On a March afternoon in the Cumberland County Prison in Carlisle, Mike Carey, the prison's deputy warden, unlocked a door to a section of the prison's segregation wing. Carey walked into a narrow hallway of steel doors, mesh-glass windows, and the unmistakable odor of disinfectant and feces.
The source of the smell was a single cell containing the section's single inmate: a mentally ill man who had been arrested in January for an alleged parole violation. As Carey approached his cell, the inmate wrapped his head and shoulders in a green blanket and cowered over the cell's steel toilet.
"He's hiding," Carey said somberly.
The blanket shuddered.
For nearly two months, the inmate had been isolated in the prison's segregation wing, nearly 24 hours a day, seven days a week, because he was too unstable to be housed with the prison's 400 other prisoners. But while isolation ensured the inmate was easier for Carey and his staff to manage, it had done little to improve his mental state.
Since his incarceration, the man had refused psychiatric medication, repeatedly banged his head against his cell walls, and shown a daily affinity for smearing his feces over every surface in arm's reach. Although evidence of that day's episode had been freshly cleaned, a faint imprint of feces-scrawled words and symbols still glazed his cell window.
Carey did not want to keep the inmate in isolation - nor, for that matter, did he want to keep him in the prison at all - but he faced a vexing problem. The inmate was so mentally ill that the prison had petitioned the court to transfer him to a state psychiatric hospital for intensive treatment. But here laid the rub: Pennsylvania's state hospital system was so full it couldn't admit any new patients.
Unable to be moved from prison and unable to appear in court until he was treated at the hospital, the inmate existed in a kind of purgatory, both physical and legal.
"We don't have a bed date yet," Carey said. "So who knows how long he will languish here until that happens."
An endless wait
Thirty years ago, in most county prisons across Pennsylvania, it took less than a week to transfer a psychotic inmate to a state hospital. Today, due to a shortage of state hospital beds and a surge in seriously mentally ill people in the criminal justice system, inmates now wait months or, in some cases, more than a year, for beds.
Lawyers and mental health experts approached by PennLive believe that Pennsylvania's mentally ill inmates might now have face some of the longest delays in the country for psychiatric hospitalization - raising a bevy of legal and human rights issues.
"It sounds outrageous," said Alan Felthous, director of forensic psychiatry at St Louis University in Missouri, in response to PennLive's findings. "It sounds scandalous and awful. As bad as things are in states where I have worked, I have never encountered anything like that."
A mentally ill inmate in a county prison is sent to a state psychiatric hospital when the courts believe that person needs to be evaluated for competency to stand trial or to be "restored to competency." A seriously mentally ill inmate can also be committed if the prison can prove that the person is a threat to themselves or others, as in the case of Carey's inmate in the Cumberland County Prison.
In most cases, a state hospital, with its teams of psychiatrists and specialized therapy, is able to stabilize an inmate so they can return to prison and to appear in court if they're facing charges.
Of Pennsylvania's seven state hospitals, only two of them - Torrance State Hospital near Pittsburgh and Norristown State Hospital near Philadelphia - handle county inmates. Those individuals are housed in secure sections of the hospitals called "forensic units." Collectively, Torrance and Norristown have 237 forensic beds - about the same number as Kansas, a state with less than a quarter of Pennsylvania's population.
Pennsylvania's forensic units are currently so overwhelmed by demand for their services that, according to state records acquired by PennLive through a right-to-know request, it took an average of 126 days for an inmate to get a bed at either hospital in the six months prior to June.
For reasons that aren't entirely clear, delays for beds at Norristown are particularly long. State records show that, over those six months, 39 inmates were hospitalized at the facility after waiting more than 300 days in county prisons. In June, one inmate was admitted after waiting 460 days - or 15 months - for a bed.
The state Department of Human Services, which oversees Pennsylvania's state hospitals, says it is working to reduce the backlog.
In response to a series of questions over several weeks, the department sent PennLive a two-page plan in late July on how it would address the problem. That plan includes the continuation of a program to send psychiatrists to county prisons to perform competency evaluations and internal changes to speed up referrals.
"We are concerned - particularly at Norristown," Kait Gillis, the department's press secretary, said in an emailed response to questions. "That is why we are moving with such a detailed and comprehensive work plan."
However, some are skeptical that those proposed changes go far enough to reverse the delays in Pennsylvania, which have been building gradually for decades.
Dr. Robert Nichols, director of mental health services at PrimeCare Medical, a prison health care contractor, said that some of the state's proposals - such as sending psychiatrists to county prisons to do competency evaluations - are things it is already doing.
