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Despite Recommendations, N.H. One Of Few States With Psychiatric Unit On Prison Grounds

New Hampshire has become the first state to launch a campaign solely aimed at breaking down the stigma around mental illness and improving treatment and prevention. But left unaddressed has been a population of mentally ill people at the state prison who are incredibly violent and have no place else to go.

When you get Tom O’Brien from Hollis talking about his childhood friend, Eric Largy, he brings up how he was the best man at his wedding and how he’s known him since the second grade.

“He never had an incident before, he was never a harmful guy – he never did anything, you know, and he was just very set in his ways, like in his mindset – in his thinking," O'Brien recalled. "But Eric was always a little, but he was a hard worker, he was this, he was that.”

But in 2009 a judge deemed his friend incompetent to stand trial for allegedly kidnapping and savagely beating his father, a former Nashua Police Chief.

Eric Largy is now 49 years old and has been diagnosed with schizophrenia and other mental illnesses. For the past five years he’s been at the state’s secure psychiatric facility at the state prison, but he’s refused treatment.  O’Brien thinks he should be in a hospital, not locked up.

Credit Paige Sutherland/NHPR
On average, eight people transfer from the New Hampshire State Hospital to the SPU each year – some stay a few months some as long as six years.

“It’s tough to separate – somebody does a heinous act and they are violent or they are this or that. You don’t want them out. I don’t want them out. You don’t want them out," O'Brien said. "But having the right facility to try to rehabilitate some of those individuals I think is important rather than just housing them.”

The state’s Secure Psychiatric Unit or SPU has 60 beds and the men and women here are typically dangerous with stories like Largy’s. Some are civilly committed, some are deemed incompetent to stand trial, some are found not guilty by reason of insanity and others are violent inmates– and they’re all housed on the same floor. 

On average, eight people transfer from the New Hampshire State Hospital each year – some stay a few months some as long as six years.

Every year the facility sees multiple suicide attempts and attacks on staff members. Stories range from one patient forging a blade onto a toothbrush to another slashing an officer’s face with a piece of metal from a light fixture.

Credit Sara Plourde/NHPR
The SPU has 40 beds - some are civilly committed, some are deemed incompetent to stand trial, some are found not guilty by reason of insanity and others are violent inmates– and they’re all housed on the same floor.

Beatrice Coulter has worked in mental health for more than three decades. She began working at the SPU last year as a nurse, but because of what she saw, she says she lasted only four days.

“You can have individuals with psychiatric illness that can be violent and labile and aggressive but we always have to remember the underlying presenting problem is illness and it needs to be treated as such," Coulter said. "So when we get to the point where security begins to trump a therapeutic approach – it’s not an accepted standard that I’m familiar with – not clinically – no," Coulter said, who since she left the SPU has become an outspoken advocate for this population.

At the SPU prison guards, not medical professionals oversee the unit.

The patients are more or less locked in their rooms or given limited access to hallways.

Credit Paige Sutherland/NHPR
For some of the unit’s most dangerous patients – there are 4x10 cage-like booths set up next to one another for group therapy sessions.

They do have access to common rooms set up with books and TVs as well as an exercise room, but they must have a guard escort. And for group therapy sessions for some of the unit’s most dangerous patients – there are 4 x 10 cage-like booths set up next to one another.

Carlene Ferrier with the Department of Corrections oversees the nursing staff, including the nine nurses who work at the SPU.  She says patients are getting the care they need even if it’s in the prison.

“A building doesn’t make a program – I think it’s the staff that are doing the day to day care," Ferrier said. "And I think we have a great team who are well-trained and committed and feels like they are doing a good job.”

Besides nurses in the unit there are three mental health counselors, a therapist, two social workers, two psychiatric doctors and two nurse practitioners.

Gov. Maggie Hassan says she would welcome a new facility off prison grounds but says the people who work at the SPU - are doing the best they can.

“I know that the staff at the SPU work extraordinarily hard to make sure whoever they are treating is getting the appropriate treatment and that for those people who are there for civil commitment that they are transferred back out of the SPU as promptly as possible," Hassan said.

Credit Paige Sutherland/NHPR
Placed in the center of the SPU is the master control room, which is managed by correctional officers who oversee the unit.

But New Hampshire is one of only a few states that places violent mentally ill people in a prison.

