Ideas

Ideas | Michael Rezendes

Recoil, reform, repeat

Jeremy Traum for The Boston Globe

Again and again, Massachusetts has promised to treat mental health patients held at the state prison known as Bridgewater State Hospital like human beings.

Fifty years ago, after the filmmaker Frederick Wiseman released a searing expose of the inhumane conditions there, authorities reacted with alarm and even revulsion.

Although initially banned, “Titicut Follies” was shown to select audiences and shocked policy makers with its frank depiction of patient neglect, including scenes of men held completely naked and a doctor smoking a cigarette while casually force-feeding a patient by running a tube through his nose. Meanwhile, in the exercise yard, an elderly patient played a mournful slide trombone to a fire hydrant.

The shock and publicity inspired significant change, but in the decades that followed, the men at Bridgewater have continued to endure barbaric conditions, horrific deaths, and treatment that often amounts to torture.

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Seven years ago, for instance, 23-year-old Joshua Messier was killed by guards during an incident covered up by prison officials until the Globe revealed the circumstances that led to Messier’s death and three guards were indicted on manslaughter charges. They are scheduled to stand trial next month.

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The indictments were unprecedented. Yet over the years, Bridgewater patients and their families have filed lawsuits, achieved what seemed like victories, and listened to a changing cast of public officials trumpet new policies at the state’s facility for men with a mental illness who are violent and have become involved in the criminal justice system.

That cycle of scandal, reform, and scandal has often seemed impossible to break, leading to an unwritten policy of “out of sight and out of mind” that inevitably carries the day. That’s partly because state workers routinely ignore the reforms approved by elected officials, and partly because of limited public support for violent patients who are difficult to cure and expensive to treat.

Indeed, the plight of mental health patients held behind bars is a growing, national calamity. Thanks to the shuttering of state psychiatric hospitals and a collective failure to fund community mental health programs, the percentage of state prisoners with a mental illness has soared to more than half, according to the Urban Institute.

And the Treatment Advocacy Center, an organization that promotes better mental health care for people with a serious mental illness, estimates that 15 percent of all state inmates and 20 percent of all city and county jail inmates suffer from a severe mental illness. That’s about 356,000 inmates, or enough people to populate cities such as New Orleans or Tampa.

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Even in this environment, Massachusetts is a noteworthy laggard. It’s the only state in the country save one that assigns management of its forensic hospital — the facility for mental health patients involved the criminal justice system — to a department of correction rather than a department of mental health. And at Bridgewater, prison officials have continued to rely on seclusion and four-point restraints, the practice of strapping a patient down by the wrists and ankles, in the face of a national movement to abandon those tactics because they are increasingly viewed as dangerous and inhumane.

Today, those distinctions pose stark questions about the state’s ability to implement lasting change for a troubled population while raising the possibility that, once again, today’s reforms will contain the seeds of tomorrow’s scandal.

Despite its name, Bridgewater is neither licensed nor accredited as a hospital. Surrounded by high chain-link fencing topped with coiled razor wire, it looks and feels like the medium security prison it is.

As in any prison, visitors and family members are searched before entering. And mental health patients, many of them sent to Bridgewater after being accused of minor offenses, such as hitting a hospital orderly, are strip-searched before and after each family visit.

And while Bridgewater is staffed by mental health clinicians and is accredited as a behavioral health provider, Department of Correction officials and prison guards control the facility and have the final word on patient decisions — a command structure that invariably favors security over care.

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At its worst, this means that Bridgewater clinicians are expected to look the other way when guards mete out a beating to a mental health patient. The routine nature of this practice was documented during a State Police investigation of a 2014 incident when a guard allegedly retaliated against a patient who had spit at him by entering the patient’s cell and repeatedly slamming the patient’s face into a wall, leading to significant injuries.

Prison officials have continued to rely on seclusion and four-point restraints, though those tactics are increasingly viewed as dangerous and inhumane.

In a State Police report released during the course of a lawsuit, Officer Scott Flaherty said he interviewed several mental health clinicians who said that as a “rule of thumb you see no evil, hear no evil, and speak no evil.” Only when a patient has been secured in a cell, one clinician said, “is it proper for medical staff to intervene.”

That’s why the news out of Bridgewater in September seemed like a sea change. For the first time, under a plan unveiled by state officials, prison guards are to be replaced by a private security force trained to handle men who are mentally ill and may act out violently.

In addition, patients who have been convicted of a crime — about 15 percent of an overall population of 270 — will be transferred to another prison. That will allow Bridgewater to become a facility primarily for men who have been sent there for psychiatric evaluations, often to see if they are competent to stand trial, as well as for those who have been found not guilty by reason of insanity.

