Criminal Justice

“Finch is Spared Death Penalty” (By Diane Brooks and Janet Burkitt, Seattle Times Snohomish County Bureau, Tuesday, November 7, 2000)

“Isaac Zamora Charged in 6 Skagit County Murders” (Associated Press, Fri Sep 5th, 2008)

“Opel Gets Life in Prison” (By Matthew Craft, Seattle Post-Intelligencer, Friday, April 18, 2003)

“Mother Held on $500,000 Bail for Killing 9-Year-Old Son” (By Jennifer Langston, Seattle Post-Intelligencer, Wednesday, October 23, 2002)

“Woman Sentenced for Leaving Newborn to Die in Hotel Toilet” (Archive, Las Vegas Sun, Friday, Nov. 7, 2003)

“Murderer Elledge is Sentenced to Death – No One in the Slaying Case gave Jurors a Reason to Spare his Life” (By Rebekah Denn, P-I Reporter, Thursday, October 22, 1998)

“Scherf Deserves Death Penalty, Jury Finds” (By Diana Hefley and Scott North, Herald Writers, Wednesday, May 15, 2013)

“Driver in Crash that Killed 4 near Marsyville Reportedly told Authorities he was Drunk” (By Nicole Tsong & Janet I. Tu, Seattle Times staff reporter, Tuesday, December 1, 2009)

“Marysville Man Charged in Fatal Shooting of 6-Year-Old Daughter” (By Diana Hefley, Herald Writer, Wednesday, November 19, 2008)

“Area Man Shoots Sibling Over Few Head of Cattle” (Sky Valley Chronicle, December 7, 2009)

“Prosecutor: Cat Told Man to Kill” (By Brian Alexander, Times Snohomish County Bureau, Friday, October 21, 2005)

“Shooting of Unstable Man to be Reviewed” (By Darrell Glover, P-I Reporter, Thursday, October 22, 1992)

“Rapist Gets 75 Years for Attack on Girls – ‘Little or No Likelihood Defendant Will Ever Change’, Judge Says” (By Darrell Glover, P-I Reporter, Tuesday, April 13, 1993)

“Hearing Focuses on Child Abuse as Sentence Delayed in Shooting” (By Scott North, Herald Writer, Saturday, August 1, 1992)

“Wrong ‘Personality’ Convicted?” (By Nancy Montgomery, Seattle Times Snohomish County Bureau, Tuesday, February 15, 2000)

“Mukilteo Woman Sentenced to 30 Years for Torturing Girl” (By Scott North, Herald Writer, Thu Nov 29th, 2012)

“Keller Pleads Innocent” (By Debera Carlton Harrell, P-I Reporter, Thursday, February 25, 1993)

“Many Hospitals Take Measures to Ensure Security of Newborns” (By Antoinette Alexander, Seattle Times, Sunday, August 24, 1997)

“Man Who Bulldozed Ex-Wife’s Home Stirs Fear with Threats – Inmate Scheduled to be Released from Prision” (By Jolayne Houtz, Seattle Times, Thursday, November 11, 1993

“Man Who Stole from Kids Jailed, Banished – the Lake Stevens Man gets 4 Years in Prison and is Banned from the County for 10 Years. He says his Dog told him to do it.” (By Diana Hefley, Herald Writer, Friday, October 31, 2008

“Irate Driver Smashes into Restaurant – Suspect Rams, Hurts Man who Gave Chase” (By Jolayne Houtz, Seattle Times, Friday, June 26, 1992)

“Woman Tries to Break into Jail, and Succeeds” (Seattle Post-Intelligencer Staff and News Services, Tuesday, April 5, 2005)

“Dangerous…And On Her Own” (By Ronald K. Fitten, Seattle Times, Saturday, August 24, 1991)

“Jail Nurse Accused of Trading Pills for Sex” (By Janet Burkitt, Seattle Times Snohomish County reporter, Friday, May 31, 2002)

 As you can see, 23 years of interviewing & assessing people in a jail was more than just interesting.  The stories I could tell…

Malingering, Manipulation, & Mental Health in Corrections

How effectively do you work with an inmate who seems to be malingering their symptoms or is trying to manipulate you in your professional role?  This can be a challenging prospect – even for the most seasoned professional – because many inmates have been using these maladaptive behaviors for years and, from their perspective, their methods of self-preservation are more important to them than how they might impact your license or reputation.

In my 23 ½ years of work as a mental health professional in a large jail, I had ample opportunities to interact with inmates who worked every angle to either gain an advantage or to avoid accountability.   In my experience, manipulation was a far more common dynamic than malingering, though they are not necessarily mutually exclusive dynamics.

My working definition of these two dynamics in the corrections field is this: Malingering can be viewed as one who is faking the symptom to get out of accountability, while manipulation can be viewed as one who is working the system to gain an advantage.  By way of review, the criteria used to rule out malingering can best be summed up with the following: 1. An overplayed and dramatic presentation. 2. Deliberateness and carefulness. 3. Inconsistency with psychiatric diagnosis. 4. Inconsistency of self-report.

The mental health professional must be alert to both verbal and nonverbal cues, taking into consideration objective & collateral reports, being very clear about roles and boundaries, and having the courage to confront if necessary.  We need to be on top of our game at all times to avoid the risk of misdiagnosing (which could lead to inappropriate treatment and associated costs) or being susceptible to unethical decisions (which could lead to personal, professional, and even legal consequences).  In such cases it is crucial to include other professionals when making determinations about treatment and/or behavior plans.  There is no substitute for time when it comes to establishing a serious mental illness diagnosis and determining if medication is indicated – have patience in the process and buckle up for the ride!

The following are some of the more notable cases from my work that highlight the dynamics of malingering and manipulation and why it is so important to be clinically competent in responding to these types of cases.

CASE #1 – “GOD TOLD ME”

Case #1 had to do with a male in his late 30s who had an extensive criminal record.  His record included convictions for Rape 1^st Degree and Assault 2^nd Degree, for which he did time in prison.

Several years prior to the current event, he was seen by a jail mental health professional (MHP) to request a change in his sleep medication.  He did not report any significant symptoms beyond sleep disturbance (a very common complaint in jail) to that MHP.  Again, four years later, he was in the jail and on his way back to prison.  He told the psychiatric nurse at that time he preferred an antipsychotic medication as it decreased his edginess and insomnia.  He reported a treatment history for ADHD and Bipolar.  He went to prison for a time and was again rebooked two years later, which brings us to the present case.

