How the system works \u2014 or doesn\u2019t<\/h2>\n Why did Adam Collier transfer so often?<\/p>\n
Advocates, inmates and family members contend that, in cases like his, a steady stream of transfers reflects a system that too often fails to adequately care for people in mental health crises. These inmates might bounce between prisons and short-term crisis beds without ever stabilizing enough to get better, they say. For some, the simple fact of being in a prison environment might trigger them to lash out against guards or other inmates.<\/p>\n\n
Corrections spokesperson Waters said in a statement that inmates can be transferred for a variety of reasons, including court hearings, medical treatment, mental health treatment, changes in security level, patient safety, staff conflicts, misconduct allegations or parole.<\/p>\n
Six of California\u2019s 34 prisons don\u2019t have mental health programs, she said, \u201cso patients requiring ongoing mental health care would need to be transferred.\u201d\u00a0\u00a0\u00a0<\/p>\n
Clinicians \u201care trained to identify and treat serious mental illness, and tailor care to the individual needs of patients,\u201d Waters stated.<\/p>\n
Mental health care in California\u2019s prisons is provided along a spectrum, designed to transfer inmates as their level of need changes. Treatments range from outpatient therapy in the general inmate population to long-term hospitalization in dedicated treatment facilities within the correctional system.<\/p>\n
At the other end of the spectrum are state hospitals, which are separate facilities that also house people who are not in the criminal justice system.\u00a0<\/p>\n
Suicidal inmates are supposed to be moved quickly to mental health crisis beds, according to\u00a0the state\u2019s mental health program guide.\u00a0The beds are designed for a 10-day stay that can only be extended by medical officials.\u00a0<\/p>\n
But the system doesn\u2019t always work perfectly. Sometimes people who need it aren\u2019t referred to a higher level of care, the Inspector General has determined in several investigations.<\/p>\n
Sometimes referrals come too late.\u00a0<\/p>\n
In 2019, mental health clinicians failed to evaluate acute suicidal risk factors in one inmate after he learned of his mother\u2019s death. They didn\u2019t place him under suicide watch or send him to a mental health crisis bed,\u00a0according to a report from the Inspector General. Soon after, he killed himself.\u00a0<\/p>\n
Adding to these concerns, the state and country face a shortage of mental health providers, which experts say has only worsened during the pandemic.\u00a0<\/p>\n\n
Waters said in an email that the department has robust recruitment and retention programs, which she calls \u201cespecially critical.\u201d\u00a0<\/p>\n
She said the department routinely assesses the number of mental health crisis beds and inpatient beds to make sure it has enough to meet fluctuating needs. \u00a0\u00a0<\/p>\n
But some say a provider and bed shortage means inmates don\u2019t always get the mental health care they need.\u00a0<\/p>\n
\u201cThe idea is, \u2018How soon can we stabilize them and get them out?\u2019\u201d said Keramet Reiter, a criminology professor at the University of California, Irvine.<\/p>\n
When inmates repeatedly get into mental health crises and act out or hurt themselves, correctional officers and even prison clinicians often view those actions as manipulative, Reiter and others said. These inmates can then be deemed more dangerous and moved to higher security facilities where people with mental illness are even more vulnerable.<\/p>\n
Those who are classified as sex offenders, as Collier was due to his indecent exposure charges, have it worst.<\/p>\n
Even if inmates are extremely sick, state hospitals are often wary of admitting those with high security levels or histories of bad behavior, said Jessica Winter, an attorney with the Rosen, Bien, Galvan & Grunfeld.<\/p>\n
Her firm is co-counsel for\u00a0Coleman,\u00a0the federal class-action suit on behalf of inmates with serious mental illness. That case has led to important reforms, she and other advocates say, including more oversight of how California\u2019s prisons treat inmates with mental illness than exists in some other states.<\/p>\n
In theory, transfers can mean the system is working, said Tom Nolan, another attorney at Rosen, Bien, Galvan & Grunfeld.\u00a0<\/p>\n
But in Collier\u2019s case, he said: \u201cIt\u2019s kind of crazy how much he got transferred around.\u201d<\/p>\n
Collier\u2019s start-over plan disintegrates<\/p>\n
Adam Collier\u2019s plan to start over in Santa Cruz was short-lived. It was 2012, and he was 35 years old when he left Oregon for California.<\/p>\n
