By Byrhonda Lyons, Jocelyn Wiener and Erica Yee
California state prisons transfer people with serious mental illness far more often than other prisoners — sometimes as many as dozens of times — according to a CalMatters analysis of newly acquired state data.
The findings underscore an investigation by CalMatters earlier this year that uncovered the state’s practice of moving around mentally ill prisoners, which some advocates say can be disruptive and harmful to these vulnerable people.
The story focused on the case of Adam Collier, who was diagnosed with post-traumatic stress disorder, bipolar disorder, borderline personality disorder, and anxiety disorder, among other mental illnesses. Collier was serving a five-year sentence for exposing himself to women in public while high on meth. Between 2016 and 2020, he was transferred 39 times – bouncing between crisis units, state hospitals and seven different prisons – before committing suicide at Kern Valley State Prison in October 2020.
CalMatters’ analysis of data from the California Department of Justice found that from 2016 to 2021, California prisoners on “extended outpatient” psychiatric treatment were, on average, three times more likely to be transferred than other prisoners.
The data shows that inmates in the system’s expanded mental health program — which provides the highest level of outpatient mental health care for prisoners — made an average of five moves during the period, compared to an average of 1.5 transfers for people in the general prison population.
A person who enrolled in and out of the mental health program moved 75 times during the six-year period. The data does not identify any person.
“It doesn’t surprise me at all,” said Keramet Reiter, a professor of criminology at the University of California, Irvine. “The severely mentally ill … bounce around a bit.”
CalMatters had requested the state’s transfer details on March 31; the department replied on August 1st and September 16th. For its June story, CalMatters collected its own prison transfer data for about a year, which generally reflects the state’s records for the same period.
“Transfers for an inmate are disruptive,” said Christopher Lisieski, the attorney representing Collier’s mother in a federal lawsuit against several prison employees. “Disrupting the routine of a seriously mentally ill person is added stress and strain and can worsen mental health symptoms.”
Lawyers, prisoners and family members claim that in cases like Collier’s, a steady stream of referrals reflects a system that all too often fails to adequately care for people in mental health crises. These inmates could bounce between jails and short-term crisis beds without ever stabilizing enough to recover, they say.
In California, mental health care in state prisons is designed to transition inmates to an appropriate level of care as their needs change. Treatments range from outpatient therapy in the general prisoner population to long-term hospitalization in treatment facilities within the correctional system.
Prisoners requiring the highest level of care could be transferred to government hospitals, which are separate facilities that also house people not in the criminal justice system.
But the system doesn’t always work perfectly. In several investigations, the Inspector General has found that people who need it are sometimes not referred to a higher level of care.
In other cases, experts say, multiple referrals can mean the system is working and people are getting the care they need.
Department spokeswoman Dana Simas wrote in an emailed statement that the state transfers prisoners for a variety of reasons, including court hearings, medical treatment, mental health treatment, security level changes, patient safety, staff conflicts, allegations of misconduct or probation.
In California, the guidelines for treating mental illness in prisons are governed by a federal class action lawsuit — known as Coleman — in favor of prisoners with serious mental illnesses.
In 1995, a federal court ruled that the department failed to provide adequate mental health care to prisoners. The court eventually approved the Correctional Authority’s plan for the provision of mental health care and appointed a special master to oversee and report on state compliance.
“The department works closely with the Coleman Special Master and others on these matters and always strives for what is in the best interest of the individual patient’s needs,” Simas wrote in an email to CalMatters.
Special Master Matthew A. Lopes Jr. did not respond to CalMatters’ request for comment.
In Collier’s case, he moved so frequently that his mother, Susan Ottele of McMinnville, Oregon, checked online “every single, lonely day” to see which prison Collier was being held in and why.
When the pandemic struck, prisons went into lockdown, and Collier served seven months in Kern Valley State Prison. It was his longest stay in prison since 2016.
“All these transfers make me dizzy,” Collier wrote in a March 2020 letter to Ottele. Months later, at the age of 43, Collier killed himself.
The inspector general’s office investigated Collier’s suicide and found that the department had “poorly handled” Collier’s case. The March 2021 inspector general’s report detailed a number of internal issues, including clinicians unduly delaying Collier’s referral to a higher level of care and failing to adequately document his history of self-harm.
Earlier this year, Ottele filed a wrongful death lawsuit in federal court, alleging prison guards failed to monitor her son and acted with willful indifference.
In court documents, prosecutors dispute these claims and say the guards were unaware of Collier’s history of attempted suicide. The Department of Corrections and Rehabilitation declined to comment on the lawsuit, citing pending litigation. Lisieski, Ottele’s attorney, said the case likely won’t be resolved for years.