic violence, obvious sadness during counseling sessions, and a history of Attention Deficit Disorder with Hyperactivity. Clearly this woman is severely depressed and experiences intermittent psychotic episodes, may suffer fi-omBipolar Disorder or other SM17is taking strong antidepressantand anti-psychoticmedications, and should not be in SHU because isolated confinement worsens her emotional disorder.

Example of:
SMI mepression, psychosis, RIO Bipolar Disorder) in SHU
Deteriorates in SHU Receives more tickets in SHU Claims bad treatment by officers

&&l ,

, (Interviewed while housed in SKU).

$4 has been in prison for close to four years for second degree burglary, and expects to be released in a year. She was sent back to SHU only yesterday, for inmate-to-inmate correspondence, and though the hearing has not occurred yet she believes she will be given a seven month SHU term. She is startingto think there is a conspiracy: while she has not informed on anyone, she thinks the staff believe that she informed on an officer who is having an inappropriateintimacy with an inmate. She has told OMH staff that she fears for her life while at Albion because of this conspiracy. She confides that she is depressed, and is prescribed Prozac and Seroquel and Depacote (this list of medications indicate more severe psychiatric problems such as a psychotic

condition andlor Bipolar Disorder). She describes recurrent depressive episodes wherein she isolates herself for weeks at a time, spends most of her time in bed, cries a lot and has no energy for anything. In response to my question whether being in SHU has an effect on her psychiatric condition, she responds it certainly does: either she gets more depressed in SHU, or, because she feels invincible (I suspect she is describing the upward, manic or hypomanic part of a mood swing here) and she gets into more trouble with the officers. Her hands tremble when she is in SHU, she feels like the walls are closing in on her, she sleeps much too much, she has difficulty concentrating, and because the women in SHU are not permitted to speak to women in adjoining cells or even in other recreation cubicles when at "rec," she feels dreadfully isolated and this worsens her depression. She reports being strip searched with male officers present in the SHU, and tells us that she is strip searched when she goes to visits while in SHU. Her clinical chart is consistent with the history she presents. Her diagnosis is Major Depressive Disorder on 1/31/04, but on 1/19/01 Bipolar Disorder is diagnosed. Her medications are confirmed except there is no notation about Depacote. Two earlier suicide attempts are noted, no attempt in DOCS. She receives outpatient therapy only.

Example of: SMI (depression, R/O psychosis, Bipolar) in SHU SHU term for inappropriate correspondence Deteriorates in SHU - manic and depressed Fears for life because of (real or imagined) conspiracy

L- CZi

(Interviewed while housed in General Population).

L G - has been in prison for fbve years and goes to the (parole) Board in
November. She was in General Population when we interviewed her, but she had been in SKU from December, 2002 through March, 2003, and then from April through July, 2003. She suffers from both a medical condition and a mental illness: depression. She reports that hearing officers do not consider her mental illness when meting out punishments. She has attempted to kill herself three times while in prison, once at Bedford Wills, once by overdosewhile in SHU, and once while in the Infirmary for a medical condition. In December, 2002, she tried to cut herself and was transferred to a Bedford Hills observation cell. She has been placed in an observation cell many times at Bedford Hills and three times at Albion; in each case she was sent to observation fiom SKU and then was t r a n s f e d back to SHU. In SKU, she is not permitted to talk to anyone, or she gets a ticket, and she finds the social isolation very distressing. She explains that a prisoner in SKU must be at her door, dressed, or she misses meals or recreation or shower -but when a prisoner is taking psychiatric medications it is difficult to pay attention and be at the door at the right time. She has received approximately25 tickets while in SKU, "because the C.0.s hassle you, for instance they say you were talking when you weren't, many more tickets are given in SHU than GP." She finds the strip searches that precede placement in SKU and placement in observationvery dehumanizing. She tells me: "At least at Bedford Hills you get pajamas; here, it's a paper gown, and there are male C.0.s standing around; at least at Bedford Hills they give

you a strap for your menses, not at Albion" (several women reported that they are given a
pad with no strap to hold it in place.). She has been left in observation naked for 72 hours. She finds it very degrading to have to use the toilet with male officers observing her. And, she reports, on most days nobody &om mental health comes to talk to her
when she is in observation - a nurse does visit her briefly to give her medications. She is
not receiving mental health treatment at present, in large part because she finds it is quite difficult to get the attention of the mental health staff when they make rounds in SHU. She complains that getting her medications is very problematic. First, she has to wait in line with hundreds of women to receive her daily psychiatric medications (that line is in the mess hall), and then she has to wait in a linethat is not as long to get medicine for her medical condition. She has to use up all of her time for recreation standing in line waiting to receive medications. The fact that in the SEFU she is issued used clothes, previously worn by other women, makes her feel more depressed. She has trouble getting along with the other prisoners at Albion, she thinks this is because she has enemies in the institution. She has received 40 tickets, she believes most are due to the fact that her mental illness causes her to have insuMicient control of her impulses. On mental status exam, she is agitated as she describes depression, low self-esteem, worthlessness and rage that comes out when she feels she is being treated unf*ly and cannot do anything about it. Her clinical chart includes diagnoses of Depression and Psychosis NOS (1/28/03). Prescription of Seroquel(600 mg. pea: day) md Zolsfi (100 mg. per day). There is also mention of Impulse Control Disorder, a seizure disorder, antisocial personality disorder, and a 4/9/01 note about paranoia.

Example of: SMI (Depression, possible Psychosis) in GP now, was in SHU Cycles from SHU to observation & back to SHU SHU worsens despair, suicide attempts Explains how prisoners with SMI miss showers and recreation Many tickets, likely driven by SM[

f3 E

. (Interviewed while housed in General Population).

R-G

has been in prison since December, 2002, with a former term of

two and a half years - most of her time has been spent at Bedford Hills. She is in

population, havingjust finished a term in SKU. She is at Albion because of alleged

inappropriaterelations with a Sgt. at Bedford Hills. She completed the tenth grade,

worked as a secretary, and has a 12 year old son. She received a three day SHU term,

and then another 43 day term once in the SHU because of an argument she had with an

officer. She has had other tickets. She claims her mental health problems are minor, but

she has a history of auditory hallucinations with depression, and she has been suicidal.

She was admitted to Jaccoby psychiatric hospital in the Bronx prior to this term, and was

treated with antidepressants and Haldol. She reports she was prescribed Seroquel and

Haldol for equivalent symptoms while incarcerated at Bedford Hills. She describes two
incidents when she was taken to observationat Bedford Hills against her will -on one

occasion the chair she was sitting in was lifted by staff and she was carried there. She did

107

not find the strip searches abusive. She never received a SHU term at Bedford Hills, but since arriving at Albion she has received 30 day Keeplock terms and has been immediately sent to SKU to serve the terms. She relates that she feels pressured by the time in SHU, and her emotional symptoms become worse. She is not currently taking medications, having discontinued them herself. She describes the routine in SKU, including the fact that if one is not "on the door" one misses recreation, showers, and even meals. She believes that prisoners with mental illness are especially prone to miss recreation, showers and meals, because they are too disorganized to get to the door when they are supposed to. She provides observations about Maria Rosato, and points out that officers tend to ignore her in spite of her seimes or black-outs. She observes staff saying mean things to prisoners suffering from mental illness. She says, in general, "the COs in SHU disrespect you to the point where you can get a ticket." She describes strange experiences in the SHU, including the conviction that a man was present in her cell, even hugging her, and then she '%bugged out." She reports that several prisoners, including some suffering from mental illness, are inappropriatelyinvolved with of?l-icers. Her clinical chart is entirely consistent with the history she presents. She had been hospitalized at Children's Hospital for a suicide attempt prior to her first bit in DOCS. She has been prescribed Haldol and Seroquel. Her diagnoses include Depression, Mood Disorder, PTSD and Substance Abuse. On a 3/23/03 "Trauma Assessment Fom" a large mount of physical and sexual abuse is noted from childhood, including adulthood
(attempt molest by M.D.at Jaccoby Hospital prior to incarceration) and within DOCS.
Mental Health Level varies from 6 to 1. Medications include anti-psychotic (Risperdal), mood stabilizer (Neurontin), antidepressant (Paxil) and minor tranquilizer QKlonopin). There are many outpatient "no shows" for medications. There is a 12/19/02note with diagnoses Mood Disorder, substance abuse and PTSD, another diagnosis of PTSD
8/25/03, and a 2/19/03 notation: "...may benefit from continued psychotherapy and
psychiatric medications to assist in managing historic abuse issues and experience with depression and related auditory hallucinations." Yet, f?om progress notes, it seems not
much psychotherapy occurred - disappointing, given the severity of her trauma history.
She has been admitted to observation and has spent time in S W .
Example of: SMI (Depression, likely psychosis, PTSD), was in SHU Depression worse in SHU M i o r ticket led to SHU, then gets more tickets in SHU Describes loss of showers and rec if suffering from SMI History of multipletraumas, therapy recommended and never offered
' : has been in prison for three years and has five-to-15 years to serve for manslaughter. She suffers from kidney failure and PTSD; she was on the OMH caseload but is no longer. She experiences tingling in her left arm,and weakness. She was in s psychiatric hospitals twice for suicide attempts prior to incarceration. At Bedford Hills she received mental health treatment but was never comfortabletalking to her therapist.

