Caged - Name, effects continues to spark debate among specialists

 LOS ANGELES (MCT):

Before group therapy begins for mentally ill maximum-security inmates at California prisons, five patients are led in handcuffs to individual metal cages about the size of a phone booth.

Steel mesh and a plastic spit shield separate the patients from the therapist, who sits in front of the enclosures wearing a shank-proof vest.

When the lock clanks shut on the final cage - prison officials prefer to call them "therapeutic modules" - the therapist tries to build the foundation of any successful group: trust.

During a recent session at a prison in Vacaville, psychologist Daniel Tennenbaum, wearing a herringbone sports coat over his body armour, sat just out of urination range of the cages with an acoustic guitar, trying to engage the inmates with a sing-along of Sitting on the Dock of the Bay.

About a decade ago, a federal judge ruled that it was cruel and unusual punishment to leave mentally ill prisoners in their cells without treatment. Since then, state prisons have spent more than $1 billion delivering care to an ever-growing population of inmates diagnosed with schizophrenia, bipolar disorder and other psychiatric problems.

State officials say they have not tried to estimate how much of that cost is attributable to the caged therapy. The value of the sessions, however, is the subject of heated debate among mental health professionals today.

an abomination

"Those cages are an abomination. They train people that they're not human, that they're animals," said Terry Kupers, a psychiatrist in Berkeley who served as an expert witness on treatment of mentally ill prisoners in the case that forced California prisons to provide psychiatric care.

"It's bizarre, it has a Hannibal Lecter quality to it," said H. Steven Moffic, likening California's procedures to the measures used to contain an incarcerated serial killer in The Silence of the Lambs.

Moffic, a psychiatry professor at the Medical College of Wisconsin, has written about treating patients in prisons under less imposing restraints. "I'm not quite sure what the clinicians think they are going to get out of it," he said of California's method.

Prison officials say they are doing their best to comply with the court order, which requires them to offer treatment to all mentally ill inmates, no matter how dangerous.

Overall, that care in 2006 cost the state $166 million to treat about 32,000 inmates, department records show. By 2009, the number of inmates had risen modestly to 36,000 but the cost of treatment had more than doubled to over $358 million.

About 3,500 of those prisoners stepped into a cage for group therapy after being sent to a segregation unit for offences committed inside prison walls, including receiving smuggled drugs, organising gangs or assaulting prison employees.

better security

Jeffrey Metzner, a Colorado psychiatrist who has advised the court-appointed special master overseeing mental health care in California prisons, said the enclosures offer better security and more freedom of movement than alternatives used in most states, which include handcuffing patients to their chairs or shackling an ankle to the floor. Once the inmates are inside the cage, their handcuffs are removed.

Metzner also advised prison officials to refer to the enclosures as therapeutic modules, not cages. "The name is important, because if you call them cages, people inside might feel like animals and respond accordingly," he said.

That is precisely why some critics object so strongly to the enclosures.

"You're not fooling anybody with some ridiculous euphemism," said Pablo Stewart, a San Francisco psychiatrist and outspoken critic of the enclosures. "This is one of the more horrendous examples of what goes on in the California Department of Corrections."

Among Stewart's concerns is the fact that some mentally ill inmates remain in disciplinary segregation units, receiving therapy in cages, until their parole dates arrive.

"So one day you're so dangerous that you have to be in a cage and the person talking to you is sitting at a distance wearing a flak jacket, the next day you're sitting on a bus," said Stewart. "That's scary."

A few mentally ill inmates are involuntarily committed to hospitals after release from prison, officials said, but most get a supply of medication and instructions to continue therapy when they are back on the street.