Group therapy with mentally ill condemned inmates at San Quentin State Prison

Of the over 700 condemned inmates on Death Row at San Quentin State Prison in California, approximately one sixth are in the prison mental health system. Actually, the percentage of mentally ill on Death Row is almost certainly much higher, but the stigma attached to being designated mentally ill is great on Death Row and many of the inmates prefer to suffer in silence rather than lose the respect of their peers. It's common to hear other inmates on death row shouting out "cuckoo cuckoo" from their cells at mentally ill condemned inmates as they are being escorted to individual or group therapy.

The prisoners in the mental health system in California prisons are divided into two categories: Correctional Clinical Case Manage-ment(CCCMS)and Enhanced Outpatient(EOP). CCCMS inmates are diagnosed with a mental illness but their symptoms are not severe and CCCMS clients, barring an emergency or worsening symptoms, meet only once every 90 days with their psychotherapist. The symptoms of the EOP clients are much worse and common diagnoses for them include bipolar disorder, PTSD, major depression, and schizophrenia and other psychotic disorders. Many EOP clients have had recent stays in the prison emergency psychiatric hospital, have had one or more suicide attempts or have frequent suicidal ideation. Because of the seriousness of their illnesses, the EOP clients are seen weekly in individual therapy by their psychotherapists and attend group therapy 4 to 5 days per week.

Classifying a prisoner as EOP can be problematic. Some prisoners who meet the criteria for EOP designation absolutely do not want to be in the EOP program because of the frequency of individual and group therapy sessions required of EOP inmates. Prisoners can get official written reprimands for failing to keep appointments, including mental health appointments, and an accumulation of these write ups will lead to loss of privileges. The condemned prisoners have few privileges and losing one or more can be devastating. Condemned inmates will sometimes fake severe symptoms as a way to get into the EOP program. The advantages to being an EOP client are that the prisoners get additional yard time, the weekend group is a "movie group," and still other groups are activity oriented, involving games and reading books. EOP clients also get out of their 5 x 9 cells more than do other condemned inmates and this both breaks up the incredible monotony of their lives and affords them the opportunity to socialize with peers. Occasionally, a high performing inmate will fake his way into the EOP program as a way to scam the other EOP clients, many of whom are seriously cognitively impaired. Others fabricate symptoms because enrollment in EOP program, and the accompanying voluminous clinical paperwork by his individual and group psychotherapists, can be useful in a state or federal appeal. Despite these occasional incidents of malingering, the great majority of the death row prisoners receiving group psychotherapy at San Quentin are unquestionably genuinely and seriously mentally ill.

Group therapy is held for 2 hours and in the group rooms at the San Quentin prison hospital, about a 5-minute walk from Death Row. Each group room consist of several small cells, called "cages" by the prisoners, which are approximately 7 feet tall x 3 feet square with a backless chair bolted into the floor. While still in their cells on Death Row, the prisoners are cuffed with their hands behind their backs and are escorted from the prison block to the group room by a Correctional Officer, who places them individually into the cages, which are then locked. Currently two condemned groups are held daily. This is done both to accommodate the large number of EOP clients who attend group therapy and also because of the stratified social system that exists in prison. Many of the condemned prisoners, even those who are severely mentally ill, refuse to attend group therapy with an inmate who has committed a crime against a child or who is a known informant. Finding a peaceful compromise is not always possible and when the inmates absolutely do have to share group therapy with such a shunned prisoner, they usually refuse to acknowledge his presence.

Group psychotherapy has been shown to be remarkably successful with many of the condemned inmates, leading to increased medication compliance, less severe mental illness symptoms and a decrease in suicidal ideation. Social skills and courtesy are emphasized and for many, these are skills that have been long dormant. Interestingly, in group psychotherapy held in the "free world," confidentiality needs to be continually reinforced but the intensity of this reinforcement is not necessary with the condemned inmates. Keeping a secret is part of the prisoner code and the clients are very good about remaining reticent regarding what is said in group therapy.

The group starts with a brief check in with each client and the clients absolutely have the right to "pass" if they don't feel like talking. Following the check in, the facilitator reminds the clients of the group rules and the group goals. These goals can vary from elementary CBT skills for depression and anxiety to more detailed DBT skills for personality disorders. Frequently, the clients will deviate from the stated goal to talk about recent events in their lives. Examples of these deviations are: the stress they are experiencing due to a prolonged "lock down" by custody, the delay in receiving a quarterly package, another inmate continuing to verbally harass them, a significant anniversary, such as a death in the family or the date of their first day of incarceration, a visit they recently had with a relative or friend, and the pride they feel in maintaining sobriety (drugs are not difficult to get in prison). It is not uncommon for them to read aloud letters in group therapy that they have recently received from people on the outside who are important in their lives. These changes in the stated group strengthen the group dynamic and in the process, the clients learn valuable coping skills from each other.

Facilitating group therapy with the death row inmates is a powerful clinical experience. With rare exceptions, the inmates are unfailingly courteous and attentive towards the facilitator and to each other, and continually striving to find meaning and purpose in their lives is indicative of the indominability of the human spirit.

Patrick O'Reilly, PhD, is a clinical psychologist at San Quentin State Prison. He is an Assistant Clinical Professor of Psychiatry at the University of California, San Francisco School of Medicine. Additionally, he is on the faculty at Alliant University, where he teaches Group Psychotherapy to Forensic Psychology doctoral students. He is former Chair of Bay Area Skeptics and past President of the San Francisco Psychological Association.