She witnessed another prisoner set herself on fire last May and this traumatized her. She is unable to sleep and has recurring images of the girl screaming. She is very anxious,
fearing that when she has an emergency there will be no emergency care - in part this
fear is based on how poorly the bum was handled. She also experiences flashbacks to the suicide of a male &end at age 16. She says when she looks at me she sees the face of the woman prisoner who set herself on fire and burned to death, She does not remember the crime that landed her in prison. She has never been in SHU, nor to observation. She believes that officers treat women with mental illness tenibly, calling them stupid and crazy. 0MH did offer group meetings after the prisoner burned herself to death. She is concerned it is hard to get medical attention in DOCS. She has been in Keeplock. She has an eight year old son who is being raised by her father in Syracuse. She does not feel her medical care is adequate. Her clinical chart reflects Mental Health Level 4, she was at CNYPC on 6110103, and a note states the PTSD symptoms are diminished, but she still suffers nightmares. She is diagnosed PTSD on 5/16/03. She has been prescribed Neurontin. Her clinical chart corroborates her history, and there are notes about trauma and anxiety. A 6110103 note summarizesflashbacks, nightmares, anxiety, etc., secondary to PTSD. She has been in and out of outpatient treatment while incarcerated.

Example of: PTSD in GP, outpatient treatment Witnessed other prisoner burn self to death

Worsening of PTSD, related to lack of adequate medieal care ,

4l.b.

'." (Interviewedwhile housed in SHU).

6 has been in prison for two years. She has been in SHU for one week.
She has discontinued mental health care. She feels the restrictions in SHU are degrading and excessive. She did 30 days in SHU at Bedford. She gets depressed in SKU. Some of her term has beetfKeeplock, once for being out of place at work. When male officers walk by her SHXJ cell at night it scares her. She can't sleep. She isolates herself, does not talk to anyone, shejust reads. She reports that a lot of women in SNU are very depressed. She was in treatment for depression, she thinksshe was taking Paxil, but they would not tell her what medication she was on so she stopped taking it. It helped her control her temper- She has a lot of trouble controlling her temper in SHU. For example, yesterday they searched her cell while having her locked in the shower. She has not been
in observation. She took Ritalin when she was in a group home growing up, and the
judge recommended that she receive mental health treatment, but she has seen mental health staff only three times in the last nine months. She has a drug problem and wants to do ASAT. She says that her mother does not know where she is. Her chart reflects no mental health notes at Albion. Diaguoses are not filled out on screening forms, she is assigned Mental Health Level 6, and it is noted she does not seem to want mental health
services.

Example of:
Depressionin SKU

Court recommended mental health treatment, not provided Drug treatment not provided Worse depression in SHU Temper worse in SHU

Auburn Correctional Institute - 10129103-10/30/03

b. g-7-

. (Interviewed while housed in observation).

6:T was transferred to observation on 7/31/03(three months in
Observation, if his history is accurate) ErQrn the ST-TU at Cayuga. He had been in prison since Jan., 2003. He says he is in observation "for personal issues." Mental Health staff at Cayuga put him on a 1-to-1 watch after he told them how he was feeling. When they took him off the watch, he tried to hang up. He tells me "I wanted to do it (die), I'll leave it at that." He had one prior suicide attempt. He is depressed but does not take any psychiatric medications. He thinks his depression is worse in S W . He can't brush his teeth, can't shower, has nothing to do, this forces him to think more painful thoughts about his family, and he becomes even more depressed. He was in SHU, his first stint, for refbsing to double-bunk at Five Points. "It's hard to be in a cell with someone you don't know, lots of dudes don't know how to communicate, and that leads to more problems." He hears voices telling him to kill himself, and that's what leads him to attempt suicide. The voices occurred for the first time while he was in the SHU at Cayuga. They continue to command him to harm himself in observation. He has not taken psychiatric medications in prison, has not been at CNYPC. On mental status exam, this man is obviously depressed, tells of hearing voices and exhibits internal preoccupation consistent with hallucinations. He is coherent, there is some anger and agitation but mostly psychomotor retardation, and a pervasive sense of hopelessness. In observation he talks to Ken daily, mostly at cell-fi-ont but sometimes for a few minutes in an office. He has a drug history and was in drug treatment in the community, but has not had drug treatment in prison. He has a daughter and her mother brings her to visit. He is clear that his suicidal behavior is related to being in SHU, but he has little psychological insight, or rather he is not open to sharingwhat is going on in his head and his emotional life. He has a lot of trouble sleeping, in SHU and in observation. He says that they are not treating him, so he would rather return to Cayuga SHU where, at least, he has earphones and recreation -here, he gets no treatment, until today when they gave him paper slippers he was without clothes, and he has nothing to do but pace. In his clinical chart there are notes at Auburn reflecting the staffs impression his emotional complaints are not authentic, m d it seems from the notes that staff are keeping him in observationto punish him or educate him about "feigning." This rnan seems credibly depressed with command hallucinations and likely other psychotic features. His mental illness is clearly worsened by the SHU. His clinical chart reflects that OMH staff at Auburn believe he is malingering command hallucinations and is not suicidal, but really wants to avoid double-celling. They conclude no Diagnosis or ASPD. If this man does not suffer from mental illness, why is he being retained in observation for months? It seems likely his

true symptomatologylies somewherebetween what Dr. Langbert thinks, i.e. no diagnosis, and what the prisoner says, i-e. depression with command hallucinations telling him to harm himself. He is both manipulative and depressed.

Example of: SMI (Depression, N O psychosis) in SHU in Medium Transfer to observation at Auburn Remain in observation long time OMH doubts there is SMI
Continue to hold him in observation without amenities - punishment?

&- 2 -

. (Interviewed while housed in observation).

&. L has been in prison for 22 years, and this is his second admission to observation. He was admitted to CNYPC for six months approximately two years ago. His OMH case was closed last Sept. per his request. He went to CNYPC because he
'broke do& -he "shut down," stayed in his bunk, forgot to eat, "went off," and tried to hurt himself. Now, he feels suicidal again, his mind is confused, hasn't eaten in 13 days, says he does not want to talk and wants to return to GP. His crimes involved bad checks.
He says this is not a depressed episode-he's been depressed -rather this is a "total
shutdown." He hasn't done much SEW time, but he was admitted to CNYPC from the Box. He does not keep track of time, and says he gets paranoid. This is his third major breakdown. On mental status exam this man has tattoos and scars from cutting on his forearms, he is depressed and somewhat confused with psychomotor retardation. He has no drug or alcohol history, and has worked in electrical. He does not think he is crazy. He was on Thorazine, 900 mg. per day, at one time. He says Prozac is not helpfid. His clinical chart reflects a 5/29/02 (second) admission to CNYPC, and transfer on 8/21/03 from Elmira to Auburn. Dr. Wilson did a 32 page psychological assessment, pointing to "malingered depression" and ASPDIpsychopath,with recommendation that fbther admissions to CNYPC would not be effective. He was placed on an outpatient Behavior Management Plan on 5/22/02, for arm cutting, pulling his toe nails, head banging, biting himself, burning himself with cigarettes, and hanging up. Medications include Zyprexa 5 mg. hs and Zolofi 200 mg. His diagnosis at discharge from CNYPC was Adjustment Disorder with Depressed Mood. This man seems to be suf5ering &om a Major Depressive Disorder, this being his third episode (at least), so it is recurrent. He needs a higher level of care than is possible in the satelliteunit. He should be transferred to
CNYPC for evaluation and medication assessment, and then he may need ICP placement
for a period of time. Of course, in his Behavior Management Plan, it is stated that he
would not benefit &om ICP and should not be re-admitted to CMYPC. Subsequent notes
reflect diagnosis Anxiety Disorder, admission to and discharge from OMH caseload, report of 'knany problems.'"

Example of: SMI (Depression, R/O psychosis) in observation from GP
Needs hospital, but Behavior Management Plan says no re-admit to CNYPC

Un-diagnosis by Dr. Wilson at CNYPC Behavior Management Plan Continued on medications in spite of un-diagnosis Inadequate treatment

C-G -

(Interviewed while housed in SHU).

C G has been in prison since 2000 and has 22 months more to serve. He says
he has a new "outside case" for using a weapon - a razor that he used to try to kill
himself. (He shows me many cuts and scars on his forearms and legs). He has been cutting himself since childhood. He also has had "imaginary" or "invisible fiiends" since childhood, He lased marijuana on the streets, no other drugs. He has been hearing voices. He explains that since he was seven or eight years he has been talking to things that can't talk back - he believes they can talk back - and then they do. Now the voices have long conversationswith each other in his cell, sometimes it sounds like someonehe knows. It was in Jan., 2003, when he was in GP, that he broke a used razor to cut himself. They said it was contraband, and they alleged that he threatened the psychiatrist with the razor - which he denies. He had been on Haldol decanoate when he came to Auburn, and here they switched him to his current medication, Seroquel600 mg. er day. He has been to CNYPC twice for cutting. He has been on medications for his command hallucinations throughout his prison term. He has been to observation quite a few times, in various institutions. One time it was because he was slamming his penis in a locker door in response to command hallucinations. The only reason he doesn't get picked on by COs like others with mental illness is that he stays out of their way. He has not been in ICP. He was referred to ICP at Elmira but he was denied, he says because "they want a more calm person." Voices tell hirn to hang up and to cut. He did hear voices telling him to attack a psych, but he did not act on the command, however he does feel the psych is out to get hirn. He admits he gets paranoid. He describes the strip cell that is observation at Elrnira, tallcs about staff opening windows in Winter to fieeze the naked occupants, and admits to smearingfeces once in response to command hallucinations. Being in SHU makes him feel like cutting. Also, he cannot read in SHU because he "can't keep my thoughts in the book." He goes off on a tangent about a Devil-worshipping cult, how the Devil came to him, how his voices are the Devil's, etc. - and as he explains all this his associationsbecome more loose and his logic more impaired. On mental status exam, this man gives crediblehistory of hallucinations; he exhibits flat affect, ideas of reference and problems abstracting. He seems somewhat bizarre and self-destructive. His logic is not rational. His thoughts are tangential, associations loose. His clinical chart is consistent with the history he presents. Medications in June, 2001, include Paxil40 rng., Depakote 1,500 mg., and Zyprexa 10 mg. There have been many suicidal crises. Officers were concerned about hirn in 4/02 because he threatened "to pull his testicle out." This man suffers fiom a severe and persistent mental illness, most likely SchizoaffectiveDisorder or Bipolar Disorder with Psychotic Features. He does better on the Seroquel600 mg. is prescribed, along with antidepressants and mood stabilizer, but conditions in SHU exacerbate his mental illness and tendency to cut himself and hang up in response to command hallucinations (which the medication does not entirely control.

