California Prison System Skirting the Law?

Does anyone care about our prisoners? After all, some may think, they are prisoners for a reason, to be punished for their misdeeds. Many of our prisoners, though, are mentally ill. And all of them are human and deserve to be treated with compassion and skill.

Is there discrimination against California prisoners who need mental health treatment?

When a psychiatric patient is treated under a different standard of care than other patients, that is discrimination.

California law and precedent mandates that a psychiatric physician be intimately involved in the care of prisoners housed by the California Department of Corrections and Rehabilitation (CDCR). But a whistleblower report tells us that prisoners with severe mental health needs are often not scheduled to see a psychiatric physician for years. For example, patients with a severe brain disorder called schizophrenia may refuse medications, after which they need to be monitored and persuaded to take the medicines they need to tame their disease. However, if a patient in CDCR is not taking medications, they are removed from the schedule of the psychiatric physician who can help save their lives. They may not be seen for years. In short, many psychiatric patients in the CDCR aren’t able to see a physician qualified to treat their mental illness.

That same report tells us that there may be a major cover-up happening within the CDCR.

Are there psychiatrists to take care of California’s prisoners, as required by law?

Psychiatrists and psychologists are not interchangeable.

Psychiatrists are medical doctors specializing in psychiatric conditions. They have a broad scope of practice encompassing psychology and physiology, and how they interact. Psychiatrists know how to determine if a psychological symptom is being caused by a brain tumor or other medical condition. Psychiatrists can determine medical and physical risks and dangers.
Psychologists are not physicians and have no medical or physical health training and no medical license. They have a much narrower scope of practice – psychology only (“talk therapy”), and they do not know how to rule out medical causes of psychological symptoms. They have no knowledge of physical/medical risks and dangers.

In CDCR, non-psychiatric patients often get reasonable medical care, with doctors and nurses available to treat them. Patients with psychiatric disorders need proper medical care too. That includes proper evaluation and care by medical doctors specializing in psychiatry. But CDCR’s policy is to have psychologists, rather than psychiatrists, direct psychiatric patient care, even in licensed inpatient and crisis psychiatric hospitals. CDCR’s policies authorize psychologists to overrule psychiatrists’ medical advice about when patients should be seen next by the psychiatrist, sometimes with disastrous results. Not all CDCR psychologists do this. But those who do are practicing medicine without a license.

It gets even worse.

We understand that California has more than 300 UNLICENSED Psychologists and Social Workers. Some of these unlicensed workers haven’t completed their training, and some haven’t yet passed their licensing examinations. These trainees or unlicensed Psychologists and Social Workers are being trained in a system that allows them to overrule a physician’s medical decision. These are the same people who may be caring for your family members once they (IF they) become licensed. The bad news for the prisoners is that these unlicensed non-physician practitioners don’t know what they don’t know, yet they and CDCR don’t seem to care.

Would you let a psychologist in the ER determine medical treatment if your family member was having a heart attack, or if your family member overdosed on an unknown substance or medication? We feel certain you’d want the person most highly trained and qualified to treat your loved one: a physician. Yet, from the Golding Report, we know, for example, that an unlicensed psychology intern overruled an experienced psychiatric physician about the need to discharge a patient from inpatient care, in just one example of inappropriate psychiatric management for these California prisoners.

Restraining prisoners without mandatory medical clearance in hospitals is illegal in California, yet is allowed in CDCR

Title 22, the regulatory system for California Prisons, clearly states that physician approval is needed for restraints to be applied in licensed hospitals. CDCR is not mandating that. Restraints are not what most laypeople imagine. It’s not like just putting handcuffs and ankle cuffs on someone. Applying restraints involves firmly strapping the person down, lying face up, so that he or she can’t move. People are often physically injured when struggling against their restraints. They can aspirate and get pneumonia, or could even die in some cases. There are very significant physical risks, yet CDCR has psychologists with no physical health or medical training whatsoever ordering restraints and expecting nurses to follow their restraint orders. This is true even in cases in which the nurse thinks the physician would not approve, whether because it is too medically risky or because the physician might prefer a more humane option, such as calming the patient down with medication.

There are distinct and critical differences between a psychiatrist and a psychologist, and it’s not okay for CDCR to skirt the law by replacing psychiatrists with psychologists or by allowing psychologists to make final treatment decisions for prisoners. CDCR’s official policy since April 2018 is that in licensed crisis hospitals, psychologists are permitted to overrule psychiatric physicians and demand a patient be discharged, even if the psychiatrist thinks the patient will be medically/physiologically in danger. This may be the first instance in the entire country in which non-medical practitioners (psychologists) are allowed by policy to overrule physicians about whether a patient needs to be treated in a hospital.

Regardless of platitudes about the importance of including psychiatric physicians in decision making, CDCR’s actions are not consistent with such platitudes. CDCR perversely deems the non-medically trained psychologist, rather than the psychiatrist (i.e., the medical doctor) to be the “primary clinician”. There is not a single psychiatry executive in CDCR. Psychologists wear name badges saying “Dr.” and not specifying that their doctorate is in psychology rather than a medical doctor. Indeed, a psychologist has been listed as the “physician to call” in at least one CDCR mental health nursing station. Psychologists in CDCR very often override psychiatrists’ judgement and/or medical orders, and the CDCR system effectively supports them in doing that rather than discouraging it. –The Golding Report

Also from the Golding Report: “”[An Official whose name is redacted] signed a memo that gave psychologists the authority to overrule psychiatric physicians’ medical decisions about the medical safety of discharging medically complicated patients from licensed hospitals. The memo said that the decision to discharge is made by “the primary clinician or treatment team”. The psychiatrist and the psychologist are both members of the treatment team. The psychologist is the “primary clinician”. It logically follows that the memo is saying that in cases where the psychiatrist and the psychologist disagree (and thus the treatment team can’t reach a decision), the psychologist rather than the psychiatrist makes the decision. Giving psychologists the authority to overrule medical doctors’ decisions with respect to potentially medically complicated patients must be one of the most radical policy decisions ever. Having no medical training, psychologists have no ability to evaluate medical issues such as whether a patient’s diabetes or high blood pressure is stable, or whether there is toxicity from a psychiatric medication, or indeed whether psychiatric medications are increasing or decreasing suicidal risk. Psychologists overruling medical doctors even in emergency situations and about discharging medically complex patients from hospitals has had a steep cost in terms of bad outcomes.”