During his first year and a half in Santa Cruz, he was arrested several times for indecent exposure. Under Jessica\u2019s Law, he was required to register as a sex offender and was barred from living many places. He cycled between homeless shelters, the streets and jail.<\/p>\n
A psychologist who evaluated Collier around that time considered him incompetent to stand trial, saying he was agitated, heard voices, needed medication, and was asking for treatment, according to court records reviewed by CalMatters.\u00a0<\/p>\n
On April 29, 2013, Santa Cruz police picked him up for exposing himself in a public place. Collier took a plea deal and was sentenced to two years in prison.\u00a0<\/p>\n
Collier served time in San Quentin and was released. His mother looked into bringing him back to Oregon to serve his parole, but said her county wouldn\u2019t allow it. She couldn\u2019t afford the move to California, though she said she contemplated coming anyway and living in her car.\u00a0<\/p>\n
Within weeks, he was arrested again in Monterey and sent to jail.\u00a0<\/p>\n
The next year, the cycle repeated. But this time, he was sentenced to five years in prison.\u00a0<\/p>\n
That\u2019s when Susan Ottele started tracking her son\u2019s movements.<\/p>\n
On March 12, 2016, according to her notes, Adam Collier arrived at North Kern State Prison.\u00a0<\/p>\n
His first transfer, to California Medical Facility in Vacaville, took place a month later.\u00a0<\/p>\n
His second, back to North Kern, was the month after that.<\/p>\n
Reiter of UC Irvine calls what happened to Collier \u2014 bouncing between crisis units and state hospitals and seven different prisons\u2014 \u201ca very sad and very unsurprising story.\u201d\u00a0<\/p>\n
There\u2019s even a term for it, she said: \u201cDiesel therapy\u201d refers to moving challenging inmates around to keep them from wearing out staff in any given facility.\u00a0<\/p>\n
\u201cIt absolutely happens often,\u201d she said.\u00a0<\/p>\n
In a February 2017 letter to his mother, Adam Collier said he believed he was sometimes moved as punishment for his behavior.<\/p>\n
Collier did lash out at prison staff, sometimes dangerously.\u00a0 CalMatters\u2019 review of nearly 600 pages of his prison medical records from 2020, shared by his mother, shows he was written up multiple times for spitting, fighting and battery against prison staff.\u00a0<\/p>\n
At one point, he was moved to segregated housing after attacking several prison guards.\u00a0<\/p>\n
\u201cYou are deemed a threat to the safety and security of this institution, its staff and inmates,\u201d\u00a0wrote the prison lieutenant who authorized that move.\u00a0<\/p>\n
Such circumstances can be taxing for all involved.<\/p>\n
\u201cStaff work in the same conditions that incarcerated people live in,\u201d said Margot Mendelson of the Prison Law Office. \u201cReally toxic environments are toxic for everyone.\u201d<\/p>\nInmates describe multiple transfers<\/h2>\n For a year, CalMatters monitored the statistical evidence of thousands of people being shuffled around the prison system. Without state data, as CalMatters requested, the full extent of these relocations over time is unknown.<\/p>\n
Several inmates who moved at least five times in the last year told CalMatters the constant transfers prevented them from establishing relationships with therapists. With every transfer, they said, they often lost their few possessions. They were shocked that someone outside the system even noticed.<\/p>\n
\u201cIt makes my mental health worse,\u201d said Steven Saucedo, 48, who has transferred at least eight times since last June, including relocations to attend court, CalMatters data shows. \u201cYou\u2019re always on the move.\u201d<\/p>\n
Cedrick Johnson, 61, said he didn\u2019t start moving until he was diagnosed with schizophrenia a few decades ago. He\u2019s been incarcerated since the 1980s.\u00a0<\/p>\n
\u201c(Transfers) are a great problem,\u201d he said, sighing. \u201cWe talk to different doctors all the time. \u2026 It doesn\u2019t make you better at all.\u201d<\/p>\n
Johnson said he has transferred at least seven or eight times since last June; CalMatters has documented eight moves to five facilities in less than a year.<\/p>\n
Randall Shrout, an Amador County public defender who represented Collier in a 2018 case, said frequent transfers are common among his clients, many of whom come through Mule Creek State Prison in Ione.<\/p>\n
\u201cYou\u2019ve got Adam\u2019s name, and there are hundreds of others,\u201d he said. \u201cI can go through 10 years of records and find you mental health cases where they bounced them all over the state.\u201d\u00a0<\/p>\n
Jennifer Hoff, whose 29-year-old son has suffered from serious mental illness since he was a young child, said he has been in at least nine different prisons, and has transferred numerous times in the past decade.\u00a0<\/p>\n
\u201cIt\u2019s meant to grind you to dust,\u201d she said.\u00a0<\/p>\n
