April 28, 2023

Liz Lozano has been incarcerated since 1995. Having spent over 20 years at the Central California Women’s Facility, the largest women’s prison in the world, she’s a big believer in the importance of mental health for rehabilitation. She also knows what works for her. In addition to talking to a therapist once a month, she jogs in the yard whenever she can. She also loves to garden. “Being out in nature helps me ground myself and find peace,” she said over the phone, her voice calm and measured. “But I can’t garden anymore because of constant lockdowns.”

When the pandemic hit in 2020, health experts quickly raised the alarm about the unique risks the virus would pose for both the physical and mental health of incarcerated people. Many of those fears came to fruition — and research and interviews suggest that the extended lockdowns introduced in the wake of the pandemic continue to take a toll on prisoners’ mental health and well-being.

In STAT’s interviews with more than a half-dozen women who are incarcerated in California, many described the post-pandemic era as their most difficult period of incarceration. Every single woman also said that these lockdowns haven’t let up in the three years since the pandemic started.

“It’s a standing joke that we can’t go 48 hours without some kind of major crisis that locks us down,” said Cecilia Fraher, who used to be incarcerated at Central California Women’s Facility (CCWF) and is now in the California Institution for Women (CIW) in Chino, California. “These crises have nothing to do with the inmates.” 

It’s well-documented that long-term lockdowns can increase anxiety and disordered thinking, as well as heighten the risk of suicide or premature death because of the physical effects of stress. The International Journal of Prisoner Health also recently published one of the first pieces of qualitative research that examines the mental health effects of pandemic-era lockdowns on incarcerated populations.

In interviews with 10 incarcerated women in California, participants described being locked in a room with anywhere from one other person to six to eight other people for 23 hours a day or more, for weeks at a time. Overall, the study claims, the extended lockdowns disrupted the resources that help people in prison feel connected to their communities and aggravated the stressors they already experience. Many participants interviewed in the study knew someone inside who died by suicide during the height of the pandemic. “They are completely trapped. And I think that is going to create a lot of trauma,” one physician who worked with incarcerated women told the study’s authors.

Women at both CIW and CCWF claim that they are still experiencing lockdowns up to four times per week. By contrast, they say, lockdowns were rare before the pandemic. “We went from almost no lockdowns to daily lockdowns,” said Fraher. At CIW, where the suicide rate was eight times the national average as of 2016, Fraher remembers getting locked down, pre-pandemic, whenever there was a death in the prison. She also remembers one lockdown due to extreme winds back in 2015. Other than that, she said, this was not a routine protocol.

The California Department of Corrections and Rehabilitation (CDCR) said in a statement that at the institutions it oversees, “it may become necessary to modify programming for multiple reasons to ensure safety and security.” It said that CIW and CCWF have not been under lockdown, defined as restricting “any and all movement in an identified area, facility, or entire prison,” as opposed to modified programs, which “can still allow the population to shower, work, and receive medication, depending on the status of their housing unit.”

“Prisons, for better or worse, are part of our social safety net,” said Jennifer James, an assistant professor at the UCSF Institute for Health & Aging and one of the authors of the study on carceral lockdowns during the pandemic. “But lockdowns are not designed to do public health work, they’re designed to punish, and that’s really debilitating for incarcerated people.” 

When prisons like CIW and CCWF go into full lockdown, all of the prisoners are called from their jobs or classes and redirected to their rooms. They’re cut off from access to the yard — their primary space for outdoor time — and the dayroom, an area that has elliptical machines, televisions, a library, pay phones, and stations where they can have video calls with loved ones. They’re also routinely “cell fed,” which means that food and medication are brought to their rooms.

When the prison announces a “modified program” lockdown, people are still locked in their unit, but they’re allowed to leave in order to take a shower, make a phone call, put mail in their mailbox, or do laundry. 

During the height of Covid, lockdowns were meant to protect the health of incarcerated people by limiting opportunities for virus transmission. But they had major negative impacts on women’s health in other ways. 

