James Mayo seems to move in and out of reality, one of the reasons his case is so difficult to manage. He is part of an increasing number of county jail inmates who are being sent to the Maine State Prison for their psychiatric care. Credit: Graphic by Coralie Cross. Photos courtesy of Somerset, York, Penobscot and Kennebec counties.

In early November, staff at a group home just outside Biddeford’s downtown noticed that a resident wasn’t taking his medication. The observation could have sent James Mayo, 48, back to jail then and there.

In 2016, Mayo punched and injured two social workers while receiving treatment at the state’s psychiatric hospital, and ever since his probation had required him to take medication for the mental illness that propels his psychosis. He can be dangerous when he doesn’t, according to court records and people who have known him for years.

His group home staff members, who help people with mental illnesses live in their communities, had tracked Mayo’s bizarre behavior in the days before they realized he was chewing his medication instead of swallowing it to avoid ingesting the full dosage. Mayo had stolen an employee’s lunchbox and dumped its contents in the woods, entered empty apartments to avoid staff and left the premises without permission, according to a report written later by his probation officer.

Staff decided to take him north to Maine Medical Center in Portland for a mental evaluation. The situation worsened. Mayo wandered into other patients’ rooms and called hospital staff racial slurs, according to the probation officer’s report. The hospital discharged him after two days, on Nov. 11, but the group home did not know because Mayo did not sign a confidentiality release form.

When Mayo returned home to Biddeford around dark, he could not get in and began yelling for his belongings, said JoAnne Fisk, chief deputy of the city’s police department. Summoned by 911 calls, police took him to the York County Jail, where he remained without bail for violating his probation by not taking his medication. Failing to take medicine is not inherently a crime, but people can return to jail or prison if they do not follow the rules of their probation.

He remained in jail until early December, when his longtime attorney, Philip Mohlar of Skowhegan, asked to switch him to a new place within Maine’s criminal justice system: the Intensive Mental Health Unit at the Maine State Prison in Warren.

Maine is increasingly relying on the prison to care for people like Mayo who are sick and aggressive, and whose cases are pending, instead of Riverview Psychiatric Center, the hospital in Augusta that has historically been the primary place for treating those involved in the criminal justice system.

Only a small percentage of people living with a mental illness will be violent. But for those few Maine has limited options to safely treat them. So since 2014, the state has opted to send more county jail inmates with severe and persistent mental illnesses to the psychiatric wing at the prison in Warren.

Overseen by the Maine Department of Corrections, it is not subject to the same scrutiny as a hospital and is not regulated as one. It is not required to submit an annual report to the Maine Legislature or undergo a formal evaluation of its performance, though a past legislative committee recommended that the unit regularly report to lawmakers about “developing issues” and operations. Unlike a hospital, it has more flexibility to restrain, seclude and subdue people.

Whether it’s a good idea to rely on a prison to treat people with mental illness is something of an unsettled issue. Some advocates believe that Maine should treat people with severe mental illness in a therapeutic setting, such as a hospital, no matter their predilection for violence. Relying on the prison instead reflects a weak spot in the state’s ability to provide mental health care to every sick person who needs it, they said.

“It’s not about criticizing the [Intensive Mental Health Unit],” said Jenna Mehnert, executive director of the National Alliance on Mental Illness Maine, noting that she is a “big fan” of the prison psychiatric ward as a place to treat people who have already been sentenced to prison. “It’s about criticizing the system and that the system lacks capacity to meet people where they’re at based on their level of need.”

Riverview’s clinical director, Dr. Matthew Davis, disgreed. The Intensive Mental Health Unit is an appropriate treatment setting for certain people, particularly those prone to unpredictable violence, he said. His hospital cannot safely handle those patients due to its design and regulations on how it can seclude and restrain people, he added.

Indeed, the Augusta facility lost its federal certification in 2013 due to overcrowding, staffing shortages, and its use of restraints and stun guns on aggressive patients. It regained accreditation in February, restoring $20 million in annual funding and continues to refer patients it won’t accommodate to the Intensive Mental Health Unit.

Treating criminal defendants who have not yet been convicted in a facility designed for convicted prisoners erodes an important legal distinction that could impinge on due process rights, several mental health and legal experts said.