What’s more, the private company that agrees to take over management at Bridgewater by March 1 — providing security, and medical and mental health care — will be expected to cut down on the use of solitary confinement and four-point restraints. “This is massive change,” said Marylou Sudders, the state’s secretary of health and human services, during a briefing for state legislators.

Others aren’t so sure. That’s largely because Bridgewater will continue to operate under the Department of Correction rather than the Department of Mental Health — a designation that cannot be changed without state legislative approval. It also means a Department of Correction superintendent — instead of a medical or mental health official — will continue to have overall authority over what happens at Bridgewater. “Removing correctional officers from Bridgewater State Hospital is a vital and important step, but it’s not enough,” said James Pingeon, an attorney with Prisoners’ Legal Services. “If you don’t have a medical director who is really in charge, it’s not going to work. The correctional mentality will eventually take over.”

Evidence that prison officials routinely brush aside even the most stringent and well-intentioned reforms is overwhelming. To cite one glaring example, previous reforms included a Bridgewater policy that says the facility will aim “to prevent, reduce, and strive to eliminate the use of seclusion and restraint.”

But the Globe found that Bridgewater officials increased their reliance on these measures, even after Joshua Messier’s 2009 death, to the point where in 2013 patients there were placed in restraints or isolation at more than 100 times the rate of patients at other state mental health facilities.

Messier, a onetime UMass student who suffered from paranoid schizophrenia, was sent to Bridgewater for a psychiatric evaluation after staff at a private hospital near Worcester charged him with misdemeanor assault and battery.

A month later, on a May evening in 2009, shortly after meeting with his mother in Bridgewater’s visiting room, Messier was dead. Prison video showed that, after an off-camera altercation with guards, Messier was hauled to a cell in Bridgewater’s infamous and ironically named Intensive Treatment Unit, where the guards wrestled him into four-point restraints.

The video also showed that two of the guards “suit-cased” Messier, pushing down on his back until his chest touched his knees while his hands were cuffed behind his back, contributing to what an autopsy concluded was heart failure. Then the guards stood around waiting for medical personnel to arrive, ignoring Messier’s motionless body and never bothering to check his vital signs, while his face slowly turned blue.

No one was disciplined after Messier’s death. And Plymouth District Attorney Timothy J. Cruz decided no one would be prosecuted, even though the state medical examiner’s office ruled Messier’s death a homicide.

But the Globe revealed that the guards, with no training in handling patients suffering from a serious mental illness, had violated more than a half dozen laws, regulations, and hospital policies while manhandling Messier into four-point restraints.

It also found that Department of Correction officials covered up the circumstances surrounding Messier’s death, ignoring an internal affairs investigation that found the guards at fault and failing to conduct a required review of Messier’s death with an outside medical expert.

As the Globe continued to investigate and publish page one stories, then-Attorney General Martha Coakley named a special prosecutor to review Messier’s death. As a result, three of the guards, including the two who suit-cased him as well as a supervisor, were charged with involuntary manslaughter and civil rights violations.

During a yearlong investigation of conditions at Bridgewater, the Globe found that Bridgewater officials were using seclusion and restraints routinely, often in violation of state law, which says those tactics may be relied upon only in cases of emergency, defined as “the occurrence of, or serious threat of, extreme violence.”

It also found that many of the checks on the use of seclusion and restraints — the product of earlier reforms — were simply ignored. Commissioner Luis Spencer, for instance, admitted during a Globe interview that he had never complied with a legal requirement to personally “review and sign within 30 days” all of the authorization forms for the use of seclusion and restraints.

Instead, he said, other department officials and top Bridgewater staffers reviewed the authorization forms during quarterly meetings, a longstanding arrangement that Spencer described as a “best practice” because, he said, it ensured that experts in the field would do the work.

But public officials in other states disagreed, insisting that reducing the use of seclusion and restraints — once routine practice in many jurisdictions — is difficult and requires a personal commitment from top administrators.

“If the senior leadership are not fully engaged from the very beginning and have a commitment to be fully engaged for a number of years, it won’t work,” said Kevin Huckshorn, a nationally recognized expert in reducing the use of seclusion and restraints and past director of Delaware’s Division of Substance Abuse and Mental Health.

Meanwhile, Department of Correction officials insisted that Bridgewater could not be fairly compared with facilities run by the Department of Mental Health, noting that Bridgewater’s patients are far more dangerous, including killers who have been found not guilty by reason of insanity.