The day after he was rebooked he broke a razor in his cell and sliced the inside of his forearm.  He received stitches in the jail medical clinic and was placed on a suicide watch in a safety cell.  I saw him that afternoon and gathered the following information:

• He reported he’d been incarcerated for a total of 14 years (most of his adult life).
• He reported a history of getting into fights (e.g., he beat up a cellmate in prison for stealing some of his items).
• He reported that he’d had a “spiritual visitation” 2 ½ years before in prison wherein God (and the TV) spoke to him that it was okay to end life.  So, he felt it was better to end his life than someone else’s life.
• He reported he’d experienced strong homicidal ideations the last 2 weeks he was at the state prison.  His ideations included plans, methods, and strategies for killing two or three families.  The day after his release from prison he stole a car and went looking for one individual but, upon seeing him, he’d left him unharmed.
• He casually reported a “consensual” sexual relationship he’d had in prison with a female staff member the year before and claimed she went to jail (NOTE: Four days after seeing this inmate, I attended an “Offender Manipulation” training wherein the presenter referred to this unfortunate circumstance.  A male prisoner/female staff relationship had ended poorly for the staff person that past year.  According to the presenter, the staff person had been skillfully seduced over a period of several months by the male prisoner who had been assigned to work in her clinic).

During our session Case #1’s character pathology came through loud and clear.  His whole demeanor was one of detached concern and aloofness from his stories and victims (both past and potential).  At no time did he appear to me to be suffering from a serious mental illness.  He did, however, appear to be very willing and capable of destroying people’s lives. I left him on a close observation watch and followed up with a duty-to-warn call to local law enforcement.  They finally located the person he’d sought out earlier and left a message with a family member.

Case #1 was seen by the part-time jail psychiatrist (who was only at the jail 8 hours a week) the following week.  He told the psychiatrist that he heard the voice of God talk to him about killing people and that he heard voices at night.  The psychiatrist went on to note that this inmate’s mood and judgment seemed to be influenced by these hallucinations and diagnosed him as Schizophrenic, Paranoid Type.  He then ordered him an antipsychotic medication.  The attending female MHP who had accompanied the psychiatrist noted that Case #1 denied suicidal ideation and homicidal ideation stating he’d be ok.  Case #1 was maintained on close observation status.

The next day another female MHP followed up with this inmate and the inmate indicated he would comply with the medication prescribed by the psychiatrist.

I followed up with Case #1 the following day.  He indicated to me that he still had some homicidal ideation.  During my interview he inquired about the female MHP who had seen him before and asked if he could talk to her again.  When I informed him that the jail MHPs rotated assignments, he replied “Oh, ok.”  I placed an alert in the medical chart for my female colleagues to have an officer present when meeting with him.

The next day a different female MHP met with him with an officer present.  Case #1 asked her for my name stating he didn’t like me.  When that MHP did not move him back to his preferred housing unit, he became irritable and accusatory.

Two more days passed and yet another female MHP met with him (again, with an officer standing by).    He denied any and all suicidal and homicidal ideation, was pleasant and calm, and stated that the medication had made him calm.  That MHP saw no evidence of psychosis and noted that Case #1 appeared to present himself as more disturbed than he truly was. By this date, he had been taking his medication for all of five days.

Two weeks later the psychiatrist met with him for a medication follow up.  No evidence of audio or visual hallucinations were noted with a much improved mood.  So, it appeared to the psychiatrist that the medication had, indeed, alleviated the inmate’s psychotic symptoms.

However, I begged to differ.  Did the medication really alleviate such serious symptoms so quickly with someone diagnosed with Schizophrenia, Paranoid Type?  Or, was the inmate’s improved presentation simply a result of sedating medications (i.e., self-reported symptoms without clinically observed justification)?  I found it hard to believe that an almost middle-aged man could be newly diagnosed with Paranoid Schizophrenia after only one session with a psychiatrist, especially after having spent so much time in prison for all kinds of crimes wherein his competency and culpability had never been questioned.  Perhaps, because the psychiatrist was only at the jail part-time, Case #1 was able to convince that doctor during their 30 minute session that he was more ill than he really was.

CASE #2 – “THE VOICES HEAR ME”

CASE #2 was a male in his mid-20s who, when booked in to the jail and interviewed by the booking officer, stated that he had been to the psychiatric hospital just two months before due to, in his words,  “I just lost it”.  Because of his self-report, the booking supervisor had him moved to the jail psychiatric unit.

There were no reports regarding CASE #2 on that unit, including self-reports or staff observations that he was suffering from any psychiatric condition.  Two months later he wrote two service requests stating, “I don’t think I belong on this floor.  I would like to move” and “I would like to be classified into the general population.  I do not really think I belong here”.   He was interviewed by the appropriate staff and moved to a general population unit that same day.

However, he was returned to the male psychiatric unit the following day because, apparently, he had complained about the noise and number of inmates in the general population unit.  He was again moved off of the psychiatric unit a few days later, this time to a smaller unit (the protective custody unit, which typically housed sex offenders).

A few more days passed when the night unit officer noted that CASE #2 had indicated that he hated “baby rapers” and, given the chance, would “take out as many as he could”.  That officer asked to have CASE #2 reviewed for different housing as he was also argumentative during routine procedures on the unit.

When the unit supervisor moved him to the maximum security unit after another refusal-to-obey incident, they found a garrote hidden in his property bin under papers.  He received infractions for making a weapon and destroying his towel, thus sealing the deal for keeping him housed in the maximum security housing unit for a minimum of 30 days.  

Within a few days, CASE #2 put in his requests to move back to the male psychiatric unit, doing his best to sound like a psychiatric inmate:

“I need to go to (the Psych Unit).  I am legally psychotic, and the voices hear me.  (The Psych unit) is the only place where I feel safe away from them.” 

And, “Please put me on (the Psych Unit).  I am clinically psychotic, and I am scared to be anywhere else.  Some people (in general population) said they are going to kill me.  I hear voices, and see faces, and I think I need to be housed on the psych unit.  I am a non-violent person, and I am scared to be anywhere else.”

And five days later:  “I need to be on (the Psych Unit).  I am psychotic, and I know people are out to get me.  (The Psych unit) is the only place where they can’t get me.  I have seen strange lights in the sky.  The C.I.A. is in Virginia.  I know very tall people.”

Really?  I am legally psychotic and the voices hear me?  To be sure, CASE #2 was not moved to the jail psychiatric unit and did not present with any psychiatric behaviors for the duration of his stay.  He was released from jail within 30 days of his infractions…from the maximum security unit.

CASE #3 – “LITTLE GREEN PEOPLE”

CASE #3 was a male in his late 30s.  He was viewed as one of those frequent flyers at the jail, spending more time incarcerated than out in the community over the years.  His crimes were largely drug and alcohol related and had already been booked into the jail many times before my first contact with him.  During that interview CASE #3 indicated he was withdrawing from crack cocaine and complained of hearing voices and seeing things out of his peripheral vision.  My treatment plan for him at that time was a strong recommendation that he pursue drug treatment.