At issue is the 14th Amendment of the U.S. Constitution, which ensures that people cannot be punished without due process, said Zach Heiden, the legal director of the American Civil Liberties Union of Maine. If some people are housed at the prison psychiatric ward as part of their punishment and others are there awaiting trial, but their days exactly resemble each other, there’s little real difference between the legal statuses of the convicted and unconvicted, he said.

For all of this unease, expanding the Intensive Mental Health Unit gained wide support from an unusual alliance of mental health and hospital advocates and the administration of then-Gov. Paul LePage in 2013. The groups wanted more options for people to receive psychiatric care, given a spike in demand, bottlenecks across the health care system and the number of sick people languishing in jail, they testified.

In 2014, its first year of expanded operation, the Intensive Mental Health Unit treated 10 people referred from county jails. The number increased every year until 2017 when it peaked at 41, before falling to 31 referrals in 2018, according to the Department of Corrections.

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Ideally, Mehnert said Maine would have another option — a hospital building with resources and security to accommodate patients with behavioral challenges. She advocated for this around the time the Intense Mental Health Unit was established and in the years that followed.

In the absence of that type of facility, even people like Mehnert agree that the Intensive Mental Health Unit is far superior to a county jail cell, which is often the alternative. The grim isolation of a cell can deteriorate the mental health of even those who don’t have disorders, said Richard Wurpel, the administrator of the Kennebec County jail in Augusta.

The Intensive Mental Health Unit, on the other hand, lets prisoners leave their cells and spend time in a two-story day room, free to work with the ward’s psychiatric staff and pass the time with games like ping pong, said Ryan Thornell, deputy commissioner of the Department of Corrections.

It provides care “at a level that would be nearly comparable to a state hospital,” he said, and its staff routinely meet with Riverview to discuss patients. In addition to the corrections officers, a doctoral level psychiatrist, a treatment director, two clinicians and four behavioral health technicians oversee about 25 prisoners every month, he said. It only accepts men.

“I’m a practical guy. That’s how I look at it,” Mohlar, Mayo’s attorney, said. But while Mayo seems to have received good treatment there, Mohlar said he wished there was both a safe and therapeutic option for his client. He just does not know what it is.

At the Intensive Mental Health Unit, clinical staff are caring for Mayo while other state mental health workers evaluate whether he is competent to understand his criminal proceedings. He has been found incompetent in the past.

“I think one of the issues is he tends to float between competence and incompetence, psychosis, not psychosis. And it changes on a daily basis,” Frayla Tarpinian, the prosecutor handling his case, told Superior Court Justice Michaela Murphy at a November hearing. They did not publicly discuss his specific diagnosis.

How a court interprets his mental condition will ultimately affect where he can stay. The state is not allowed to keep people who are found incompetent in a prison. In those rare cases, the state has six months to restore their mental health at Riverview. If that’s not possible, it must drop the charges. On even rarer occasions, the state has sent challenging patients to a psychiatric facility in South Carolina run by that state’s department of corrections, forcing their families to travel hundreds of miles to see them.

Mehnert’s imaginary third option would be a place to keep people like Mayo near their loved ones, she said.

Credit: Contributed by NAMI Maine

The person who might provide some answers about what’s best for him — Mayo himself — cannot. He is in a locked facility, and the Department of Corrections denied a request to speak to him because he’s not well. What Mayo would like to see happen is impossible to know right now.

Public records, however, provide glimpses into why it’s difficult to decide the best way forward in Mayo’s case and others like his. Court and police documents show how officials have tried to find him treatment and keep the community around him safe, over and over.

‘The system is failing’

Mayo witnessed extreme family violence when he was growing up in Cornville, north of Skowhegan, said his mother, Carmella Mayo. He was intelligent but did not apply himself in school, she said, and started getting into trouble early. Once, he and a friend stole their neighbor’s car, drove it to Massachusetts and wrecked it, his mother said.

His adult criminal record in Maine starts in 1989 and goes on for 61 pages, with convictions for crimes such as misdemeanor theft, felony burglary, criminal mischief and terrorizing.

Jacob Underwood of Cornville got to know Mayo about 15 years ago when their wives became friends. But in the wake of Mayo’s divorce and losing custody of his kids, Mayo began to harass Underwood’s family, in addition to other people, businesses and churches in the area, he said.