A joke of a “psychiatric evaluation” and padded documentation. If you were in prison, and someone standing outside your cell held up a laptop so you could talk to a psychiatrist on the computer screen through the narrowest window-slit in the cell door (telepsychiatry) for a few minutes—all with your fellow prisoners nearby–should that count as a psychiatric evaluation?? The CDCR may believe so, as they apparently report those encounters as full psychiatric evaluations, despite the lack of privacy and lack of depth of discussion.

Logging this “telepsychiatry” visit as an actual medical evaluation makes CDCR appear to meet required benchmarks. So does using the prisoner transfer system to change due dates for psychiatric visits. And gaming the scheduling system also makes the CDCR appear to be following the benchmarks required of it. But none of this is based in reality, it seems.

Patient harm has been documented, yet that hasn’t been enough to change the system.

How many patients should suffer needlessly before something is changed??

In one disturbing example, a woman removed, then ate, her own eye four hours after an evaluation by a psychologist and being placed on suicide watch. —Julie Small

Bob Egelko wrote for the San Francisco Chronicle:

[The] woman who had been refusing to take medications was diagnosed as gravely disabled by a staff psychologist and placed in a prison hospital on suicide watch, attended by a nurse, the report said. After screaming periodically for four hours, the woman, while lying on the floor, pulled out her left eye, and then, after guards arrived, put her eye in her mouth and swallowed it. Prison psychiatrists reviewing the incident agreed that the woman should have been medicated, by force if necessary, Golding said.

But when patients are to be transferred to a licensed psychiatric hospital, there is not even a mandated phone call to a psychiatric physician to make sure that medications are not needed, nor is a thorough medical evaluation performed to rule out medical causes of psychiatric issues. Because the psychiatric physician did not have to be contacted by mandate to evaluate a a patient in an emergency when the patient was to be admitted to the crisis hospital – the non-medical psychologist’s evaluations was deemed sufficient — a psychotic patient screamed for hours and received no calming psychiatric medications. Then, the psychotic patient pulled out her eye and ate it. Later, Golding said, a prison safety committee, whose members had no medical training, found no connection between the patient’s self-mutilation and the lack of medication. How tragic and utterly ridiculous.

That patient was reportedly never seen by a psychiatrist who could have appropriately diagnosed and treated her and could very likely have prevented this horrific outcome. And we wonder how that event might be related to the resignation of the Chief Psychiatristof the California Institute for Women, who was given no power to change the culture and policies of the CDCR to improve patient care.

CDCR has one of the highest suicide rates in the country for a prison system.

The problems have been reported and documented, yet nothing has changed.

Well, that’s not entirely true–some things have changed.

CDCR Psychiatrists are speaking out, and they’re being retaliated against

Dr. Michael Golding is the brave psychiatrist who is behind the Golding Report that set off a whole chain of events within and outside of CDCR. CDCR was about to cut its psychiatry ranks by firing (or otherwise letting go) about 79 psychiatrists. After all, if all the benchmarks are being met or exceeded, surely there must be overstaffing, right? (Nevermind that the numbers were apparently inaccurate.) After the Golding Report came out, the staffing changes were abandoned. But that doesn’t mean CDCR is happy about it.

What’s happening now:

The Golding Report was submitted by attorneys to a judge, The Honorable Kimberley Mueller. The attorneys are representing CDCR prisoners in lawsuits claiming psychiatric mistreatment. Judge Mueller decided to make the Golding Report public, shining some sunlight on the ugly underbelly of the CDCR.

Unsealed by Judge Kimberley Mueller in October 2018, the Golding Report alleges that data put out by the California Department of Corrections has been inaccurate and misleading, that this has adversely affected patient care, and that CDCR policies facilitate overreach of scope of practice on the part of psychologists, preventing inmates from getting appropriate psychiatric medical care.

A neutral expert investigator was appointed by Judge Kimberley Mueller to look into the data-related allegations in the Golding Report. The neutral expert will be reporting his findings to the Judge by April 22, and Judge Mueller is expected to respond within the next few weeks. The scope of practice overreach issue is still to be addressed.

California legislators, Judge Mueller, and the people of California need to understand the medical dangers California prison inmates are subjected to because of this poor care and corrupt system.

What needs to happen now and how you can help:

CDCR must abandon its policy of having a psychiatric system led and run by psychologists.
Psychiatrists need to be directing psychiatric patient care, not psychologists, particularly in the complex prison population. Psychologists are excellent therapists but should not be determining psychiatric medical care. Psychiatrists should be the treatment team leaders.
CDCR must obey the law (CA Title 22), and stop enabling non-medical providers to practice medicine without a license.
CDCR needs transparency, including making data available to the psychiatric leadership to guide care throughout the California System. Without transparency, issues adversely affecting patient care remain hidden and are less likely to be fixed.

Write a letter to the editor of a newspaper or the Medical Board of California (or send them this blog) to let them know you think everyone, including prisoners, deserves physician-led care:

Sacramento Bee
LA Times
Medical Board of California