I met him for the second time 2 years later during another booking after he complained of feeling depressed, irritable, and having anxiety attacks.  He reported to me that he had been using drugs (“anything”) and alcohol a long time, had been clean and sober for 4 years and had relapsed the past year with continued drug use.  I referred his case to the jail psychiatrist for consultation & review.  The psychiatrist deferred treatment and requested further observation for ongoing symptoms.

Now fast forward several more bookings over the next year.  CASE #3 returned to jail and after several months of lockup started complaining of anxiety, exhaustion, decreased sleep and appetite.  When I met with him he reported several classic symptoms of depression: poor sleep/energy/motivation/concentration, with increased anxiety and an overall miserable mood.  He reported hearing voices from the grave and, again, indicated seeing shadowy figures peripherally.  I referred him to the jail psychiatrist who, in turn, offered a medication for his depression.

A few days later the unit officer was making rounds and noticed CASE #3 with both hands in his toilet.  When the inmate was directed to remove his hands from the toilet the officer noticed there was blood on the inmate’s hands.  CASE #3 had scratched his wrists with his thumbnails and told the officer it was because “you are persecuting the Jews.”  His wrists were bandaged by a nurse and he was placed under close observation on the maximum security unit.  I saw him the following morning and observed that he had a blanket draped over his body with long johns wrapped around his head like a turban, so that only his eyes were visible.  His coveralls were on the cell floor and when I asked why he stated, “I don’t want to wear them anymore.”  His explanation for his behavior was that he was tired of the Jews being persecuted.  He told me he was not suicidal and said the medication had helped initially but not recently.

He was seen by the psychiatric ARNP (herein referred to as ARNP) the following day.  CASE #3 told the ARNP he thought he had been hearing the Jews.  He also told the ARNP that he saw “little people” and had “for a long time”.  The ARNP adjusted his medication for depression.

CASE #3 was seen again by the ARNP 3 weeks later for a medication review.  CASE #3 complained that the medication wasn’t working anymore.  He reported hearing voices “in my head – God talks with me, or my mom.”  He expanded on the “little people” stating he saw them run around in his room “smiling & waving.”  Medication was again adjusted for depression and the ARNP noted that psychosis seemed doubtful.  CASE #3 was released from jail the following month.

When CASE #3 returned 2 bookings and approximately 3 months later, he requested to get back on his previous medication.  He was seen by the ARNP that same week and reported hearing voices with suicidal ideation.  He also claimed that he still saw “little green people”.  Medication was prescribed for depression & psychosis.

The ARNP followed up with CASE #3 two weeks later due to his complaint of increased voices with suicidal ideation.  During that review, he corrected the ARNP about the little people: they were not green; they were “little people in green clothes.”  His medication was adjusted.

CASE #3’s treatment was monitored over the next year by the ARNP, both at the jail and in the community (the ARNP was at the jail 4 hours a week and worked full-time at the community mental health center).  However, due to CASE #3‘s pattern of no-shows at the community mental health center, he only received medication at the jail.

Toward the end of that year, CASE #3 received a forensic evaluation for competency after visiting the state hospital.  In that report, it was suspected that CASE #3 was malingering psychosis even though his medication for depression was continued.  When CASE #3 returned to the jail he continued to complain of voices and pressed for increased medication over the next few months.

I saw him about 4 months later during the same incarceration period.  He reported a voice in his head that told him to “come home with us” and/or lash out at others.  He described it as a “battle inside my brain.”  While reporting this, though, he did not appear distressed or disturbed.  He was again seen by the ARNP that same week.  He reported to the ARNP that either the medication had stopped working or that he was getting much worse.  When the ARNP reminded him how poorly things had gone for him two years previously, he responded with “this is the best I’ve ever been”; then added, “what do I have to do to show you I’m getting worse – hurt myself or someone?”

Though he claimed he had been getting worse over the past 5 months in jail, he hadn’t hurt himself or others.  The ARNP reviewed his treatment plan with him and, when pointing out that the state hospital had actually stopped his antipsychotic medication, he stated “I wasn’t psychotic then.”  When he realized he wasn’t getting an increase in the antipsychotic medication, he accused the ARNP of rejecting him stating, “I’ve been rejected all my life.”  He went on to ask the ARNP for therapy, where “you lie on a couch and talk.”  The ARNP noted that CASE #3’s malingering seemed much clearer along with Antisocial Personality traits.

CASE #3 wrote a kite to the ARNP 3 months later stating “seriously manic depressive, hearing voices, seeing little people”, “they’re coming to take me to the other side”, “Mary was a big girl”, and that he “can’t bear it.”  However, the day before writing that kite he had been seen by the MHP while he was in the jail law library and did not present or verbalize any such signs/symptoms!

Over the next six years CASE #3 continued his quest for more and more increases in his medications at the jail.  In his kites he complained of “screaming voices”, “severe voices”, being “completely delusional”, and even wrote a letter to the ARNP’s community mental health office indicating that the ARNP had “devastated” him by not raising his meds.

He was seen or reviewed by jail psychiatry 38 times over 10 years and 40 jail bookings….plenty of time to establish CASE #3’s consistent pattern of behavior and mental health profile.  As a result, he was no longer given medications at the jail.  He then spent countless hours in the jail law library filing motions against the jail’s medical department for not providing treatment.  He was seen 2 more times by the state hospital for competency evaluations.  Both times the forensic reports indication that CASE #3 was malingering psychosis.

At that point I thought that CASE #3’s treatment issues were behind us.  However, after another 9 years had passed, the county attorneys requested that jail mental health see him again to determine whether CASE #3’s legal claims were valid (yes, CASE #3 had continued to occupy the jail law library filing countless motions that eventually reached a decision point for the civil court).  I went with the new psychiatric ARNP to see CASE #3 and we spent close to an hour interviewing him.  I meticulously wrote up a 4 page assessment with thorough documentation of his self-report and my clinical observations.  Here are some examples of what I documented: CASE #3 reported “screaming voices in my head” but was able to focus by “seeing your lips moving”.  He reported “When it starts getting real bad, I see this little guy appear, smiling, runs around my cell – I haven’t seen him in a long time.”  He was extremely polite and calm, with no evidence of psychosis or thought disturbance.  The ARNP was in agreement that CASE #3 was malingering his symptoms in order to get medications.

The court threw out his claims and he eventually quieted down with no further requests for medications.

CASE #4 – “CLOWN IN THE COURTROOM”

One day I received a phone call in my jail mental health office from CASE #4’s ex-girlfriend.  She indicated she’d known this male (in his early 20s) for 3 years and had watched him deteriorate over time.  She cited the following behaviors of concern:  he used to hear voices, had excessive energy, violent outbursts, and paranoia.  She stated she hadn’t known him to use drugs for quite some time.  She ended the call asking if the jail could help him.  When I looked CASE #4 up in the jail management system, I discovered that he had been held at the jail overnight and was already being transported to another county jail on a warrant.