Her son, Matthew, has schizophrenia. He was charged with terrorism in 2012 at age 19, his mother said, after he walked, unarmed and off his medication, into a bank and passed a sticky note to the teller threatening to blow himself up if they didn\u2019t give him $1,000.<\/p>\n
In prison, he has repeatedly harmed himself, including carving up his face with a needle, she said. Some years he has been transferred between facilities nearly a dozen times, she said. Each time requires him \u2014 and his family \u2014 to start over with new staff and new routines.\u00a0<\/p>\n
\u201cYou can\u2019t possibly keep up with the transfers,\u201d she said. \u201cHow engaged can you possibly be in a system that\u2019s meant to make you go away completely?\u201d<\/p>\n\u2018I guess this is my lot\u2019<\/h2>\n Every day for four years, Susan Ottele would log onto her computer to check on her son\u2019s whereabouts.<\/p>\n
She kept a list of the various prisons\u2019 phone numbers. Every time he moved, she called all the numbers on the new facility\u2019s phone tree until she knew how to reach someone if something went wrong.\u00a0<\/p>\n
Something always went wrong.<\/p>\n
She felt a growing sense of helplessness.\u00a0\u00a0<\/p>\n
\u201cIt\u2019s like being strapped to a chair watching your child being tortured,\u201d she said. \u201cOnce you get in the prison system, there isn\u2019t much you can do.\u201d<\/p>\n
Collier wrote to his mother, often complaining about back pain that drove him to tears.\u00a0\u00a0<\/p>\n
\u201cI guess this is my lot,\u201d he wrote from North Kern State Prison in May 2016. \u201cSee why heroin and vodka seems appealing?\u201d<\/p>\n
At times, he sprinkled in words of reassurance, along with updates on his sobriety:<\/p>\n
\u201cPlease don\u2019t worry about me.\u201d \u201cI\u2019m not suicidal.\u201d<\/p>\n
Trying to get him help, Susan Ottele penned certified letters in loopy cursive begging prison wardens to give her son Tylenol and heating pads.\u00a0<\/p>\n
\u201cAdam\u2019s pain management is crucial to his mental + physical health,\u201d she wrote. \u201cAllowing him to suffer needlessly is neglectful and a form of torture to say the least.\u201d<\/p>\n
In February 2017, Adam Collier attempted suicide again. He was sent to California Health Care Facility, Stockton and then to Atascadero State Hospital for three months. He did well there, his mother said, but was returned to Valley State Prison in Chowchilla in late June. From there, things unraveled.\u00a0<\/p>\n
With a parole hearing approaching, he told his mother he was afraid of being sent back out to live on the streets. He slapped a prison guard.\u00a0<\/p>\n
He was transferred again. And again. And again.<\/p>\n
The following year, in January 2018, he was accused of threatening and kicking a prison guard at Mule Creek State Prison, and was ordered into solitary confinement.<\/p>\n
In an appeal, Collier wrote that multiple guards had handcuffed him and beaten him until he was unconscious. Susan Ottele wrote to the warden, who replied that the staff\u2019s actions were in compliance with the department\u2019s use of force policy.<\/p>\n
Oversight weak, documentation \u2018lax\u2019<\/h2>\n Susan Ottele filed several complaints with the independent Office of the Inspector General about Collier\u2019s medical care at Mule Creek and the alleged use of force.<\/p>\n
The oversight body is known for scathing public reports about prison misconduct. That\u2019s about all it can do. In 2011,\u00a0lawmakers stripped the office of its authority\u00a0to investigate prison employee misconduct, effectively leaving the Department of Corrections and Rehabilitation to police itself. Last year,\u00a0legislative staff recommended\u00a0the inspector general\u2019s authority be reinstated. It wasn\u2019t.<\/p>\n
CalMatters analyzed 372 critical incident case summaries from the office since 2018. Of 67 inmate suicides reviewed by the inspector general, 81% percent were determined to be \u201cpoorly\u201d handled by the state. Among those suicides, CalMatters identified 38 where the office dinged state mental health professionals for not referring inmates to a higher level of care, keeping lax documentation or returning people to their housing units despite increased mental health symptoms, among other things.<\/p>\n
Over the years, Adam Collier\u2019s letters were often punctuated with allegations of brutality and victimization: a cellmate he said knocked him unconscious, prison guards sodomizing him with a baton. His medical records, meanwhile, describe him acting out against guards, spitting at them or hitting them with his cane.<\/p>\n
For a while, he went on a hunger strike.<\/p>\n
During his time in prison, Collier was prescribed at least 19 different psychiatric medications. He would take them for a while, his mother said, then stop due to the side effects.\u00a0<\/p>\n
