System Failure, System Frozen

By Edd Conboy

Note: This is the follow up segment to Edd's previous post System Failure, System Reboot. In these powerful stories, Edd humanizes the ways that our mental health and criminal justices systems often fall short - for precisely the people in the most critical need.

Update on Roxanne: Since the posting of the first installment, the hospital official, who intervened on Roxanne’s behalf to ensure that there would be an effective treatment plan for her going forward, was able to schedule a hearing before a judge to name a guardian for Roxanne. An attorney was engaged by the hospital to represent her. Subsequently, the judge appointed a guardian, and now he is in the process of finding a suitable nursing home for her that can manage her medications and other needs. Just to give you an indication of how far Roxanne has come: She has HIV. A high viral load count is usually measured in the thousands. 10,000 copies/mL is considered high. Roxanne’s viral load was 23,000,000 copies/mL. Her white blood cell count was negligible. Today with medication her viral load count is negligible, and her white blood cell count is near normal.

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The writer, Christopher Hitchens, once said that one of his highest aspirations was to, at least one time, write or talk about the North Korean regime, and the culture it has spawned, without using the descriptor “Kafkaesque”. He failed continually. So, it appears that, when I describe some of the systems failures in our prison system, I will probably suffer the same fate.

As with the previous posting involving Roxanne’s experiences with the health system here in Philadelphia, I will attempt to crystalize the implications of “systems thinking” as it pertains to the prison/mental health system here in Philadelphia (and perhaps nationally) with the experiences of one individual.

In this case let’s call her Tiffany.

Tiffany is a homeless, transgendered person in the early stages of transitioning. This means that, although she is anatomically male (for the most part), she identifies herself as female, and has been living as a female for a number of years. Like many people in her situation, she has had the unshakeable felt sense for most of her life that she is in “the wrong body”, but for a number of reasons – mostly financial – she was unable to change that significantly. Tiffany is also diagnosed with Bi-polar Disorder, and needs medication to control that condition. She has been living outdoors in Philadelphia for several years.

A year and a half ago Tiffany was in the ER at a local hospital trying to get medication to control her mood swings when she was involved in what appeared to be a mild altercation with the security guards. Since she has no medical insurance, Tiffany is a regular visitor to that hospital, and well known to the staff there. For reasons still unclear, this time the security officials decided to have her arrested and charged with felony assault, even though there were no significant injuries to anyone during the altercation.

Since Tiffany was unable to post the $4,000 bail, she was remanded into custody and taken to the county jail.

When most of us hear “county jail”, what do we think of? Perhaps a several story building downtown near the courthouse. Few of us would envision a 25-acre complex comprising six separate “major correctional facilities” in the farthest corner of the city limits. A facility that is extremely inaccessible by public transportation, meaning extremely inaccessible to poor people. This may be the first questionable “systems thought” in this scenario: Why so inaccessible? What are the implications of this decision? Who made it in the first place?

At this point in the narrative the specter of Franz Kafka may begin to emerge. Since Tiffany is in possession of a penis, she is considered male by the correctional authorities. Fair enough. However, since she identifies as a female, if assigned to the general population, she is at risk of being sexually assaulted by other inmates. The solution to this problem is clear to the officials: “administrative segregation” for her own protection. This is, of course, a euphemism for solitary confinement.

So for several months Tiffany was held in solitary confinement without proper medication before she was scheduled for her first court appearance. Once she was in court the judge found her not competent to stand trial. She was returned to administrative segregation. Her condition began to deteriorate markedly.

It is well documented in the research that one of the most powerful coercive tools available to the state is its capacity to confine an individual for varying lengths of time with virtually no human contact. Many modern societies consider it a form of torture. Tiffany was in this situation for the better part of a year.

So, now “the system” is faced with another dilemma: they have an inmate who is charged with, but not convicted of, a serious crime. She is unable to stand trial, and no small reason for that is due to her isolation within that very system. The solution that the decision-maker made was to house Tiffany in a psychiatric prison facility outside the city. In this facility she is given medication to sedate her, but very little else. Since she no longer has access to hormone therapy, her beard has returned, and of course she is not allowed to have razor blades. In addition the staff (including social workers) continue to refer to her with male pronouns further alienating her. She receives no therapy or medication for her Bi-polar disorder. And every sixty days there is a competency hearing. Every sixty days she is found not competent to stand trial.

Finally, in a large part because of the decision to isolate Tiffany, her mental state has deteriorated to such an extent that, even if she were released, and she were able to afford surgery, she would not do well enough in a psychiatric assessment to be cleared for any such surgery. This means that the most likely outcome is that Tiffany will spend the rest of her life trapped in a body that is alien to her psyche.

At every turn in this narrative – from the decision to charge her with a felony, to isolating her in the county prison facility rather than housing her with other transgendered inmates, to transferring her to a psychiatric prison hospital ­– “decision were made”. Yet, it is difficult to determine who made them, what was the thinking behind them, and if there were other alternatives available. At every turn, unlike the previous scenario with Roxanne, the system appeared to do the thinking without any discernable human intervention.

From my perspective (and perhaps this is one shared by other members of the Whitman community) the key factor missing in this scenario that showed up just in time in the previous installment is the emotional one. At one crucial moment a human being literally “felt for Roxanne” and made a different decision. That health professional’s critical thinking changed dramatically when that interplay between emotional clarity and critical thinking was able to lead her to effective action.

So far, perhaps because of the different context of the penal system from the health system, no such individual with similar authority to intervene has spoken up on behalf of Tiffany.

But at times even Kafka wasn’t all that Kafkaesque.