Dostoevsky said that the degree of civilization in a society is measured by the way it treats its prisoners. Such a statement could not be more true than when the prisoners are youth in dire need of mental health treatment.
In the best of circumstances, youthful offenders with mental health issues face formidable hurdles. However, at a time when resources are dwindling and legislators are "tough on crime," we are faced with difficult questions about the rights of this troubled population—and our responsibilities to them. Our care of these youth, who are perhaps in the greatest need of counseling, treatment, and education, implicates fundamental legal and moral concepts that do indeed reflect on our society. These issues are of particular significance in California, which has one of the highest rates of incarcerated juveniles in the United States, and specifically in the cases handled by the California Youth Authority (CYA).
Falling at the bottom of the "least restrictive environment" continuum, the CYA is the end of the line in California's juvenile justice system. Housing approximately 6,000 youth (referred to as "wards" within the CYA), in eleven correctional facilities, four rural conservation camps, and two institution-based camps, the CYA is the largest juvenile justice agency in the country. It is also a system that historically has struggled to provide even the minimum of required mental health care to its wards.
In contrast to the adult correctional system, the juvenile justice system is not intended to be punitive. State law articulates the CYA's mission as the protection of society from the consequences of criminal activity through the correction and rehabilitation of youthful offenders. Mental health care is obviously a critical aspect of the function and purpose of the CYA.
Incarcerated youth are entitled to adequate mental health care under a variety of laws, both state and federal, including the U.S. Constitution. Although the U.S. Supreme Court has not addressed the appropriate source of constitutional protections for incarcerated youth, courts generally consider the Fourteenth Amendment the appropriate benchmark for these issues. This reasoning rests on the rehabilitative nature of the juvenile system. For example, the Ninth Circuit in Gary H. v. Hegstrom, 831 F.2d 1430 (9th Cir. 1987), applied the Fourteenth Amendment standard to conditions of confinement of juveniles in an Oregon facility because they had not been "convicted." More recently, the Eighth Circuit reaffirmed the use of the due process standard in A.J. v. Kierst, 56 F.3d 849 (8th Cir. 1995), in part because juveniles are in a system whose purpose is rehabilitative and not punitive in nature.
To give meaning to the due process standard, courts often look to Supreme Court cases involving adult populations also entitled to Fourteenth Amendment protections. In Youngberg v. Romero, 457 U.S. 307 (1982), a case involving institutionalized developmentally disabled adults, the Court held that conditions representing a substantial departure from accepted professional judgment violate the due process standard. In a case regarding conditions for adult pretrial detainees, Bell v. Wolfish, 441 U.S. 520 (1979), the Court articulated that conditions that "amount to punishment" constitute a violation of the protections of the Fourteenth Amendment. These guidelines, of course, inform any analysis of whether the conditions within a juvenile facility are constitutionally adequate. As a result, courts frequently look to the professional judgment of experts in the field, as well as conditions and standards in analogous adult facilities, to measure the conditions in juvenile facilities.
In addition, under the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 (requirements of which are triggered by receipt of federal funds), juvenile facilities are obligated to make their programs, services, and activities readily accessible to and usable by wards with disabilities. The Ninth Circuit held in Lee v. Los Angeles, 250 F.3d 668 (9th Cir. 2001), that mental health services undertaken by law enforcement and provided by correctional facilities to those incarcerated are "services, programs, or activities of a public entity" within the meaning of the ADA. These disability statutes have been used in the adult correctional context on issues related to provision of medical and mental health care. For example, prisoners with mental disabilities in the New Jersey prison system filed suit claiming that their rights under the ADA and Eighth Amendment were violated when they were denied treatment for their conditions. The New Jersey District Court approved a settlement requiring improvements in the state prison system, D.M. v. Terhune, 67 F.Supp 2d 401. The legislative history of the ADA specifically anticipated such scenarios, describing how people with disabilities frequently are arrested inappropriately and deprived of medications while incarcerated.
California state law also delineates the rights of these youth. For example, the California Constitution, Article I, Sections 7 and 17, provides rights analogous to the U.S. Constitution, guaranteeing the right to due process and prohibiting cruel or unusual punishment. Section 4730 of Title 15 of the California Code of Regulations specifically guarantees the right to adequate medical care within the CYA. Finally, Government Code Section 11135, the state law analog to Section 504 of the Rehabilitation Act, requires recipients of state funding to provide full and equal access for people with disabilities to the benefits of any program or activity. Each of these state laws establishes the rights of juvenile offenders to adequate mental health care.
