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Treatment replaced by turmoil
COALINGA, CALIF. -- Two years after California opened the nation's largest facility designed to house and treat men who have been declared sexually violent predators, Coalinga State Hospital is described by both patients and staff as an institution in turmoil.
Convinced that they stand little chance of being released and angry about perceived deficiencies at the hospital, patients are engaged in a tense standoff with administrators, according to interviews with more than 40 patients and staff members.
Almost all of the detainees at Coalinga have served time for serious sexual offenses. But instead of being released after completing their sentences, they were transferred to the state hospital system under a 1995 law that allows the state to declare certain high-risk sex offenders mentally ill and commit them to psychiatric facilities.
Detaining someone under the law is constitutional provided that the patient receives treatment. But today, significant treatment at Coalinga is rare. Administrators acknowledge that three-quarters of the hospital's 600-plus detainees refuse to participate in a core treatment program, undermining a central piece of the $388-million hospital's mission.
Some patients have also declined to eat for days at a time to protest alleged inadequacies in psychiatric and medical care as well as less important issues, including limited access to phones. Many have boycotted educational and improvement programs that include anger management workshops, computer training and Spanish classes -- a protest known inside the hospital as a "strike."
A severe staff shortage has further impeded treatment, patients and staff members say. As of last week, 26 of the hospital's 37 budgeted staff psychiatrist positions were vacant. On many wards, hospital police officers fill roles assumed by clinicians at other hospitals.
"We've got guys who camp out, waiting for clinicians to show up," one staff member said.
Staff members describe feeling overworked and harassed by patients who bang angrily on the nursing station glass if technicians or hospital police officers are a few minutes late to escort them on smoke breaks.
"We're calling it the Titanic State Hospital," said a psychiatric technician who, like most other current employees, spoke on condition of anonymity, fearing reprisal from administrators. "We've lost control. I've been saying for a couple of months now that the monkeys are running the circus."
Patients, meanwhile, are despairing.
"It's hopeless," said Robert Bates, 41, who was sent to Coalinga after serving a 10-year prison term for committing a lewd and lascivious act. "This is a therapeutic setting, supposedly. But it's nothing more than a mock-up prison. They can call it what they want. But it's prison."
State officials acknowledge the unrest, though they say there hasn't been as severe a disruption as patients and some staff members contend. They say they are doing the best they can with an unusually challenging patient population.
"When you undertake something of the magnitude of Coalinga, there is a growing and learning experience," said Stephen W. Mayberg, director of the state Department of Mental Health. "Where we are right now is certainly, I think, moving in the right direction."
Mayberg said the hospital can't force patients to take part in treatment.
"Am I disappointed that so many folks choose not to participate? Yeah. Do I think that's indicative of their illness, or their condition? Yes, I do," he said.
Coalinga opened in September 2005 amid promises of a new era, both in protecting the public and in treating sex offenders. Even empty, the facility stood out; its sleek architecture and tidy topiaries presenting a jarring contrast to the tumbleweeds and dust devils that dominate the surrounding landscape.
But the operation of Coalinga -- the only mental hospital built in California in half a century -- was never going to be effortless.
Sex offenders are a notoriously difficult group to treat. More than half the men confined at Coalinga are pedophiles, and many have had numerous victims. And sex offenders tend to be manipulative and charismatic, traits that helped enable some of their offenses in the first place.
Most Coalinga patients don't have mental illnesses that can be treated with medication, and there is no sure-fire way to rid the men entirely of their impulses. Many psychologists do not believe that hard-wired sexual deviance can be "cured"; instead, officials focus on what they call "relapse prevention."
From the start, Coalinga patients rejected their confinement, calling it unconstitutional. Then, last fall, California voters overwhelmingly approved Proposition 83, a tough crackdown on sex offenders.
Jessica's law, as it is known, made it easier for authorities to designate someone a "sexually violent predator" and hold him indefinitely, and to put restrictions on patients' ability to challenge their confinements.
Staff members say that because such a wide spectrum of sex offenses qualifies people for post-prison commitment, decisions about who is released and who is detained are largely random. Some staffers question whether all the patients at Coalinga belong there.
Michael Feer, a psychiatric social worker with more than three decades of experience, worked at Coalinga for a year before leaving this spring. He now works in San Diego County with recently paroled sex offenders, men who in some cases committed the same crimes as those at Coalinga but who are being released into the community, he said.
Feer said that although all Coalinga patients qualify as violent predators on paper, he believes that more than a third of them would pose no threat if released.
"They did their time, and suddenly they are picked up again and shipped off to a state hospital for essentially an indeterminate period of time," Feer said. To get out, he added, "they have to demonstrate that they are no longer a risk, which can be a very high standard. So, yeah, they do have grounds to be very upset."
