CRANSTON � To reach D-mod, a specialized unit at the High Security Center of the Adult Correctional Institutions, you must pass through a series of steel doors manned by guards inside fortified control...

CRANSTON � To reach D-mod, a specialized unit at the High Security Center of the Adult Correctional Institutions, you must pass through a series of steel doors manned by guards inside fortified control booths. You must be escorted by at least one correctional officer � on this day, William Galligan, a lieutenant. Louis A. Cerbo, the Department of Corrections� clinical director, joins him on a tour.

Each of D-mod�s 12 cells holds a single prisoner. Each cell has cinder-block walls, a high ceiling, one fluorescent light, a camera, a tiny window facing outside, a larger window facing in, and a bunk and steel toilet/sink fixture, both bolted to the concrete floor. The metal mirror, warped by age, distorts your reflection. The total floor space of each cell is 76 square feet. There are no radios, televisions, or computers. It is eerily quiet, except when someone is in crisis.

A small number of D-mod inmates, diagnosed with severe mental illness, spend most of their days alone in these cells.

During the hour or sometimes more that they are out, they take outdoor �recreation� in steel cages, watch a group TV, visit the library or classroom, or receive counseling and related services. When they shower, liquid soap is poured into their palms, since a bar could be used to attempt self-asphyxiation, or, wrapped and swung in a towel, used as a weapon.

These men on D-mod, home of the Observation and Stabilization Unit, are among the sickest people at the ACI.

Galligan says their care has improved since Cerbo was hired in late 2011: correctional officers have undergone training and they belong to mental-health teams created by the clinical director. Galligan says his job these days includes what he calls �a social-worker aspect.�

�We don�t throw them in a cell and forget them,� he says. �We try to make it a little bit better, rather than exacerbate the situation. We get them medicated, we get them compliant, we get them stabilized.�

�We work together,� Cerbo says. �We have to understand their perspective and they have to understand ours.�

The same approach, says Cerbo, is used elsewhere at the ACI, including in High Security�s other modules. According to department spokeswoman Susan Lamkins, 17 of High Security�s 94 inmates, as of last Monday, were classified as �high risk� � men diagnosed with schizophrenia, post-traumatic stress disorder and other severe disorders who have exhibited unruly, self-injurious or suicidal behaviors. Another 31 were classified as �moderate to low-risk mentally ill offenders.�

Treatment teams include doctors, social workers, and education and discharge-planning specialists, according to Cerbo.

�The primary goal of this multidisciplinary team,� he says, �is to identify the specific needs of each offender, develop long and short-term goals for treatment and intervention, and to establish a strong and open line of communication that transcends all of the various disciplines involved in the care and custody of the High Security Center�s offender population.�

But Cerbo does not assert that prison is the best setting for psychiatric care, or that the resources available to him are sufficient for what ideally he would do.

�With the limited resources we have,� he says, �we try to do a credible and the best job we can.�

�

Some of the several inmates that Mental Health Advocate Megan N. Clingham represents are incarcerated at High Security. All were too sick to consent to an interview.

Clingham credits Cerbo, his staff, and correctional officers such as Gilligan, with a dedicated effort, given the limitations. Still, she believes prison is not where most people with mental illness belong.

She finds the isolation particularly egregious.

�Imagine being in a room 23 hours a day while you�re hallucinating and you don�t know what�s real, what�s not, or what�s happening to you,� she says. �Lots of studies show that putting somebody who�s in a severe psychiatric crisis in solitary confinement makes the sickness get worse. Some people you just can�t medicate out of their symptoms. They need a treatment facility, a treatment setting, rather than being locked in a cell for 23 hours a day.�

During one of his many stays at the ACI for non-violent crimes, Clingham�s client John Vitale, 48, diagnosed with major depression and bipolar and mood disorders that began to disrupt his life while he was a student at the University of Rhode Island, spent time at High Security. He is currently homeless, not incarcerated.

�You�re stuck in a cell 23 hours a day with nothing, absolutely nothing, for your mind,� he says. �It made me want to commit suicide. It made me incredibly paranoid. Then you walk in a kennel for an hour, if you�re lucky, Monday through Friday.�

Still, says national authority James McNulty, head of the Mental Health Consumer Advocates of Rhode Island, �there are times people living with mental illness need to be hospitalized or kept in a facility like the forensic unit or the prison.