Lozano started going through menopause at the same time the pandemic unfolded. When she recalls those months, she remembers hot flashes, headaches, body aches, losing her appetite, and suicidal thoughts brought on by depression. She also remembers taking showers. “Showering is one of my coping skills,” she said. “Whenever I’m feeling something negative, I go into the shower and let the water run over me.” Every night, Lozano’s roommates at CCWF heard her crying. “It helped me release what I was feeling inside,” she said.

In 2020, she said, she was often locked in a cell for 23 hours per day or more, for weeks or months at a time. She had no access to fresh air and would have to wait days to shower. It felt impossible — and terrifying — to cope with both the pandemic and the hormonal changes happening in her body.  

Tomiekia Johnson, who is incarcerated at CCWF, said that her period hasn’t stopped for the past two years. A vigorous notetaker, she’s tracking her cycle, along with her other symptoms that have cropped up in the wake of the pandemic, such as insomnia, vertigo, and hair loss. She attributes many of these changes to the stress she’s experienced in the wake of lockdowns.

“When there’s a lockdown, you’re not going to be able to work that day, you’re not going to be able to go to school that day, you’re not going to be able to go to the yard that day,” Johnson said. “I’ve been incarcerated for 12 years and I’ve experienced what it’s like to go to the yard at will, to go to group [programming], to work my job. This has totally changed things, and the quality of my life has diminished significantly.” 

Johnson used to work as a fitness instructor at the prison gymnasium, but she hasn’t been able to return to her job because there are still empty beds sitting in the gym — ready to be used in the event of a Covid surge.

Tomiekia’s sister, Terressa Johnson, talks on the phone with Johnson every week. As lockdowns became more prevalent at CCWF, she found that she had to lift Tomiekia’s spirits every time they spoke. 

“She’s stressed the majority of the time,” Terressa Johnson said of her sister. “She doesn’t have an outlet because she can’t go to work, or she can’t go to the fitness center, or she can’t take the classes she was taking. The last three years have been the worst for her mental health.” 

While lockdowns were mostly used during the start of the Covid-19 outbreak to mitigate the disease’s spread, the protocol is now used for a myriad of reasons. The women interviewed for this story say that sometimes they’re given official reasons for lockdowns, such as officer trainings, drones flying over the facilities, and staff shortages.

Other times, they don’t even know why they’re in a multi-day lockdown. “I feel like the staff will use any excuse to lock us down because it’s obviously a lot less work when we’re locked in our rooms,” Fraher said. 

As of last July, incarcerated folks at CIW and CCWF received access to electronic tablets, which allow them to send messages, play games, read books, watch movies, and stream music.  “Now that we’ve got tablets, we’re all supposed to just be quiet — you might as well put us in a drawer,” said Fraher. “If we didn’t have to come out and get showered occasionally, [the officers] would never have to do anything.” 

For most of the women I spoke with for this story, keeping busy during lockdowns isn’t the hard part. Many of them read, do homework, paint, crochet, or watch movies on their tablets. “We recently got the Calm app, and that’s my new go-to for stress,” Lozano said. Lozano lives in the honor dorm, an incentive unit with extra privileges for people who have demonstrated good behavior. 

But lockdowns do take away many of the minimal freedoms incarcerated people rely upon to maintain their physical and mental health. “You’ll hear of all these in-cell fights happening outside [of the honor dorm] when we’re locked down,” Lozano said. “Mental health should be a top priority in here because you could have four people in a room, but maybe there’s really 100 personalities in that room — it makes a huge difference when you have the option to decompress by having yard or dayroom access.” 

Inmates say their inability to exercise during lockdowns has also adversely impacted their long-term physical and mental health. Fraher, who is 66, suffers from ongoing heart and lung conditions that make her completely pacemaker-dependent. Her conditions require regular surgery, so she walks at least three hours per day to stay in shape. “The only way to survive is to keep my lungs as strong as possible,” she said. “When we’re locked in, I can’t get out and work out.”

Lozano, who is 48 and also suffers from a heart condition, tries to regularly jog. But as yard time disappeared with more lockdowns, her cholesterol shot up — a change she attributes to the lack of exercise. 

