>> thank you for being here and also alisa roth your wonderful book and for me to serve as a moderator so i have done some reporting on prisons and how difficult it is your book has seen that the l.a. county jail the chicago jail the women's prison in oklahoma among many others behind the walls of these institutions that are notoriously difficult to get into. how did you do that?

>> some places were very welcoming you mentioned the cook county jail in chicago to bring awareness to this crisis through the criminal justice system and they feel that it is part of his job to see what is going on so he even has an open letter on his website from across the country the way that they respond to the crisis i was invited to i jail in virginia i felt they were letting me look under the bed to say we do the best that we can. other places when i was doing reporting in alabama he said i

need a letter from your editor soma editor kindly wrote a letter we went back and a set i'm sorry i cannot let you come. they said can we talk about this or negotiate? so finally after back-and-forth he said i suggest you investigate another state. [laughter] >> it sounds like my experience in florida. so tell us very early in your book you talk about what you see as a crisis. what is the crisis and what you saw? >> start with the facts of the people in the jail and prison have a mental illness. on the mental health side we can talk about a lot of people do with mental illness at a crisis management level so in

oklahoma if you go into a community mental health center with symptoms of mental illness unless you're actively suicidal or psychotic likely to see a psychiatrist about four months. >> so why should we worry about this? should that alarmists ask if i am unknowing looking at your book i may think mentally ill people should be put in prison makes the street safer in the subway safer so why is this a

problem? the we are treating people with mental illness we should be treating them properly but with criminal justice reform we have seen across the political spectrum, we talk about race and poverty and mental illness be met just the sheer numbers? or that people are entering institutions? >> both. we have actively shutdown the states psychiatric system. we have effectively created all of those conditions with

the understaffing and overpopulation and overmedication the warehousing of people and we created that. >> tell us about that your book tells us of the conventional understanding of where we are in those verses that the people are mentally ill or have mental illnesses so what god is here? >> that story to shut down the asylums moves to the jail is not nice and has a cause and effect if the reason people end up in jail and prison they are not treated for mental illness now is to treat it in the will and up there anymore but then if you dig deeper the

population of those hospitals is largely elderly white with schizophrenia people who have developmental disabilities if you look at the jail and prison population is mostly whale -- male and not white and that is closer to what we see in the outside world but just more concentrated. i think this is a story not about incarceration but he have left a tremendous amount we have caught huge numbers of people with mental illness in part through the tactics that grew the criminal justice

system so we talk about the war on drugs if you look at the population of incarcerated people, 80% have some type of disorder if you are chasing down people who have drugs or dealing drugs or selling drugs it stands to reason you will have a lot of people with a mental illness. >> so it is a sense that we have locked up too many people generally this is just one more population proportionately? be met exactly. >> you talk a lot in your book that people are winding up in prison better getting treatment in those communities aren't happening so tell us about that. >> it is very, very difficult

to access mental health care particularly if you don't have insurance or have public insurance. i touched on the situation in oklahoma at one point i tried to see what it looks like in new york city for somebody who was on medicated and needed a psychiatrist how he accepted medicated how he accepted new patients i spent two or three days trying to track down simply list of every psychiatrist in foxboro who accepted medicaid and i could not do it i was doing it not worried about where i was going to sleep or filling a prescription i had all the time in the world finally i went to one of the hospitals medicaid office very nice lady handed me a sheet of paper and said it depends which plan you

are on go online to see who they are then called them and see if they accept patients. i don't know who has that kind of time and energy to figure that out even if you didn't have a mental illness with all these other extenuating circumstances. >> and reporting i have done we also do reporting in florida there was a report done in 2008 about the task force of the state put together called the unfortunate and undeserving safety net for mentally help people particularly those that were poor coming from mismanaged communities. >> i think that is true in every city and every state in this country.

it is just very, very difficult to get healthcare then people are caught up, prisoners are the only group in this country who have a constitutional right to healthcare that includes mental health care. so it's not that they are going to jail to get treatment but that's where they end up getting treated. >> what about the quality? >> for the most part it is terrible. one case i looked at in alabama a man diagnosed as a six or 7-year-old was getting some treatment in the community through his life he ended up in prison in his early 20s with a bipolar disorder with other issues so he really needed help he asked for the help but didn't get it. they would come by every two