When admitted to CNYPC for two days ending 5110102 for cutting arms and smearing feces in the cuts, he was given the diagnosis of Impulse Control Disorder with Borderline Personality Disorder, even though he was prescribed Tegretol; but on 5/20/02 on an Admission Screening Form and on 6119102 on a "Face Sheet," he is given diagnosis Schizoaffective Disorder, Bipolar Type with Borderline Personality Disorder. Then, on 6/14/02, during second admission to CNYPC, Dr. John Wilson does a psychological assessment and writes an "Outpatient Behavior Management Plan." He diagnoses include no Axis I mental illness except substance abuse and Attention Deficit Disorder, but on Axis 11he diagnoses psychopathy and other personality disorders. The Behavior Management Plan recommends no fbrther CNYPC admissions, no ICP, return to DOCS with outpatient mental health treatment including current anti-psychotic and mood stabilizingmedications. The chart I reviewed goes through 6117/02, at which time the plan was to discharge him to GP, and his acting out and smearing feces was still being managed with "as needed" doses of anti-psychoticmedications. This prisoner is seen often by OMH, but remains in SHU, where he repeatedly threatens or carries out selfharm, often in response to command hallucinations. He needs to be removed fiom SHU and transferred to a residentialtherapeuticsetting- CNYPC or ICP. Ifthere is an "outside case" secondaryto contrabandweapon as part of suicide attempt secondaryto command hallucinations, OMH should step in and prevent fiuther prison time for what would obviouslybe a suicide attempt driven by SMI.

Example of: SMI (Schizoaffective Disorder or Depression w Psychosis) in SHU Tickets for self-harm in response to command hallucinations Outside court case secondary to self-harm (contraband) Un-diagnosed, subsequently re-diagnosed during crisis Then un-diagnosed by Dr. Wilson at CNYPC and put on Behav. Mgmnt Plan Deterioration in !3J3U

k,.

,. (Interviewed while housed in SHU).

X. C a has been in prison three and a half years doing his second bit, and he is due for release in 2009. He has been in SHU since July, 2001, He was doing well in Wende GP but received a ticket for a fight with another prisoner that led to 30 days
Keeplock. Once he was in seg, he proceeded to accumulate other tickets, which brought him to SHU, &st at Southport. By now he has received seven tickets while in Keeplock or SHU, and has a nine year SHU term. Currently he is on the loaf and staff are denying him showers. He had a history of anxiety and panic disorder prior to incarceration. He was also in SpecialEducationbecause of emotionalproblems. He was raised by a good family. He has not been admitted to CNYPC, but he has been in observation 30 or 40 times. When asked why he goes to observation so often, he responds "they take me off my medicines, I take a rope and try to hang up, they put me in a strip cell for a few days, then they start giving me my medicine again." He was prescribed Xanax in the community, but correctionalphysicians refuse to give him that, so he was on Seroquel and is now prescribed Remeron. When he is transferred from one institutionto another,

113

they usually stop his medications, and the doctor at the new place starts something else. Me hears voices when he experiences panic episodes. I3e has been hearing voices a lot in the last few months (one wonders if this is a result of his being in SIIU and having his anti-psychoticmedication, Seroquel, discontinued). He hears the voices of friends cheering him on (command hallucinations) to do violence. He also gets very depressed. He has asthma, and when he is put behind glass (Lexsan), he panics because he fears he won't be able to breath nor to summon help when he needs it. In the last month his anxiety has mounted and he has been hearing the voices more. Meanwhile, he keeps
getting tickets, they've put him on the loaf -he's a h i d he's given up. The depressionis
worse. "SHU makes you have a short temper, there's more anxiety, you become a different person, at times I feel like I'm going crazy. Mental health staff have given input in his disciplinaryhearings. He tries to read to stay calm, but while he was a good reader, he has a lot of trouble concentrating when he's in SKU and then he cannot remember what he's read. He says he does not see eye-to-eye with Dr. Larnbert, the prescribing psychiatrist. He was taken off his medications until a month ago. He says he is behind glass because he flooded his toilet - he tells me it was stopped up and he didn't do anything to it. He gets very claustrophobic behind glass, and he believes that since he has Hepatitis C, he should not be on loaf for health reasons. He has not received Tier 3 tickets at Auburn, but was transferred here with a term behind glass still riding. On his clinical chart there are treatment plans for 6/3/03 a ~ 7d/15/03, but the chart reflects that staff think he may be malingering, and therefore they deny him treatment. This man clearly suffers from serious mental illness - a combination of anxiety/depression/and very severe reaction to isolated confinement that includes hallucinations and losing control of his temper and experiencing panic episodes. S t a t r e a t him as if he is malingering, his diagnosis is substance abuse and ASPD, and thus they medicate him inadequately and he continuesto deteriorate. He has cycled from S W to observation and back many times for self-harm. Progress notes reflect many signs of anxiety/depression/agitation.Meds at various times include Klonopin, Paxil, Clonidine. There is no psychological assessment, and there is no paperwork &om any CNYPC admissionsin chart. A 10/28/02 "Treatment Plan Review7'says he is mostly manipulative, should be subject to DOCS disciplinaryprocedures, and if he attempts selfharm he should be given emergency medical care only and returned to his cell (i.e., no more observation admissions). He cycles often between SKU and observation and back to SHU. He needs to be removed from SHU and transferred to a residential mental health treatment setting such as an ICP.

Example of: Atypical SMI (Anxiety, panic, with psychosis and hallucinations) in SHU Tickets accumulate in SHU, where he had few in GP Deteriorates in SHU, gets suicidal Very many admissions to observation -cycling from SHU to observation and back to SHU Viewed as malingerer Inadequately treated

'E @ 43

,. (Interviewed while housed in SHU).

has been in prison since 1999 and will be released in seven months. He has been in and out of SHU since 2001. He was in the ICP h m August to ' September, 2003, then a CO thought he was talking to him when he claims he was not, and he was kicked out of ICP and sent to SHU 9/30/03. He claims his mental health record did not play a part in the disciplinary hearing, even though he told the hearing officer about his mental illness. He has experienced auditory hallucinations since 2002.
#I,
But his history of serious mental illness goes back much M e r in time. In school he had a lot of problems, and his teacher thought he was retarded. His mental illness was not treated in the community. He has been hearing auditoryhallucinations for a year, or sincehe was in the Greenhaven SHU. He also has difficulty in GP because he is paranoid. He tells me that at Adirondack Corr. Facil. something awfbl happened in 2000, pictures were taken, and until today officers poke fun at him because of it. He is prescribed Seroquel500mg. per day, which he reports is better than Geodon. He has been in observation many times, mostly on account of suicide attempts. He thinks about suicide a lot, and wants to die. He doesn't believe he is human. He does not want to talk about the situations that haunt him. Officers disrespect him repeatedly, and he silently curses them. Since Adirondack, he doesn't actually say anything, but the COs tell other prisoners about the incident. His clinical chart contains an 8/27/03 chart progress note in
the ICP, reporting a rape at Adirondack and fears about HN status. He is reported to
have had no mental illness history prior to the rape, but has been intermittentlyanxious and suicidal since it happened. Diagnoses in chart include Depressive Disorder w Psychotic Features, Delusional Disorder, SchizoaffectiveDisorder, or, upon admissionto Observation at Auburn on 5/3/02, Depressive Disorder NOS. Meds include Paxil and Risperdal(2 mg. bid.) Repeatedly admitted to observation for suiciderisk. Spent a lot of time in SKU, e.g. at Ivfarcy CF SHU 200 in August, 2001. He was admitted to CNYPC on 4/15/03. A 1012103progress note by Dr. Langbart reflects: "Tbis individual has failed to show up to receive medications. According to policy they will be discontinued." Dr. Langbart's notes reflect that this prisoner suffersdelusions, by 10/7/03 he was in observation on account of paranoia and suicide plans, and Dr. Langbart discusses prescribing Geodon or Seroquel, yet he discontinues medications when the prisoner non-complies, and he supports discharge h m ICP on account of a ticket the prisoner received while not taking the medications. When he was delusional and suicidal
and admitted to observation on 10/7/03, he had been back in SHU for a short time. He was not seen by a therapist or Dr. Langbart over a weekend, and was discharged from