Unbeknownst to me at the time, approximately one month later CASE #4 was rebooked into our jail on a murder charge.  He was charged with fatally stabbing his ex-girlfriend in front of her two young children.  CASE #4 was placed in the intake unit as he was cooperative with jail operations.

Within a week or two the inmate’s family called the jail expressing concerns about CASE #4’s mental health.  When I looked him up in the jail management system I discovered that he was the person the victim had spoken with me about one month earlier.  I was shocked and dismayed in finding out that the ex-girlfriend had been the victim and knew I was not the right MHP to follow up with him right away.  I asked one of my colleagues to see him and respond to the inmate’s family.

My colleague saw CASE #4 and noted that he presented as extremely calm and detached from the seriousness of his legal situation.  CASE #4 displayed a rather cocky attitude when answering questions and denied any overall problems or psychiatric issues (including any history of such).  His sleep and appetite were reported as within normal limits.  My colleague referred him to the psychiatrist for review and noted that a possible move for closer observation should be considered.

The following day, the jail’s program administrator had CASE #4 moved to the male psych unit and placed on a 10 minute suicide watch.  I saw CASE #4 the day after that move was made.  He was out of his cell for a supervised break, seated at a table working on a puzzle when I spoke with him about his suicide watch.  He said he didn’t know why he had been moved as he wasn’t suicidal, neither did he appear to be in any distress.  I discontinued the suicide watch and he was moved to the maximum security unit at the request of Classification staff.  His behavior was monitored there for up to 30 days and eventually moved back to general housing.  There were no referrals to MHPs until a month later.

CASE #4 was moved back to the maximum security unit due to a phone restriction that could only be monitored in a 23-hr lockdown unit.  Classification staff contacted the MHP office about CASE #4 now being possibly suicidal after being moved there.  When my colleague met with him, the inmate indicated he felt more anxious/agitated in lockdown and asked the MHP what would happen if placed on a suicide watch (he inquired if he could move to the male psych unit).  The MHP assessed CASE #4 as not being suicidal and deferred housing to Classification.

That same month, the inmate’s attorney requested a forensic evaluation for competency at the state hospital and the inmate was sent to the hospital the following month.  He returned on after 2 weeks and was seen by my colleague who noted that the state hospital had given CASE #4 a diagnosis of Schizoaffective Disorder.  He told my colleague that he had taken some type of medication at the state hospital but did not remember the name; he said it helped him calm down.  CASE #4 classified to the maximum security unit due to potential assaultive behavior toward custody staff.

A few days later the Classification staff contacted the MHP office about CASE #4 being suicidal in the maximum security unit.  My colleague followed up with him and noted the inmate’s report of feeling “very scared” and that he might hurt himself.  He reported difficulty sleeping in that unit, similar to sleep problems he reported at the state hospital.  He also complained of decreased appetite and said he went 3 days without eating recently (though he did eat lunch that day).  CASE #4 was irritable and upset because my colleague did not know the status of his public defender and court hearings and said the jail was not doing anything to help him.  He also complained that he could not talk privately with the MHP and generally blamed jail staff for his current situation.  He finished the interview by telling my colleague that all he really needed was some fresh air during his time out (this request was passed on to the custody officer on duty).

Over the next two weeks CASE #4 began to escalate and engage in unusual behaviors.  He was moved to the male psych unit where my colleague saw him and noted that he acted strangely: A sock was tied around one ankle and his towel was wrapped around his head; when he moved around in his cell he dragged his leg; his bedding had been draped over the bed and desk area, creating a tent under which he crawled; he told the MHP he was afraid of the medicine we were giving him.  He was referred to the psychiatrist to be seen later that week who discontinued his medication at the inmate’s request.

Two days later I saw CASE #4 and noted that he requested to have the wrist restraints removed when out of his cell.  He spoke in a raspy voice without much inflection and still wore a towel around his head.  He reported that he believed the water was poisoned and didn’t want to shower due to “radiation”.  I asked what had happened to make his voice so raspy and he gave no reply.  He did, however, acknowledge my explanation for why restraints were required when he was out of his cell, even though he had not been in restraints when at the state hospital or on the maximum security unit.

Later that day the unit officer noted he had talked with CASE #4 about being out with others at the tables when eating meals, but that he would have to leave the towel in his cell and not limp around (i.e., drag his leg).  The inmate told this officer he would try to do so and made a start by cleaning his cell.

On the following day the unit officer noted that CASE #4 was moving around real good and playing cards with other inmates (though still in wrist restraints).  The officer documented that CASE #4 talked differently to staff than to inmates and believed he was, in his words, “gaming a lot.”

Another day passed and the unit officer documented that CASE #4 made threats to stab him while he was out at the lunch table.  The officer placed him back in his cell and requested his housing unit be reviewed based on those threats.

 Due to safety and security reasons, CASE #4 was transferred back to the maximum security unit the following morning.  He had a court appearance that afternoon and my colleague was in attendance in order to observe his behavior there.  My colleague noted that CASE #4’s behavior was increasingly bizarre in the courtroom: making animal-like noises, pointing at other inmates who were in front of the judge, singing, speaking gibberish, and even managed to lie down on floor under table.  My colleague suspected that CASE #4’s behavior was volitional and completely under his own control.

When it was CASE #4’s turn to go before the judge, his attorney stated that CASE #4 was not cooperating with him on matters related to his case.  The prosecutor responded by stating CASE #4 was faking psychotic behavior to avoid prosecution.  It was clear that the judge had to make further deliberations beyond the scope of that hearing and stayed proceedings.  CASE #4 had to be dragged from the court room as he went totally limp.  He was placed back in the maximum security unit where my colleague attempted to interview him, but CASE #4 only made monkey sounds (and even stood on his head).

A few days later the unit officer had a talk with CASE #4 about the prospect of having a tray meal instead of a sack lunch (he had occasionally tossed his trays out onto the floor of the unit, thus earning sack lunches).  CASE #4 agreed that he would not cause any issues if given a tray meal.  As soon as the dinner tray was placed onto the fool slot in his cell door, CASE #4 dropped his pants and started to rub his penis into the rice while asking “Is this funny?”  He was placed on sack lunches until further notice.

The following week I went to see CASE #4.  His cell was a mess and reeked of urine/feces due to an unflushed toilet.  I observed him rocking back and forth on his bed, his arm shaking.  He complained of bad dreams, his head hurting from his thoughts, and was afraid he might hurt himself.  He requested meds from the Dr.  Though I viewed his behavior as volitional and somewhat theatrical, I placed him on a 20 minute observation watch with property restrictions, and referred his medication request to the psychiatrist.

Later that day I returned to check on CASE #4.  He had been hiding under his desk out of view from the unit’s tower officer who was making 20 minute log entries.  CASE #4 said he didn’t want the tower watching him.  Then he told me he would be good.  I had him moved back to the male psych unit for continued observation.