months and talk to him through a cell door. it is really hard to hear what the other person says if you say good morning how are you doing let alone anything more complicated or intimate like a doctors appointment. he would repeatedly cut himself those units for those that were the most sick in the system and that was the treatment he was getting effectively in solitary confinement although they did not call it that although he was by himself and rarely got out. >> you explore that in a chapter that has the most shocking title of your chapters that is sanctioned torture most people associate that with guantánamo or other grave -- or what the regimes

did in the past of the political dissidents. are you suggesting torture is rampant in our prison system? >> i think we have to differentiate -- differentiate the torch that you will -- the torture that you wrote about that was unsanctioned. >> i wrote a story about the mental health ward in a place called the dade correctional institution where prisoners were pretty routinely beaten and verbally accosted and humiliated and starved. then eventually it came out they were subjected to a form of horrific torture in the shower that a group of guards had set up to basically

torture and punish and torment mentally ill prisoners who were on the wrong side of them and they did this to a number of the inmate at this facility june 2012. they took one prisoner who was arrested on a cocaine possession charge and put him in the shower and he collapsed and died. his body was covered in burns. nobody investigated this. it was detailed in a heavily redacted report that was not initially released. there was no effort to hold anyone accountable. except the story was leaked by an inmate who heard him screaming from his shower and eventually it made the miami herald they wrote about in the new yorker was a horror story

much like from rikers that people read about in the new york times with the deliberate and systematic and intentional but there is another kind of abuse that you are suggesting that is more common? >> to have a severe mental illness to be locked in prison in itself is a form of torture. to not get the treatment that you need to be kept in a tiny cell 23 hours a day and kept from friends and family in the form of torture but we talk about solitary confinement which is used as a form of punishment and being put into a room like a small bathroom.

that a man can reach both walls with his hands often no windows and no contact with anybody else. we have heard over 200 years that can trigger mental illness in people who did not have it before or exacerbate the problems for somebody who already has it. this is perfectly legal but it is extrajudicial you are not subject to time in solitary confinement it happens after you go to jail and correctional officers decide if you have broken a rule and decide to send you to solitary confinement without telling you you will get out you could be sent there indefinitely effectively. and then you can get in trouble while in solitary for

breaking a rule and have more time added on. this is widely used it is called by a variety of names so it is hard to tell exactly but 80000 people on a given day are in some form of solitary not all of them have a mental illness but it is hard to know because if you put somebody in then they come out with it for those symptoms. but there other forms of torture. the man i wrote about when he would get in trouble they would deny his visits with his family. he would bake he said i wanted to see my father i cannot see my father. or people in solitary are cut off but all sorts forms of

torture that we see that is perfectly legal and part of the system. >> what about excessive force? >> we don't know how common but in part because it is so hard to get in but we know it happens a lot. one of the more stanching parts that i have encountered is a cell extraction somebody is supposed to come out and doesn't want to for whatever reason the corrections officers really come in with ryan again with the shields in the masks and the helmet and the pepper spray and basically break into the cell to pull somebody out. i have watched people and actual videos it is terrifying

even if you are not the subject of the extraction. >> by the way as a footnote to your comment us not knowing how many people are in solitary confinement, the mental health unit was not called solitary confinement but every so there was and they were let out for one hour a day because they wouldn't let them into the rec yard so it seems from your reporting about the similar situations what is called solitary but essentially it was putting people in isolated cells pretty much all the time. >> doesn't necessarily intended as punishment but the mental health unit it has been determined it is too dangerous

to have a cellmate. but it ends up being solitary confinement so they bring them out for their one or two hours a day and l.a. county when you come out it's not like you talk to other people but you are chained to a table like a dog. if you are well behaved sometimes they will take you to the rec yard which again it looks like the dog pen at the kennel. so somebody can run back-and-forth. >> the prison that i looked at was amends -- men's prison many of yours are facilities housing meal are those more affected? >> women prisoners actually

have a higher rate than males. the numbers get a little deep because looking at the overall population but among the female prisoners you see much irate of mental illness. and in some cases you see the mental illness being made worse by the confinement in a lot of cases they are the sole caretakers of the children and when they are incarcerated they left children behind and met several people in oklahoma who either already lost custody of their kids or were terrified they were going to. so regardless of what was going on they had tremendous level of anxiety and depression worried about their family. >> so a higher percentage of

women prisoners at this point who are exhibiting her fall into the category from the aggregate. >> the numbers are lower but the percentage is much higher but if you look at, like the number of people who experience trauma in their lives up to this point those experience serious trauma. >> you spent a lot of time detailing these for a thick cases it is not easy reading but it is important but you also do something that i think is rare in books that are a direct document of the political justice system, you don't talk in a condemning way. on the other side of this with the institutions with correction officers or mental health providers.

