Before group therapy begins for mentally ill maximum-security inmates at California prisons, five patients are led in handcuffs to individual metal cages about the size of a phone booth. Steel mesh and a plastic spit shield separate the patients from the therapist, who sits in front of the enclosures wearing a shank-proof vest.
When the lock clanks shut on the final cage — prison officials prefer to call them "therapeutic modules" — the therapist tries to build the foundation of any successful group: trust.
During a recent session at a prison in Vacaville, psychologist Daniel Tennenbaum, wearing a herringbone sports coat over his body armor, sat just out of urination range of the cages with an acoustic guitar, trying to engage the inmates with a sing-along of "Sitting on the Dock of the Bay."
About a decade ago, a federal judge ruled that it was cruel and unusual punishment to leave mentally ill prisoners in their cells without treatment. Since then, state prisons have spent more than a billion dollars delivering care to an ever-growing population of inmates diagnosed with schizophrenia, bipolar disorder and other psychiatric problems.
State officials say they have not tried to estimate how much of that cost is attributable to the caged therapy. The value of the sessions, however, is the subject of heated debate among mental health professionals today.
"Those cages are an abomination. They train people that they're not human, that they're animals," said Terry Kupers, a psychiatrist in Berkeley who served as an expert witness on treatment of mentally ill prisoners in the case that forced California prisons to provide psychiatric care.
"It's bizarre, it has a Hannibal Lecter quality to it," said H. Steven Moffic, likening California's procedures to the measures used to contain an incarcerated serial killer in "The Silence of the Lambs."
Moffic, a psychiatry professor at the Medical College of Wisconsin, has written about treating patients in prisons under less imposing restraints. "I'm not quite sure what the clinicians think they are going to get out of it," he said of California's method.
Prison officials say they're doing their best to comply with the court order, which requires them to offer treatment to all mentally ill inmates, no matter how dangerous.
Overall, that care in 2006 cost the state $166 million to treat about 32,000 inmates, department records show. By 2009 the number of inmates had risen modestly to 36,000 but the cost of treatment had more than doubled more than $358 million.
About 3,500 of those prisoners stepped into a cage for group therapy after being sent to a segregation unit for offenses committed inside prison walls, including receiving smuggled drugs, organizing gangs or assaulting prison employees.
Jeffrey Metzner, a Colorado psychiatrist who has advised the court-appointed special master overseeing mental healthcare in California prisons, said the enclosures offer better security and more freedom of movement than alternatives used in most states, which include handcuffing patients to their chairs or shackling an ankle to the floor. Once the inmates are inside the cage, their handcuffs are removed.
Metzner also advised prison officials to refer to the enclosures as therapeutic modules, not cages. "The name is important, because if you call them cages, people inside might feel like animals and respond accordingly," he said.
That's precisely why some critics object so strongly to the enclosures.
"You're not fooling anybody with some ridiculous euphemism," said Pablo Stewart, a San Francisco psychiatrist and outspoken critic of the enclosures. "This is one of the more horrendous examples of what goes on in the California Department of Corrections."
Among Stewart's concerns is the fact that some mentally ill inmates remain in disciplinary segregation units, receiving therapy in cages, until their parole dates arrive.
"So one day you're so dangerous that you have to be in a cage and the person talking to you is sitting at a distance wearing a flak jacket, the next day you're sitting on a bus," said Stewart. "That's scary."
A few mentally ill inmates are involuntarily committed to hospitals after release from prison, officials said, but most get a supply of medication and instructions to continue therapy when they're back on the street.
At institutions where space is tight, the therapy modules have been arranged in the middle of inmate living quarters with multistory cell blocks towering overhead; their bored occupants are looking down, taunting.
"You go down for therapy and there are guys screaming and yelling at you from every floor," said Jane Kahn, an attorney who represents inmates in the ongoing litigation. Aside from making the sessions difficult, exposure to other inmates obliterates the sense of confidentiality essential for worthwhile therapy, Kahn said.
Prison officials recognize the problem but say they don't have much choice. "That's a function of not having the space for clinicians to do their jobs," said Terri McDonald, chief deputy secretary of the California prisons. "If you were to ask us if that's the preferred way to do business, the answer is no."
Last month, the U.S. Supreme Court heard arguments on whether tens of thousands of inmates should be released so the prisons would have enough room and an adequate staff to deliver medical and mental healthcare that meets constitutional standards.
Although some California prison psychologists insist the individual therapy enclosures are ultimately a good thing, even they can be taken aback the first time they see them.
"To come in here and realize that was how they do group therapy, it was super-hard to get used to," said Angela Gross, a prison psychologist who started working with the modules in 2006.
Tennenbaum, the music therapist, says the work is useful despite the circumstances. "We talk, we write songs, we do stuff like that all week. It's really helpful," he said.
Despite the votes of confidence from prison staff, there are indications that the state might be moving away from the enclosures.
Sharon Aungst, California prisons' chief deputy secretary for healthcare, noted that other states have found less restrictive ways to handle security in group therapy sessions. Prisons in New York, she said, have begun using chairs with desks that come down over inmates' legs, locking them in but leaving them free to move their arms and giving them a writing surface.
"We are looking at another option to these therapeutic modules," Aungst said. "They're not my favorite either."