The number of incarcerated people in California state prisons with mental health issues has risen over the past 10 years even as the overall population of prisoners has dropped, according to a 2017 Stanford Justice Advocacy Project analysis of data from the CDCR. Lockdowns, of course, compound this issue, further isolating incarcerated populations. “Prison is such a punitive environment to begin with,” said Courtney Hanson, a coordinator at California Coalition for Women Prisoners, an advocacy group. “This type of punishment becomes so cruel for folks who have chronic health conditions and are already vulnerable.” 

Today, Lozano is a vocal advocate for more mental health resources at CCWF. She already co-founded the Juvenile Offenders Committee back in 2009, which supports women who were sentenced as adults when they were juveniles with trauma education and substance misuse workshops.

Lozano also wants to work with local animal shelters and bring a cat therapy program to the prison, as she believes that healing can start with nurturing others. She’s currently trying to start a group where incarcerated women can openly talk about going through menopause. But she’s still worried about the future.

“I’m not hopeful because lockdowns seem like our new normal,” she said. “A correctional facility’s objective is to correct — to rehabilitate. Lockdowns prevent rehabilitation because you’re stuck in your cell without fresh air, sunlight, or exercise. It doesn’t allow us to mentally and physically release stress so that we can work our rehabilitation, and ultimately our healing, to eventually be released and become the people we were created to be.”

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by CHJ Fellow Lila Seidman

April 13, 2023

While campaigning for mayor in mid-August, Karen Bass spoke about a brand-new three-digit mental health crisis hotline — 988 — and its promise to save lives of people suffering from mental illness by avoiding deadly confrontations with police.

As a member of Congress, she had examined more than 100 lethal police encounters throughout the country and found that at least 40% involved a mental health crisis, she said. The figure dwarfs the often-cited national statistic that a quarter of all people who die at the hands of law enforcement have serious psychiatric problems.

 In Los Angeles, police reported a similar figure in 2022: 39% of the people their officers shot were in the midst of a mental health crisis.

Now, that would change, Bass said at the news conference highlighting the launch of the 988 Suicide and Crisis Lifeline.

“I’m so proud to know that L.A. is going to be on the forefront of having a solution,” she declared.

But the rollout of 988 and related psychiatric emergency services has so far failed to live up to that promise, a Times investigation has found.

On July 15, 2022, one day before the 988 hotline went live, the L.A. County Department of Mental Health proclaimed the county was ready for a “seamless” rollout of the service that would include “trained psychiatric mobile crisis response teams who can be connected to through the 988 line when necessary.”

The county would hire privately contracted teams so crisis therapists could respond 24/7, up from 18 hours a day, the county statement said.

More than eight months later, none of that has come to pass: Hotline workers cannot directly dispatch mental health teams, and callers often wait hours for an emergency response.

Although the county mental health department has a fleet of mobile teams dedicated to responding to people in psychological distress, in more than 9 of 10 cases, those unarmed mental health workers take more than an hour to respond to callers in need of emergency services, a Times analysis of county data found.

About half of the time, teams take more than four hours; sometimes callers wait days.

Meanwhile, the phone and computer systems that city and county agencies use to help residents in crisis remain disconnected from 988.

Crisis counselors who answer the 988 hotline — via the nonprofit Didi Hirsch Mental Health Services, based in West L.A. — cannot dispatch emergency teams. Instead, they must transfer a person in crisis to a separate county hotline, which can opt to send mental health workers — bouncing the caller around the system.

Sam Blake, who runs a home for people with severe mental illness in Sylmar, has pretty much given up requesting a mobile crisis team when a client becomes unstable or aggressive, which can happen weekly for residents with hard-to-treat disorders. He said teams usually take four to six hours to show up. The last time, they didn’t come at all.

“They’re too slow, and they’re not sufficient,” Blake said of the teams. “Our first choice now is either call the police or at least get the client to stop being destructive.”

