Broken Regimens

One man’s story shows how mental health treatment is an uphill battle in jails and prisons

by Kelsey Hamlin

[This post was originally published with Real Change News.]

It was October 2015. Michael Hayes and two social workers met his lawyer at King County’s drug court. Everything was white: the walls, the marble floor, the ceiling. They waited for the court’s doors to open. Others slowly trickled in for their own appearances and held some small talk. Eventually, the small talk thinned out. So did the air. The weight of collective anticipation made the hallway feel like it wasn’t holding enough oxygen.

Hayes arrived at drug court that day to turn himself in for a probation violation. He had relapsed into using drugs again, got mugged while out on the streets and was in Harborview for his injuries.

Waiting for the drug court, Hayes and his social workers felt prepared. They hoped to arrange Hayes’ sentencing in tandem with the drug court’s recovery program.

Michael Hayes (right) goes over plans with previous PPEP worker Michelle Conley as he waits for drug court, his Harborview medication sitting between them. [Photo: Kelsey Hamlin]
There had been weeks of anxiety and anticipation for this day. Would the court help Hayes transition to the outside world through its clean-and-sober housing, check-ins and weekly classes?

The drug court’s doors opened. Except things didn’t go as planned.

The judge, Cheryl Carey, told Hayes he had to be put in holding because he wasn’t eligible for drug court. Hayes had a previous voyeurism charge — having stolen money from a woman who was naked — which disqualified him from the program. Hayes was handcuffed and taken from the room after relaying the details of his Harborview prescriptions to the escorting officers.

Hayes, after diagnosis, realized he has been living with post-traumatic stress disorder and schizoaffective disorder for 30 years. Before he understood his mental illness, Hayes began using drugs to alleviate his symptoms at the age of 13. Going in and out of Washington’s incarceration system makes them that much more difficult to treat. His struggle to stabilize his mental state while in the system is just one of many.

Hayes’ jail medical records, obtained with consent, paint a picture of unmedicated struggles within a jail system that’s overworked. A place that is often viewed as rehabilitative is in fact not.

Drug court was Hayes’ chance to get the help he needed. But he was nevertheless sent back to jail, where his mental illness could easily go unaddressed.

He is in his 40s and has cycled in-and-out of juvies, jails and prisons since he was 13.

“You would think there’s a mental health problem if you have 24 felonies and 42 misdemeanors,” Hayes said. “Don’t you think there’s a mental health problem there?”

Hayes holds a nonviolent criminal record that spans four decades and covers four states. Records show that Hayes has been convicted a total of 66 times, with another 13 charges for which he was not convicted.

Retired physician William Watts puts his hand on Michael Hayes’ back after Michael was told he wouldn’t be accepted into King County’s drug court. [Photo: Kelsey Hamlin]
When Hayes is properly medicated, he is coherent, charismatic and calm.

Standing before a judge, Hayes waited respectfully, hands crossed. Earlier that month, sitting on a bed in Harborview’s psychiatric ward, a woman yelled and sobbed, breaking down in the hallway, but Hayes held a highly emotional conversation, recounting traumas. When a loud and abrupt voice emitted from a speaker without warning, Hayes remained calm, despite how much anxiety it gave him.

Hayes typically uses drugs to self-medicate. He said this happens when he doesn’t have access to the prescribed medication he needs, like when he is in prison and jail, Hayes said. This really balloons into a problem when he’s released with a very limited supply of his prescription, typically enough for three days.

Without money to buy medication, without a stable environment, without someone watching over him, it is incredibly difficult for Hayes to stay on his prescriptions. As soon as he’s off, his illnesses kick in and he thinks everyone is out to get him. It scares people — though no one more than Hayes.

Michael Hayes reconvenes with those he arrived to the drug court with before being escorted to a holding cell. [Photo: Kelsey Hamlin]

Health care on the inside

Mentally ill people in Washington’s jails or prisons struggle with prescription adherence. It takes days to register and verify medical information from outside facilities (like hospitals) or from officials (like psychiatrists). It becomes harder still because the list of approved medications can vary from prison to prison, jail to jail, said Mike Stanfill, a psychiatric and social services director for Jail Health Services (JHS), a branch of Public Health for King County correctional facilities in Seattle and the Regional Justice Center in Kent. These organizations are responsible for inmates’ medical, dental and psychiatric needs.

The 14th Amendment’s Due Process Clause requires states to take responsibility for inmate medical care. But patients are often left on their own to make sure their needs are met.

The check-in process with JHS largely relies on self-reporting. Generally, if new inmates say they have a medical or psychiatric issue, JHS checks up on it. But if an inmate doesn’t report an issue, JHS can’t really verify what wasn’t self-reported, Stanfill said.

The day after Hayes was booked into the King County Jail on Jan. 23, 2015, he had standard evaluations done. This includes checking blood pressure, pulse, temperature, respiration and oxygen levels.

Hayes reported having no medical, drug, alcohol or dental problems, according to JHS records. He was incarcerated for a parole violation, different from the one he was in the drug court for later in October 2015. Records show Hayes self-reported only that he attempted suicide in the past.