“I don’t think they were saying 'oh gosh we are going to do this to get better treatment for the patients,'" said John Wallace, who was the legislative director at the state's division of mental health when this policy transfer was drafted back in 1986. "I don’t think that was first and foremost in the motivating factor - no.”

He says many factors led to it - including the safety of the staff and neighborhoods around the state hospital, the fact that the state at the time was building a new prison but mostly - he believes - it came down to making sure the state hospital received accreditation.

Wallace said at the time the hospital’s administrators thought housing such a dangerous population might interfere with the hospital becoming federally licensed and getting Medicaid money.

The SPU has never gone after such certification - meaning it is not an accredited hospital and doesn’t have any external oversight.

Credit Paige Sutherland/NHPR
Even women are housed at the SPU, but they are set apart from the male inmates. The unit did; however, have to put up screenings on the female's ward to prevent the male patients from inappropriately looking in.

The Department of Corrections provides the only oversight. And in the last 30 years there have been zero outside performance audits specifically directed at the unit.

And because the SPU is located on prison grounds it cannot receive federal Medicaid dollars, which would mean having to meet another layer of federal standards and qualifications.

The unit had been granted accreditation with the American Corrections Association, but that lapsed in 2011. 

Paula Mattis with the Department of Corrections - oversees the SPU and said not being accredited doesn’t mean the unit’s treatment is not up to par.

“We do look at the standards that are out there," Mattis said. "No, we may not have the certificate or plaque on the wall to show that but we hire skilled qualified people who are up to date in their fields who bring forward ideas and information.”

The state’s overall mental health care for inmates did get looked at in 2011 and 2014 but the SPU was not part of that inspection.

Credit Paige Sutherland/NHPR
The unit's access to the outside world is this concrete slab about the size of half a basketball court that is fenced in entirely and offers views to other prison housing.

The forensic psychiatrist hired to do those reports was Dr. Jeff Metzner. He’s examined treatment of mental health in jails and prisons in nearly 40 states.

“You’ll get adequate treatment in jails and prisons but jails and prisons are no place to be provided treatment because it is a punitive environment – it is not a therapeutic environment – it is certainly not a hospital environment,” Metzner said.

Bottom line –Metzner said when it comes to deciding whether a facility offers the best care for its patients – there’s only one question that needs to be answered:

“Would you, whether it’s New Hampshire or someplace else, would you want your family member who needed psychiatric hospitalization to go there?," Metzner asked. "If the answer is no – then it’s a problem.”

Most people you talk with about the SPU agree this setup isn’t ideal. Two separate legislative study commissions concluded -- people who’ve never been convicted of a crime should be treated in a hospital, not the prison.

And John Wallace, who was with the state’s mental health division, agrees.

“Back then yeah it probably seemed in balance a reasonable thing to do because the prison that was being built at the time had accommodation for it but it got revisited and there have been a couple studies that said yes the state should build a secure place and put it back under the hospital," Wallace recalled. "But those recommendations in legislative study committees never went anywhere," he said. "‘Why do you think that?" NHPR reporter Paige Sutherland asked. " Money,” Wallace replied almost instantaneously. 

Credit Sara Plourde/NHPR

The latest report in 2010 recommended the state build a new high security psychiatric facility on the grounds of the New Hampshire Hospital.

But that called for more than $13 million.

Rep. Renny Cushing chaired the 2010 commission and introduced a bill this session to ban the transfer policy. It’s been referred to interim study – more or less killing it.

“Is in a way in competition with the fact that we don’t have enough beds right now for other people who are not as severe who are seeking mental health treatment, we have a drug and alcohol addiction crisis – we don’t have enough beds to treat them," Cushing said. "Unfortunately, in New Hampshire the legislature has a tendency to take the position – out of sight, out of mind.”

Scroll down below to read the full report on the 2010 study commission.

And it’s also more than five times cheaper to house a patient at the SPU than at the New Hampshire Hospital – $1,350 a day at the state hospital - compared to $270 a day at the SPU.

Tom O’Brien, whose friend Eric Largy is at the SPU, said he gets it’s about the money but questions how much longer the practice can go on.

“It’s been passed off saying well they are safe here because they are behind bars and the community is safer, so let’s take care of these bills," O'Brien said. "How long do you keep putting something like this on the backburner?”

Advocates and legal experts involved in this issue – think at this point – a lawsuit is the only thing that will spark any change. 

Read the Final Report from the 2010 Study Commission

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