On the last day of Adam Collier’s life, he had breakfast in his cell in Kern Valley State Prison. He wrote two letters, one to his mother, the other to the guard who would later find his body.
During the previous four years in prison, Collier had been hospitalized for mental health crises 14 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 exposing himself to women in public while high on meth.
The prison system’s response to Collier’s increasing anguish?
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.
On Oct. 17, 2020, at age 43, he killed himself.
Three decades 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 people behind bars are male) prison is not a place to heal. It is a place to disappear.
The constant relocation 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, a CalMatters investigation has found.
After Collier’s death, state overseers found the department had “poorly handled” his case. The Office of the Inspector General, which provides independent oversight of prisons, described an array of internal problems, including clinicians improperly delaying Collier’s referral to a higher level of care and failing to adequately document his history of self-harm. Earlier this year, his parents filed a wrongful death complaint in federal court.
The California Department of Corrections and Rehabilitation failed to respond to several requests by CalMatters for an interview but sent written answers to emailed questions. Department representatives declined to comment on Collier’s case, citing health privacy laws.
Corrections spokesperson Vicky Waters said the department, along with California Correctional Health Care Services — which are jointly responsible for medical services to the state’s prison inmates — provide “quality medical and mental health care.”
“Much like it works in a community health care setting, individuals may need to physically move to the appropriate facilities to receive the necessary level of care,” Waters said.
Several attorneys and researchers steeped in advocacy for this population said they were stunned by the speed at which Collier was shuffled around the system. Some told CalMatters they initially didn’t believe it until they saw the documentation.
“I don’t think the system is designed where anybody says, ‘Stop. Take a step back. What does he really need?’” said Margot Mendelson, an attorney with the Prison Law Office, co-counsel in the ongoing federal, class-action suit about the state’s treatment of inmates with mental illness, known as Coleman.
For many inmates, the churn continues.
The Department of Corrections and Rehabilitation agreed on May 5 to release transfer data that CalMatters had requested in March, but has thus far failed to provide it. However, data collected by CalMatters from the department’s public website between June 2021 and May 2022 showed that, while most of the state’s prison inmates rarely move, a subset is being transferred frequently. According to CalMatters’ analysis of the data, of the 86,118 inmates who had been incarcerated at least 12 months prior to last June, 1,988 moved at least four times this past year and 32 moved eight times or more. Several of the inmates who moved the most frequently told CalMatters they were being treated for mental health conditions.
Even as the state shrunk its overall prison population in recent decades, the ranks of inmates with mental illness continue to swell. In April 2000, one in eight California prison inmates had a diagnosed mental illness. This year, one in three do, according to data provided by attorneys from San Francisco-based Rosen, Bien, Galvan & Grunfeld, which is co-counsel in the Coleman suit.
Long before he arrived at Kern Valley State Prison in March of 2020, Collier was diagnosed with post-traumatic stress disorder, bipolar disorder, borderline personality disorder and anxiety disorder, among others. He had spent five years in Oregon State Hospital and several months in a California state hospital.
Prisoners’ rights advocates have long argued that prison is not the right setting for people with serious mental illnesses. For the many who wind up behind bars anyway, Collier’s story poses a critical question: Are frequent transfers a good solution for anyone?
A sensitive child suffers trauma
As a child, Collier was sweet-natured and sensitive, a tow-headed boy who made friends easily and loved teddy bears, chess and snuggling with his dog, Jessica, his mother recalled. In his first five years, his family lived off the grid in the mountains near Grants Pass, Oregon. After moving to Santa Cruz for a time, his parents divorced when he was 7. His mother moved Adam and his older brother back to the Portland suburbs.
Susan Ottele still has a note Adam carefully printed out for her in wobbly letters during that time: “How was work today? I missed you all day.” A few years later, he brought home a certificate from CF Tigard Elementary School, commending him for being kind-hearted.
In middle school, he met a crew of close friends, including his best friend, Anton Engelmann. After Engelmann shared his personal troubles with Collier, Engelmann recalled, Collier regularly brought him home for a meal and a shower.
Engelmann said he remembers watching Collier jump up to hug his mother whenever he saw her. But Susan Ottele was gone a lot, too. A single mom, she sometimes worked as many as 18 hours a day.
Left to their own devices, Collier and his friends would skip school to egg houses, set off illegal fireworks and smoke pot, Engelmann and other friends recalled.
Only much later did his friends and family discover the extent to which Collier had been living a nightmare during those early years. At various points, several different men abused him physically and sexually, according to his mother, friends and prison medical records.
That trauma tormented him for the rest of his life. He attempted to kill himself when he was 12 or 13, according to medical records obtained by his mother. He would try again at least seven more times.
Beginning in his 20s, Collier was arrested multiple times in Oregon for exposing himself, the same crime that would eventually land him in prison in California. In Oregon, Collier was found “guilty except for insanity” and sent to Oregon State Hospital for five years in February 2007.
While there, Collier underwent surgery to address chronic back pain. Something went wrong — the spinal screws snapped. From then on, according to medical records, Collier lived with intense pain, which compounded his stress. At one point, he pounded the wall of his room in the state hospital so hard he broke his hand.
In December 2011, Collier was discharged from the Oregon State Hospital. For a few months, he lived in his mother’s house in McMinnville, a quaint wine country town outside Portland. The next summer, Collier decided to move closer to his father’s family in Santa Cruz.
He was ready, he told his mother, to start over.
How the system works — or doesn’t
Why did Adam Collier transfer so often?