A new way to show up: Sending therapists instead of cops

A person who breaks their leg, faces a robber at gunpoint or flees a house in flames can count on paramedics, police or fire personnel to rush to their aid. There is no equivalent in much of the U.S. to assist an individual battling psychological demons.

“That is what we are trying to change here in L.A. County,” Supervisor Janice Hahn said in a statement.

In Los Angeles, policymakers and law enforcement officials have long known that what’s in place wasn’t working. They began efforts to change the system years before the national 988 number came along.

Both the LAPD and Los Angeles County Sheriff’s Department pair mental health clinicians with specially trained officers in an effort to deescalate crises without using force. The law enforcement agencies began rolling out those specialized teams in the early 1990s. The county mental health department also began building its civilian mobile response more than two decades ago.

Calls to scale up these programs became more urgent in recent years, prompted by disturbingly frequent incidents of police killing people — particularly Black men — who were in the midst of mental health crises.

Sharon Watkins, who fought for the passage of a state law that funds non-police local crisis responses, is keenly aware of that urgency.

On the night of Feb. 11, 2015, Watkins got a call that Phillip Watkins was talking about killing himself. Her 23-year-old son appeared to be having a psychotic break.

She drove furiously to get to the scene but was met with police tape.

The Santa Clara County District Attorney’s Office said Phillip ran toward two San Jose police officers with a folding knife, “intent on dying that day.” Seven bullets were found in his body. His mother said Phillip’s 2 ½-year-old daughter was in earshot of the guns going off.

“It’s hard to explain if you’ve never been through it, not to rush — and how important it is to get it right,” Watkins said of developing alternatives to police response. “Because to me, even one death is one too many.”

A breakdown in the system: waiting hours for someone to come

With the launch of the 988 hotline in mid-July, Los Angeles officials hoped to put in place a system to avoid such tragedies.

County officials don’t plan to completely remove police from responding to mental health crises. Instead, they aim to reduce and refine law enforcement’s role so they respond only in the most dangerous or volatile situations.

That goal has support from a wide range of groups involved in the system. In March, the largest Los Angeles Police Department employees union said it would seek to have officers stop responding to mental health calls in which there is no threat of violence or criminal activity.

“I don’t think there’s ever going to be a situation where we can say law enforcement is not going to be” involved, said Jennifer Hallman, alternative crisis response manager for the mental health department. “But we want to make sure that we minimize that, right — that it’s not law enforcement just because they can get there faster or it’s what people know to do.”

A shift to civilian response, however, requires having someone else who can rapidly show up when residents need in-person help, as well as agreement on how to gauge the severity of calls.

Instead, the in-person piece of the puzzle — the number of civilian response teams — has remained stubbornly stagnant even as the volume of people calling the 988 hotline has grown and the focus of the call centers has broadened, bolstered by an infusion of what’s risen to nearly $1 billion by the federal government.

Services at the roughly 200 centers scattered across the country — including 12 in California — have expanded from primarily providing suicide prevention to soothing an array of mental health issues, including substance use problems and advice on how to help a loved one in crisis. Only a fraction of those calls require an emergency response.

Didi Hirsch Mental Health Services, which handles 988 calls from Los Angeles, Orange, Riverside, San Bernardino, Ventura, Imperial and Inyo counties and is also the lead agency for the state, reported a 22% jump in calls, texts and chats in the first six months since the launch. The call center has also grown, bringing on an additional 106 volunteers and 77 staffers.

In a step toward meeting the increased need, the mental health department modified two contracts last year — one in August, one in December — to expand its fleet of 33 civilian mobile crisis teams. But only two contracted teams are up and running — bringing the total to 35. The hours of operation haven’t budged, with teams available from 8 a.m. to 2 a.m.

The county would require 138 teams within the next few years to meet the needs of its 10 million people spread across 4,753 square miles, according to a report by an outside consultant assessing the system’s needs.

The county’s current goal is to scale up to 60 teams by the end of the year. Three are expected to begin operating this month, said Lisa H. Wong, director for the L.A. County Department of Mental Health.

“This capacity will allow us to provide 24/7 coverage as well as reduce response times so those experiencing a mental health crisis can receive timely care,” Wong said in a statement.