Credit: Courtesy of Jacob Underwood

Once, Mayo entered the family’s home without permission and carved a “satanic symbol” into the floorboards to “drive out the devil” and “to save us,” Underwood said. The carving has since faded to a light brown star on the floor of the master bedroom.

Underwood knew that Mayo was ill, but that did not make his actions less frightening, especially when Mayo seemed to target children, he said. It meant the police often had to respond.

“Our goal is for everyone, including James, to be safe and live the best life we all can. Right now it’s obvious to us that the system is failing both James and the public at large,” he said.

In September 2013, Mayo forced the Cornville Regional Charter School into lockdown because he threatened to kill everyone in the building and stood outside of it, making shooting motions with his hands, according to court records. Mayo was ultimately convicted of felony terrorizing, after a criminal proceeding that touched on his mental health.

When an attorney or a judge suspect that those accused of crimes are not well enough to understand the charges against them, the court can transfer them to Riverview for an inpatient evaluation. It’s what happened with Mayo following his arrest at the school.

Riverview serves an important role in this regard. If someone is incompetent, the 92-bed psychiatric facility must prioritize them for treatment over other patients within the criminal justice system. That’s because a court has ordered them a treatment bed, and the U.S. Supreme Court has ruled it unconstitutional to keep an incompetent person in jail.

It’s difficult to know how many times officials and mental health workers have intervened in Mayo’s life because his medical records are confidential. What’s more, it’s difficult to track all of his interactions with law enforcement agencies across myriad towns and counties. There is not always a public record for when police chose not to arrest him.

But available court and police records paint a picture of a man who has cycled through hospitals, jails and communities for decades, not finding help that makes a long-term difference.

In Somerset County alone, Mayo has been booked at the Somerset County Jail 15 separate times in the past 15 years and spent a cumulative 843 days in the facility, according to Sheriff Dale Lancaster.

Police arrested him twice during the first weekend of October 2015 in Skowhegan, prompting the series of events that led to his current situation.

On Oct. 2, 2015, Mayo banged on the door of a home in Skowhegan and, when the people inside would not let him in, threatened to come back with a 9 mm handgun and silencer and kill everyone inside, including police if they intervened, according to police. Two days later, police responded to a report of someone throwing rocks at cars and found Mayo in violation of his bail because he said he had been drinking.

Since the attacks at Riverview, Mayo’s trips to jail have mostly been for violating his probation, not new criminal activity. The courts have justified sending him back to jail because of his history of violence, his lawyer said, but the result has been that he does time whenever his mental health deteriorates.

Credit: Callie Ferguson

One slip happened when he lived in a group home on Ohio Street in Bangor. After a few other interactions, police arrested him in the emergency room of a local hospital on April 10, 2017, when he punched a nurse in the bicep and tried to bite her, according to Bangor Sgt. Wade Betters.

“They ultimately dismissed that case,” Mohlar, Mayo’s attorney, said. But his client stayed in jail for nearly a year because a judge was reluctant to release him until another group home could take him, he said.

The cycle continued.

In one instance, on Jan. 16, 2019, Skowhegan police brought Mayo to Redington-Fairview General Hospital “because he was in crisis,” according to a police report. There, Mayo threatened to punch the blood work technician in the face, yelled and swore at a nurse, slammed his hospital room door “repeatedly” because staff would not immediately bring him food and threatened to kill two police officers when they said they were taking him to jail, Skowhegan Officer Jacob Boudreau wrote in the report.

When he did not respond to police commands to turn around so they could place him in handcuffs — and twice raised his right hand instead — the officers used a Taser to subdue him and took him to the Somerset County Jail, Boudreau wrote.

A nurse told the officer afterward that “James had cut a hole into one of the stretcher beds with a knife he had hidden,” possibly in his underwear.

This fall, on Sept. 26, police again arrested Mayo a little after midnight near the Athens Corner Store in Athens after Somerset County deputies found him “banging” on the back of a U-Haul truck he had appeared to be driving, according to Lancaster, the sheriff. Mayo told deputies he was helping his mother move, and the Hells Angels were trying to kill him, the sheriff said.

In October, Mayo stayed in a holding cell at the Kennebec County jail while the court decided its next step, according to court filings. When a spot at the group home in Biddeford opened up, the jail released him in early November.