But the Globe identified several forensic hospitals in other states with similar populations that relied on the use of seclusion or restraints far less frequently, including the Whiting Forensic Division at Connecticut Valley Hospital, which the Baker administration is now using as a guide in its plan for Bridgewater’s future.

While underscoring the risks of Bridgewater’s approach to treating mental health patients, the Globe discovered that two additional patients — 34-year-old Bradley Burns and 45-year-old Paul Correia — died there after being placed in restraints.

Messier, Burns, and Correia all died in the Intensive Treatment Unit while Deval Patrick was governor. And near the end of his term, Patrick produced a comprehensive package of Bridgewater reforms, only to see them tabled by a state Legislature waiting for a new governor to take office.

Then, in April, as the Baker administration considered possible solutions to the problems at Bridgewater, a fourth patient died in the ITU. This time, Leo Marino, a 43-year-old father of two teenagers, took his own life by swallowing wads of toilet paper while being monitored by Bridgewater staffers.

Boston’s Disability Law Center investigated Marino’s death and issued a scathing report, attacking both Bridgewater staff and the overall management by the Department of Correction. “It is abundantly clear that Bridgewater State Hospital, as controlled by the Department of Correction, is incapable of providing the appropriate medical and mental health staffing necessary for the care and treatment of patients with mental illness,” the report said.

Tragically, the Dickensian tactics and recent deaths at Bridgewater only echo the conditions exposed during earlier cycles of scandal and reform.

After Wiseman’s “Titicut Follies” was released in the late 1960s, the state’s Supreme Judicial Court barred Wiseman from distributing the movie commercially, ostensibly to protect the privacy rights of Bridgewater patients. But Wiseman was permitted to show the film to mental health clinicians, lawyers, and social workers. And though it was banned for more than 20 years, the film sparked legislative hearings and reforms, including the demolition of the facility’s dungeon-like main building and the construction of what is now the Bridgewater State Hospital campus.

But in the 1980s, scandal struck again when five patients died over the course of a year, three of them by suicide, and the Civil Liberties Union of Massachusetts filed suit.

Settled in 1987 with an infusion of state funds to pay for more mental health clinicians, the lawsuit also yielded an agreement to monitor patients more closely and curtail the use of seclusion and restraints — a cautionary note for Baker administration officials now seeking the same changes.

State officials also established a new investigative unit to probe allegations of patient abuse and a special commission to review Bridgewater’s role in the state’s criminal justice system. “It is our firm belief that Bridgewater is now on a course of development which will yield a new and higher standard for the care and treatment of the most afflicted citizens among us,” said then-Correction Commissioner Michael Fair.

But 10 years later, scandal struck again, when two more patients committed suicide and a review by an outside psychiatrist concluded that Bridgewater had no system for maintaining quality care — or for closing a widening chasm between the prison officials who ran the facility and the mental health clinicians who worked there. “The security vs. treatment issue at Bridgewater seems to permeate the operating atmosphere, with security being clearly dominant and treatment a secondary consideration,” the psychiatrist wrote in his official report.

Twenty years later, little has changed. State lawmakers, loath to approve reforms that could lead to a tax increase, prefer to ignore Bridgewater and the troubled men who live there as long as death and scandal can be held at bay — until the next scandal, of course.

At the same time, the clash between security and treatment lives on, with security generally prevailing, while the tension between reform-minded elected officials and the state workers who actually run the government and call themselves “we-be’s,” (as in, “we be here long after you’re gone”) remains a continuing argument for the status quo over even the most well-crafted reforms.

Even now, with the state accepting bids from companies able to replace prison guards with a trained security force while providing better medical and mental health care, no one knows how the state will cover the cost.

Two years ago, the Globe reported that housing a mental health patient at Bridgewater State Hospital costs about $145,000 a year. By contrast, housing a patient in a Department of Mental Health facility costs an average of $400,000, while the price tag for housing a patient at the Whiting Forensic Division, in Connecticut, runs to nearly $500,000.

Still, state officials have managed to find money for the Department of Mental Health to study the possibility of moving Bridgewater patients sent there for psychiatric evaluations, and perhaps those found not guilty by reason of insanity, to a separate facility outside the jurisdiction of the Department of Correction.

That would mean patients like Joshua Messier and many others never convicted or even accused of committing a serious crime would not have to endure prison conditions while being psychiatrically evaluated and receiving mental health care.

Coupled with the plan to replace Bridgewater prison guards with a security force trained to handle men with a serious mental illness, it might also mean that the pernicious cycle of scandal, reform, and scandal will finally be broken.

Michael Rezendes is a reporter with The Boston Globe Spotlight Team.