"Diesel therapy": How the state prison system shuffles around inmates with mental illness

By Jocelyn Wiener and Byrhonda Lyons

On the last day of Adam Collier’s life, he had breakfast in his cell in Kern Valley State Prison. Then he penned two letters, one cursing the guard who would find his body, the other telling his mother he loved her.

During the previous four years in prison, Collier had been hospitalized for mental health crises at least 11 times. His many letters to family and friends wobbled between lucidity and gibberish. His medical records proffered graphic descriptions of self-harm. Collier had originally landed in prison for masturbating in public while high on meth. Ashamed and delusional, he tried to castrate himself with a broken plastic cup because he believed it was God’s desire.

The prison system’s response to Collier’s increasing anguish?

Transfers.

Between 2016 and 2020, the California Department of Corrections and Rehabilitation transferred Collier 39 times, ping- ponging him between mental health crisis beds and increasingly high security prisons at a pace so fast he told his mother, Susan: “I’m fucking dizzy.”

On Oct. 17, 2020, he killed himself.

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More than 25 years after California’s prisons first came under court monitoring for rampant abuse and neglect of prisoners with mental illness, the system is still failing to protect its sickest inmates. For many of these men (the vast majority of prisoners are maleen) prison is not a place to heal. It is a place to disappear.

The constant movement that Collier experienced is a symptom of the system’s brokenness. Too often, in lieu of an effective treatment plan, challenging inmates are simply moved along.

After Collier’s death, state overseers found serious problems with the department’s actions: Tthe Office of the Inspector General, which provides independent oversight of the prisons, described an array of concerns, including clinicians improperly delaying Collier’s referral to a higher level of care.

Collier wrote to his mother, often complaining about back pain that drove him to tears.

“I guess this is my lot,” he wrote from North Kern State Prison in May 2016. “See why heroin and vodka seems appealing?”

“Death,” he said in another letter, “would be a relief.”

At times, he sprinkled in words of reassurance and advice, along with updates on his sobriety: “Please don’t worry about me.” “I’m not suicidal.”

Trying to get him help, Susan Collier penned certified letters in loopy cursive begging prison wardens to give her son Tylenol and heating pads.

In an appeal, Collier wrote that multiple guards had handcuffed him and beaten him until he was unconscious. Susan Collier wrote to the warden, Joe Lizarraga, who replied that the staff’s actions were in compliance with the department’s use of force policy. (Lizarraga would retire two years later, under investigation for theft and cover-up).

The independent Office of the Inspector General received several complaints on Collier’s behalf about this medical care and use of force, on Collier’s behalf, for this and other incidents.

The oversight body is known for scathing public reports about prison misconduct. That’s about all it can do. In 2011, lawmakers stripped the o Office of its authority to investigate prison employee misconduct, effectively leaving the Department of Corrections to police itself. Last year, legislative staff recommended the inspector general’s authority be reinstated. It wasn’t.

The independent Office of the Inspector General received several complaints on Collier’s behalf about this medical care and use of force, on Collier’s behalf, for this and other incidents.