Though no self-harm ensued, CASE #4’s antics continued in earnest as his legal case moved forward.  About a month later the unit officer noted that they had to clothe him so he could go to court as he had been laying on the floor under his desk howling like a wolf.  At court the prosecutor upped the charge from 2^nd degree murder to 1^st degree murder.  The following day the unit officer noted that CASE #4 was very loud, had defecated in his uniform, and had to be carried to court.  However, upon his return, CASE #4 was playing cards with another inmate while engaged in quiet conversation.  When the officer asked CASE #4 to take a shower, CASE #4 mumbled and went back to his cell without showering.  The next month, he was transported to the state hospital for further forensic evaluation of his competency and returned to the jail two weeks later.

Three days after returning the unit officer noted that CASE #4 was crying & laughing for no apparent reason, and was disrupting the unit.  Due to his disruptive behavior, CASE #4 was taken to a booking safety cell to give the other inmates on the unit a break.  When he returned to his cell on the unit he wrapped a towel around his head and exposed himself to the other inmates through the cell door window.

Over the next several days his behavior was unremarkable with mixed reports of “manageable & no problem” and “responds to discipline/correction by withdrawing or trying to intimidate by acting strange”.  Then his behavior escalated as he pounded and kicked on his cell door while demanding to be let out.  The unit officer informed him that he could only come out of his cell if fully clothed, instead of wearing only his shirt without pants on.  His laundry items were scattered on the cell floor while he yelled loudly.  When he talked he did not use words; rather, he made baby sounds.

CASE #4 went to court two weeks after returning from the state hospital.  My colleague was, again, in attendance to observe the proceedings and noted that CASE #4 continued to act out by singing, speaking with a high voice tone, and denying who he was with “I am not (his name), I am JP Patches!”  CASE #4 consistently disrupted court proceedings and babbled nonsense.

The next day the unit officer moved CASE #4 to a cell away from direct observation as he seemed to enjoy showing his naked body to those passing by.  No other reports were generated over the next several weeks as his behavior seemed to improve with less attention (even more appropriate socializing on the unit).

Another month passed and my colleague met with CASE #4 due to his request to restart medication.  He told the MHP that he had been feeling violent towards himself & others, his moods were up and down every day, he was getting only 2-3 hours of sleep (used to sleep all day), and sometimes didn’t want to get out of bed at all.  The MHP noted that CASE #4 had been observed socializing on the unit and his self-report did not match staff observations.  A referral was made for the psychiatrist to review the following week.  However, later that evening, CASE #4 escalated his behavior per the unit officer’s documentation.

Prior to this escalated behavior, the unit officer had noted that CASE #4’s behavior had significantly improved in recent days: his shuffling feet, slurred or slow speech had stopped; he had regularly participated in module activities; associated with other inmates including card playing, scrabble, chess and some horseplay; full privileges had been restored; allowed out at all normal hours; been included in module clean-up and movies; had even done extra volunteer work by helping strip floors; and, was moved to the upper floor to a non-segregation cell.

So, later that evening after my colleague had seen him, the unit officer observed CASE #4 sitting at the top of the stairs.  The officer told him to move and he did.  About 15 minutes later CASE #4 was sitting underneath the stairs where a sheet and been tied above.  Some of his hair had been pulled out and was next to him.  The officer told him to lock down, but he did not respond.  A sergeant and response team then came and escorted CASE #4 to an observation cell.  The unit officer documented that, perhaps, CASE #4 had begun acting out as a way to influence the referral outcome that the MHP had just made to the psychiatrist.

I followed up with this inmate the following day.  He did not present with any odd behaviors or comments.  He told me he had been feeling down about his case and that suicide had seemed like an option.  CASE #4 expressed a desire to be out of lockdown and we discussed his behavior as the key to his housing restrictions.  I placed him on a step-down status for continued observation.

A few weeks passed with no negative reports on CASE #4’s behavior.  Then, one day, the unit officer noted that CASE #4 had walked out onto the unit with feces in his hair and on his upper lip (like a mustache).  He was directed to shower and he complied by showering.

A couple of weeks later officer notes indicated that CASE #4 had not eaten for several days.  When the MHP tried to talk with him, CASE #4 only looked at the MHP and would not talk.

Another four days passed and CASE #4 went to court for sentencing (he had pled guilty just before his trial date when the judge agreed with the state hospital’s forensic competency evaluation report stating that CASE #4 was competent to proceed and that most of his behavior was considered malingering).  My colleague was present in court and noted that CASE #4 made noises throughout the hearing, similar to laughing, and also turned around and stared at various individuals present in the court (including the son of the victim). CASE #4 did appear to accept and understand what was being said in court (e.g., his response to the judge about pleading guilty prior to the actual sentence helped minimize the severity of the sentence)…even though the prosecutor had asked for an exceptional sentence.

CASE #4 was transported to prison the following month.  His behavior at the jail settled down dramatically after sentencing and, prior to leaving, he apologized to jail staff for his behavior.

 CASE #5 – “THE VOICES ARE NOW TALKING THROUGH ME!”

CASE #5 came to jail on as female in her mid to late 30s.  She was referred to the MHP office due to making suicidal statements to both the arresting officer and jail staff in booking.  She also reported taking 3 psychiatric medications which were with her when she came to jail.  She was seen by my colleague shortly after she completed the booking process.

The MHP noted that CASE #5 had been a previous client in the community with a reported lengthy history of mental illness and multiple hospitalizations.  The most recent hospitalization had been within the past week.  CASE #5 was friendly and cooperative, organized in her speech and somewhat pressured, labile in her mood, affect was intense, and she did not appear to be psychotic.  She smelled of alcohol and might even have been somewhat intoxicated.  She denied being suicidal & denied any past attempts.  My colleague noted that it was difficult to determine if CASE #5 was an accurate historian.

I met with CASE #5 the following day as her cellmate had reported that CASE #5 was crying, anxious, and talking about voices.  CASE #5 was initially calm & cooperative.  She reported she was hearing voices, had been hearing them for quite a while, and needed to be in a hospital right away.  She then added that she got in trouble with law due to the voices.

CASE #5 became adamant and stated that people who hear voices and who feel suicidal should not be in a jail, rather, they belonged in a hospital.  As I attempted to obtain a treatment history from her, she became increasingly irritable and defensive.  She stated that her father heard voices and that her whole family had problems.  I redirected her to my question about her treatment history, but she complained of not being able to remember specifics about treatment, medications, or symptoms.  She then stated “I don’t even know today’s date or the time” (an unsolicited remark to portray that she was not oriented).

When asked if any medication decreased the voices, she stated “Xanax” (a benzodiazepine, not an antipsychotic). Later, she said Risperdal & Depakote helped in the past, but said she’d not taken them consistently (even though these were her currently prescribed medications).