RCTP back to SHU on 10/15, even though it had been noted that he was experiencing a psychotic decompensation. There is discussion in the notes of his wish to return to lCP, but he could not because he had a 90-day SHU term to serve and he had assaulted an officer who is in ICP. In January, 2004, he is back in RCTP because he is paranoid and suicidal. He has been in SHU in the intervening time. Staff want to send him somewhere
safe until he goes to CNYPC for discharge planning, but there is nowhere to send him.
Notes consistently reflect paranoid delusions and other signs and symptoms of SMI. He is sent to GP, where he gets into trouble and becomes paranoid and needs re-admission to RCTP. Then he is assigned to InvoluntaryPC. On 3/17/04he is re-admitted to RCTP again, having "survived" in IPC, but remaining delusional. His diagnosis throughout this period is Schizoaffective Disorder/Depressed, and he is given anti-psychotic medications. A 5/20/04 admission note to CNYPC inpatient reflects paranoid delusions and thought disorder, a diagnosis Paranoid Schizophrenia, and a recommendation that he be civilly committed to a psychiatric facility after release fiom prison. In summary, this man suffers fi-om a serious mental illness, likely Paranoid Schizophrenia. Throughout his incarcerationhe is repeatedly in SHU for behaviors related to his mental illness, and time in SHU worsens his condition. He is prescribed anti-psychoticmedications while staff
also admit him to observation repeatedly, to ICP, etc. He is kicked out of ICP for alleged
assault on an officer, and given 90 days in SHU. But he is delusional and taking antipsychotic medications all along, Then, he is repeatedly sent back to SHU, the OMH staff, including Dr. Langbart, agree he needs ICP but cannot go back to ICP because of assault on staff, and finally he is sent to CNYPC for discharge (from prison) planning, is diagnosed Paranoid Schizophrenia, and civil commitment after release is recommended. If he is seriously mentally ill to the point of needing civil commitment, why was he repeatedly kept in SHU and permitted to cycle to observation? While there are notes along the way about his being manipulative, he was consistently diagnosed psychotic while in DOC. Dr. Langbart discontinued his medications at one point because he failed an appointment, but OMH did not intervene in disciplinary proceedings even though he was clearly delusional when he received tickets.

Example of: SMI (Psychosis, likely Paranoid Schizophrenia) in SHU Was kicked out of ICP for behavior Tickets related to SMI, but OMH not active in process Being recommended for civil commitment after release

4 *T

(Interviewed while housed in ICP).

T - 7 1 has been in prison for six years. He has been in ICP for a year. He previously spent two years in SHU because of three tickets, all given while he was
hearing voices. He began hearing voices on the street. He saw a psychiatrist in the community, but was not prescribed medications. He self-medicated with marijuana, which he reports calmed his nerves. When he entered prison, the voices became worse and began commanding him to kill himself. Risperdal was prescribed when he was incarcerated at Rikers Island. He is currently prescribed Haldol Decanoate, and

Gogentin. He has been assaulted while in a psychotic state, but he received a ticket and a year of SHU time anyway. He gets very paranoid in the Box, and loses control so that he receives more tickets. In ICP he does much better. He did have a relapse in May, 2003. He was admitted to CNYPC for two months because he was hearing voices, and they changed his medication from Risperdal, which caused a lot of side effects, to the Haldol he is currently taking. He had prior relapses (psychotic episodes) when he was in the Box, especiallywhen he was taken off his medications. Prior to his admissionto CNYPC, he had been taken ~Emedicationsat ICP and consequently got into trouble with
officers and received five tickets -the chargeswere dropped and he was sent to CNYPC.
He did have breakdowns in SHU, and he spent a lot of time behind glass (Lexsan), he
does not know why. In SHU, the loud noises bother him,especially in A Tank. He got
agitated, he lost memory, he lost his mind, he got confised, his thoughts started going
faster and faster. He does not think he would have had as many relapses if he had not been in SHU. His last ticket was in December, 2002. That's when he was granted a
time-cut and transferred to ICP. He believes that if you get a Tier 3 ticket in ICP you get kicked out and cannot return. He was bom in Guyana and came to the USA in 1989,but he faces deportation after he is released fiom prison. On mental status, he has flat affect, gives credible descriptions of command hallucinations and psychotic decompensation, he is concrete and there is a thought disorder.

This prisoner's thick chart corroborates his history. Notes consistentlydocument recumng psychotic episodes, diagnosis is Schizophrenia, Paranoid Type, meds are Haldol or Risperdal, e intermittently fails to comply, was admitted for the first time to CNYPC from 9 to 11/01 and spent some time in 5-point restraint while hospitalized. He was admitted to CNYPC again from 6/5/03 through 8/6/03. He had multiple admissions to observation at the RCTP while in SHU. In summary, this man suffers firom chronic severe mental illness, most likely Schizophrenia or a related condition. He is in ICP, which is an appropriate placement, and he is responding positively to medications and the treatment milieu. He was known to have a history of serious mental illness, and should
never have been placed in SHU, where his conditiondeteriorated. His SM.was not
given enough attention in the disciplinaryprocess, and consequentlyhe spent a lot of time in SHU where his condition worsened.

Example of: SMI (Paranoid Schizophrenia) currently in ICP
Was in SRU,deteriorated in SHU
Cycles from SHU to observation and CNYPC and back to SHU OMH is not sufficiently involved in the disciplinary process

k Us

.- (Interviewed while housed in ICP).

L ci has been in prison for one and a half years. He has been in ICP for
one week. Previously he was in SHU at Attica for four months, and then for th~ee
months at Auburn. He received a time-cut, and is currently on Keeplock. He reports that COs teased him incessantly when he was in the Box. He tells us that on March 24 of this

year, as he was returning from a visit, a CO wanted to see the picture he was carrying. The CO hit him. Later, the same CO came to his cell and he threw an orange at him, had
a meltdown, broke his t.v., the COs beat him,and he was given eight months in the SHU.
He complains of panic attacks, worse in SWU, and he often awakes in a panic. He is prescribed Seroquel,Depacote and Dilantin. Prior to incarceration he went part way through college, but was admitted to psychiatric hospitals several times for a psychotic disorder. He reports he is diagnosed anxiety and depression by OMH, but he has a history of paranoia and being diagnosed Bipolar or Schizophrenicin the community. He has been prescribed Depacote for many years. In SKU, he learned to keep his mouth shut and not respond to taunts. He told a CO about being raped, and ever since he has been teased by C 0 7 sabout it. He was behind glass (Lexsan) the whole time he was in the SHU at Attica. He thinks he is treated well at ICP, but he hasn't seen his counselor for a month. He was admitted to CNYPC twice, and has been in observation many times. He was in ICP at Attica prior to going to SKU. He didn't like Attica ICP as well as the one at Auburn because at Attica he had to mix with GP more. On mental status exam this man is restless, moving his legs constantly and grimaci'ng, he has obvious facial tics, he is quite flat, bizarre, anxious and agitated. He cannot answer whether he hears voices. His clinical chart reflects diagnosis of Schizophrenia,Undifferentiatedtype on 4/19/02. He ' was prescribed ZoloR 100mg., Zyprexa 20 mg., Depakote 1,500mg., Haldol Decanoate '180 rng. q. 4 weeks, and Dilmtin on 4/4/02. He has been admitted to CNYPC and discharged back to SHU. No clinician doubts his diagnosis, and he cycles fkom SKU to observation and CNYPC and back to SKU. In summary, this man suffers fkom longstanding chronic and severe Schizophrenia,with a history of treatment preincarceration and the prescription of anti-psychotic and mood-stabilizingmedications as well as ICP treatment currently (for one week). His case illustrates the problem of officers teasing prisoners with SMI, the consignment of prisoners who should be in ICP to SHU for disciplinaryreasons, and the problem of a prisoner with SMI telling officers too much (about a rape) and then being harassed as a result. He has only been in ICP for a week, so it is guite possible he will cycle again to SHU for behaviors driven by his mental illness.
Example of: SMI (Schizphrenia) in ICP one week, was in SHU Deteriorates in SHU Cycles from SHU to observation & CNYPC & back to SHU Teased by officers
G ,~l . (Interviewed while housed in the ICP).
has been in prison for four years on his fourth term. He is to be released in early 2004. He is confused, his memory is severely impaired, his affect is flat and there are absences during our i n t e ~ e wwhere he stares blankly and cannot continue a coherent narrative. He does not remember his ID number. He has not been in SHU. He has been in observation, and is angry about being left in a strip cell, naked, for four days. He cannot tell me when this happened. He does not know what treatment he

receives. He knows he received SSI disability on psychiatric grounds prior to incarceration. This man is severely disturbed and incoherent, he is practically mute. His very thick clinical chart contains diagnoses of Schizophrenia, Undiff. Type, substance abuse and ASPD. Medications include Zyprexa and Vistaril. He also suffers from medical ailments, including hypertension. Commitment papers to CNYPC reflect that he sits for days refusingto talk (catatonia?). He is reported to be difficult to treat because he does not respond and does not comply, and he is very delusional. He was denied parole in Sept., 2002, because he rehsed to sign papers.

Example of: SMI (Schizophrenia) in ICP Very disturbed

E b

. (Interviewed while housed in General Population).

E

has been in prison since the age of 24. His psychiatric medications

were stopped when he came to Auburn. He hears voices all the time, including during

our interview. He arrived at Aubum fiom CNYPC. He witnessed a fight, be~amescared,

refuses to come out of his cell, and is not eating. He rarely goes to recreation. He tdlks

to the voices he hears in his head. He intermittently feels suicidal. The other prisoners

h o w he is melitallyill, h t he does not seek mental health treatment. He has been

admitted to CNYPC once, and did not like it because "there are too many crazy people."