The hospital, Feer said, "is a setup" -- ostensibly a treatment hospital but one built with a wink to a public that has little compunction about locking up sex offenders forever.
Coalinga administrators insist that there is still a clear path to release, provided a patient completes the hospital's exhaustive treatment program.
"I wouldn't be working in this field if I thought it was a scam," said Deirdre D'Orazio, director of program development and evaluation services at the hospital. "I don't believe that there are any wastebasket cases, individuals who are so abnormal that they can't learn to put aside their deviant impulses."
The core sex offender treatment involves such activities as a "psychological autopsy," a detailed accounting of decisions that preceded an offense.
Patients offer a variety of reasons for declining to participate. Some believe they can overcome deviance on their own. Others believe, mistakenly, that mere participation could be viewed as their first public admission of guilt. But many patients shun treatment because they have become convinced -- not without reason -- that no matter what they do, they are never going to win their freedom.
As of August, two years after Coalinga opened, not a single patient had been released because of completion of the treatment program. Of the more than 600 sexually violent predators who'd been committed to the facility as of August, the latest figures available, 17 patients had been released, all of them after petitioning in court.
Hospital administrators argue that patients should participate in treatment not just because they want out but because they want to acknowledge and address their problem.
"They need to say, 'My freedom is less important to me than never creating another victim,' " D'Orazio said.
Coalinga patients are keenly aware that they are not a sympathetic crowd. So they have tried to sell their cause -- to hospital administrators, healthcare reformers and advocates for the mentally ill -- as a matter of governmental responsibility.
"They've sold this as a wellness-and-recovery program," said patient Greg Peters, 49, a former studio percussionist who served a five-year prison term for raping two adult women before being routed into the mental health system. "But they are deceiving the public. You guys are out there paying taxes for this."
Like most patients at Coalinga, however, Peters said he harbored little hope that he will ever get out. He says staff shortages have resulted in a failure by the hospital to monitor and document patients' progress, an important part of convincing a court that they are ready to be released.
The staffing shortage stems in part from the decision by state officials to build the hospital 60 miles southwest of Fresno, in an isolated, dusty pocket of California's Central Valley otherwise dominated by huge almond farms, hardly the stuff of recruitment posters.
Compounding the staff shortage, an ongoing salary dispute makes it possible for many of the people hired there to make more money doing the same job elsewhere. And many of those who do go to work at the facility leave quickly.
Between November 2006 and October 2007, the hospital hired 468 people, but 147 left.
Extraordinary turnover isn't limited to rank-and-file employees; state officials are conducting a national search for the hospital's fifth executive director -- including people who have held the job on an interim basis -- in 18 months.
A single clinician is often left to supervise a unit of more than 50 patients. Mandatory overtime is routine, as is burnout, according to staff members.
"It's a miserable place to walk into," said one psychiatric technician. "Morale is horrible."
A growing sense among patients that they have been effectively railroaded into a life prison term formed the seed of discontent during the summer and fall.
Administrators have since challenged the patients' account of the "strike," saying the percentage of people participating has been far lower than patients and some staff members contended. They said, however, that they did not have attendance figures for educational and improvement programs.
But both patients and staff acknowledged that in the highly charged environment at Coalinga, even the most trivial of disagreements had ballooned into full-fledged disputes over civil rights.
In August, for instance, according to staff members, a group of patients taped small protest fliers to their hospital-issued identification tags. Most read: "When injustice becomes law, resistance becomes duty." Hospital officials ordered patients to remove them.
"They said they were defacing government property," a clinician said. "But they were just making this up as they go."
It did not end well; officers eventually hauled away one patient who refused to take off his protest flier.
"They made a martyr out of him," the clinician said. "The next day, patients had bigger pieces of paper taped to them that said: 'Please don't hit me because I'm wearing this piece of paper.' "
Patients, meanwhile, have developed a list of complaints and concerns. They say, for example, that the hospital drags its feet before allowing them outside the walls for specialized medical care.
The hospital denies having a problem, though a former employee familiar with the hospital's medical operation acknowledged that patients weren't seeing necessary specialists. The employee said the issue was complicated by the fact that physicians in nearby communities refuse to contract with the facility.
"Nobody can decide what we are," said Niles Carr, 38, who was routed into the mental hospital system in 1998 after serving time for molestation. "But as long as we're stuck here, we need to be treated properly."
Some of the patients' demands -- such as Internet access -- aren't likely to gain much traction with the public.
Others, however, have gained the attention of a congressionally charged, federally funded group that advocates on behalf of people with physical and mental health disabilities. Protection & Advocacy Inc. attorney Sean Rashkis said the group was investigating patients' concerns.
"They have done their time and have moved into a civil commitment which is based on treatment," he said. "Some of the patients argue that that's not what they are getting. It may be the case. We'll have to see."
One in a series of occasional articles on California's troubled mental health system.