The inability to hit those goals so far is not due to a lack of money: The department is budgeted for about 50 teams for the current fiscal year, according to a January report. The county Board of Supervisors has invested $152 million in state and federal funding into beefing up its alternative crisis system, including expanding its mobile crisis teams and call center services, according to a recent motion.

County officials say it’s been difficult to hire for work that requires clinicians to leap into the field — including during weekends and all hours of the night — to treat some of the sickest residents.

Since the COVID-19 pandemic prompted many therapists to transition to telehealth, clinicians can opt to work from home, making hiring for field jobs even harder.

Since COVID, “it has become a challenge to hire staff because competition out there is pretty high,” said Miriam Brown, deputy director for the emergency outreach and triage division at the mental health department. “I myself, I’m a licensed clinical social worker, I get a lot of offers left and right.”

County leaders anticipated this problem ahead of the 988 launch, “so we sped up the hiring process and offered bonuses and loan forgiveness,” said Hahn, who represents the county’s Fourth District. “This hasn’t been enough.”

Supervisors Hahn and Kathryn Barger authored a motion, approved earlier this month, calling for the creation of a pilot program to explore additional incentives.

“We can only be successful in our efforts if we have enough teams to respond when and where they are needed,” the supervisors said in their motion. “We must do everything we can to fill these positions.”

Why the police show up faster: a history of delays

Response times for the county’s psychiatric mobile crisis teams have worsened since the start of the pandemic, according to data analyzed by The Times. In 2019, about 10% of teams dispatched took more than eight hours to respond. That number ballooned to 34% in 2022.

The pandemic decimated resources as people fell ill or burned out of the workforce, slowing down response, according to the county mental health department. In some cases, mobile crisis workers waited hours with patients until ambulances, facing similar shortages, arrived to transport patients to hospitals, department officials said.

Even before the pandemic, however, wait times were staggering: In 2019, nearly 88% of dispatched teams took longer than the goal of one hour to respond, while 25% took longer than 4 hours.

By contrast, the Sheriff’s Department’s 34 Mental Evaluation Teams took about 18 minutes on average in 2021 to arrive, according to Capt. John Gannon, who previously oversaw the units.

Those who use, work in and oversee the crisis system have long been aware of how slow the civilian teams are. Yet as of October, officials with the mental health department said they were not routinely tracking or analyzing data.

Department officials said they improved their dispatch processes in February and are working with labor unions on ways to speed up mobile crisis interventions.

The inadequacy of the civilian response has created a vacuum filled by other emergency services — typically law enforcement.

When a family calls for help, it means they’re afraid of a bad situation, said Lt. Annadennise Briz, a former county mental health clinician who leads the Sheriff’s Department’s Mental Evaluation Team. Families in crisis typically can’t wait hours for a civilian team to arrive.

“To keep the family from living in fear until [the civilian team] gets there, they will call us and we will go out,” she said.

A long endgame amid an urgent crisis

Proponents of the 988 system stress that it’s in its infancy and will take time, effort and money for reality to match the long-term vision of transforming the nation’s crisis response.

Developing a policy and financing framework for the new system will be a lengthy process, in California and across the country, said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Assn. of California.

“There’s the downstream ambitious goal or vision that some people have, that 988 will be that portal and that conduit to connect people to something much more, and then there’s the sort of work that we need to do to build out toward something like that,” Cabrera said. “I would say that there are still a lot of gaps to establish 988 as that conduit or portal — and that’s OK.”

In the interim, however, people with serious mental illnesses continue to die in confrontations with police.

Less than five months after the news conference at which Bass lauded 988, LAPD officers called to a Westlake apartment fatally shot Takar Smith, a father of six who was diagnosed with schizophrenia.

Officers huddled outside of the apartment didn’t loop in LAPD’s Mental Evaluation Unit when planning how to respond — although his estranged wife, Shameka Smith, had mentioned several times on her call to police that he hadn’t been taking medication to treat his psychotic disorder.

“I begged them not to shoot him,” she said.

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