He has been in observation severaltimes. He was in a strip cell in A Tank for a month

when he first came to Auburn, he had no mattress and no clothes. Mental health staff

came to see him occasionally, took him to a room once. He reports many depressive

symptoms, including voices. The voices are multiple, one being the Devil, and some

command him to hurt himself When he is in a cell by himself he gets increasingly

anxious and depressed, the voices become more intense and self-castigating. He was in

ICP once. He has abistory of psychiatric hospitalizationspre-dating incarceration, going

back to age nine or ten when he was at Bronx State Hospital for years. He was in Special

Education at school. His family does visit. On mental status this man is internally

p~eoccupiedd, isplays strong First Rank Symptoms including thought insertion and the

belief that OMH staff read his mind. He elaborates delusionally about the doctors

suckinghis thoughts out of his mind with a magnetic force instrument. There is flat

affect, memory deficiencies. His clinical chart reflects discontinuation of psych meds in

12/02. He was diagnosed Bipolar Disorder and Impulse Control Problem along with

ASPD. He made multiple suicide attempts, some serious but some gestures. But then he

was admitted to CNYPC on 11/12/02 fkom Sing Sing, where he was suspected of

malingering. His medications included Depacote, Remeron, and at other times,

Risperdal, Trazadone and Celexa A long report of psychological assessment by Dr. John

Wilson concluded that he has low intellectual functioning but no Axis I pathology, he
scores high on Hare's psychopathy checklist, and he malingers - yet he is kept in a strip

cell for a month. Dr. Wilson includes in his assessment the recommendation that

antipsychotic and mood-stabilizingmedicationsmay be helphl, but this should not be

taken to mean he suffers from a serious mental illness. He has been in SKU and ICP but

119

is currently in GP. Tn summary, this very disturbed man is actively hallucinating,but he
has been denied adequate mental health care after returning from CNYPC, where he was assessed as not suffering from SMI and put on a behavior management plan.

Example of: SMI (Active psychosis, likely Schizophrenia or Schizoaffective) in GP Has been in SHU, deteriorates in SHU Describes harsh conditions in A Tank Un-diagnosis at CNYPC Continued on psychiatric medications Inadequate treatment for active psychosis

D, 0 , (Interviewed while housed in General Population).

-

has been in prison since 1996. He is not in mental health treatment,

but believes he can get it if he asks for it. He is a loner. He experiences absences and

memory problems. He calls them black-outs. He was admitted to CNYPC in the early

199OYst,ransferred fiom jail. They diagnosed Black-Outs, Depression and Multiple

Personality Disorder. An alter-ego (possible multiplepersonality?) is named James. He

spent three months in the Box in 1996. Mental 'health staffhave told him there's ~othing

they can do for him - he used to put in slips requesting help, but he has given up. He is

not permitted to see the psychiatrist. He is told he has been in fights,but he does not

remember the fights. Or, things are moved and he doesn't recall when or how that

happened. He once took Prozac, but that didn't help. He has other (imaginary) people -

"Timmy," "Johnny KooS7-who come around and talk to him. On mental status this man

is confused and a little bizarre. His thin clinical chart contains diagnosis Multiple

Personality Disorder. Around 1993he spent 22 months at CNYPC,with a diagnosis

Multiple Personality Disorder, and Rx Prozac.

~ x a k ~ofl:e Mental Illness in GP Mental Illness (Dissociation, possible Multiple Personality Disorder) does not fit categories for which treatment is offered in DOCSIOMH, so he goes without treatment Need to rule out psychosis

F ~d -

.. (Interviewed while housed in SHU).

F fd :has been in prison for 12 years on his second bit, and is serving a 40-
to-life prison sentence. He has been in SHU since 2002, and is currentlybehind Lexsan. He entered SKU with a nine month term, but attempted suicide in SHU and as a result was given a ticket which resulted in an additional eight month term. In September he was in observation and was admitted to CNYPC, and then returned to Auburn SIitT (he had been at Great Meadow). He says he has been in observation since July (three
months) at one institution or another. He was in A Tank,strippednaked. His problem is

he cuts his wrists in suicide attempts. He was also on a hunger strike. He has made other suicide attempts. He was given forced intramuscular medications at CNYPC. He does
not take any medications at Auburn, but he is sent to observation. He has asked for
medications several times, but they have refbsed his requests. The hearing officer who added eight months to his sentence did talk to mental health. He has no pre-incarceration psychiatric history, and only the one admission to CNYPC. He did try to kill himself by hanging in the countyjail. Being in SHU makes him feel like he is suffocating, he gets very anxious, he experiences panic attacks, be gets paranoid, he gets up two or three times in the middle of the night afraid someone is attacking him, and he is unable to concentrate and cannot read the Bible as he usually does -he says he never had feelings
like these prior to being in SHU. This is his first time in SHU, and he had no SHU and
no trips to observation between 1991 and 2002. He reports he has been kept naked for long periods as he was transferred fiom the MEXU (observation) to A Tank and then to the Hospital, but the worst was the MHU. On mental status examination, there are scars on both wrists from suicide attempts months ago, and he speaks in halting English, exhibits depressed affat, anxiety, some agitation, and psychomotor retardation. His clinical chart reflects no psychiatric history prior to incarceration, but several suicide attempts while in prison. He did well in prison, getting his GED and holding various jobs in honor block,
until he received a tier 3 ticket in 2002 for assault that sent him to SHU. He had been
diagnosed Bipolar for a while, and was prescribed various medications, including Risperdal. He was admitted to CNYPC for the Grst time on 8/25/03, was noted depressed and suicidal, was prescribed Benadryl and Rerneron (15 mg./day). He tends to be underdiagnosed, as Adjustment Disorder with Disturbance Of Conduct, but on 8/22/03 he was diagnosed Major Depressive Disorder, single episode. On 8/25/03 he was transferred from RCTP at GMCF to CNYPC with this note: "Admitted to the unit on 8/19, fiom Upstate CF after his returning there, been in the unit twice in past two weeks. Last night was making suicidal gestures, put a sheet around his neck. Hopeless, and helpless. Decrease in his appetite, wants to die. Very labile. Between tears and laughter?rocking. Not sleeping at all." Upon discharge &om CNYPC on 9/18/03, he was given "no diagnosis" on Axis I, after a psychological evaluation By Edwin Debroize found no diagnosis on Axis I and high Hare psychopathy score. He has been repeatedly suicidal since being in SHU, and was in observation for at least two months in Sept. and Oct., 2003. This man clearly suffers £?omsevere depression, made worse by SHU. His treatment needs are not adequately addressed subsequent to a psychological evaluation at CNYPC where they opined no diagnosis on Axis I. He needs to be in a settingproviding more mental health treatment, e.g. ICP.

Example of: SMI (Depression with Psychosis, R/O Bipolar) in SHU Deteriorates in SHU More tickets in SHU secondary to suicide attempts Hearing officer considered mental health issues Cycles from SHU to observation and CNYPC and back to SHU Un-diagnosis at CNYPC Continued on medications

C3.G

$, (Interviewed while housed in SHU).

has been in prison for 11years on a 25-to-life term. He has been in
SHU or long-term Keeplock for seven or eight years. He came to Auburn eight days ago, and has been trying to get mental health treatment. He is on the OMIH caseload, but has never been admitted to CNYPC, and had no psychiatric history on the street. He is not taking psychiatric medications. He has never been to observation, but three days ago he
tried to hang up -nobody knows about it. He hears voices commanding him to hurt
himself or someone else. He was taking psychiatric medications until three or four months ago. He has been asking to see a psychiatrist to get medications, but he is told by mental health staff he doesn't need them. He used to take Elavil, P a i l and Hddol - the Haldol helped with the voices. The voices have been with him since 1995. He has trouble sleeping in SIFU, and he is depressed a lot. He thinks OMH diagnoses him Paranoid Schizophrenia. He does not tell hearing officers about his mental health problems. He was in a stabbing incident in 2000 that led to a 15month SHU sentence, but he was acting in response to command hallucinations at the time. He has never been in ICP but would like to be. The isolation of SHU makes his psychiatric symptoms worse, but he prefers SHU to population because he is afi-aid of others in GP. On mental status examination he speaks credibly of command hallucinations that get worse when he is paranoid, he hears the voices of an uncle who molested him when he was a child. His clinical chart contains a mental health screening, with diagnosis Adjustment Disorder and Anxiety. Many notes say there is no mental illness, and list no symptoms. He periodically goes to observation briefly. He asks to have medications re-instated, but his request is denied and he is returned to SHU, where OMH staff say he has no symptoms. But in 12/03, he is started on Zyprexa at Southport, and by 4/26/04, he is prescribed Ziyprexa 20 mg. per day, Vistaril50 mg., and Remeron 15 mg. per day, for a Diagnosis of Adjustment Disorder with Anxiety - and I found no notes to explain why he is on antipsychotic and antidepressant medications. In summary, this man suffers fiom serious mental illness, is not being treated adequately and is in SHU. He reports that command hallucinations led him to the violent acts that resulted in his SHU term. OMH notes reflectno psychiatric problems, but then he is prescribed anti-psychotic and antidepressantmeds. His chart makes no sense. He needs a relatively secure residential treatment setting such as ICP.

Example of: SMI (Depression and Psychosis) in SHU

Deterioration of mental health in SHXJ Un-diagnosis or lack of diagnosis by OMH But then he is prescribed anti-psychotic and antidepressant medications Tickets seem related to mental illness

B-P*.

. (Interviewed while housed in SHU).

