A federal judge is requiring Arizona’s prison system to find and hire hundreds of new mental health care workers to protect the lives of people who are incarcerated. Now, the judge is about to issue an urgent hiring deadline aimed at undoing years of unconstitutional and inhumane care for people in prisons run by the Arizona Department of Corrections.

The task will require colossal effort and is long overdue, civil-rights advocates say.

The Department of Corrections’ “failure to hire sufficient competent staff means prisoners with serious mental health needs are ignored,” U.S. District Judge Roslyn Silver wrote. “The consequences of this understaffing are dire.”

The 200-page remedial order from Silver came in January. It followed her 2022 ruling that found the Arizona Department of Corrections is violating the constitutional rights of people detained in state prisons through its lack of adequate medical and mental health care and the conditions of solitary confinement.

Specifically, the Arizona Department of Corrections, led by recently-appointed Director Ryan Thornell, is violating constitutional Eighth Amendment rights meant to protect against cruel and unusual punishment.

Thornell replaced David Shinn who was appointed by Ducey in 2019 after the previous director, Charles Ryan, stepped down amid scandals and prison-safety issues. Ryan led the department for 40 years.

The 2012 case, Jensen v. Shinn, has dragged on while people detained in the jail have endured harm and inhumane care. The process has included a 2015 settlement agreement that hasn’t been completed, which has put the state prisons in contempt of court twice and resulted in the remedial order.

Most mental health care inside Arizona state prisons is provided by unlicensed associates, technicians and corrections officers, said mental health care expert Pablo Stewart in court testimony. Stewart is an attending psychiatrist at the Oahu Community Correctional Center.

“It’s hard for me to adequately express how significantly ill the individuals that I encountered are,” Stewart said. “They were among the most mentally ill individuals that I have seen throughout my 40 years of being a psychiatrist.”

The remedial order reviews in detail many horrifying cases of patients’ unnecessary suffering, including that of “J.R.” — a prisoner at Eyman state prison in Florence. He was diagnosed with schizophrenia and described as “overtly psychotic.” But J.R. wasn’t prescribed or taking any medication.

Stewart called it “the ultimate example of deliberate indifference. That is, the staff acknowledge that J.R. is psychotic but are not doing anything to address it.”

Arizona has only six physician psychiatrists and an additional 25 advanced practice providers acting as mental health providers in the corrections department, as of the time of an investigation related to the trial, healthcare consultant Robert Joy said in an expert witness report during the trial.

These personnel serve about 24,000 people in the nine state prisons.

In her ruling, Silver said that the amount of staff and the licensure that they have does not meet constitutional requirements, creating “substantial risk” for people in prison. 

Arizona state prisons need to increase medical and mental health staffing to the minimum adequate requirements within three months of when she issues her final order.

This final order will not come until after late March, when both the Department of Corrections and the American Civil Liberties Union have had opportunity to comment, said Corene Kendrick, deputy director of the ACLU’s National Prison Project.

Kendrick said that no matter how equipped the system is to respond to these needs “they’re going to have to do it.”

“There’s no ignoring the order or else they’re going to be in very big trouble with the courts,” she said.

The shortage is severe, Joy’s report shows.

The prisons need an estimated 417 behavioral health technicians but as of September 2021, had employed 27 and contracted with 29. Similarly, the prisons need 358 mental health clinicians but employed 75 and contracted with 100.

An emailed response from Arizona Department of Corrections Communications Director Judy Keane said staff are still reviewing the order with their lawyers and would not comment at this time.

Recruiting mental health care workers will be tough. They are in high demand across various fields in Arizona.

And it’s not just a problem in Arizona. According to the U.S. Bureau of Labor Statistics, the number of jobs for mental and behavioral health counselors nationwide is expected to jump 22% by 2031.

Gov. Katie Hobbs issued an executive order in January to form an independent and bipartisan commission to study and review prison staffing and medical and mental health care. The 12-person panel is due to return a preliminary report by Nov. 15.

Arizona has long lacked transparency, accountability and urgency in oversight of the state’s correction system, Hobbs said in a news conference.

“Individuals who are incarcerated should receive humane treatment during their incarceration and be prepared for successful reentry into society,” Hobbs wrote. “External oversight of Arizona’s corrections system will facilitate improvements to fiscal management, operations, and healthcare within the corrections system.

Workers needed

Physician psychiatrists can prescribe medication and provide therapy. They are medical doctors with an M.D. or D.O. degree and board-certification or a specialty in psychiatry.