what does this crisis mean? >> it is easy to say that system tortures the people who are caught in the system. but i think it is a form of torture for everybody who is involved so you talk about corrections officers in some cases are some -- quasi- law-enforcement others are actual sheriff deputies that are responsible for the care of these people the same deputy that would stop you for a traffic stop but for the most part they are underpaid, overworked, i have heard stories in florida of people who try to leave at the end of a 12 hour shift literally would not open the gate and

make them work a double shift. i heard a couple of stories i could not corroborate the corrections officers actually calling the cops to say they were held captive in the prison because they could not get out to go home. and worst of all this is what they signed up for but not with a trained for so effectively they are working as a psychiatric technician or low-level mental health and a have received little or no training. and on top of it this is true across the board that they are being subjected to the same unpleasant circumstances of working in the jail so with the patdown or the lockdown of the jail goes on lockdown they will shut down the whole jail and there is no movement so doctors describe how

frustrating it is to go home but when you cannot pick up your kids from school because of the lockdown or worse, cases you are witness to something like treatment of a prisoner and you feel for your own safety you cannot intervene in any way. because you could be subjected to violence. >> what about the people who work in these facilities? what about their role in all of this? >> i met some really amazing doctors and psychologists and clinicians who really felt drawn to do this work and this was their calling that they were meant to do.

and they were making a difference to go in to make it best of a terrible situation. we have heard horrible stories of what is happening but especially lately the staff that is doing phenomenal work developing behavioral health unit like you would see in a regular hospital. a physician who used to work in the prison system said nobody graduates from medical school and says i were to go work in a prison. it is underpaid, it is a tough population to work with me the toughest cases love people who have lasting mental illness that have never been treated in the and therapeutic environment and these are the

least qualified people to do that. >> so i will push back against the idea they are caught in the system so that the prison in florida they were starving prisoners, torturing them, they killed some and could have killed others they actually did another prisoner died but none of the mental health staff with one exception challenge the guards to say this is unacceptable it is a violation of basic rights. so shouldn't the staff that are in the facilities who were there to serve the patient's shouldn't they be standing against? not just the obvious abuse but

like solitary confinement? >> there is an interesting piece to this because the clinicians talk about the loyalty because on the one hand the phrase that people use you are a guest in their house like a cold correctional facility you are there to serve for that purpose and you are subject to their rules. that is true also in terms that you are dependent on them for your own safety there are plenty of people would not necessarily want to be left alone with so i heard a lot of stories from psychologist and psychiatrist in particular when a corrections officer is angry with you you make the powers that be mad you don't have access to your patience

or a young woman social worker walked in a cell with a big guy with a psychotic disorder and the officer wanders away. you are beholden to them on that topic it at the same time as a clinician you are supposed to be taking care of people so you are left in this odd place talking about solitary confinement often they are asked determine they have started to limit the use for people with mental illness so they take the prisoner to the commissioner to say are they fit to be in solitary? it puts the clinician in an awkward position on multiple levels you don't want to be determined if you're patient is fit or not or subject or patient to that and in a

larger sense by saying that they are fit or not implicitly you are suggesting that it is okay. >> and i have heard that issue the difficult situation of the people on the front lines like applebaum who was the director of the mental health stem in massachusetts department of corrections who tried very hard to push the organizations like psychiatric association to say something about this and to take a stronger stand. they have put out policy statements but they tend in a sense to nod to the department of corrections through the criminal justice system that this isn't our business you

set the terms so he and a few others have taken the position that isn't good enough. anyone who has a severe mental illness or just a mental illness will likely deteriorate in solitary confinement as an organization they have to have a stronger policy on that. does that make sense to you in the sense we need more light shed on this in a stronger position from the outside? >> i think part of the problem is because people don't know what is going on, they really don't know what is happening in there. it is hard to say this is not acceptable so talk about solitary confinement i don't think most people realize how common it is for it is what we do to hannibal lector of the

world. so it is very difficult to get people to have that outcry because there is a seven that they deserve to be there. i think also legally there is a reluctance to step into the jail or prison world at the county level you have a warden who was senior and a lot of what goes on is nobody's business. nobody knows. >> so to have that indictment it is true that a lot of people don't know but a lot of people don't want to know that