Advocates, inmates and family members contend that, in cases like his, a steady stream of transfers reflects a system that too often fails to adequately care for people in mental health crises. These inmates might bounce between prisons and short-term crisis beds without ever stabilizing enough to get better, they say. For some, the simple fact of being in a prison environment might trigger them to lash out against guards or other inmates.
Corrections spokesperson Waters said in a statement that inmates can be transferred for a variety of reasons, including court hearings, medical treatment, mental health treatment, changes in security level, patient safety, staff conflicts, misconduct allegations or parole.
Six of California’s 34 prisons don’t have mental health programs, she said, “so patients requiring ongoing mental health care would need to be transferred.”
Clinicians “are trained to identify and treat serious mental illness, and tailor care to the individual needs of patients,” Waters stated.
Mental health care in California’s prisons is provided along a spectrum, designed to transfer inmates as their level of need changes. Treatments range from outpatient therapy in the general inmate population to long-term hospitalization in dedicated treatment facilities within the correctional system.
At the other end of the spectrum are state hospitals, which are separate facilities that also house people who are not in the criminal justice system.
Suicidal inmates are supposed to be moved quickly to mental health crisis beds, according to the state’s mental health program guide. The beds are designed for a 10-day stay that can only be extended by medical officials.
But the system doesn’t always work perfectly. Sometimes people who need it aren’t referred to a higher level of care, the Inspector General has determined in several investigations.
Sometimes referrals come too late.
In 2019, mental health clinicians failed to evaluate acute suicidal risk factors in one inmate after he learned of his mother’s death. They didn’t place him under suicide watch or send him to a mental health crisis bed, according to a report from the Inspector General. Soon after, he killed himself.
Adding to these concerns, the state and country face a shortage of mental health providers, which experts say has only worsened during the pandemic.
Waters said in an email that the department has robust recruitment and retention programs, which she calls “especially critical.”
She said the department routinely assesses the number of mental health crisis beds and inpatient beds to make sure it has enough to meet fluctuating needs.
But some say a provider and bed shortage means inmates don’t always get the mental health care they need.
“The idea is, ‘How soon can we stabilize them and get them out?’” said Keramet Reiter, a criminology professor at the University of California, Irvine.
When inmates repeatedly get into mental health crises and act out or hurt themselves, correctional officers and even prison clinicians often view those actions as manipulative, Reiter and others said. These inmates can then be deemed more dangerous and moved to higher security facilities where people with mental illness are even more vulnerable.
Those who are classified as sex offenders, as Collier was due to his indecent exposure charges, have it worst.
Even if inmates are extremely sick, state hospitals are often wary of admitting those with high security levels or histories of bad behavior, said Jessica Winter, an attorney with the Rosen, Bien, Galvan & Grunfeld.
Her firm is co-counsel for Coleman, the federal class-action suit on behalf of inmates with serious mental illness. That case has led to important reforms, she and other advocates say, including more oversight of how California’s prisons treat inmates with mental illness than exists in some other states.
In theory, transfers can mean the system is working, said Tom Nolan, another attorney at Rosen, Bien, Galvan & Grunfeld.
But in Collier’s case, he said: “It’s kind of crazy how much he got transferred around.”
Collier’s start-over plan disintegrates
Adam Collier’s plan to start over in Santa Cruz was short-lived. It was 2012, and he was 35 years old when he left Oregon for California.
During his first year and a half in Santa Cruz, he was arrested several times for indecent exposure. Under Jessica’s Law, he was required to register as a sex offender and was barred from living many places. He cycled between homeless shelters, the streets and jail.
A psychologist who evaluated Collier around that time considered him incompetent to stand trial, saying he was agitated, heard voices, needed medication, and was asking for treatment, according to court records reviewed by CalMatters.
On April 29, 2013, Santa Cruz police picked him up for exposing himself in a public place. Collier took a plea deal and was sentenced to two years in prison.
Collier served time in San Quentin and was released. His mother looked into bringing him back to Oregon to serve his parole, but said her county wouldn’t allow it. She couldn’t afford the move to California, though she said she contemplated coming anyway and living in her car.
Within weeks, he was arrested again in Monterey and sent to jail.
The next year, the cycle repeated. But this time, he was sentenced to five years in prison.
That’s when Susan Ottele started tracking her son’s movements.
On March 12, 2016, according to her notes, Adam Collier arrived at North Kern State Prison.
His first transfer, to California Medical Facility in Vacaville, took place a month later.
His second, back to North Kern, was the month after that.
Reiter of UC Irvine calls what happened to Collier — bouncing between crisis units and state hospitals and seven different prisons— “a very sad and very unsurprising story.”
There’s even a term for it, she said: “Diesel therapy” refers to moving challenging inmates around to keep them from wearing out staff in any given facility.
“It absolutely happens often,” she said.
In a February 2017 letter to his mother, Adam Collier said he believed he was sometimes moved as punishment for his behavior.
Collier did lash out at prison staff, sometimes dangerously. CalMatters’ review of nearly 600 pages of his prison medical records from 2020, shared by his mother, shows he was written up multiple times for spitting, fighting and battery against prison staff.
At one point, he was moved to segregated housing after attacking several prison guards.
“You are deemed a threat to the safety and security of this institution, its staff and inmates,” wrote the prison lieutenant who authorized that move.
Such circumstances can be taxing for all involved.
“Staff work in the same conditions that incarcerated people live in,” said Margot Mendelson of the Prison Law Office. “Really toxic environments are toxic for everyone.”