= i has been in prison for over 16 years. He is in SHU, and has been in SHU for 30 days. His total SHU time is three or four years. He believes he was set up by COs, who planted a weapon in his cell. He has scars on his face fkom knife fights, mostly at Rikers. He says he has no psychiatric problems, is not in mental health treatment and is not taking psych meds. In SHU, he feels very frustrated and feels that the COs hassle the prisoners, for example by saying he can't have earphones when he should be permitted earphones. If he "gets into it" with the CO, his anger mounts and he
gets in trouble. Surviving in SKU depends on who your neighbors are. Ifthey make
noise, you have trouble concentrating. He feels the COs in this SHU do not treat the prisoners with compassion. They do "banging therapy": if they don't like you, they put you next to a prisoner with serious mental illness who bangs and makes noise all the time. In A Tank,the COs control the toilets, keep the lights on all the time, and generally harass the prisoners. '"They press your buttons."

Example of: Denies mental health problem, in SHXJ Complains of harsh treatment in A Tank

T 7

. (Interviewed while housed in SHU).

- w
Y

had been ~ ~ ' S HsinUce 10/8/03, and is now behind Lexsan. He was

given two years, and has outside charges. He takes Prozac, Atarax and a sleeping

medication. He can't breathe in SHU because he has asthma He has received a ticket

for not being ready in time to go to sick call. He has been admitted to CNYPC, and has

been in the Five Points STP for nine months. He requested a transfer out of STP, so they

put him back in SHU. He wanted to go to ICP. He thinkshis problems result fiom the

COs harassing him in retaliation for what they think was his participation in the riot of

1991. He reports being beaten by COs on June 14. He has had about 30 tickets in SHU,

compared to only a few in GP. He has been in and out of prison. He does not receive

psychiatric treatment on the outside. He stays in his cell all the time because he is &aid

of a possible attack by COs. He believes most of his tickets were due to being set up by

COs. On mental status, he is anxious, wide-eyed, with pressured rapid speech.

Example of:
Possible SMI (Depression?- unclear, chart not reviewed) in SHU
Went to STP and back to SHU

APPENDIX E

Suicide Statistics from 1995-2004

1995 - total of 11 suicides. 4 of these ( v ~ E, @ tt3as,&&,T ,bJ.g3 ) occurred in isolated
confinement housing areas (36%). Na M. 3,may have been in the RCTP dorm rather than in
observation. We do not know the locations of 2 (M N.k, M MbI).

1996 - total of 13 suicides. 6 of these ( 0,p ,D,o,i"l., H . @ ,& ,W &W,b,Y .H.Inz,,id, R .) occurred

in isolated confinement housing areas (46%). We do not know the location of 1 (N ,tJ L, ).

bi.& committed suicide in the dormitory area of the

- &B 4 . was in the RCTP fjrornthe

SHU at the time of the suicide.

1997 - total of 14 suicides. 3 of these C C*L,,I%.P. 4, E,G e) occurred in isolated confinement
housing areas (21%).

1998-totalof14suicides. lOofthese(i ~ -,0P b \ ~ . , L u,t 5 ~,,@*,*x,*IJ&$,
@I . ,) D ,M,&Up 'X56,) occurred in isolated confinementhousing areas (71%).
g: .LaS was in the D housing unit at Downstate which is an area for psychiatric cases. The patients ate not dways on observation status. 6.d..3. was not on ~bStl:rVaai~stnatus.

. 1999- total of 8 suicides. 3 of these (2,, C,D, , 3 M ) occurred in isolated confinement

housing areas (37%). In addition, M ,g, was in isolation in the infirmary;

Q was out

to court at Rikers Island fiom Southport (he was a SHU prisoner at the time of the suicide);

N x a was housed in E building at Downstate although it does not appear that he was on
keeplock status (E building is described as disciplinary keeplock and when necessary, overflow

of mental health inmates who normally would be housed in D building).

2000-totalof17suicides. 9ofthese("ga~, p*. ~ , c p a ~ c s,. ~Q,S,aaH., N,@.N,,E , E s ~ * ,
@, ,A. A, Q-) occurred in isolated confinernenthousing areas (53%).

2001 - total of 7 suicides. 4 of these ( P , a ,5, ,o$. Q . , K E ) occurred in isolated
confinement housing areas (57%).

2002 - total of 14 suicides. 5 of these ( Y . P. .,

,

, g , p ) occurred in

isolated confinementhousing areas (36%). We do not know the locations of dof these suicides

(. A,~~,,"-H.F*,,cy~, TM*,).

2003-totalof15suicides. 6ofthese(&fl.Zg, @.&At P.N , Zt~efi,,L,T.t3,&,*A, )
occun-ed in isolated confinementhousing areas (40%). *Ido not know where the information about &,@,&,waosbtained. The SCOC report indicates GP without mentioningKeeplock. We
need to veriQ Keeplock status of A .. We do not know the locations of 3 of these suicides
( .r*x*ca*-, K , X-%X*O).
2004 - as of 11/17/2004 we know of 5 suicides and know that at k t 2 of the 5 occurred in

isolated confinement housing m a s (40%).

Year

Total Known Suicides

1995

11

1996

13

1997

14

1998

14

1999

8

2000

17

2001

7

2002

14

2003

15

2004 (incomplete)

5

TOTAL

118

i
Suicides Known to be in Isolated Confinement 4
6 3 10 3 9 4 5 6 2 52

1
Percent Known to be in Isolated Confinement 3 60/0 46% 21% 71% 37% 53% 57% 36% 40% 40% 44%

APPENDIX F Summary Tables of the 98 Inmates who are Included in Both the 2002 and 2004 SHU Studies* Inmates whose Diagnosis was Changed from Axis I to Axis
Personality Disorder
i2
Oh t4 Q\

I

1 with mixed disturbance of I or condition on Axis I I

I

I I I

qotiohs and conduct

, or Axis II

1 - 293.83 Mood Disorder due to V71.09 - No Disorder 1

I general medical condition . or condition on Axis I

4

Yes No

or . h i s =,

309.24 - Adjustment Disorder V71.09 - No Disorder 6

6

No

No

with Anxiety

or condition on Axis I

- 311 DepressiveDisorder
NOS

or xis II n/a

2

1

1.

I
No I No

300.4 - Dysthymic Disorder nla

1

2

No

No

296.3 - Major depressive

V71.09 - No Disorder 1

Disorder, recurrent

or condition on Axis I

La I - I or Axis IJ

4

No

No

I

I

Jnmates whose Diamosfs was Chan~edfrom Axis I1 to No Diaenosis

ndition on Axis I or Axis

Inmates who Received a Diagnosis but were Classifled as OMH Level 6 in Either 2002 or 2004

_2002*SHU Study

1. ist

$

297.1 - Delusional 297.1 -

Disorder

Delusional

6

1

No Yes 2002

-. 3w-l2k&
2.

- 301.7 Antisocial

VD7is1o.r0d9e-r

.
No

6

6

No No 2002

: Personality

Disorder or

' Disorder

condition on Axis

I

I or Axis 11

J

Inmates whose MH Level Chanced to 6 from Another Level

I I

Dlsorder NOS .

contrql Disorder NOS

i V7 1.09 - No Disorder or
; condition on Axis I or Axis E

I WO Anxiety Disorder

3

Inmates whose MH Level Chan~edfrom 1 to Another Level

6

I I No

No

u

1

( Personality Disorder

I

* Note: When analyzing the data concerning the inmates included in both the 2002 and 2004 SHU studies, we were unable to
determine particular information for a few of the inmates due to the layout of the original SHU study spreadsheet, For this reason, these inmates were not included in certain counts; had they been included, there is a chance there would be a greater number of inmates who fall into the above-listed categories. The inmates who were not included in some of the comparisons are:

APPENDIX G
GLOSSARY OF ACRONYMS, PSYCHOTROPICMEDICATIONS, AND INDIVIDUALS (WITH POSITIONS)
Glossary:
Assessment Program Preparation Unit (ASPIT): A unit at Clinton Correctional Facility that offers a 'Viagnostic and treatment program" to help victim-prone or fearful individuals be able to move back into the general population.
Academic Vocational Preparation (AVP): A program at Green Haven Correctional Facility comparable to the Intermediate Care Programs (ICPs) at other facilities.
Antisocial Personality Disorder {ASPD): A personality disorder listed in DSM-IV that features a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood and continues into adulthood. ASPD is not the same as Psychopathy (see below).
Atmica1 Anti~svchoticMedication: The new generation of psychotropic medications that are prescribed for the treatment of psychosis (see list below).
Axis I Disorder: Part of a "multi-axial" format in DSM-TV that lists "Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention."
Axis IIDisorder: Part of a "multi-axial" format in DSM-IV that lists personality or
character disorders and Mental Retardation, as distinct from Axis I Disorders.
Behavioral Health Unit fBHU1: A planned expansion of OMH services designed to
taiget prisoners with mental illness who have poor behavioral controls and a diminished capacity for emotional regulation which may be exacerbated by extensive isolated confinement. The purpose of the BHU is to assist these inmates in developingthe necessary skills to assimilateback into the general inmate population.
Behavior Management Plan (BMP): Plan designed by CNYPC to treat inmates with mental illness and behavioral disorders.
Borderline Character Disorder: A diagnostic category listed under Axis I1of DSM-W, but this condition can include intermittent episodes of psychosis and severe disability.
m e Box": Colloquial term for SHU
Case Management: A form of mental health treatment intervention, where a clinician follows a patient with serious mental illness over a long time period and manages the
case, coordinating services rather thannecessarily providingthe actual treatment.
Cell Extraction: Forcible removal of a prisoner from a cell, most ofken conducted by a team of security staff in isolated confinement settings.

