State of Mind

This Is What Mental Health Care Looks Like in Prison

A federal judge ruled mental health care for incarcerated Arizonans is so bad it amounts to cruel and unusual punishment.

A hand holding pepper spray against a blue backdrop.
Photo illustration by Slate. Photo by Getty Image Plus.

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Shortly before her death, Tracie Otero, who was incarcerated in Arizona, met with a psych associate. The visit lasted three minutes. The unlicensed associate determined Otero—who was enduring extreme pain due to fibromyalgia, and had previously been assessed as suicidal and suffering from anxiety—was not a danger to herself or others.

A week later, Otero, 47, died by suicide.

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On Jan. 14, 2021, Austin Georgatos underwent a five-minute mental health assessment after he was transferred from jail to an Arizona prison. The assessment found that he was not receiving his prescribed medication for anxiety and depression but concluded he had “no emergent [mental health] issues.” On Jan. 25, he submitted a heath needs request to Arizona prison officials, writing “I need to see psych doctor about the voices I am hearing in my head. They returned since I stopped taking medications.” Georgatos was not seen by health care staff.

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Three days later, Georgatos, 20, died by suicide.

On April 7, 2021, Jason Rothlisberger reported he was depressed, anxious, and worried he would hurt himself and others. He hadn’t slept for days, he said, and had “placed a rope around his neck to get the attention of staff due to fear for his life.” His sister called the prison, concerned he would end his life. He was put on suicide watch. “At some point between April 12 and April 15, Rothlisberger was discharged from crisis watch,” court records note, “and there was no record this occurred or why.”

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On April 15, 2021, Rothlisberger, 45, died by suicide.

Otero, Georgatos, and Rothlisberger are just three of the 23 people who died by suicide in Arizona prisons between 2019 and September 2021, according to a class action lawsuit against the Arizona Department of Corrections, Rehabilitation, and Reentry. The lawsuit was initially filed in 2012 and has “outlasted judges, named plaintiffs and prison administrators,” the Arizona Republic notes. It argues that the state prison system’s inadequate medical, dental, and mental health care and overreliance on “isolation units” (solitary confinement) amount to cruel and unusual punishment under the Eighth Amendment.

In 2015, the parties reached a settlement, which required the state prison system to comply with a lengthy list of performance measures—but there is little evidence anything has improved. Between 2016 and 2021, the state prison system was held twice in contempt of court and fined, literally, millions of dollars. Finally, in July 2021, federal judge Roslyn Silver vacated the settlement. In November of that year, she held a three-week trial, which led her to conclude “the conditions are now the same, or worse, than the conditions present at the outset of this litigation.”

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In a searing 200-page ruling published June 30, Silver wrote that the case boiled down to two questions: “Are Defendants violating the constitutional rights of Arizona’s prisoners through the existing medical and mental health care system? And are Defendants violating the constitutional rights of a subset of Arizona’s prisoners by almost round-the-clock confinement in their cells?”

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The answer to both questions, she wrote, is yes.

When the lawsuit was filed in 2012, the Arizona corrections system directly provided mental and medical health care in its facilities. But a few months later, thanks to a state law that privatized prison health care, the reins were handed over to Wexford Health Services. Less than a year after that, Corizon Health Incorporated took over. Finally, in July 2019, Centurion of Arizona won a $216 million annual contract to provide healthcare in ADCRR’s 10 complexes, which as of September 2021 held more than 27,000 people.

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About a quarter of those people, according to court records, receive medication for mental health conditions. In prisons, the Arizona case makes clear, insufficient medical care worsens the mental health crisis, and insufficient mental health care is its own medical crisis.

And while the mental health treatment incarcerated individuals receive in Arizona is horrific, it is unfortunately not unique. People with mental illness are overrepresented in America’s jails and prisons—around two in five incarcerated people have a history of mental illness, which is twice the rate of the overall population, according to the National Alliance on Mental Illness. People with mental illness are much more likely to be victims than perpetrators of crime, but they are often caught in the justice system thanks to systemic factors that make it difficult to access community resources and adequate legal representation.

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Once in prison, 63 percent of people with a history of mental illness do not receive mental health treatment, according to the National Alliance on Mental Illness, and more than 50 percent discontinue medication.

Evidence suggests that the privatization of carceral health care often worsens this crisis.

In Arizona, one of the key barriers to providing care to the more than 8,500 individuals that require “ongoing treatment for an active mental health diagnosis” is a dire lack of staff.

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“As of August 2021, only 149.55 mental health care staff were hired in contrast with 199.00 required under the contract with Centurion, reflecting only 75% of positions are filled,” wrote Silver. “Defendants have structured the system to have the vast majority of care provided by lower-level individuals. Thus, the majority of individuals providing mental health care are behavioral health technicians, nurses, or psychological associates.” Centurion’s staffing allocation—even if it were fulfilled—calls for only seven psychiatrists across all 10 prison complexes, with only two of them working on site.