CASE #5 reported to me that she had recently used alcohol due to her medication “not working”.  She again became insistent on needing to be in a hospital.  When I offered to contact her attorney to convey her concerns/issues, she became verbally agitated and blurted, “Those f****ing doctors at (the hospital)!” followed by the qualifier, “See, the voices are now talking through me!”

I again told CASE #5 I would contact her attorney and informed her that an MHP would be at the jail over the weekend to check in on her.  CASE #5 stated she didn’t want to be in jail even one night and concluded by stating I was like all the others who hadn’t helped her (though earlier she said she wanted to be in the hospital with ”lots of doctors” so that she could interview them for a change to determine which one could help her).  She did not want assistance from her mental health agency; she wanted the hospital, period.

Due to her labile mood, agitated affect, and entitled attitude, all leading to the possibility of her acting out to go to the hospital, I determined that she needed to be kept safe in an observation cell with property restrictions and limited time out.

CASE #5 was seen by my colleague and removed from observation status within 48 hours.  Though CASE #5’s mental health history was confirmed by the county mental health office (psych hospitalizations multiple times, plus cocaine/heroin use), she did not demonstrate any extraordinary behaviors for the remainder of her stay and was released the following month.

CASE #6 – “SLITHER TO SILK”

CASE #6 was a male in his early 30s who requested psych meds.  He was brought to the MHP office for the initial assessment where he reported the following information:

• Extensive drug use since age 15 (e.g., PCP & Acid)
• He reported experiencing voices & visions at age 20 (visions were of dragons, demons, and large men); including command hallucinations to harm himself
• Suicide attempt at age 26 (hanging); self-harm behavior also (cut wrist/arms)
• Took medication in prison before but no treatment in the community

He reported current voices were “not too bad” and presented as alert, oriented, able to track, with mood/affect/thought process all within normal limits.  He was referred to the psychiatric ARNP for the following week (only scheduled at the jail 1 day a week) for medication consideration and was assessed as appropriate for a general population unit.

I followed up 4 days later with CASE #6 to respond to his kite, in which he stated “I’m hearing voices, seeing things, very nervous – need meds today”.  During my interview with him he got up once and peered out the office door to “check it out”.

As we continued with my interview, CASE #6 was preoccupied with the jail getting his treatment history from the prison and a hospital where he claimed he was treated.  He wanted my business card and documentation from the jail provider “in case the meds mess me up” (he reported he’d had a medication-induced seizure once and also Tardive Dyskinesia, both very serious side effects).   However, in spite of these potential side effects, he stated that medication would decrease the voices.  When I asked about the nature of the voices, he said they were antagonistic and had urged him to threaten his cellmate.  CASE #6 was then quick to say he wouldn’t do that and that the medication would decrease such risk.

I was not convinced that CASE #6 was psychotic but I erred on the side of caution and contacted the ARNP who agreed to prescribe for him a low dose of Zyprexa (antipsychotic).  In the meantime, I made it clear to him that I could not leave him in a general population unit (where he wanted to remain) for safety reasons and had him moved to the maximum security floor.

One week later CASE #6 threatened to hit his head on the cement desk in his cell because he wanted more meds. He was moved to a safety cell and placed on close observation.  My colleague followed up with him the next morning. The MHP assessed CASE #6 as being clear and cogent with no evidence of a thought disorder but invested in wanting to appear as mentally ill.  The MHP informed him that, based on his recent & current level of functioning, his medication dose appeared to be appropriate.  Within moments of hearing this, CASE #6 reported he no longer heard voices, was not suicidal, was “doing fine”, and requested a general population unit again.  He was returned to the maximum security unit to await a review by the classification committee.  His status was reviewed that week and he was moved to a general population unit.

Two weeks went by without any word about CASE #6 to the MHP office.  Then he was moved to the psych unit because he said he was hearing voices telling him to kill himself or someone else.  When I followed up with him the next day he told me he had been moved from one housing unit to another, which had caused him to feel more paranoid and he wanted to move out.  At that point, he had been moved back to the maximum security unit.  It was there that his voices began to tell him to kill himself or someone else.

On the psych unit he told me he felt ok and wanted to either remain there or return to the previous general population unit.  I assessed him as having no remarkable psychiatric symptoms: His speech was coherent & within normal limits, mood/affect were also within normal limits, he was oriented, able to track, with no evidence of a thought disorder or paranoia.  He was also able to discuss some of the aspects of his legal case.  He was not remiss to report that the medication he was currently taking did help him.  It appeared to me that he was using psych symptoms when it suited him and that his behavior in that regard was certainly volitional.

CASE #6 was, again, placed in a general population unit and remained there 3 months without any issues.  He was then referred to the MHP office again due to him telling the unit officer that he would “flip out” if he didn’t get to talk to the MHP.  When he was brought to my office he looked around suspiciously, acting somewhat nervous.  I asked him what was going on and he said he was feeling weird.  He then abruptly got down on his hands and knees (which startled me) and peered under my desk.  He claimed he had seen a snake: “Did you see that snake…over there on the floor!”  I quickly regained my composure and calmly informed him that, to my knowledge, there were no snakes in my office.  He teared up briefly, collected himself rather quickly, and, within moments of his alleged hallucination, he commented on the photos on my wall and on my attire with “That’s a very nice silk tie you’re wearing…my father made silk ties.”

CASE #6 told me he still wanted a medication he’d taken in prison because that medication was “smooth”.  He claimed the Zyprexa was helping “only a little”.  Before we finished, he said he already felt better just talking and would not flip out (only said that to see me quicker).  Also, he requested to not be seen by my colleague due to that MHP’s “attitude”.  And his legal case?  He planned on some sort of mental health defense based on his prison treatment records. Which, ultimately, did not prevent his return to prison.

Other Clinical Cases

Suicide Risk: “Hanging From The Hoop”

This case was my inauguration as a first responder to suicidal behavior.  It occured early on in my work at the jail and made very real to me how deadly serious some people can be when contemplating suicide:  This man started out in the general housing unit.  After a phone call did not go to his liking, he slammed the receiver down.  When his behavior was addressed by the officer on duty, he angrily cussed at the officer who, in turn, ordered him to cuff up.  This man then made threats towards the officer.  The officer requested assistance and he was taken to the disciplinary housing unit for lockdown.

Later that evening, the unit officer was doing his rounds on each inmate and stopped to look in this man’s cell.  The officer observed him laying on the floor with his wrists tied behind his back and his right leg looped through his arms, pinning them behind him.  The man’s face was dark purple, with mucus trailing out of his nose and mouth, and he did not appear to be breathing.  The officer radioed for help and entered the man’s cell.  He pulled away the collar of the man’s coveralls and found a leather shoelace wrapped twice around his neck and tied off.  Another officer quickly responded, cutting the lace and removing it from the man’s neck.  The man began to wheeze and gasp for air as more officers responded to the scene.  Once he stabilized, he was removed to the jail’s booking area and placed on close observation in a safety cell.