�Unfortunately, the lack of resources for the community mental-health system means that some avoidable crises deteriorate to actual crisis, which sometimes leads to violent acts and tragedy. It does not happen often, but it could happen less often with better resources and training.

�Very few individuals living with mental illness are violent � somewhat fewer than in the general population � but when they are, we as a society have the right to protect ourselves.�

�

To address the larger issue of the hundreds of people with mental illness throughout the entire ACI, Clingham supports sweeping statewide changes.

Police need comprehensive training in dealing with people with mental illness, she says, and access to diversion services that would keep many of the people committing such petty crimes as shoplifting and trespassing out of prison. More community housing and employment opportunities are required, she says. And what once was the gold standard of public mental-health systems needs to be rebuilt after years of budget cuts, fragmentation and neglect.

�If the community mental-health agencies had more resources, they would be better able to reach out to people,� Clingham says. �They�d be able to provide more intensive services for people to keep them in the community as opposed to the never-ending loop of hospital, homelessness, hospital, homelessness, jail.�

Clingham also argues for more psychiatric beds in the private sector and the state�s Eleanor Slater Hospital. With its population of some 500 people with severe mental illness, the ACI has more adult �beds� than the combined total (396) of adult psychiatric beds at Slater (140) and these private hospitals with such units: Lifespan�s Rhode Island and Newport hospitals (72), and Care New England�s Butler and Kent hospitals (184). Clingham contends that math is warped.

As things stand now, says James McNulty, �the sad truth is that there is nowhere else to put them. Particularly in colder weather, police officers do not want to see people on the street when they know that mental illness is involved.

�It�s also a lot easier to get someone in at the ACI than into the mental-health system if you�re in a hurry. Even trying to put someone in a psychiatric bed at one of the hospitals is hard. Often there are no beds available.�

Like Clingham, McNulty argues for comprehensive, not piecemeal, reform.

�There�s no single thing that can be done to correct the situation of having 16 to 20 percent of the ACI population having a serious mental illness,� he says.

�

Craig Stenning, director of the state Department of Behavioral Healthcare, Development Disabilities and Hospitals, which operates Slater Hospital and has jurisdiction over the public mental-health system, also endorses comprehensive change. To that end, he hopes soon to convene an apparently unprecedented meeting of providers, advocates and representatives from law enforcement, the mental-health community and others.

�We tend to �silo� the issue,� Stenning says. �We look at it as the homeless that are mentally ill, the people involved with the criminal-justice system who are mentally ill, the veterans who are suffering. We need to look at this globally because the solutions apply to all of those populations.�

Says deputy BHDDH director Rebecca L. Boss: �You have the Department of Children, Youth and Families that�s responsible for this, BHDDH which is responsible for that. The Department of Corrections has some responsibility for their mentally ill population. The Department of Education has some responsibility. We haven�t all come together.�

Stenning also says the time may have come for the General Assembly to reexamine the state�s Mental Health Law, which took effect in 1966 and has not been substantially revised since. Stenning says modifications could give authorities greater leeway in intervening in situations before a person with mental illness becomes gravely ill and begins to act in ways that draw the police.

�

As of now, solutions are mostly just talk.

McNulty worries that Rhode Island will remain complacent, with potentially dire consequences beyond the mistreatment of individuals.

�The disinvestment in community mental health has not happened in a dramatic fashion,� he says, �so most of the public and elected officialdom conclude that there really is not an emergency of any sort. This is akin to the public approach to climate change. It seems to take something like the Ebola virus to get people stirred up to some sort of action.

�Prisoners, folks living with serious mental illness, people who are homeless � these folks are not something people want to think about. Unless something is done to stop the drift here, I am not optimistic that there will be change, and sooner or later something major and ugly will happen.

�Probably the most important lesson I�ve learned working in this field is that bad things don�t always happen in a big explosion � they seem to happen slowly, culminating in disaster, as in death by a thousand cuts.