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The reliance on psychological associates and other low- and midlevel staff was part of what one expert witness identified as a “disturbing pattern” of “mental health staff without pharmacological training serv[ing] as de facto gatekeepers of patients’ access to psychiatric prescribers.” According to a Centurion job listing, psych associates need a master’s in psychology, social work, counseling, or a related field. Two years of “experience with direct care for individuals with mental illness” is “preferred.” While the job listing requires associates have a mental health professional license in Arizona, court documents show that 14 out of 59 associates in Arizona prisons were unlicensed.

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Staffing shortages also led to what the court called “drive-by mental health encounters”—in which staff assess patients in intervals of two to five minutes. In one mind-boggling section of testimony, defense expert Joseph Penn, a psychiatrist and professor, claimed that a one-minute encounter could “certainly” be sufficient to determine if someone was at risk for self-harm or suicide (“if the mental health staff member knows the inmate, has reviewed the chart, has spoken to staff, and is a qualified mental health professional,” he said).

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The list of other issues is lengthy. Psychiatric medications are not distributed at regular intervals. Incarcerated people who need to be transferred to in-patient facilities aren’t, and even those who are don’t get the care they need. Individuals in isolation are offered “cell-front encounters” with mental health staff that are neither private nor confidential—and if they do request a private session, they are strip searched, restrained, and placed in the “treatment cage.” Non-English speakers and people who are deaf and hard of hearing don’t receive sufficient interpretation. In one case, lacking interpretation, a psych associate assessed a deaf patient on suicide watch via writing (patient’s answers in bold):

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Homicidal? Kill Others? No

Hallucination No

Eating ok ok

Sleeping ok ok

Feeling anxious no

Depressed no

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The consequences of the lack of qualified mental health staff are alarming. In her ruling, Silver cited an email between ADCRR employees on Feb. 12, 2020 to discuss the case of a mental health patient who had been self-harming by banging his head. The email described how staff used pepper spray against the patient:

In an email sent today the Regional Director of Mental Health basically said to continue using OC spray as needed while the on site mental health team comes up with a treatment plan. … This inmate now has wounds on the back of his head and on his forehead from the head banging. There are staples holding the wound edges together on the back of his head but the forehead wound remains open as the two previous attempts to staple his frontal wound have failed because of the continuous head banging.

We just received a copy of an I/R [incident report] completed by security staff from last evening indicating that the mental health RN was encouraging the inmate to bang his head so that the restraint chair could be used. At the time of this nurse/patient encounter, the patient was NOT participating in head banging but began banging his head after the nurse told him to do so … . which resulted in a Use of Force event. This entire event was captured on video. …

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The psychiatrist tasked with treating this patient, the email explains, would be out of office for the next 12 days. Administrators “did not know” if there was another psychiatrist who could see the patient.

This example was not exceptional. Another patient, diagnosed with schizophrenia and schizoaffective disorder and who was repeatedly placed on suicide watch, “had chemical agents used against him on July 5, 2021 (twice), July 7, 2021, July 8, 2021, July 9, 2021, July 12, 2021, and July 13, 2021 (twice).” (“Chemical agents” refers to things like pepper spray.)

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And chemical agents are only one of the weapons undertrained and overstretched staff use against incarcerated people. One patient examined by plaintiff’s expert Pablo Stewart, a psychiatrist and professor, was marked with “bruises on the left side of his torso where custody staff had fired a paint ball gun at him during a psychotic episode.”

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For now, the future of mental health care in Arizona prisons is unclear. As the Marshall Project’s Beth Schwartzapfel and the Arizona Republic’s Jimmy Jenkins wrote in October, right before the trial began, the recent decision “could spell the end of privatized care in Arizona prisons—or, in a more extreme outcome, the end of Arizona’s control over its prison health care entirely.” Silver could decide to appoint an outside official to oversee the prison health care system under a model known as receivership, which was implemented with some success in California in 2005, Jenkins reported in the Arizona Republic.

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This may be the only hope for improving health care in Arizona prisons. ADCRR, after all, seems to have learned little over the past 10 years of litigation.

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What is abundantly clear is that the death and suffering outlined so excruciatingly in this lawsuit were preventable. Arizona prisons just didn’t care enough to prevent them.

In 2016, plaintiff’s expert Craig Haney, a professor specialized in psychology and law, visited a 17-year-old girl who had spent more than two months in solitary confinement. Alarmed, Haney requested defense counsel be notified she was at “serious risk of self-harm.” Soon after, the girl turned 18 and was transferred to a different maximum custody unit.

A few weeks later, she died by suicide.

​​If you need to talk, or if you or someone you know is experiencing suicidal thoughts, text the Crisis Text Line at 741-741 or call or text 988 to reach the Suicide & Crisis Lifeline.

State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.

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