This man was seen the following day by my colleague.  He reported he had no history of self-harm or suicide attempts and admitted he was going through heroin withdrawals.  He stated he would not hurt himself at the jail and added that he would continue to use heroin upon his release.  My colleague noted that he had a very flippant and negative attitude, and did not want any help from the jail mental health staff.  He was moved to the psychiatric unit for continued observation.

On the very next day, as I was in my office (around the corner from the psychiatric unit),  I heard a loud commotion coming from that unit.  I rushed to the unit and saw several inmates pointing in the direction of the unit’s outdoor recreation area.  As I hurried toward that area, I looked through the window saw this man hanging from the basketball hoop (somehow, he had found a sheet and tucked it under his coverall top during his brief time-out period).  Though stunned, I noticed that two or three other inmates were trying to support his body weight by lifting him up.  I grabbed a chair and entered the area to assist the unit officer.  I placed the chair in front of  the man and the officer stood on it and began cutting the sheet off of the basketball hoop.  I joined the other inmates by wrapping my arms around his legs to provide support while the man gagged for breaths.  The officer cut through the sheet and as we let him down I noticed that his hands were, once again, tied behind his back.  Medical staff responded and assessed his condition.  As he came around, he became combative and was placed on the restraint board for safety.  I called the court and attorneys who, in turn, issued an order to have him sent directly to the state hospital for treatment as a danger to self.

This experience taught me a lot about taking all suicide gestures, comments, and behaviors seriously.  And, with respect to jail operations, to remove and/or reduce the means by which inmates attempt suicide.  In this case, the jail removed the basketball hoops from all of the recreation units, to make sure there would be no further instances like this one.

Psychiatric Emergencies: “The Benzo Battle”

This case was a medical/psychiatric nightmare to manage:  With very little initial treatment history available, our health services staff worked very hard together to stabilize this inmate when he arrived to the jail.  Due to his altered mental status – marked by confusion, agitation, and memory deficits – this inmate was unable to provide our treatment team with any real helpful information about his care.   We were, however, able to determine that he had recently been to the local hospital emergency room to receive treatment for alcohol-related seizures and stitches for a leg laceration.

His agitiation escalated and he became combative with corrections officers.  He was placed securely on a restraint chair and then checked by medical staff.  Medical staff were able to determine that this inmate had lice and scabies in addition to the multiple scratches & abrasions on his legs and arms.  They were further able to assess that his altered mental state was likely due to alcohol and benzodiazapine intoxication (he reported taking 3 different benzos along with his alcohol).  Due to the potential risks inherent with that type of withdrawal, the jail had the inmate sent out to the hospital for further assessment.

When the inmate returned, the jail’s psychiatric provider intiated the alcohol/benzo protocol to safely get him through his withdrawals.  The inmate was only semi-cooperative and had to be placed in a single cell for observation, where he continued to yell and pound on the cell door.  It took several days of medical treatment and frequent visits by our mental health staff to safely get him through those initial days.

Over the next few weeks, as this inmate stabilized and his mentation cleared, our treatment team continued to reassess him for his reported psychiatric disorder of anxiety.  It became clear to us that the inmate’s underlying – and previously undiagnosed – condition was, instead, Bipolar I Disorder.  He was placed on a mood stabilizer and improved significantly (no more benzos)!  For the first time in several years, he was able to reconnect with his family and transitioned back to his home town when his jail time was completed.  And…he followed up with appropriate psychiatric treatment in his community, with no more visits to the jail.

Crisis Intervention: “A Crash Course”

I received the following information from the arresting officer regarding this case:  A woman had been drinking and got into an argument with her husband.  He went to work and later received a text from his wife that she had his gun.  He left work and went to their motel where he took the gun without incident from his wife, locked it up, and returned to work.  The woman, in response, got into her car and proceeded to ram his truck, which he had left parked at their motel.

When the police investigated, the husband told them that his wife had attempted to hang herself several years before. The woman told the police that she was, indeed, suicidal and did not want to live.  When she arrived at the jail, she was place in a safety cell for close observation.

By the time I talked with her to assess her risk factors, she was sober and able to have a clear conversation with me.  Here are some of the things she shared with me:

• She and her husband had been married for several years and they had no children.
• She told me that she had experienced a lot of bad things in their marriage.  When I asked her to give me an example of what she meant, she described her husband as not nice and very controlling of her spending (she was currently unemployed).
• She’d been using alcohol for several years to cope with her marriage stressors and was going to AA meetings for help. She admitted to drinking prior to her arrest incident.
• She indicated a history of self-harm when she was a teen (she had cut her wrists) and was subsequently treated for depression with an anti-depressant medication for a while (which she had not taken in recent years).
• In the past month she had seen a provider who started her on anti-depressant medication for her complaint of anxiety & depression. Within a few days of taking the medication, she had cut her wrist (superficially).  She was currently seeing a professional for individual counseling.
• She explained to me that she had increasingly felt trapped in her situation with her husband and had wanted a way out. She had hoped that when she texted him about having his gun, that he would see how serious & desperate she was.  When he simply locked it up and went back to work, she got ‘lost it’ and rammed his truck with her car.

This woman was a very softspoken individual, cooperative & respectful, and embarrassed by what she had done (she had never been in trouble with the law before).  When I talked with her about her recent suicide statement to the police and having the gun, she was clear that she had not wanted to die. Rather, she was wanting a way out of her stressful situation.  She told me her parents lived out of state and that she planned to visit them as soon as possible.  And, now that the court had issued an automatic No Contact Order between them, he could not prevent her from leaving.   She expressed gratitude to me for listening and thanked me for helping her move forward.

Mental Health: “Early Indicators”

A few days after this 18 year old man came to jail, his mother called and reported his recent troubling behavior:  He had been expelled from high school 3 months before due to threatening another student and verbally abusing school staff (during his final weeks of high school).  Since that time, he had been obsessed over being kicked out of school, with escalating anger outbursts towards his mother, blaming her for the incidents.  Two or three times he had taken some of her clothing and soiled them with food.  The mother was wanting a mental health evaluation for her son to determine if he qualified for treatment.  When I asked the mother about any mental health issues in the family, she stated that her son’s father, who had left when he was very young, was diagnosed with Schizophrenia and had a history of psychiatric hospitalizations and taking medications.

I met with this young man in my office to assess his mental health.  He was cooperative and pleasant while talking with me.  While he did not demonstrate any obvious mental health symptoms during the interview, it became clear to me as he talked about his recent history that he would benefit from a full psychiatric work up.

He reported that over the past few months he had not experienced any disturbance in his sleep, appetite, energy, or concentration.  He had, in fact, found a job at a car dealership and was following up with an alternate high school program to obtain his diploma.  He did endorse problems with his mood; mainly, feeling sad & angry.  Regarding his sadness, he explained that one of his friends had died in a car accident a couple of months before.  Regarding his anger, he reported he had assaulted two former students after being expelled.  At times, this young man had had fleeting suicidal thoughts but no intent or specific plan to kill himself.  He also denied any and all homicidal ideation.