Central New York Psychiatric Center (GNYPC):
1) The forensic a m of 0Mt-Ithat provides and oversees both inpatient and outpatient services to prisoners in DOCS' correctional facilities.
2) The inpatient psychiatric hospital in Marcy, New York.
Command hallucinations: "Voices" that order the hallucinating individual to do something, such as attempt suicide.
Communitv Orientations and Re-EnW Promam [COW): A program at Sing Sing Correctional Facility that prepares prisoners for release and helps plan post-release arrangements in the community.
Decompensate: Generally, a psychiatric crisis or "breakdown"; more specifically, an acute exacerbation of a psychotic disorder.
DevelopmentalDisability: A physical or mental condition that exists corn childhood, includingbut not limited to Mental Retardation.
Department of Correctional ServicesDOCS): The agency created by the State of New
York for the purpose of operating prison facilities within New York.
The Diamostic and Statistical Manual of Mental Disorders, 4&Edition CDSM-TV): A volume published by the American Psychiatric Association in 1994,wherein are listed the officially recognized diagnostic categories and criteria for their diagnosis.
Dual Diagnosis: Co-occuning mental illness and substance abuse.
Extravvramidal Svndrome (EPS): A side effect of anti-psychotic and other medications, involving excess salivation and involuntary muscle spasms.
Ferpslson Gown & Ferwson Blanket: A gown and blanket made of material that is difficult to tear, for use with a patient in observation for suicide risk.
First-rank Svm~tom(sFRS): A set of symptoms that are typically found in Schizophreniaand other psychotic disorders, reflecting problems distinguishingbetween inner and outer reality or between self and others. An example is "thought insertion," the symptom characterized by the belief someone is inserting thoughts into one's mind. Also known as Schneider's First-rank Symptoms, after Kurt Schneider, who first described the symptoms in Schizophrenic patients.
GeneralPo~ulation(GP): A classificationstatus and the name for the areas and programs of prisons where most of theprisoners are confined.
Global Assessment of Functioning (GAR: By convention,GAF is Axis V of the multiaxial system of diagnosis in DSM-IV. It is a scale of functioning h m 0to 100, where 100 denotes superior functioning and 1 denotes persistent danger of severely

hurting self or others or being incapable of caring for oneself. GAF scores below 60 denote moderate to severe psychiatric impairment.
Good Time: The time, usually measured in days, that are subtracted from an inmate's prison term for good behavior. A recommended denial of good time can be a disciplinary sanction.
Hare's Revised Psvcho~athvChecklist (PCL-R): A psychological assessment instrument utilized to detemine the presence of psychopathy,
Ideas of Reference: Paranoid ideas.
Intermediate Care Prosam (ICPP: DOCS programs that arejointly staffed by 0MH and DOCS. Prisoners housed in ICP have been deemed unable to h c t i o n in the general population due to the effects of a mental illness. ICPs are one form of a "step-down program."
Internal Preoccupation: An obsemed sign of body language, facial gestures and eye movements indicating that the patient being examined is paying attention to internal events such as hallucinated voices. The patient subjectivelyreports a "syxnptom'~- the
voices -but the clinician objectivelyobsmes the "sign" - intern1preoccupation.
Involuntary Protective Custody (nTP): Confinement for an inmate who may be a potential victim or a witness likely to be intimidated, or who lacks the ability to live in the general facility communityand who may for good cause be restricted b m
communication with the general inmate population, and who does not voluntarily accept
admission into protective custody status.
Isolated Confinement: A designated area of a prison where prisoners are kept isolated &om other prisoners, have minimal contact with staff, spend nearly 24 hours per day in their cells, participate in very few if any programs, eat alone in their cells and are mostly
idle, Isolated confinement in N Y DOCS includes SHLJ,Keeplock, Administrative
Segregation and Protective Custody that involves lockdown.
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO): A national accrediting agency for hospitals and healthcare organizations.
Keeplock: A disciplinary sanction that involves cell confinement (isolated confinement) for a specified length of time, which may be canied out in the prisoner's location or may involve transfer to a special cellblock or to SKU.
Loose Associations: A sign discovered during a mental status examination of a thought process involving ideas that are not connected to each other in a logical way, usually a sign of psychosis, typical of Schizophrenia
Maior Mental Illness: A loosely defined collection of diagnoses, including Schizophrenia, Bipolar Disorder and Major DepressiveDisorder, that has been utilized to establish treatment priorities in correctional settings. It is distinct from Serious Mental

Illness (SMI), which considers functional capacity and includes a broader set of diagnoses.
Malingering: The feigning or exaggeration of symptoms for secondary gain.
Mental Health (Service) Level: A classification system utilized by OMH and DOCS to identify prisoners' need for services. Prisoners are assigned a level ifrom 1 to 6 (there is no level S), where 1 signifies a need for intensive mental health services and 6 signifies no need of treatment.
Mental Health Unit TPYMU): Located in five maximum security facilities and seven medium security facilities, these units do not have any full time mental health or medical clinicians and require only a minimum of eight h u r s of psychiatric services per week. Southport and Upstate, all-SHU maximum security prisons, have Mental Health Units.
Mental Retardation: A disorder characterizedby subaverage intellectual functioningwith onset prior to age 18 and continuing deficits or impairments in adaptive functioning. It . can co-exist with a serious mental illness, and is noted on Axis I1 of the multiaxial diagnostic formulation.
Mental Status Examination: The objective portion of a clinical assessment in psychiatry and related mental health fields.
Mew1Cooper Unit: A therapeutic community in the maximum security Clinton Annex. The program is designed primarily to help prisoners prepare for post-release life in the community.
Mood-stabilizer: a medication that limits the highs and lows of mood that accompany Bipolar Disorder and other Mood Disorders. The original medication in this group was Lithium, but a series of other medications have been found to be as eEective (see list, below).
Neuro~s~choloCZicCalNeuropsvch) Testing: l?sychological assessment that focuses on the interplay between functional mental disorders and biologically based brain disorders, examiningthe relationshipbetween behavior and brain hctioning in the realms of cognitive, motor, sensory and emotional hctioning. Includes intelligence testing and testing for organic brain disorders such as closed head trauma.
Not Otherwise Svecified INOS): A term that can be added to the end of a diagnosis, signifying that the diagnosisis relevant but criteria for h l y establishing a specific subcategoryof the diagnosis have not been met. Thus, for example, Mood Disorder NOS signifies that the patient suffer from disordered mood but does not meet the criteria for a
finn diagnosis of a specific condition such as Bipolar Disorder or Major Depressive
Disorder; similarly Psychosis NOS signifies the presence of psychosisbut insufficient evidence to specifically diagnose Schizophreniaor Delusional Disorder.
Observation Cells: Individual cells or rooms modified to safely house and provide close monitoring for agitated inmates or those at risk for suicidal behavior.

Office of Mental Health [ O m : The agency created by the State of New York for the purpose of controlling, providing and supervising the State's mental health services for New York State residents with mental illness, includingmental health servi-s for prisoners.
Protective Custody RC): Confinement for an inmate who may be a potential victim or a witness likely to be intimidated, or who lacks the ability to live in the general facility community and who may for good cause be restricted &om communication with the general inmate population, and who voluntarily accepts admission into protective custody status.
Posttraumatic Stress Disorder (PTSD): A diagnostic category that requires a history of a traumatic event and the continuing presence of a list of symptoms, which might include (but does not necessarily include) flashbacks, heightened startle reaction, constricted emotional range and so forth.
Psvchomotor Retardation: A slowing of thinking and behavior, often a sign of depression.
Ps~chopathv:A diagnosis that is not included in DSM-N, but is widely applied in forensic and correctional contexts. It overlaps the diagnostic category Antisocial Personality Disorder, and implies an especiallyintransigentcal-llousnessand lack of care about the feelings and rights of others.
Ps~chosociaRl ehabilitation: See Psychiatric Rehabilitation.
Psvchotrmic medications: A category of medications with psychiatric effwts - see list below.
Psychiatric Rehabilitation (or Psvchosocial Rehabilitation or Social Rehabilitation): A variety of treatment interventions; including group therapy, vocational training, supported living in the community, day treatment, psycho-education, case management and other educationalprograms, aimed at helping the psychiatrically disabled individual participate fully in psychiatric treatment, remain stable, and enjoy the best quality of life possible, given the disability.
Reception: A facility within a correctional system where newly admitted prisoners spend a period of time at the beginning of a term being evaluated and a s s i ~ e da security classification.
Residential Crisis Treatment Promam IRCTP): Mental health observation cells and a d o m area where prisoners may be admitted and housed within the SatelliteMental Health Unit.
Re-traumatization: Repeat trauma in someone who had been traumatizedearlier, for example the rape of an adult who had been sexuallymolested as a chiM constitutes retraumatization.