Scope of the Problem
Increasingly, the population within the CYA's institutions is comprised of young men and women facing significant mental health problems. As a result these legal protections are ever more important for wards. Described by some as a dumping ground for youthful offenders with mental health needs, the CYA has reported that 44 percent of its male wards and 61 percent of female wards have problems in at least one mental health area. Mental health issues, both within the CYA and in the juvenile justice system generally, are often compounded by substance abuse problems. CYA data show that 38 percent of males and 50 percent of females within the system have both mental health and substance abuse treatment needs. These mental and emotional disorders include major depression and schizophrenia and manifest in multiple ways, including severe behavior problems and suicide attempts. Such special problems, combined with the inherent psychological effects of incarceration on children and young adults, represent a dramatic and urgent demand for mental health services within the system.
Despite demonstrated need and the legal obligations outlined above, mental health care at the CYA historically has been alarmingly sub-par, with the agency itself describing its evolution in this area as haphazard-a decentralized development by often unqualified staff. The result is what the CYA has labeled a "patchwork of . . . programs" lacking an organized delivery system.
Mental health treatment within the CYA faces myriad problems: the severe lack of trained and qualified staff, appropriate intake procedures, and sufficient resources, to name a few. The result is a systemic failure to screen and treat youth with mental health needs, a situation confirmed by a recent CYA statement: "The present configuration of mental health programs does not come close to meeting the diverse mental health needs of our population . . . many wards will not receive the mental health services required."
For example, according to national standards, the CYA is seriously understaffed, with a ratio of one psychologist for every 288 wards-despite the fact that national standards recommend a ratio of one to sixty. Its treatment units contain only 523 beds for mental health treatment, woefully inadequate given that, according to the CYA, approximately 3,000 wards require treatment. In addition, mental health units are not available at every facility, meaning wards who should be placed in one of these programs often continue to reside within the general population-where treatment has been described as vague and informal.
Services for wards on lockup are particularly problematic. Lockup operates on a regime commonly referred to as "23/1"; wards stay inside their cells for 23 hours a day, with one hour of "program" time outside the cell. These sessions take place in cages referred to as Special (or Secure) Program Areas. When wards on lockup attend counseling sessions, they do so either in a cage or through a small slot in the cell door, while the counselor sits outside. Wards on lockup often are denied reading material, television, or radio, and their opportunities to keep in contact with families through telephone calls and visits are severely curtailed. This type of isolation often exacerbates mental health problems and dramatically limits access to services, which are already scarce.
Conditions within the CYA are no secret in California. As the CYA reported in a recent request for additional funding, it has been subject to "extraordinary scrutiny" from the public, the media, and the legislature. As the agency noted, among the problems identified by external reviews are "failure to follow operating policies and procedures, inadequate training, the need for the enhancement and development of policies and procedures, and a lack of sufficient resources to provide adequate treatment for programs, such as mental health care, substance abuse and sex offender."
In 2000, public safety committees from both the state Senate and Assembly received testimony about CYA conditions from former wards and CYA employees, parents, and community advocates. These committees heard about shortages of staffing and places in intensive treatment programs, and about treatment of wards by extraordinarily undertrained and overburdened staff. As a result, the committees recommended that the CYA develop and institute medical and mental health programs that at least meet standards within the California Department of Corrections. Numerous studies by governmental and academic authorities have echoed the findings reported here.
The CYA's failure in mental health care finally resulted in litigation against the system. In 2000 the Youth Law Center, suing on behalf of a pediatrician, won a court order directing the CYA to obtain licenses for its mental health facilities. Currently, the CYA is the subject of an additional lawsuit addressing conditions of confinement in a variety of areas throughout the system, including CYA's systemic failure to provide mental health services to its wards. Other states have faced legal action under similar circumstances, Georgia and Arizona among them; the vast majority of these actions have produced negotiated requirements for improved standards of care. It is now time to talk about a fix in California.
Above and beyond the legal obligations of CYA officials, failure to provide adequate mental health care for incarcerated youth is simply poor public policy. By housing these youth in massive, prison-like institutions yet failing to treat the causes of their symptoms, we compound the problem and seriously delay resolution. If there is an inevitability within the juvenile system, it is that wards will be released back into society. It is our choice how they return: having received appropriate treatment, or having spent their formative years in punitive environments with inadequate treatment for significant mental health needs.
In order to address this situation, California must not only provide legally adequate mental health care within the CYA but also develop additional ways to respond to the crisis. One example of an alternative approach is Santa Clara County's juvenile mental health court, the first of its kind in the nation. Established in 2001, the court is a multidisciplinary response to the needs of youthful offenders with mental health issues that combines treatment with accountability. Although still in its infancy, the mental health court provides an innovative alternative to traditional methods of addressing the challenges of this population. Lawmakers must begin to initiate and evaluate alternative programs such as the juvenile mental health court, and improve quality of care for youth incarcerated in state facilities, if we are ever to address the needs of this at-risk population. California must make a decision how it will choose to treat youth who have already come to the end of the line-a decision that will indeed reflect deeply on us as a society.