But that option did not work out. When both Maine Medical Center and his group home discharged him, the only place left was the York County Jail. At that point, said Tarpinian, the prosecutor handling his case, he had no place else to go.

‘No suitable bed is available’

Jails typically do not house inmates in the throes of psychosis with other inmates because they are a danger to themselves or others. So jail officials often keep them isolated in holding cells near the busy intake area where corrections officers can keep a close watch. The fluorescent lights never turn off.

The experience can be so punishing that Maine jails are not allowed to discipline inmates through this kind of segregation for more than 30 days, according to a May 2019 report by the Maine Advisory Committee to the U.S. Commission on Civil Rights.

In August 2012, Glenn Ross, then the sheriff of Penobscot County, and Carol Carothers, then the director of NAMI Maine, wrote a joint letter to Mary Mayhew, who was the commissioner of the Department of Health and Human Services, asking her to help find a more humane approach.

“Our experience has been that these individuals can be rejected by both [the criminal justice and health care] systems because each system feels they belong in the other and/or because there is no place that has an opening that can accommodate their complex needs,” they wrote.

They wanted an option other than Riverview. Amid a spike in demand for beds for people in the criminal justice system, the hospital had “extremely limited” space and was strained to safely care for “difficult and aggressive patients,” according to a 2014 legislative committee report. Hospital staff were suffering injuries that put them out of work “for long periods of time and, in some cases, out of this line of work forever,” Riverview’s then-Superintendent Mary Louise McEwen later testified before the Legislature.

In 2013, the hospital lost its accreditation. In response, LePage submitted an emergency bill to create the Intensive Mental Health Unit, allowing an existing psychiatric wing of the Warren prison to accept county jail inmates who were eligible for inpatient care but for whom “no suitable bed is available” elsewhere.

Credit: Erin Rhoda

The prison is able to accommodate this difficult population because it can take proactive measures to address aggression and violence, said Davis, who became Riverview’s clinical director in 2018. It can keep prisoners in locked cells and use restraints in situations other than an emergency, he said.

The Intensive Mental Health Unit used restraints — such as a restraint chair, chemical spray, handcuffs or leg shackles — on prisoners three times in 2017, three times in 2018 and five times in 2019, said Thornell, with the Department of Corrections.

Riverview’s regulations, on the other hand, limit how staff can respond to violence to mostly reactive measures in emergency situations, he said. The patients who are recommended to the Intensive Mental Health Unit tend to commit unpredictable acts of violence, or “predatory violence,” that would jeopardize the safety of other hospital patients and staff, and be disruptive to the hospital’s therapeutic milieu.

Having the Intensive Mental Health Unit also frees up Riverview to treat more people, said Mehnert, with NAMI Maine. She knows of a recent case in which Riverview admitted a man who had a history of aggression, so the hospital created a single room for him, eliminating space for other patients, she said.

What’s more, national criminal justice organizations such as the Vera Institute of Justice in New York have praised the Intensive Mental Health Unit as a model for keeping sick prisoners out of solitary confinement.

But for those who have not been sentenced, Maine needs “a small, free-standing [secure] hospital that can provide hospital-level care, single rooms for people who entered the criminal justice system but may not belong there,” Mehnert said.

Credit: Gabor Degre

It’s hard to evaluate the level of care the Intensive Mental Health Unit provides compared with a hospital. It is not required to submit performance reports to the Legislature or state government, Thornell said. Outside of Maine, experts are still studying psychiatric facilities within jails and prisons.

That said, Thornell said the department is proud of the Intensive Mental Health Unit and frequently invites people to tour it in the name of transparency. No one has ever raised constitutional issues to him about housing convicted prisoners alongside people whose cases have not yet been resolved, he said.

Rather, he said that people who have been in prison and in stable condition for a while act as good peer support to the prisoners sent from county jails.

Mayo is still awaiting an evaluation for his mental competency, his lawyer said Wednesday.

If he is found incompetent, the state will be required to remove him from the Intensive Mental Health Unit. If he isn’t, he will likely be asked to enter a plea on his probation violation at his next court date in mid-February. Either way, he will one day leave the Intensive Mental Health Unit. What is less certain is where he will go from there.

Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to mainefocus@bangordailynews.com.

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Callie Ferguson

Callie Ferguson is an investigative reporter for the Bangor Daily News. She writes about criminal justice, police and housing.