By 2019, he began sending her long screeds praying for plagues to rain down on the United States, along with lists of elaborate burial wishes: the broken screws in his back should be removed upon his cremation and placed in the parking lot of the Oregon State Hospital; his ashes should be scattered in Santa Cruz Harbor at 4:30 a.m.\u00a0<\/p>\n
His medical records describe him cutting himself in order to \u201cburn my blood for my God.\u201d The records also mention him asking for more consistent mental health treatment.<\/p>\n
That July, he again attempted to kill himself. A month later, he tried to castrate himself. He begged his mother to help him get mental health care.\u00a0<\/p>\n
\u201cI believe good ol\u2019 \u2018Job\u2019 did his best,\u201d he wrote in one letter, referring to the Biblical character who is tormented to test his faith in God. \u201cPatience hath an end.\u201d<\/p>\n
\u201cFeed kitties treats 4 me,\u201d he added.<\/p>\nCOVID-19 slips into the prisons<\/h2>\n On March 11, 2020, according to his mother\u2019s notes, Adam Collier transferred one last time.\u00a0<\/p>\n
Kern Valley State Prison, a maximum-security facility 40 miles northwest of Bakersfield, is one of six prisons named in a motion in\u00a0a federal class action lawsuit\u00a0alleging correctional officer abuse of people with disabilities. In a\u00a02020 report to the Legislature, it was listed as having among the highest annual average suicides, due to being a high security facility that houses and treats inmates with severe and chronic mental health and behavior problems.<\/p>\n
Inmates there, said Margot Mendelson, of the Prison Law Office, \u201clive in terror.\u201d\u00a0<\/p>\n
Around the time of Collier\u2019s arrival, the country\u2019s first COVID cases were popping up in Northern California. Soon, with prisons buckling under massive outbreaks, Gov. Gavin Newsom issued an executive order temporarily halting transfers.\u00a0<\/p>\n
Collier hated it at Kern Valley. During those first months of the pandemic, he described to his mother how isolated and depressed he felt, too terrified of prison guards and other inmates to leave his cell.\u00a0<\/p>\n
On one piece of lined paper, he scrawled a single sentence: \u201cI loosing it mom.\u201d<\/p>\n
He was 43 years old then, and walking with a cane. His body was etched with scars from various attempts to kill himself.<\/p>\n
On May 22, 2020, he tried again.<\/p>\n
A week later, he told the psychologist who interviewed him that he had done so because he was high on meth and afraid of retribution for an unpaid drug debt, his medical records show. He asked to be sent to a state hospital or into solitary confinement for his own protection until he was eligible for parole the next January. The psychologist noted a history of \u201cexaggerated, staged behaviors to manipulate CDCR staff to promptly respond\u201d \u00a0and that she deemed \u201cintentional to drive\/control the responses of others.\u201d She also noted an increased risk of future self-harming events.<\/p>\n
\u201c\u2026if you send me back, I\u2019ll just keep doing this stuff,\u201d the psychologist\u2019s notes quoted Collier as saying. \u201cI don\u2019t want to die. I want to parole and never come back to prison. I want a cat, a surf board, a truck, a life, and now that Vegas is back open, strippers and to see my mom and dad.\u201d<\/p>\n\n<\/div>\n<\/aside>\n
Friends who spoke to him during that time detected something wrong.<\/p>\n
\u201cWhen I first met him, he was just this bright shining light, and it was barely a dull lightbulb by the end,\u201d said his former girlfriend, Rhapsodee Murray.\u00a0<\/p>\n
In July 2020, Collier wrote a letter to his mother describing a tiny cricket that wandered into his prison cell. He named it Jiminy, and talked about feeding it crumbs of graham crackers and pretzels. He liked to balance it in his hand and watch it sing.\u00a0<\/p>\n
\u201cOut of 100 cells,\u201d he marveled, \u201che chose mine.\u201d<\/p>\n
He was desperate, he told his mother, for a hug.<\/p>\n
Susan Ottele says she called the prison 13 times that year, begging for help.<\/p>\n
She and her son both held out hope that he would get transferred to a state hospital soon.<\/p>\n
But Collier did\u00a0not meet the \u201cemergency transfer criteria\u201d\u00a0in place during COVID-19, according to a report on his suicide by a court-appointed expert. Instead, he stayed in his cell, getting sicker.\u00a0<\/p>\n
In October 2020,\u00a0he refused 22 group treatment\u00a0sessions, the report stated.<\/p>\n
\u201cYou\u2019re like my 30th clinician this term; love the continuity of care in CDCR,\u201d Collier reportedly told one therapist.<\/p>\n