He also was disappointed there was no firm goals or deadlines to reduce wait times.
"I'm not saying what they are doing won't help," Nichols said. "I'm just wondering how much it will help - and obviously there's no mention of increasing beds."
'Abnormally long' waits
Due to the different ways that states handle commitment orders, and the different ways of measuring wait times, it's difficult to compare delays for forensic beds in Pennsylvania with other states.
However, whether it's the average 297-day wait for a bed at Norristown or the 51-day wait for a bed at Torrance, legal experts approached by PennLive said that wait times at both facilities sounded excessive.
"I think that's abnormally long," said Michael Perlin, professor emeritus of law for New York Law School. "I think it's problematic on many, many levels. The chances are that the person at risk is in need of some kind of evaluation and some kind of treatment much sooner than that."
Ideally, Perlin said, a mentally ill defendant shouldn't wait longer than a week to be transferred to a state hospital for treatment.
In many cases, according to corrections officials and attorneys interviewed by PennLive, mentally ill defendants in Pennsylvania who have been found incompetent to stand trial are now spending almost as long, if not longer, in county prisons as they would have spent if they had been found guilty of their charge and sentenced.
Perlin said that those delays raised serious constitutional questions about a defendant's right to due process.
"They are in jail pending a trial," he said. "They haven't been found guilty - competency has nothing at all to do with factual guilt."
For those reasons, a handful of states have faced lawsuits in recent years over excessive wait times to transfer mentally ill inmates to state hospitals.
In 2002 in Oregon, a disability rights group sued the state after it was found inmates were waiting an average of a month to be sent to forensic beds. A federal judge ordered the state to cut wait-times to less than a week.
In 2009 in Louisiana, the ACLU of Louisiana and disability rights groups sued the state after it was discovered inmates were waiting an average of 195 days, or about six months, for forensic beds. The state agreed to cut wait times to less than a month and ensure that they are significantly shorter for certain inmates.
More recently, a similar alliance of groups sued the state of Washington last year over wait times that were "weeks and months" long. In April, a federal judge ruled that the state, like Oregon, had to cut wait times down to less than a week.
And in California, just last month, the ACLU of Northern California and disability rights groups sued the state after it found defendants with mental disorders were waiting an average of more than 75 days for forensic beds.
Approached with PennLive's findings, Michael Risher, a senior attorney for the ACLU of Northern California, said that the delays in Pennsylvania sounded as unconstitutional as they are in California.
"Based on what you have told me, if in fact you have people waiting in jail for months and months after a judge has ordered treatment, that sounds like a violation of due process rights," he said.
Witold Walczak, legal director for the ACLU of Pennsylvania, said that his office was investigating Pennsylvania's wait times for forensic beds.
Degenerative damage
Entangled in those legal issues are serious ethical questions about the treatment that inmates receive while they wait in county prisons.
With limited space and limited psychiatric staff, most county prisons are overwhelmed by the task of handling and treating a psychotic inmate for months. In many cases, those inmates are placed in solitary confinement - much like Carey's inmate in the Cumberland County Prison - for the near-entirety of their wait.
"The only time he gets out of his cell, it's usually when he's banging his head," Carey said.
Most mental health researchers condemn isolating mentally ill people because it typically causes their mental health to deteriorate further. As a testament to that concern, a United Nations expert declared in 2011 that placing mentally ill people in solitary confinement was a form of torture.
County prison officials say they are aware of those potential consequences but, again, say they have few options when handling psychotic individuals.
"We only have 'X number' of housing units," said Gene Berdanier, warden of Schuylkill County Prison. "We don't have an area we can just put special needs people in. So they almost have to be isolated until we can put them in a more appropriate setting."
In July, a seriously mentally ill inmate in Berdanier's prison was admitted to Norristown State Hospital after waiting more than a year for a bed - most of his time spent in solitary confinement.
Like isolation, corrections officials across Pennsylvania also say they don't relish using restraint chairs on seriously mentally ill inmates - another practice that is controversial in the mental health community.
"We use the restraint chair on someone who is trying to harm themselves, trying to cut their wrists, jump off of things," said Ed Sweeney, director of Corrections for Lehigh County. "And some of them are in and out of the restraint chair twice a day."
Even in large, well-resourced prisons, care is not ideal for mentally ill people who need hospitalization.
Bruce Herdman, chief of medical operations for the Philadelphia Prison System, said that while his prison has a 64-bed psychiatric facility it still can't provide the same kind of care and therapy as a forensic unit at a state hospital.
In particular, Herdman said, the prison's facility still looks like a jail, compared to the expansive campus of Norristown State Hospital. His prison also doesn't offer the same kind of therapy and training for patients, like Norristown's focus on preparing inmates who are incompetent to stand trial to appear in court.
