Wednesday, December 13, 2006

Building mental health prisons without economic, geographic or sociological considerations prevent addressing of inmate mental health issues- John Bry

One problem that was properly identified by public health workers is the need for mental health facilities for prison inmates to help with their rehabilitation to potentially become a well adjusted, useful member of society. In California, it was decided that new facilities that could house the inmates in the most need of help would be built and staffed to better address their needs.

The facility built was the Coalinga State Hospital in the middle of the central valley, about 70 miles southwest of Fresno and hours from either San Francisco or Los Angeles. The hospital was built to house 1500 patients and included a gym for inmates and a common area with a restaurant for the 550 mental health professionals that would be needed for staffing, and all of this was built for $400 million of public money (1).

The facility was billed as the perfect solution to overcrowding of smaller, older facilities located throughout the state that used to perform the same functions. However, one year after opening, there are currently fewer than 400 patients in the facility, each costing between $100,000 and $150,000 a year, compared to $37,000 for a regular inmate, with a comparably small staff. In addition, a large number of the mental health inmates are refusing treatment all together; many have already completed prison sentences, but were deemed unsafe and sent for rehabilitation (1). These problems could have been foreseen even before groundbreaking of the facility and should have been thought of at the start of the planning. The public health practitioners who came up with this course of action to treat the problem were not thinking about how geographic location might affect staffing levels, not considering how salaries for public health employees is below what private workers make, and not considering how basic sociological factors might predispose inmates from not wanting treatment.

Geographic location is the easiest problem to see and understand since the further a facility is from a populated area, the harder it will be to attract the needed number of employees. The facility is located in a very remote area. It seems ideal for the inmate situation since it is centrally located between northern and southern California, so inmates from all over the state wouldn’t have to be transported very far from their original prison, and it is located near an already crowded state prison. Another positive aspect is location’s distance from populated areas eliminating the public fear of having inmates near by. It is obvious that these were the main concerns of the planning board, although it seems that getting inmates to the facility should be the last concern. If an inmate can be transported 200 miles, they can just as easily be moved 500 miles or more. What is much more difficult is moving mental health professionals, since they are going on their own free will.

Maslow’s hierarchy of need can be used to see how location would affect staffing levels. Maslow’s third level of need includes that love/ belonging to a family or group of friends are both needed to sustain a happy, healthy person. Consider the situation in which mental health professionals from the two biggest metropolitan areas, San Francisco and Los Angeles (also the closest), decided to work at the hospital. They would have one-way commutes of 190 and 203 miles, respectively. In a typical work day they would spend an average of about 5 to 6 hours going to work. If a practitioner lived in nearby Fresno, the commute would be roughly two hours. This length of a day means that little time will be left for the worker to spend with family and friends. The love and belonging they need will be absent, or have to be gained only when on an extended break from work. Maslow’s theory predicts that many of the workers will not be very happy which may lead to them either doing a poor job counseling the inmates, or quitting the job. Had the hospital been in a more reasonable location where the professionals would have a reasonable commute, the staffing levels might not be in the crisis they are today.

The second factor that should go into planning a prison mental health facility is the amount professionals would have to be paid to stay on staff. This can be regarded either in conjunction, or not with the geographic location. Obviously when a professional has to travel large distances, a higher salary is needed to retain them as full-time employees, but for this paper, I will only be considering salary independent of location of facility. The average psychiatrist in the United States makes between $170,000 and $190,000 (2). When the prison hospital in Coalinga opened, they listed their average salary at about $150,000for a full time psychiatrist. This discrepancy is something that would be a clear deterrent for mental health professionals. Why work for a public agency that pays lower than if you went into a private field? The only people who would be willing to take a lower paying job would be the professionals who truly wanted to help the inmates, but from the lack of staff at Coalinga, it is clear that these types of people are very rare.

Maslow’s second level of need, safety, can be used to understand the reluctance of mental health professionals to take on the lower paying job. Safeties of body, employment and of the family from a person’s worries are all needed. Working with inmates poses an obvious physical risk to a staff member, but there is also the residual risk that the threats could trickle back to the family. If a public health agency looking to staff the mental health hospital wanted to lure professionals from private practice to work with dangerous patients, the salary would have to be at least commensurate with what the professional was previously making.
The administrators of the hospital in Coalinga are starting to see the errors of their ways with respect to both of these first two problems. Since the hospital has already been built, moving its location is not an option and abandoning it would be a huge waste of money. Administrators are considering using small aircraft from LA and SF to make commute times smaller and also admitting that the base salary level will have to be raised to at least $200,000 (1) and possibly as high as $300,000 (3) according to some experts. These two options may alleviate the problems being faced for staffing levels, but had they planned these beforehand, could have been avoided completely.

However, another pressing matter remains: how to get inmates to accept treatment at all, assuming there are enough professionals for every inmate. These patients have committed crimes and have become social outcasts of the state. This can give prisoners a false mindset that they are second-rate and not worth the hassle (4). Now that the state wants to help them, the inmates have low self image and a low perceived efficacy of the treatments. This goes hand in hand with the labelist theory towards certain groups of people (4).

Labelist theory postulates that inmates have a perceived image of themselves and how they should act and what they are worth. This self-image is the major roadblock to willingness of treatment. The inmates don’t see a point to treatment since even if they were deemed cured and fit for society they would still be considered prisoners and outcasts. This deals with a more fundamental problem with the prison system in general rather than just with this hospital facility. It is easy for society to make generalizations about inmates and label them as “bad”, but it is much more difficult to change these generalizations since the change needs to start with the population as a whole. If there is no longer a negative social image of inmates, but rather as people who have made a mistake, repented, and are ready to come back and make positive contributions to society, then maybe inmates wouldn’t have such low expectations and be willing to accept mental health treatment. To my knowledge this problem has not been addressed the literature because it is not an obvious issue. Administrators and public health officials need to more deeply research this issue with former inmates and psychiatrists in order to address the problem of self perception and self efficacy.

I have discussed three things that were not considered by the officials of California when deciding on the best solution to crowded mental health facilities. In the future, whenever public facilities are being planned, if for prison use, or any other need, geographic and economic considerations are highly visible aspects that must be properly worked out, and a less obvious, but equally as important issue of the groups intended to use the facilities.

1. Sterngold, James. "Costly Hospital Sits Nearly Empty." SFGate.Com. 18 Sept. 2006. 3 Oct. 2006 .

2. "Average Psychiatrist Salary." Salary.Com. 3 Oct. 2006 .

3. "Prison Health Worker Pay Increases Recommended." CaliforniaHealthline.Org. 13 Sept. 2006. 3 Oct. 2006 .

4. Greek, Cecil E. "Howard Becker's Labeling Theory." Criminology. Florida State University. 3 Oct. 2006 .

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