On October 17, 2020, Collier was given breakfast in his cell, according to the federal lawsuit filed by his parents. He didn\u2019t show up for lunch. Despite his documented history of self-injury and suicide attempts, no one checked on him for eight or nine hours, the complaint said.<\/p>\n
At 3:32 p.m., a prison guard found his body.<\/p>\n
An hour later, the phone rang inside Susan Ottele\u2019s home.<\/p>\n
The dreaded phone call<\/h2>\n On a rainy day this spring, Susan Ottele sat in the living room of her neat beige and white prefabricated home in McMinnville, Oregon. The property is dotted with dogwood, fir, oak, maple and cedar. A series of bird feeders is visible out the back window.\u00a0\u00a0<\/p>\n
A year and a half has gone by since she answered the phone, then collapsed to the ground, screaming.<\/p>\n
Two weeks after her son\u2019s death, Susan Ottele climbed into her 20-year-old GMC and drove 15 hours to Bakersfield to view his body and begin her search for answers to an unbearable question: Why did he die?\u00a0<\/p>\n
She has accumulated a collection of clues that, to her, point to institutional indifference: the fat metal spinal screws that were returned to her, snapped in half, after her son\u2019s body was cremated. A binder full of his letters and her scrupulous documentation.\u00a0<\/p>\n
\u201cHe was crying out in pain,\u201d she said. \u201cThe louder he got, the less they heard.\u201d<\/p>\n
His ashes sit on the dining room table in a blue velvet box, waiting to be scattered in the Santa Cruz Harbor. She keeps a collage of photos from his memorial service in the living room; as long as they\u2019re up, she feels like he\u2019s still with her.<\/p>\n
Other people have also tried to unravel any missteps that might have contributed to Collier\u2019s death.<\/p>\n
In its review of his suicide, the Office of the Inspector General found that the prison department \u201c\u2026.failed to adequately document self harm incidents, failed to provide proper risk ratings, and failed to follow procedure for referral to a mental health crisis bed.\u201d\u00a0<\/p>\n
A Special Master appointed by\u00a0the court to investigate inmate suicides under\u00a0Coleman\u00a0found that providers had underestimated Collier\u2019s mental illness and failed to look at his case as a whole \u201cwhich should have created a sense of urgency as he spiraled into hopelessness and psychosis.\u201d Collier\u2019s death, the expert\u2019s report said, might have been preventable had he \u201creceived an appropriate level of care and adequate treatment.\u201d<\/p>\n
Six months after Adam died, a box was delivered to Susan Ottele\u2019s front door.<\/p>\n
Inside was almost everything her son left behind. Stained sweatpants. Long johns. Holey socks. A plastic bottle of instant Folgers coffee. The white plastic cup he drank it from. A bottle of cinnamon. Another of garlic salt.\u00a0 A volume of inspirational sayings that she had sent to him, along with a dictionary, an explainer on bipolar disorder and a biography of Gandhi. The two final letters he\u2019d written, the one to her still in a sealed envelope.<\/p>\n
Also in the box: a piece\u00a0of the instrument he\u2019d used to take his life.<\/p>\n
If you or someone you know is having thoughts of suicide, there is help available.\u00a0<\/span><\/em><\/p>\nCall the National Suicide Prevention Lifeline 1-800-273-8255 (TALK) for resources and support. Free, confidential, available 24\/7.<\/span><\/em><\/p>\nText \u201cHOME\u201d to the Crisis Text Line\u2014741-741\u2014to reach a trained crisis counselor. Free, confidential, available 24\/7.<\/span><\/em><\/p>\nFor more information and resources, visit:\u00a0SpeakingOfSuicide.com\/resources<\/span><\/em><\/p>\n<\/div>\n[ad_2]Source link <\/a><\/p>\n","protected":false},"excerpt":{"rendered":"[ad_1] On the last day of Adam Collier\u2019s life, he had breakfast in his cell…<\/p>\n","protected":false},"author":1,"featured_media":32498,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[24],"tags":[],"class_list":["post-32497","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-theory"],"_links":{"self":[{"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/posts\/32497","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/comments?post=32497"}],"version-history":[{"count":1,"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/posts\/32497\/revisions"}],"predecessor-version":[{"id":32499,"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/posts\/32497\/revisions\/32499"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/media\/32498"}],"wp:attachment":[{"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/media?parent=32497"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/categories?post=32497"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/cjstudents.com\/index.php\/wp-json\/wp\/v2\/tags?post=32497"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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