Herdman said he believes that his prison system could offer those services, but it would likely require the construction of an entirely new unit with state assistance. For now, Herdman said, his prison has about 36 inmates, stuck in legal limbo, who urgently needed care at Norristown.
"For those individuals, they are just not getting the care that they need in a timely way," he said.
Felthous, the director of forensic psychiatry at St Louis University in Missouri, said that it was for all those reasons that not only were the delays ethically concerning but they were self-defeating for Pennsylvania's mental health care system.
"The longer that people go without getting treatment, the more likely the mental illness will cause degenerative changes and the more resistant the mental illness becomes to treat," he said. "So they end up in the hospital for longer periods of time, occupying beds for longer periods of time, and requiring higher doses of medication - which means a greater risk of side effects."
Counties turn to forced medication
The delays for state hospital treatment have become so problematic in Pennsylvania that some county prisons have been forced to take matters into their own hands.
Todd Haskins, vice president of operations for Prime Care Medical, which contracts with 29 county prisons in Pennsylvania, said his company has increasingly sought court orders to forcibly medicate inmates who are waiting for forensic beds in order to stabilize them.
Under Pennsylvania law, county prisons can't administer medication against an inmate's will unless they have a court order. By contrast, a state hospital doesn't need a court order to forcibly medicate a patient after they've been committed, which is one of the key differences between care in a prison compared to a state hospital.
Cumberland County Prison, from 2011.
Haskins said that while forced medication was not the company's preference it was often the most humane course of action.
"Because they reach this plateau," he said, "they may stop eating, they stop bathing, they may be a threat to someone else because they're very aggressive. So our choice, because we can't get them into a hospital, is to go to our attorney who will petition for a court-order to forcibly medically manage them and psychiatrically manage them."
Haskins said that over the past five years, as delays for forensic beds have grown in Pennsylvania, the company has forcibly medicated about 300 mentally ill inmates. In most cases, he said, it has significantly stabilized those individuals to a point where that person is willing to take medication voluntarily.
"Because of the court's willingness to allow us to do that forced medication we have actually been able to remove them from the waiting list," Haskins said. "It happens a lot."
However, Haskins and other representatives for the company stressed that forced medication was not their preference nor was it an alternative to treatment at a state hospital.
Nichols, the company's director of mental health services, said that the difference in the care provided in a state hospital over a county prison was incomparable.
"They pretty much have programming from eight in the morning till dinnertime," he said. "It's not just a warehouse where they go get their medication. Whereas we are in a prison, we don't have those kind of things, we're not set up for it."
Forced medication is also controversial among legal experts and in the mental health community.
Perlin, the professor emeritus of law for New York Law School, said that he found the prospect of forced medication in correctional settings particularly troubling.
"In some cases the medication does return people to competency," he said. "In some cases - if it's not done properly - it might make the person less competent."
Felthous, the director of forensic psychiatry at St Louis University, shared those concerns.
"My main concern is that it becomes an excuse for not getting people to the level of care they really need," he said. "If somebody for the first time needs medication with a needle and some strong arms, you don't do it in their apartment, you don't do it in an outpatient clinic, you do it in a hospital."
The wait goes on
In the Cumberland County Prison, Carey's inmate - the man with the affinity for smearing his feces over his cell - was one of those who was forcibly medicated.
He, however, did not stabilize.
It wouldn't be until mid-April, after waiting more than 50 days on the waiting list, that the inmate was finally admitted to Torrance State Hospital. Compared to the delays faced by many other inmates in Pennsylvania's county prisons, particularly those waiting for beds at Norristown, he was one of the lucky ones.
After he spent about a month in Torrance's forensic unit, the man stabilized and was returned to the Cumberland County Prison. Carey said he had rarely seen such a fast turnaround: The man even apologized to correctional staff for smearing feces over his cell.
"It was like 'wow, who was this guy?'" Carey said.
But there was a catch. On his first day of admission at Torrance State Hospital, still psychotic, the inmate assaulted a staff member. When he returned to Cumberland County Prison he was promptly transferred to Westmoreland County Prison to face new charges - another twist in the man's long journey through the correctional system.
Meanwhile, in early August, Carey faced a new problem. He was expecting to soon receive the results of a psychological evaluation for another inmate who was particularly unmanageable. He believed the results would almost certainly show that the man needed to be hospitalized.
After that, the wait would begin anew.
"We get rid of one and we get another one in," Carey said. "That's just the way it works at times."
Graphics by Nick Malawskey