Nurses do standard evaluations regularly. Stanfill noted that if patients present with issues on examination, this could be a cause for JHS to inquire further or prescribe medication. But it’s all “on a case-by-case basis.”

“I don’t know that there’s any other mechanism for getting medical attention in the jail if you don’t ask for it and you’re not a previously known,” said Dr. Becky Bay, a physician and consultant who previously worked as a general doctor in jails, including King County’s, for 14 years.

Stanfill explained that JHS staff handles hundreds of bookings a day, and thousands of already-booked patients to see, which makes the staff limited.

Seven days, no meds

There are instances within the jail system where people aren’t given the medication they need. That in and of itself is concerning — it can alter lives — but it’s not so simple. The communities in jail and the world outside function differently in terms of drug traffic. The jail has to take that into account when it determines what to supply.

Asking JHS to buy up and keep stock of the number of medications a person could need would be impossibly expensive.

“Having worked in prisons and jails for 14 years, they cannot be reasonably expected to stock every medication for every patient,” Bay said. “In the jail, we have to be really careful what we prescribe to people.”

But on a smaller scale, it works like this: Once people self-report, JHS staff then verifies what conditions and medications the patient listed, Stanfill said.

In order to seek medical or dental care, an inmate has to file a written request called a “kite.” Hayes filed a couple during his stay in January of 2015. One of Hayes’ kites asked why a medication called Vistaril, a sedative used to treat anxiety and tension, wasn’t continued. The reply from Jail Health staff on Jan. 31 read, “sleep is not treated with medicine in this jail,” and “some anxiety meds are not used in this jail.”

On Jan. 30 — one day before Hayes’ kite response about Vistaril — records show JHS verified Vistaril was indeed a medication Hayes was taking just a month and a half earlier.

Hayes said he has trouble getting his prescriptions when he’s in jail, despite these interactions and records. In fact, he filed a written complaint, known as a grievance, about his medications during his January to February stay.

After Real Change requested this file specifically, Stanfill said there is no record of the grievance because he unknowingly shredded the original, thinking it was a copy. The grievance said, “I want my meds,” Stanfill said.

Bay verified that the medications Hayes was eventually given by JHS were appropriate for his schizoaffective disorder. But they were prescribed approximately halfway through his 16-day stay.

Stanfill said the delay in medication is because Hayes didn’t self-report it, and so the fact that he got any medication at all was due to JHS staff validating the meds themselves.

Ari Kohn, Post-Prison Education director and case manager of Hayes, recalls it differently. He heard from Hayes first-hand that he wasn’t getting his meds. Kohn then complained to the jail, and Hayes’ mother called in to report that he needed the medication. After a couple more days, Kohn threatened over email to sue, at which point JHS validated the prescription history, and Hayes got his medication.

Ari Kohn, Post Prison Education Program director, looks on as Michael Hayes goes over his medication with an officer. [Photo: Kelsey Hamlin]
For Hayes, being denied medication creates a vicious cycle when he’s in the jail and when he’s released. Each person responds to medication differently; it’s hard to say exactly how Hayes’ unmedicated week in jail impacted him.

“Some medications can take up to five days to get them stabilized in the blood,” Bay said. “On some of the antipsychotics you can get more psychotic, with some of the antidepressants, you can get withdrawal symptoms. Withdrawal symptoms are medication specific, and how long it takes for action is medication specific.”

Bay said that if someone who is booked isn’t a known person, and isn’t familiar to staff, it would require a call from their medical clinic or a family member who reports an illness to the jail to find out about the medication.

“There is no other way for the jail to know,” Bay said. “Lots of patients are frequent fliers, so if they’ve been in the jail before, the jail knows about them.”

In this case, it seems Hayes would’ve gone without his medication had it not been for calls from Hayes’ mother and Kohn threatening to sue.

Many patients are reluctant to immediately tell an official they struggle with mental health or drug abuse.

“There’s kids with diabetes who wouldn’t acknowledge it, or people with seizures that were ashamed,” Bay said.

She emphasized that families and providers in Seattle need to know how to contact the jail medical department and leave a message about someone who has been recently booked and needs medication.

Hayes had gone days without medication in the jail, received it a week later and then was released to the streets.

“He’s manic off his meds. He’s just everywhere, it’s hard to communicate,” Kohn said. “So he has to be on his meds forever, has to be away from drugs, has to.”

Kohn has known Hayes for approximately 10 years.

Hayes says when they don’t give him the medicine and he’s having a hard time with his mental health, the only way he knows how to keep functioning is to self-medicate. This can be amplified when Hayes is given only a very limited supply of his medication upon release.

In fact, a record from one of Hayes’ other bookings in 2015 with the King County jail notes he was released without medication.

“So if I’m really manic, I grab a beer,” Hayes said. “If I’m really depressed, I grab meth. And if I’m in a lot of pain for something, then I grab oxys or heroin. I contribute a lot of that on my end, being all loaded. But there’s some of it, just some of it, was partially because they let me out without no meds.”

Stanfill explained that JHS can release people with up to seven days of medication, but there’s not a standardized process for this.