Rule out N O ) : A phrase preceding a possible diagnosis, signifying that the diagnosis must be considered.
SatelliteMental Health Unit: Mental health treatment programs administeredby O m in most DOCS maximum s d t y facilities. Southport and Upstate, both maximum security all-SHU prisons, do not have SatelliteUnits.
Schneider's First Rank Smptoms: (see F h t Rank Symptomsor FRS)
Serious Mental Illness (SMI): A substantial disorder of thought or mood which significantlyimpairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life.
Serious and Persistent Mental Illness SSPMI): A tern utilized by the federal government to guide states in establishing community mental health services. This category takes diagnosis and disability or level of hctioning into consideration, and is supemded by and incorporated in the tern Serious Mental Illness (SMIJ.
Social Rehabilitation: See Psychiatric Rehabilitation
Special Housing Unit ISHUI: Twenty-three hour disciplinary isolated confinement unit in which prisoners are confined in small cells.
Special Needs Unit (SNU3: Residential units with programming for inmates with developmental disabilities andlor mental retardation.
State Commission on Correction (SCOC): The state oversight agency which investigates and oversees correctional facilities.
Social Security Disabilitv (SSI or SSA): A federal income supplement plan administered by the Social Security Administration which provides cash to meet the basic needs of aged, blind and disabled people with little or no income.
Specialized Treatment Program (STP): A program that provides assessment and treatment to seriously mentally ill inmates who, due to their disciplinary status, are housed in SHU.
"Step-down P r o m " : A non-technical term for mental health programmingthat is a step down fiom the intensity of inpatient (hospital) treatment, but more intense than outpatient treatment.
Tangential thinkino: An aspect of thought disorder where ideas are more tangential than linear.
Tardive dvskinesia: Involuntarymovements due to brain damage secondary to taking older anti-psychotic medications for a long time

Thou~&Dt isorder: A term that evolves from the distinction in psychiatry between mental illnesses that involve abnormal thought processes (such as Schizophrenia and other psychotic conditions) and mental illnesses that involve abnormal affect.
Twelve Step Program: A leaderless group experience, modeled on Alcoholks Anonymous, where participants traverse twelve organized steps of self-healing in the process of becoming "clean and sober." The term and the process have been generalized to other addictions.
Un-diamosis: The process whereby the diagnosis of an individual who had been diagnosed with a serious mental illness is downgraded inappropriately to a less serious diagnosis or no diagnosis.
Word salad: a string of words that does not make sense, a sign that occurs in psychosis.

Psychotropic Medications:
(Listed by brand names, with generic name in parentheses)
Anti-psychotic: Thorazine (Chlorpromazine) Mellaril (Thioridazine) Waldo1 (Haloperidal) Prolixin (Prophenazine) Serentil (Mezoridazine) Stelazine (Trifluoperazine) Trilafon (Perphenazine) Navane (Thiothixene) Loxitane (Loxapine) Moban (Molindone) Orap (Pirnozide)
Atypical Antipsychotic: Clozaril (Clozapine) Geodon (Ziprasidone) Zyprexa (Olanzapine) Risperdal (bsperidone) Seroquel (Quetiapine) Abilify (Aripiprazole)
Mood Regulators/Mood Stabilizers Lithobid, Lithonate, Eskalith (Lithium) Depakote, Depakene, Depacon (Valproic Acid, Divalproex) Tegretol (Carbamazepine) Neurontin (Gabapentin) Lamictal (Lamotrigine) Trileptal (Oxcarbazepine) Topmax (Topiramate)
Antidepressants Effexor (Venlafaxine) Remeron (Mirtazapine) Serzone (Nefazodone) Wellbutrin, Zyban (Bupropion) Nardil (Phenelzine) Parmate (Tranylcypromine) Prozac (Fluoxetine) Celexa (Citalopram) Lexapro (Escitalopram) Zoloft (Sertraline) Luvox (Fluvoxamine) Paxil (Paroxetine)

Anafranil (Clomipramine) Desyrel (Trazadone) Elavil, Endep (Arnitriptyline) Tofranil (Imipramine) Sineqw, Adapin (Doxepin) Vivactil (Protriptyline) Norpramin (Desipramine) Sunnontil (Trimipramine) Asendin (Amoxapine)
Anti-anxiety Valium (Diazepam) Librium (Chlordiazepoxide) Klonopin (Clonazeparn) Xanax (Alprazolam) Vistaril, Atarax (Hydroxyzine) Tranxene (Clorazepate) Ativan (Lorazepam) Buspar Q3uspirone) Centrax (Prazepam)
Anti-histamine that can be prescribed for sleep Benadryl

---tDr. DavidBarry

'hysician; Member of the Medical Review Board of the rTew Yorlc State Commission of Correction

Jefiey Bea

ieutenant, Attica [DOCS]

r--John Culkin Anthony DeVito

lirector of Mental Health Services [DOCS]
4ssociate Director of Quality Management [CNYPC] Former Satellite Unit Chief, Wende

$

Charles Gordon

Mental Health Program Specialist @OCS]

I Gary Greene

Superintendent, Great Meadow [DOCS]

I

I Charles Henmanu

Associate Director of Quality Management for CIYYPC; formerly Director of Risk Management for CNYPC

L
Leslie Kellam

Program Research Specialist III [DOCS]

( Nancy Key

Forensic Unit Chief, Sing Sing [CNYPC]

I Sharon Keyser

Unit Chief, Albion [CNYPC]

I Loretta Klein

Retired (Formerly Forensic Unit Chief Shawanguak and Sullivan [CNYPC])

New Yo* State Commissioner of Correction

1

I

Psychiatrist, Former Acting Clinical Director, Auburn

[OW

t-William Lape

Currently Superintendent at Marcy; was Deputy Superintendentat Five Points until June 2003 POCS]

L
Lucien Leclaire

DOCS Deputy Commissioner [DOCS]

Elaine Lord

Superintendent, Bedford Hills [DOCS]

Richard Miraglia

Associate commissioner of Forensic Services [OMHI

Dr. Adele Pace

Peter Russell

Harold (Hal) Smith Jayne Van Bramer Dr. Bruce Way Larry Woodward Dr. Lester Wright

ExecutiveDirector [CNYPC] Director for Quality Management [OMHI Assistant Director of Operations [CNYPC] ICP Unit Coordinator,Elmira POCS] Deputy Commissioner and Chief Medical Officer [DOCS] .


[CONTENT] May 28, 2002 | Disability Advocates, Inc. | 42 | the U.S. District Court | the Southern District | New York ||| the New York State Office of Mental Health | the New York State Department of Correctional Services | DOCS | the Eighth Amendment | Americans | ADA | the Rehabilitation Act ||| New York |||  ||| the District Court | Gerard E. Lynch | October 31, 2002 ||| 2006 ||| April 2007 | Lynch | April 27, 2007 ||| Special Housing Units | SHU | 2 hours | RMHU | as many as 4 hours | an hour |||  ||| 405 |||  ||| Intermediate Care Program ||| 100 | Residential Mental Health Unit | RMHU | 4 hours | SHU ||| 310 |||  |||  ||| SHU |||  |||  |||  |||  |||  |||  |||  ||| State ||| $50 million | $2 million | 2007-2008 year | $9 million | nearly $2 million | DOCS | 2007-2008 fiscal year [SUMMARY] On May 28, 2002, Disability Advocates, Inc., along with other public interest groups, filed a civil rights lawsuit pursuant to 42 U.S.C. § 1983 in the U.S. District Court for the Southern District of New York on behalf of state prisoners with mental illness.  The complaint alleged that the New York State Office of Mental Health [OMH] and the New York State Department of Correctional Services [DOCS] were deliberately indifferent to the serious mental health needs of state prisoners with mental illness, in violation of the Eighth Amendment, the Americans with Disabilities Act (ADA) and the Rehabilitation Act.  Specifically, plaintiff alleged that a cycle of torment existed within the New York state prison system: a lack of adequate mental health care resulted in the placement of prisoners with mental illness in isolated confinement, which in turn caused greater psychiatric harm to those prisoners.   Plaintiff sought declaratory and injunctive relief.

Defendants filed a motion to transfer the case which was denied by the District Court (Judge Gerard E. Lynch) on October 31, 2002.  Thereafter, the parties conducted discovery through 2006.  

In April 2007, the parties reached a settlement, which Judge Lynch approved on April 27, 2007.  The settlement requires that prisoners with serious mental illness confined in Special Housing Units ("SHU") will now receive a minimum of 2 hours per day of out of cell treatment and that prisoners in the RMHU receive as many as 4 hours, in addition to an hour of recreation.

The settlement also provides: <ul><li>Multiple reviews of disciplinary sentences for prisoners with mental illness for the purpose of removing prisoners with serious mental illness from isolated confinement. 
<li>Residential programs for 405 prisoners with serious mental illness. 
<li>215 Transitional Intermediate Care Program beds for prisoners with mental illness in general population. 
<li>90 additional Intermediate Care Program beds for prisoners with mental illness who cannot tolerate the prison general population. 
<li>A 100 bed Residential Mental Health Unit ("RMHU") which will provide 4 hours per day of out-of-cell programming for prisoners with serious mental illness who would otherwise be in SHU. 
<li>The above are in addition to 310 residential mental health programs beds which the state instituted after the litigation commenced. 
<li>An additional 20 psychiatric hospital beds for prisoners in need of acute care. 
<li>Universal and improved mental health screening of all prisoners at admission to prison. 
<li>Improved suicide prevention assessments, now required upon admission to SHU. 
<li>Improved treatment and conditions for prisoners in psychiatric crisis in observation cells. 
<li>Limits on the use of observation cells, where prisoners in psychiatric crisis are deprived of most possessions and clothing. 
<li>Limits on punishment of prisoners with mental illness who hurt themselves because of their illness. 
<li>Limits on the use of the punitive 'restricted diet' (a loaf made from bread and cabbage) as a punishment for misconduct by prisoners with serious mental illness. 
<li>Elimination of isolated confinement of prisoners with serious mental illness in cells that have solid steel doors that severely isolate and restrict communication. </ul>The new state budget provides monies to carry out the State's commitments in the settlement agreement. These funds approximate over $50 million in capital construction costs; $2 million for additional OMH staffing for the 2007-2008 year to grow to $9 million when construction is complete; and nearly $2 million for additional DOCS staffing for the 2007-2008 fiscal year.