we do actually have some awareness that solitary confinement is used for those professional organizations but it is like an inconvenient thought and in a sense it gets to the third part of your book that is less in the indictment or a plea for the alternative approach. so tell us what is in it and why you put it there that you think there is some room for hope? >> there is some for hope. i was very heartened just about every single person i spoke to for this book whether the prisoner of the family or the prosecutors or the defense attorney or the judges, there

was absolute agreement that what we are doing is wrong and it isn't serving the people any of us. so to me that is helpful that we acknowledge it shouldn't be happening but now we have to change it. the hard part is the criminal justice system is a full series of tiny systems so that change has to come in tiny pieces. we are starting to see that so moving to trained police officers and this is going on for a while those that are the first responders in many cases to a mental health crisis how to respond and not escalate the situation to d escalate to

see how they can be helpful or find the way to get the prisoner the help that they need. the second piece is to train the police officers how to respond but if there is no place to take them the police will take him to jail anyway because that is a fast if you have ever been in the er and you know you could be sitting there for two days before you see somebody no cop wants to do that for supervisor wants their -- officer sitting there for hours so in san antonio they have created a center they can bring a people in crisis to be treated for a couple of days then connected to services in the community it has been very successful and it is copied all over the country. and then we see virgin

programs ways to get people out of the criminal justice system once it is obvious they don't belong there and then for them to seek treatment and helping them rather than locking them up. >> talk about the program in miami that you write about. >> that is a diversion program a judge who has been at the forefront of changing things that once you are in the judicial system side. and basically if you are picked up on a nonviolent maybe just a few felonies almost automatically you are diverted out of the system and connected to treatment come back to check in with a fellow judge periodically to make sure you're on track that they

have been so successful they could shut down an entire wing of the jail and that is being copied all over the country. >> i want to give the audience a chance to ask questions that one more question. how unique is america in all of this? it isn't an easy population to treat generally speaking. how much worse are things here than in norway or france? >> start with the criminal justice system we incarcerate by magnitude more people than any other country so look at the closest contender which i think is russia there is that

where we are off the scale and then on the healthcare side if you talk about norway one prison was nicer than some of the public schools i have been in here you walk in and you are hit with these awful smells but in norway it is like coffee and cinnamon buns (but because they have universal healthcare and health records that are accessible that is extremely rarely talk about people who were getting treated it is common if somebody is booked in jail it is the first time they are properly assessed or treated for mental illness the psychiatrist told me rarely that happens the only time you

see that if somebody has been a substance user for so long they have moved completely off the grid so not only can they see they have been treated but say he had a break at 18 we treated him with this and it works a break at 20 to that didn't work. so they start ahead of the game where here often even coming from jail to prison which is technically not the same system somebody arrives they start all over again. >> that is a very striking point you make because of the supreme court decision where they challenge the system the supreme court rules the constitutional right for prisoners for regular american

citizens otherwise that is socialism and we don't want that so so let's have some questions from the audience to make just going off that point do you feel primarily it is a problem? >> i feel it is a parallel track problem we can't access mental health care it is hard to access it is hard to stay in the treatment once you get it with your one visit and that's it but it is also a criminal justice problem.

>> so working at the prison in ohio this is very specific but there are a lot of programs run by the mental health programs like thinking positive with all these different programs and other things so i am wondering like the nonprofessionals running these? >> we are starting to see more of that pennsylvania recently embrace like a pierce support program tracking those with mental illness with help and guidance for the fellow

prisoners which is what we see in the community through support networks but then there are outside groups that come in i did see some think it was either alcohol awareness or the aa meeting with volunteers from the outside but because the budgets are so low any type of treatment the prisoners really depend on the volunteers to fill in those gaps. >> so what are they charged with? >> it is really easy to find things to charge people with. i was out on a ride along with the state police officer trying to catch people texting

and driving he said i could stop any car i want to the tail light is out when you change lanes and we know that officers often use that to arrest disproportionately people of color but in the case with mental illness could be on the sidewalk, disorderly conduct, with passersby you name it they can find a way to charge someon someone. >> just building off of that we didn't talk much about race and class how much this is a story not about healthcare at large but also concentrated disadvantage in certain places

that then becomes catastrophic when you had mental illness into those communities of color that really were that concern should lie or does that transcend those barriers? >> it is both. you do see wealthy people with mental illness picked up. a firefighter in virginia developed bipolar disorder and was arrested the first time because he was writing an elevator and they call the cops on him he was charged with indecent exposure even though it was a misdemeanor he spent three days in prison. he ended up spending six months in jail before the

