In early November, staff at a group home just outside Biddeford’s downtown noticed that a resident wasn’t taking his medication. The observation could have sent James Mayo, 48, back to jail then and there.
In 2016, Mayo punched and injured two social workers while receiving treatment at the state’s psychiatric hospital, and ever since his probation had required him to take medication for the mental illness that propels his psychosis. He can be dangerous when he doesn’t, according to court records and people who have known him for years.
His group home staff members, who help people with mental illnesses live in their communities, had tracked Mayo’s bizarre behavior in the days before they realized he was chewing his medication instead of swallowing it to avoid ingesting the full dosage. Mayo had stolen an employee’s lunchbox and dumped its contents in the woods, entered empty apartments to avoid staff and left the premises without permission, according to a report written later by his probation officer.
Staff decided to take him north to Maine Medical Center in Portland for a mental evaluation. The situation worsened. Mayo wandered into other patients’ rooms and called hospital staff racial slurs, according to the probation officer’s report. The hospital discharged him after two days, on Nov. 11, but the group home did not know because Mayo did not sign a confidentiality release form.
When Mayo returned home to Biddeford around dark, he could not get in and began yelling for his belongings, said JoAnne Fisk, chief deputy of the city’s police department. Summoned by 911 calls, police took him to the York County Jail, where he remained without bail for violating his probation by not taking his medication. Failing to take medicine is not inherently a crime, but people can return to jail or prison if they do not follow the rules of their probation.
He remained in jail until early December, when his longtime attorney, Philip Mohlar of Skowhegan, asked to switch him to a new place within Maine’s criminal justice system: the Intensive Mental Health Unit at the Maine State Prison in Warren.
Maine is increasingly relying on the prison to care for people like Mayo who are sick and aggressive, and whose cases are pending, instead of Riverview Psychiatric Center, the hospital in Augusta that has historically been the primary place for treating those involved in the criminal justice system.
Only a small percentage of people living with a mental illness will be violent. But for those few Maine has limited options to safely treat them. So since 2014, the state has opted to send more county jail inmates with severe and persistent mental illnesses to the psychiatric wing at the prison in Warren.
Overseen by the Maine Department of Corrections, it is not subject to the same scrutiny as a hospital and is not regulated as one. It is not required to submit an annual report to the Maine Legislature or undergo a formal evaluation of its performance, though a past legislative committee recommended that the unit regularly report to lawmakers about “developing issues” and operations. Unlike a hospital, it has more flexibility to restrain, seclude and subdue people.
Whether it’s a good idea to rely on a prison to treat people with mental illness is something of an unsettled issue. Some advocates believe that Maine should treat people with severe mental illness in a therapeutic setting, such as a hospital, no matter their predilection for violence. Relying on the prison instead reflects a weak spot in the state’s ability to provide mental health care to every sick person who needs it, they said.
“It’s not about criticizing the [Intensive Mental Health Unit],” said Jenna Mehnert, executive director of the National Alliance on Mental Illness Maine, noting that she is a “big fan” of the prison psychiatric ward as a place to treat people who have already been sentenced to prison. “It’s about criticizing the system and that the system lacks capacity to meet people where they’re at based on their level of need.”
Riverview’s clinical director, Dr. Matthew Davis, disgreed. The Intensive Mental Health Unit is an appropriate treatment setting for certain people, particularly those prone to unpredictable violence, he said. His hospital cannot safely handle those patients due to its design and regulations on how it can seclude and restrain people, he added.
Indeed, the Augusta facility lost its federal certification in 2013 due to overcrowding, staffing shortages, and its use of restraints and stun guns on aggressive patients. It regained accreditation in February, restoring $20 million in annual funding and continues to refer patients it won’t accommodate to the Intensive Mental Health Unit.
Treating criminal defendants who have not yet been convicted in a facility designed for convicted prisoners erodes an important legal distinction that could impinge on due process rights, several mental health and legal experts said.
At issue is the 14th Amendment of the U.S. Constitution, which ensures that people cannot be punished without due process, said Zach Heiden, the legal director of the American Civil Liberties Union of Maine. If some people are housed at the prison psychiatric ward as part of their punishment and others are there awaiting trial, but their days exactly resemble each other, there’s little real difference between the legal statuses of the convicted and unconvicted, he said.
For all of this unease, expanding the Intensive Mental Health Unit gained wide support from an unusual alliance of mental health and hospital advocates and the administration of then-Gov. Paul LePage in 2013. The groups wanted more options for people to receive psychiatric care, given a spike in demand, bottlenecks across the health care system and the number of sick people languishing in jail, they testified.
In 2014, its first year of expanded operation, the Intensive Mental Health Unit treated 10 people referred from county jails. The number increased every year until 2017 when it peaked at 41, before falling to 31 referrals in 2018, according to the Department of Corrections.
Ideally, Mehnert said Maine would have another option — a hospital building with resources and security to accommodate patients with behavioral challenges. She advocated for this around the time the Intense Mental Health Unit was established and in the years that followed.
In the absence of that type of facility, even people like Mehnert agree that the Intensive Mental Health Unit is far superior to a county jail cell, which is often the alternative. The grim isolation of a cell can deteriorate the mental health of even those who don’t have disorders, said Richard Wurpel, the administrator of the Kennebec County jail in Augusta.
The Intensive Mental Health Unit, on the other hand, lets prisoners leave their cells and spend time in a two-story day room, free to work with the ward’s psychiatric staff and pass the time with games like ping pong, said Ryan Thornell, deputy commissioner of the Department of Corrections.
It provides care “at a level that would be nearly comparable to a state hospital,” he said, and its staff routinely meet with Riverview to discuss patients. In addition to the corrections officers, a doctoral level psychiatrist, a treatment director, two clinicians and four behavioral health technicians oversee about 25 prisoners every month, he said. It only accepts men.
“I’m a practical guy. That’s how I look at it,” Mohlar, Mayo’s attorney, said. But while Mayo seems to have received good treatment there, Mohlar said he wished there was both a safe and therapeutic option for his client. He just does not know what it is.
At the Intensive Mental Health Unit, clinical staff are caring for Mayo while other state mental health workers evaluate whether he is competent to understand his criminal proceedings. He has been found incompetent in the past.
“I think one of the issues is he tends to float between competence and incompetence, psychosis, not psychosis. And it changes on a daily basis,” Frayla Tarpinian, the prosecutor handling his case, told Superior Court Justice Michaela Murphy at a November hearing. They did not publicly discuss his specific diagnosis.
How a court interprets his mental condition will ultimately affect where he can stay. The state is not allowed to keep people who are found incompetent in a prison. In those rare cases, the state has six months to restore their mental health at Riverview. If that’s not possible, it must drop the charges. On even rarer occasions, the state has sent challenging patients to a psychiatric facility in South Carolina run by that state’s department of corrections, forcing their families to travel hundreds of miles to see them.
Mehnert’s imaginary third option would be a place to keep people like Mayo near their loved ones, she said.