“We’re constantly trying to strike that balance between aftercare and resource demand,” he said. “It’s a difficult balance to find.”

Imperfect system

Stanfill said JHS has limited resources. The program is limited by the ability to find people who want to work in jails and prisons, and by its budget, which is set by the King County Council.

The program serves 2,000 patients with 10 independently licensed therapists and nine psychiatric providers “working various hours per week,” Stanfill said. This equates to 6.5 full-time equivalent positions. There are also six social workers providing aftercare planning and care coordination for those with chronic or acute medical, psychiatric and substance abuse issues.

“The simple math of that is that not everyone is going to be seen every day or every week,” Stanfill said, adding that “you will always have more demands than you have resolutions for us.”

Stanfill called the entire mental health system “broken and underfunded.”

“That doesn’t make it right, but that’s a part of what the issue is, that the constitutional right to health care only exists in jail,” Stanfill said. “Unfortunately, what’s happened is jails and us have become primary care providers for a huge chunk of the population. The criminal system was never designed to manage health care, and unfortunately that’s what it’s become.”

Stanfill, however, said JHS provides a list of programs to inmates. Some of these include group therapy, long-term psychotherapy and post-traumatic stress disorder programming. Some programs are reserved only for the inmates at the Regional Justice Center, a population, he said, that’s typically in the jail for longer periods of time.

He also warned that sometimes one person’s experience might not represent the whole.

“Is the system perfect? Absolutely not,” Stanfill said. “I regularly get calls from attorneys saying their client isn’t getting x, y, z. People get frustrated with the system, and sometimes what they say doesn’t really line up with what actually happened. But that’s not to say the frustrations aren’t real.”

Bay suggested a greater focus on jail diversion and giving drug courts more services for mentally ill patients. She said none of this should be jail-based.

“The correctional systems are being expected to manage mentally ill patients with minimal financial and personnel resources,” Bay said. “The ill, mentally or otherwise, belong in hospitals, not in the jail.”

The paradox of instability

Hayes said one of the hardest aspects of his condition is being forced to the extremes of self-medication, so it’s hard to say which symptoms are a result of drug use and which are aspects of his mental health.

Some of the dozens of charges leveled against Hayes were due to instability in his life, but some of the current instabilities he has are also resultant of the charges. They make it harder to find housing, find a job and get on Social Security.

People who receive their meds, Hayes said, can participate in regular conversations with other people.

“Alls I’m trying to do is not feel,” Hayes paused to find the right words, “messed up.”

A ‘safe place’

In October 2015, Hayes sat on one of two beds in a room at the Harborview Medical Center psychiatry unit.

“I didn’t want to make it,” Hayes said. “I’m on the psychiatric ward for a reason.”

He lifted his hat and ran his hands through his gray, curly hair.

Hayes reflected on the experiences he had being released from prison.

“It’s like having a car with no brakes and going really, really fast,” he said. “When you first get out of prison, you got your foot on the gas, and you went to go check the brakes and there’s no brakes. You didn’t check to make sure there were some brakes there.”

Hayes added that people facing mental illness and drug addictions, or those just getting out of prison, should take it slow and get help.

“Twice I’ve seen [Hayes] just do really well, and both were for six month periods. So I know he’s capable,” Kohn said. “When clean and sober and properly medicated, he does phenomenally well.”

Michael Hayes’ stack of PPEP records. [Photo: Kelsey Hamlin]
Hayes still hopes to go back to Bellevue College.

When he was later released from the drug court, there weren’t arrangements for what Kohn deemed “appropriate housing” — with daily sobriety checks and supervision for medication adherence. In an ironic turn of events, Kohn tried to make it so Hayes would stay in jail until housing was determined, but was unsuccessful.

“The despair of being mentally ill and chemically addicted, the despair is so bad that you don’t wanna make it,” Hayes said. “So we need to help people. They need to know that there’s a safe place to go and that they don’t have to be afraid of the police.”

Hayes later went to King County’s mental health court, a diversion program meant to help people in the criminal justice system with mental illnesses. But he ended up with another unsuccessful recovery.

“This guy will either go back to prison — which will probably save his life — or he’ll die,” Kohn said. But even that ultimatum isn’t enough to stop the cycle.

A few months ago, Hayes got a service dog for people with special needs, and Kohn thought things were turning around. Hayes was in an apartment, supervised and sober.

Then Hayes felt like his medication was preventing him from performing the best he could at work.

It often takes years for people with a mental illness to figure out what medication is right for them. Instead, like many, Hayes got frustrated and stopped altogether.

Then he lost his dog, and had a psychotic break.

The cycle restarted.

Kelsey Hamlin is a reporter with South Seattle Emerald, and interned with the publication this summer. She also works with various Seattle publications. Currently, Hamlin is a University of Washington student, and the President of the UW Chapter’s Society of Professional Journalists. Hamlin is a journalism major at the University of Washington with interdisciplinary Honors, and a minor in Law, Societies & Justice. Find her on Twitter @ItsKelseyHamlin or see her other work on her website.