judge told him to get out of town and not come back he was largely in solitary confinement he was convinced the officers would kill him so they threw him in solitary. but largely to talk about criminal justice and talk about poverty they all overlap we know they are not getting mental health treatment so it all goes together but category the likelihood you are rested goes up and then the outcomes to get out the same problem that we see in communities of color generally. i was at rikers visiting one day i was in line to go when

you have to wait in line to go through security there was a woman who was white clearly affluent and was perplexed by the system to have quarters for the lockers and take off your shoes i was talking her through she was visiting her son who was picked up on a heroine charge of some sort i said that's terribl terrible. what are the prospects of his case she said an attorney will come see him later she had differentiated herself and for most everybody that was locked up because he had an attorney coming to visit him that they paid for so i'm sure his outcome will be different. >> that definitely resonates.

>> i am curious in chicago they say thinking of torture i think of the chicago pd so i am curious with the relationship between police and mental illness if there is one side of that if the police department is rather progressive does that affect mental illness worth the system really does try to deal with it? does that affect with the police officers are doing? what is the relationship? >> it depends where you are talking about but often there were places i talked to the sheriff he would say i can't

deal with it i have too many people in my jail i said do you ever say stop bringing people to me? take him to the hospital and he said i can't do that that is their business they make the policy. that is a striking example because the prisons are terrible they have done a terrible job to deal with people they have subject to a bunch of lawsuits how they treat people with mental illness. one of the people i write about what in solitary confinement was in prison in illinois he was depressed and suicidal they threw him into a cell by himself with no close he was freezing and miserable. who wouldn't be? but the sheriff has really made it his mission to improve things so in chicago even

before you are booked into the system they are big cages for the everybody until they are booked then every single person that comes in their and try to get them the medication and this isn't just true to say i need my insulin that is the piece of the system that we talk about.

>> do tell this through mental illness or the lens of mass incarceration? and that became a much bigger story? >> i was looking at criminal justice and i kept hearing about poverty and rate and then you realize it really is about mental illness in a lot of ways but nobody was really talking about it. but they didn't feel that it was understood in a systemic way and when i started to travel around the country going to these different jails

i realize very quickly the way the criminal justice system comes out in local ways. >> these months be pretty variable and do you have data on the racial composition for those that are diagnosed with mental illness? with those latinos and the heavy populations? >> that diagnosis question is tricky and interesting because how many people you deal with

theories on how you define that. so they say you can't put people with severe mental illness with that designation into solitary confinement then all of a sudden the numbers of people with severe mental illness dropped dramatically not because they were suddenly being cured but when the attorneys in new york

>> one of those pieces is the gatekeeper somebody that has very little to say i go to my physician but somebody who takes my blood pressure but mostly that person doesn't decide if i can see the doctor or not. in the prison system and look at the numbers they had way too few people for people of

their size. >> going with ptsd with that population so a great portion of that is trauma and and during the incarceration is there any differentiation to speak to that? and those that we know happen and with sexual assault if you look at the population there

is the trauma to be told take off your clothes and all of these contribute to the whole mess. >> i haven't read the book what you talk about substance abuse and if not why? or why not? >> i talk about in the context it can be very difficult to have substance abuse disorders with those pharmaceuticals used on the outside they are

not allowed because of currency and they are traded. alcohol use is a big problem in the jails in particular if you don't identify that can be very dangerous. there is not enough mental health treatment for substance abuse. >> a lot of the public may hear about this to say that terrible and it's unfortunate to say they are shooting or have signs of mental illness

and that impulse from the public safety perspective this is how society should deal with this. what do you say to that person? >> incarceration is really expensive and they require more regards we are very good to have money on public safety so to build more jails and prisons to protect us is a popular thing to do. nobody wants to do that.

>> can that change x. >> and we are wasting money wasting money on the backend and then they go to prison. often in that case that was highlighted in the report if they were sleeping on the bench or add a joint to bother someone and attacking the officer but all of the resources very few resources

in the community for mental health and the report basically said from the practical point of view with that report thousand eight i'm not sure how much progress but it seems like the progress on the mark -- mass incarceration is a way of resources and did not get very far. and then wait a minute and with higher education with a similar argument cannot be made? even with physical healthcare

we all know people who have it and there is no shame we have seen some cases to have healthcare for pregnant women and we need to treat that population because it is down the line but with mental health care. >> other questions? >> looking at this there are

horrors in the criminal justice system. so thank you. [applause] . . . .