Behind the Gates of Gomorrah: A year with the Criminally Insane

In Behind the Gates of Gomorrah (Gallery Books. September, 2014), Dr. Stephen Seager describes what goes on behind the barbed wire fence at NAPA State Forensic Hospital in California where persons with serious mental illness found not guilty by reason of insanity, unfit to stand trial or were convicted in spite of mental illness are housed. It is perhaps the best horror book ever written. No special effects needed. As the psychiatrist responsible for "Unit C" he chronicles the daily beatings of those with mental illness by others with mental illness and how mental health advocates make it impossible for caring staff to stop it. I highly recommend it for those who run state and county mental health departments, because it shows the consequences of offloading the most seriously ill to criminal justice. It should also be read by civil libertarians and advocates. By preventing medication over objection, and removal of guns from the seriously ill, they are forcing tens of thousands of the most seriously mentally ill to live out their lives in the 24/7 horror of forensic units.

Today, largely as the result of our failure to prioritize the most seriously mentally ill for treatment, there are ten times as many mentally ill incarcerated as hospitalized. NAPA State is one of two hundred state forensic hospitals and in the opening Dr. Seager notes, "A forensic hospital is not a safe place....The patient rights system and current mental-health laws, both well-intentioned, conspire to make a system in which the rights of patients are paramount and often detrimental to staff and other patient's safety."

He uses stories of the pervasive oppressive violence to discuss the idiocy of restrictive commitment laws, treatment laws, and the well-intentioned, but misguided advocates who created the problem and oppose reform. Those beaten are young, old, and some are wheelchair bound. They live and sleep in small rooms with three other psychotic individuals who may not have showered in a year, taken a pill in longer, and sometimes slip into their bed at night to rape them. Resist and they can beat you with impunity because the forensic hospital is the last stop. When untreated patients beat a staff member or another patient, no charges are filed unless the victim is hospitalized for injuries for at least two days. And even then, little happens.

Dr. Seager explained on CSPAN why NAPA, which he calls, Gomorrah after Sodom and Gomorrah, is a "Free Assault Zone." A patient who commits an assault at Gomorrah came to Gomorrah because they'd already been judged incompetent or mentally ill for a previous crime. So if they were charged, they're likely to be found incompetent again. And they'll be sent back to Gomorrah again. Usually to the same ward. And even the same room or bed where the original crime took place.

What is touching about the book is the heroic yet unsuccessful attempts by Dr. Seager and other staff members to make life better for the patients. While the book contains a litany of beatings, it never turns patients into villains. Patients are simply too sick to know they are sick and laws prevent them from being treated until they're well enough to recognize they need it. Even after being in the hospital for a psychotic fuelled murder, laws still give them the right to refuse treatment. It's a horrible Catch-22.

Dr. Seager doesn't propose solutions to how to serve people with serious mental illness in the communities, but does propose a few commonsense solutions to protect those in forensic units.

The first step is mandated patient treatment. If someone avoids jail because they're sick, they should have to take treatment to make them well. And that means medication. More medications equal fewer assaults.

He proposes creating "intensive care units where the ten percent of patients who commit ninety percent of the assaults can be segregated." Dr. Seager notes that the single most frequent request from the patients themselves is to have their own rooms but when the idea was proposed in the state capital, federally funded disability rights attorneys objected. "The attorneys argued that this would be too isolating."

Behind the Gates of Gomorrah covers other problems with the care and treatment of the most seriously ill, but is at its best when it describes what happens to the seriously ill when the mental health system protects their right to be psychotic rather than their right to treatment.

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DJ Jaffe (@MentalIllPolicy) is Executive Director of Mental Illness Policy Org. a non-partisan think-tank on the policies surrounding serious mental illness.