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.