Mental health clinicians include psychologists and psychology associates, they provide therapy but cannot prescribe medication. They may have a Psy.D., Ph.D., or a masters degree and a required number of hours.

Advanced practice providers include physician’s assistants and nurse practitioners. They do not have a medical degree, but have advanced training and specializations. They can prescribe mediation in the state of Arizona and may provide therapy if they specialized in psychiatry.

Behavioral health technicians handle welfare checks and conduct group activities. They may not have a bachelor’s degree requirement.

Could colleges and universities help solve the labor shortage?

There is no single program or track for people entering the mental health-care field. They come from many majors and degree levels. They may be psychology majors, pre-med, sociology, counseling or something else entirely.

Arizona universities do have programs for students interested in pursuing counseling and mental health care, but there appear to be none specifically geared toward mental health within jails and prisons.

However, counseling students at Grand Canyon University, a private Christian college, can apply their education with justice-involved individuals by volunteering with Along Side Ministries, a Phoenix nonprofit organization that helps formerly incarcerated Christian people with their transitions back into the community.

Several programs around the state offer behavioral health technician certification programs, which don’t necessarily require a degree.

There is “a huge deficit” for mental health counselors across Arizona, said Denise Krupp, the lead instructor in GCU’s counseling program. Students are in demand when they graduate.

“I don’t see it happening in my lifetime that somebody as a counselor is not going to have a job,” she said.

Long wait for help at the jail

Although this order does not apply to Arizona’s six private prisons or county or city jails, those facilities face the same issues.

Pima County Sheriff Chris Nanos said there are 35 people in the Pima County jail under a return to competency court-order who have been waiting months for their initial hearings.

Nanos said that many individuals have non-violent charges and have been in jail awaiting competency screenings for longer than their potential maximum sentence.

Pima County Sheriff Chris Nanos

Return to competence is the process by which someone who is found incompetent to stand trial — there is evidence that they don’t understand what is happening to them at the time of the scheduled court appearance — is supposed to be taught to understand the process and stakes of their trial.

The court requires an evaluation to confirm whether a person is incompetent to stand trial, but there is no law setting a timeline for that assessment. Because of that, schedules can drag out until a judge, attorneys and clinicians can meet with the person.

Since 2022, two people died while awaiting competence restoration, after having been deemed incompetent to stand trial. 

Yunan Tutu died inside the Pima County jail in January 2023 after the court ruled him incompetent to stand trial. The court charged jail wardens to care for Tutu and work to “restore competency.” The 26-year-old man languished inside one of the nation’s deadliest jails for six months.

When a doctor checked on Tutu two weeks after Christmas, he was reportedly refusing food and eating his own feces. He was found dead in his cell on Jan. 10.

“We’re turning our jails into asylums. And I can’t even say it’s the courts’ fault,” Nanos said. “It is society saying, ‘What do we do with these people? Where are we going to put them?’”

Competence evaluations and restorations inside the Pima County jail are supposed to be provided by its healthcare contractor, NaphCare.

Nanos said that these evaluations can and should be conducted outside of the county jail system by referring defendants to hospitals and psychiatrists.

“My jail is not a mental health facility,” Nanos said. “It is designed to hold pre-trial detainees.”

Despite not being equipped or staffed to be mental health facilities, that is the reality for county jails and state prisons.

‘The most callous and inhumane indifference’

Gov. Hobbs’ commission and Judge Silver’s rulings are first steps in improving conditions in correctional facilities.

Silver is expected to give the state prison system a deadline for hiring healthcare staff. Her outrage — that changes are taking so long while people are suffering — flows through her writing. 

Silver described the “profoundly disturbing” case of a woman who has been in prison since 2015. In 2017, she started developing symptoms of multiple sclerosis, a potentially disabling disease. She didn’t receive diagnostic tests or treatment until 2020 as medical staff ignored her worsening symptoms for years.

By 2021, she was unable to walk, incontinent, suffering from “debilitating muscle spasms” and had never received medication for M.S. 

The judge wrote that words like “appalling” don’t cut it and “substantially understates the pain and indifference she has suffered.”

The way the woman was treated, Silver wrote, “was — and may continue to be — a paradigmatic example of the most callous and inhumane indifference.”

El Inde Arizona is a news service of the University of Arizona School of Journalism.

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Samantha Larned is a senior journalism student at the University of Arizona, with an interest in social issues and popular culture coverage.