There were many times during Khasiem Carr's tumultuous journey through Pennsylvania's mental health and prison systems when it seemed things couldn't get worse. Then, they generally did.
For instance, after two months in solitary confinement at the Bucks County prison, Carr was refusing food and water, and was rushed to the hospital to be treated for dehydration and malnutrition.
After more than a year in solitary, he entered a guilty plea in hope of getting out of the hole and into mental-health care in a state prison. Instead, he would spend four more months in solitary confinement.
By the end of that time, he had lost 100 pounds, and was talking about suicide. "He looked like a zombie," recalled his mother, Karen Dunston-Carr of Telford. "He said, 'Mom, I can't take it. I don't know if I'm hearing voices or if it's the thoughts in my mind.' "
Khasiem, now 32, known as "KC," was one of more than 1,000 Pennsylvania inmates with mental illnesses kept in isolation for 90 days or more between May 2012 and May 2013. About 250 were in isolation for a year, causing "mental deterioration, psychotic decompensation, and acts of self-harm," according to a U.S. Department of Justice investigation released in February. Many, the department found, were in solitary because of their illnesses.
Last year, the nonprofit Disability Rights Network sued the state in federal court to curb the practice, calling it cruel and unusual. The Justice Department joined the suit, and the parties are working toward a settlement.
But all sides agree that won't resolve the root of this issue: the state's failure to fund community-based mental-health services following the closure and downsizing of institutions such as Byberry and Norristown State Hospital. Without those services, they say, the influx of mentally ill offenders will continue.
Even Pennsylvania Secretary of Corrections John Wetzel thinks it's unacceptable that he's managing a mental-health roster of 10,000 people, or 21 percent of all inmates.
"It's not great public policy for the secretary of corrections to be responsible for mental-health care to a greater degree than anyone else in the commonwealth," he said.
KC's story is a study in those public-policy failings - starting with the lack of mental-health services, continuing with the limitations of mental-health courts to divert cases, and culminating in an 80-square-foot isolation cell.
He was 24 years old, 6-foot-3 and an amateur boxer, when he began exhibiting paranoia, hearing voices. He was diagnosed with schizoaffective disorder. He was, Dunston-Carr said, "a gentle giant." But "when he was in it, he'd slip and curse. And then he'd say, 'Mom, I'm sorry,' because he knows I don't allow cursing in my home."
After he deteriorated, he was committed to Norristown State and stabilized. But after he was released, while being tapered off one medication and onto another, KC began displaying psychotic behavior, lunging at strangers. In August 2011, he punched a woman in the face in a drugstore.
Panicked, Dunston-Carr said she took him to two hospitals; each discharged him after a day or two, saying they couldn't safely manage him. When police arrested him, he swung at them, too. Later, he hit correctional officers at the Bucks County jail.
KC said he regrets those actions - but he doesn't view himself as a criminal. He described a cacophony of voices and intense headaches that clouded his thinking.
"The voices, they was taking over me. I wasn't thinking right. I was believing stuff I shouldn't have been believing - crazy thoughts," he said.
The attacks, even the prosecutor seemed to agree, were symptoms of his illness. The Doylestown Intelligencer reported in 2012 that the judge who sentenced Carr to 1½ to 4 years recommended he be sent to State Correctional Institution (SCI)-Waymart, to the forensic psychiatric treatment unit there. "The state prison system is better equipped to deal with someone who has the mental health issues the defendant has," the prosecutor was quoted as saying.
But KC wasn't put into treatment. In Bucks County, he was placed in solitary for three months, sent to Norristown State to restore competency to stand trial, and then returned to solitary for about a year. (His bail was set at $750,000, he said, more than the family could afford.)
After pleading guilty to assault, he was not sent to Waymart. He landed in SCI Mahanoy, where he spent about four months in solitary, he said. He said he had no opportunity to shower or clean his cell during that entire stretch.
Carr believes her son nearly died in solitary.
She worries about what kind of person he will be when he's released, and how she'll care for him.
"He needs medication, therapy, treatment. You can't normalize him by punishing him," she said. "The prison system is not equipped to handle people with serious mental-health issues."
That's a reality corrections officials nationwide are grappling with. The Pennsylvania Department of Corrections has been working on it since 2011, according to Wetzel.
Among the improvements he described as industry-leading are mental-health first aid training for all 16,000 department staffers, and the training of 400 inmates as certified peer specialists.
The department received $20 million in 2013 and this year to boost staffing, and has consolidated mental-health services in 14 state prisons, with residential treatment units to replace what were formerly called special-needs units. Mental-health workers are now consulted in all disciplinary proceedings against inmates with mental illness.
In response to the lawsuit, the department has also revised policies on solitary confinement (restricted housing in prison jargon): Now, mentally ill offenders in restricted housing for more than 30 days must be allowed at least 20 hours out of their cell per week. Wetzel said that in a recent count, there were 109 inmates with mental illness in solitary.
Disability Rights Network lawyer Robert Meek, who is negotiating the settlement with the state, said that's a start, but a total ban on isolation for inmates with serious mental illness remains a goal.
Jeffrey Metzner, a University of Colorado psychiatrist who has studied prison mental health extensively, said even 30 days in solitary can be dangerous for people with serious mental illness.
"Your highest risk of suicide in segregation is your initial 30 days," he said.
The Department of Justice reported that 70 percent of suicide attempts in Pennsylvania prisons from January 2012 through May 2013 were in solitary.
Inmates, it found, were confined for 23 hours a day, subject to "unsettling noise and stench, harassment by guards, and the excessive use of full-body restraints."
Louisa Botteri of Yardley said that represents her son's experience in state prison, where he spent three years, mostly in solitary. Her son, who has bipolar and dissociative disorders, was doubled up in a cell with another man, a common scenario according to Meek.
According to complaints her son wrote from prison, his cellmate dragged him by the feet from the top bunk so that his head hit the concrete floor, then kicked him in the head repeatedly as guards looked on, until he required hospitalization. In another incident, he claimed a guard taped a box of feces to a ventilation hole in his cell door.
Cultural change, Wetzel said, is a new focus, along with an "increase in skill sets and an increase in value on the humanity of all offenders."
Angus Love of the Pennsylvania Institutional Law Project, which worked on the lawsuit, said it is unclear how long the settlement might provide for monitoring by watchdog groups.
For now, he is informally tracking inmates such as KC, to see how their treatment is changing.
For KC, things have improved recently. He was moved from solitary to a secure residential treatment unit at Graterford. He can make phone calls and get visitors now, though he can speak with them only from behind a thick pane of glass.
He gets 20 hours out of the cell per week, in the TV room, group therapy, or an outdoor exercise cage.
That may not be ideal, but advocates' goal right now is to ameliorate a bad situation.
Someone like KC, said Love, "would have never been in the prison system 20 or 25 years ago. It's just a symptom of the larger problem: that we've criminalized mental illness."