When we discussed his thought process & content my referral for follow up became clear.  He endorsed he had been hearing voices at times that were familiar to him, both positive & negative, but could not really describe them clearly (other than one of them coming from his deceased friend).  He also believed that when he watched TV he had received special messages that were meant for him.  Similarly, he told me that once he thought he had heard a police radio call him out (thankfully, he did not respond and look for any incidents involving law enforcement).  When I asked about any drug or alcohol issues, he indicated he’d used marijuana before but not for the past 8 months; he did admit to heavy drinking at times on the weekends.

My clinical impression was that he had been struggling with the early onset of schizophrenia and was in need of psychiatric care.  I wrote a letter to the inmate’s attorney recommending further psychiatric evaluation and included an excerpt from the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR) regarding the onset of schizophrenia, “…the majority of individuals display some type of prodromal phase manifested by the slow and gradual development of a variety of signs and symptoms (e.g., social withdrawal, loss of interest in school or work…unusual behavior, outbursts of anger)”.  His attorney was able to coordinate a treatment plan with his mother and he was released for follow up care one month after coming to jail.

 Substance Abuse: “The Mental-Dental Connection of Meth Madness”

Talk about a wild and crazy case – this one I’ll never forget: A man was arrested and brought to the jail for the charge, Felony Harrasment – Death Threats.  He had been at the hospital emergency room asking for help.  However, his request for help included frantic demands that the medical staff pull his teeth out, because something was wrong with them.  When the medical professionals quickly assessed that he was not in his right mind, the man escalated and, from his back pocket, he pulled out a pair of pliers.  He inserted them in his mouth to start removing his teeth when hospital staff restrained him.  This infuriated the man and he threatened numerous times to kill them all for not doing their jobs.

After he arrived at the jail, he was placed on the psychiatric unit for closer observation.  He was extremely psychotic & paranoid and was unwilling to work with our mental health staff or consider taking medications.  However. we were able to find out from him that he had been a heavy meth user for the past 5 years with no history of mental heatlh treatment.  He continued to believe there was something wrong with his teeth and kept demanding that the jail dentist pull them out.  His defense attorney could not get him to cooperate with his legal proceedings so he had the judge order him to the state hospital for a full competency work up.

While at the state hospital, it was determined that psychotropic medication was needed to restore his competency before he could continue with his legal proceedings.  Once he’d been medicated for several weeks he returned to the jail a much calmer individual and ready to proceed with his attorney.  He was still delusional, though, and revealed to us that he believed a Lithuainian crane fly was inside his body, traveling through his blood vessels, and up into his teeth.  No wonder he had initially been so agitated and determined to have all of his teeth pulled out!

After serving jail time for his crime, he followed up with mental health services in the community and remained engaged in services – he even followed up later with the jail dentist at the dentist’s office in town….for routine dental work, mind you.

 Serious and Persistent Mental Illness: “Aliens & Nazis”

This was a middle-aged woman serving 11 days in the jail’s Work Release program for a Petty Theft crime.  The Work Release supervisor requested that I see her to determine if she could manage in their program as she had reported taking medications and had a history of psychiatric hospitalizations.

I met with her and she was agreeable to talk with me.  She initially was calm but within a few moments became very intense and animated as she talked about her battle with aliens and Nazis.  She reported to me that she was currently in a special military unit for the alien war and that her boyfriend, who worked at the UN, was assisting her.  She reported that she tended to stay at home most of the time due to the Nazis being everywhere.  According to her, the Nazis has messed with her when she was staying at a crisis bed facility and she had earlier survived a bomb blast due to the ongoing war.

When I asked about her treatment history, she indicated that the psychiatric hospital had placed her on the right meds 3 months before and that she liked going to the community mental health center for her treatment.  She calmed herself and told me that she would be okay in the Work Release program, because keeping busy helped her.  She requested assistance in contacting her daughter and made a comment that perhaps the phone company was tapping her calls.

I thanked her for meeting with me and reported back to the Work Release supervisor.  I told him that while she did have bizarre beliefs, she did not have a history of harm to herself or others.  He agreed that they would monitor her behavior and call me if needed.  She made it through her 11 days without any incidents with the other residents…I’d say a fairly remarkable accomplishment for someone who suspected that she was surrounded by aliens & Nazis!

Correctional Mental Health/Mentally Ill Offenders: “I’m Famous – Believe Me or I’ll Kill You!”

This inmate was both fascinating to talk to and challenging.  He was initially arrested for Threats to Bomb or Injury Property charges.  The arresting agency included in their report information that this person frequently roamed the area acting bizarre by telling people popular songs and movies were actually about him.  The police recommended that the court order a psychiatric evaluation.

Two days after coming to the jail I met with this inmate.  It did not take very long at all for me to determine that he was, indeed, experiencing mental problems.  He was very eager to share his story with me, his speech was pressured, and he cut me off any time I tried to interject a question or comment.

His belief system was as follows:  He believed his father was the Green River killer, so he reported him to the police and FBI several years before.  When the police and FBI did not believe him and conspired together to silence him, Hollywood found out about the cover up and began making movies about him (the inmate).  This, apparently, was done by Hollywood to protest the government’s actions and prevent riots.

He stated that he would not actually light fires or harm others but was trying to get the police to take his story seriously.  He flatly denied any and all mental health problems.   I had difficulty ending the interview due to the inmate’s incessant talking and asking me repeatedly to contact the FBI to verify his story.  I supported the arresting agency’s request for a full psychiatric work up and, over the course of the next few months, the inmate was eventually sent to the state hospital for competency restoration.

Fast Forward a Few Years:  This inmate continued to return to the jail on various offenses with no improvement in his mental condition.  He persisted in his belief that he was famous (listing dozens of movies & songs that were about him) and, over time, began to escalate when he could not get others in the criminal justice system to agree with him.  During an 18 month stretch at the jail, he wrote over 100 threats with phrases such as “kill you”, “be killed”, or “you’re dead” to various persons/agencies including the President, the FBI & CIA (yes, he was seen by the Secret Service but not deemed an immediate threat to the government), law enforcement, public defenders, the state hospital, the jail director, the jail mental health staff, and me.

The court had this inmate again go through the competency restoration process.  When the judge finally released him he was placed in the local psychiatric hospital for ongoing treatment.  Something must have finally clicked, because he did not return to the jail.  I saw him briefly a few years later in a community setting as I was heading to a meeting.  He shook my hand and asked if I had seen a recent action movie.  I knew where the conversation was heading so I smiled and wished him a good day as I got on the elevator.  Well, he was still delusional but at least he was staying out of trouble.

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