By Robert Canning
Like a number of people, I watched the live video stream of the Carlos Dominguez competency “trial” in Department 10 of Yolo County Superior Court last week and will watch again when the trial reconvenes.
As a forensic and correctional psychologist for the past twenty years with experience working in and consulting to jails and prisons on mental health treatment issues, I was amazed and appalled watching the spectacle unfold in real time. The trial is to determine the competence of a young man whose severe mental illness is on display daily in open court for all to see. The law requires the jury decide first whether Mr. Dominguez suffers from a mental disorder, and then if the mental disorder interferes with his capacity (competency) to understand and reason about the charges against him, and whether he can aid in his own defense.
What is most appalling to me is that his mental illness has been allowed to worsen while in custody. If the Yolo District Attorney had not requested a jury trial then Judge McAdams would have been the sole source of the decision about Mr. Dominguez’ competence. Given his comments this week to the public defender, I believe he would have found Mr. Dominguez incompetent to proceed weeks ago. In that case Mr. Dominguez would have been able to receive treatment for his mental illness sooner, possibly in a state hospital setting. If this treatment was provided, it is possible that Mr. Dominguez could be restored to competency in a matter of months.
The law requires that detainees in jails receive adequate medical and mental health care. This has been guaranteed since 1976 when the Supreme Court decided in favor of inmates in Estelle v Gamble. Subsequent case law has reinforced the right to appropriate care and emphasized the role of correctional systems in providing that care.
Because we have a public trial with testimony from mental health and medical experts and jail staff, we can see some of the glaring inadequacies of mental health care in our county jail.
Given what the Dominguez trial has revealed, I do not believe that jail inmates suffering from serious mental disorders in Yolo County Jail are receiving adequate and appropriate care under the law and state regulations. Add to this the unwillingness of Woodland Memorial Hospital to be of assistance, and what is on display is an appalling example of the inadequacy of the criminal justice system to deal with some of our sickest and most disabled individuals. The county Health and Human Services Agency and the Sheriff should put in place safeguards to insure that adequate mental health care can be provided for jail detainees. There are a couple ways to do this.
First, the county should demand better psychiatric care for severely mentally ill detainees in the jail. Wellpath, the provider of mental health care in the jail should provide in-person psychiatric services for severely mentally ill jail detainees. Most small jails in California (who mostly use outside contractors) cannot afford full-time psychiatric staffing and use telepsychiatry for routine mental health care. A nationwide shortage of psychiatrists has, in part, contributed to this shift in treatment delivery. Telepsychiatry is fine for working with patients who are stable and cooperative with medications – the primary form of treatment of mental illness in jail settings. But for those individuals who suffer from serious mental illness and may be suicidally depressed, actively psychotic, or suffering from manic episodes, telepsychiatry is not recommended. A recent set of guidelines from the American Psychiatric Association cautions against using telepsychiatry for the most acutely ill patients (such as Mr. Dominguez). If the psychiatrist who had video interviews with Mr. Dominguez had seen him in person there is a chance that she would have acted more promptly to order emergency antipsychotic medications and facilitated a court-order for ongoing medications as was discussed between Judge McAdams and attorney Hutchinson on July 27. And despite the nurse manager’s protestations that the use of emergency medications is only for individuals who are a danger to themselves or others, the law (Penal Code Sec. 2603) allows their use in cases of grave disability, whose criteria Mr. Dominguez seems to fit. (In addition, it is unclear to me why Mr. Dominguez had to wait 12 days for his first psychiatric visit when the social workers who testified seemed quite aware that he was suffering from a psychotic illness.)
Let’s be clear, Yolo County jail is not a psychiatric facility. The recently constructed medical wing is simply a six-bed infirmary, and as the nurse manager described in court she has a “skeleton crew” and needs to plan carefully for working with severely mentally ill patients. There are policies in place to administer emergency psychotropic medications and as she testified, they have other detainees who are under court order to take medications. But given the testimony of the Wellpath social workers and the two mental health experts, by the end of May Mr. Dominguez’ mental condition had significantly deteriorated since his detention on May 4, yet he had had only one telepsychiatry visit in his first two weeks of detention. Why did Wellpath not start earlier to prepare for the possibility of implementing the legal process for involuntary psychiatric medication administration? Maybe if he had been seen earlier and in-person by the psychiatrist he would now be in better shape. The county should demand more information from its contractors.
Another point is that when jail detainees have serious psychiatric disorders, they should get the care they need up to and including inpatient psychiatric care. But they often do not. This is an example of the discrimination that mental health patients suffer in the criminal justice system. Medical patients who need a higher level of care while in jail are admitted to local hospitals for care and then returned to the jail when stable. But mental health patients like Mr. Dominguez who are detained in small jails in California are rarely admitted to local inpatient facilities because of a lack of bed space, inadequate infrastructure, or often, the reluctance of a local facility to put up with the security demands of having a jail detainee as a patient. It also costs the counties lots of overtime pay to provide staff to guard a patient in an outside facility. It is easy for local facilities like Woodland Memorial to refuse to admit mentally ill jail detainees by simply (and conveniently) not finding that they meet the criteria for involuntary hospitalization. Yolo County is not alone in this plight. In Monterey County Natividad Medical Center simply refuses to accept jail inmates into their emergency room. And unlike the large urban jails, which run their own inpatient psychiatric units, smaller counties like Yolo must rely on what little help they can get from local hospitals, who too often refuse to admit severely mentally ill jail inmates.
What can the county do to improve the care for the most severely mentally ill jail detainees? First, they can demand that Wellpath provide better psychiatric care by making sure that telepsychiatry is only used for routine mental health care and that when, for example, grossly psychotic or suicidal individuals are detained they are afforded in-person psychiatric evaluations and follow-ups until stable. Second, the county should demand that when detainees with severe mental illness are detained that Wellpath act proactively to prepare to submit court paperwork for the use of psychiatric medications. And finally, although a difficult challenge, the county should endeavor to obtain an agreement either with Woodland Memorial Hospital or another nearby facility to provide inpatient psychiatric care for the most debilitated jail detainees.
Fortunately, the county HHA has now submitted a petition from the Wellpath psychiatrist to begin administering antipsychotic medication to Mr. Dominguez. This process can take up to three weeks and should have been started weeks ago. But at least it is happening now.
The law demands that mentally ill jail inmates have the right to adequate and appropriate mental health treatment. They should not be allowed to deteriorate and decompensate while in custody as Mr. Dominguez has. The county (HHA and the Sheriff jointly) has the responsibility to provide the care for jail inmates and should work with its contractor Wellpath and Woodland Memorial to improve that care.
Davisite 
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