However, after a few hours at the hospital, a doctor cleared Thompson to return to jail. With that decision, he went from being a mental health patient to a Dauphin County Prison inmate. At that point, he was expected to comply with orders — or be forced to.

Within hours of returning to jail from the hospital, Thompson was locked in a physical struggle with corrections officers. His story is one of more than 5,000 “use of force” incidents that were recorded in 2021 inside Pennsylvania county jails.

Thompson’s story is culled from an investigation, , that reviewed 456 “use of force” incidents from 25 county jails in Pennsylvania, during the last quarter of 2021. Among the reviewed cases, nearly 1 in 3 involved a person who was having a mental health crisis or who had a known mental illness.

In many cases, guards used weapons like stun guns and pepper spray to control and subdue incarcerated people with severe psychiatric conditions that may have prevented them from following orders — or understanding what was going on.

Records show that when Thompson ran away from jail staff during an attempted strip search, an officer pepper-sprayed him in the face and then tried taking him to the ground.

According to the records, Thompson fought back, and additional officers flooded the area, handcuffing and shackling him. An officer covered Thompson’s head with a hood and put him in a restraint chair, strapping down his arms and legs, according to the records, and about 20 minutes later, an officer noticed something wrong with Thompson’s breathing. He to the hospital.

Days later, The district attorney declined to bring charges. The DA, warden, and county officials who help oversee the jail did not respond to requests for interviews about Thompson’s treatment, or declined to comment.

Most uses of force in jails don’t lead to death. In Thompson’s case, the immediate cause of death was “complications from cardiac dysrhythmia,” but the way that occurred was “undetermined,” according to the county coroner. In other words, he couldn’t determine whether Thompson’s death was due to being pepper-sprayed and restrained, but he also did not say Thompson died of natural causes.

Dauphin County spokesperson Brett Hambright also declined to comment on Thompson’s case but said nearly half of the people at the jail have a mental illness, “along with a significant number of incarcerated individuals with violent propensities.”

“There are always going to be use of force incidents at the prison,” Hambright said. “Some of them will involve mentally ill inmates due to volume.”

During the investigation, mental health and legal experts said that practices employed by corrections officers every day in county jails can put prisoners and staff at risk of injury and can harm vulnerable people who may be scheduled to return to society within months.

“Some mentally ill prisoners are so traumatized by the abuse that they never recover; some are driven to suicide, and others are deterred from bringing attention to their mental health problems because reporting these issues often results in harsher treatment,” said Craig Haney, a psychology professor at the University of California-Santa Cruz who specializes in conditions in correctional facilities.

Corrections experts said the use of physical force is an important option to prevent violence among those in jail, or violence against guards. However, records kept by correctional officers at the 25 Pennsylvania county jails show that just 10% of “use of force” incidents were in response to a prisoner assaulting someone else. Another 10% describe a prisoner threatening staff members.

WITF found that 1 in 5 uses of force — 88 incidents — involved a prisoner who was either attempting suicide, hurting themselves, or threatening self-harm. Common responses by jail staff included deploying the tools used on Thompson — a restraint chair and pepper spray. In some cases, officers used electroshock devices such as stun guns.

In addition, the investigation uncovered 42 incidents in which corrections staffers noted that an inmate appeared to have a mental health condition — and guards deployed force after the person failed to respond to commands.

Defenders of these techniques said they save lives by preventing violence or self-harm, but some jails in the U.S. have moved away from the practices, and administrators have said the techniques are inhumane and don’t work.

The human costs can extend far beyond the jail, reaching the families of incarcerated people who are killed or traumatized, as well as the corrections officers involved, said , a civil rights and criminal defense attorney in the Philadelphia area.

“And even if the human costs aren’t persuasive, the taxpayers should care, since the resulting lawsuits can be staggering,” Schultz said. “It underscores that we must ensure safe conditions in jails and prisons, and that we should be a bit more judicious about who we are locking up and why.”

‘All I Needed Was One Person’

Adam Caprioli’s experience began when he called 911 during a panic attack.

Caprioli, 30, lives in Long Pond, Pennsylvania, and has been diagnosed with bipolar disorder and anxiety disorder. He also struggles with alcohol and drug addiction, he said.

When police responded to the 911 call in fall 2021, they took Caprioli to the Monroe County Correctional Facility.

Inside the jail, Caprioli’s anxiety and paranoia surged. He said the staff ignored his requests to make a phone call or speak to a mental health professional.

After several hours of extreme distress, Caprioli tied his shirt around his neck and choked himself until he passed out. After corrections staff saw Caprioli with his shirt around his neck, officers wearing body armor and helmets rushed into his cell. The four-man team brought the 150-pound Caprioli down to the floor. One of them had a compressed air gun that shoots projectiles containing chemical irritants.

“Inmate Caprioli was swinging his arms and kicking his legs,” a sergeant wrote in the incident report. “I pressed the Pepperball launcher against the small of Inmate Caprioli’s back and impacted him three (3) times.” Attorney said prison staffers often justify their use of physical force by saying they’re intervening to save the person’s life.

“The vast majority of people who are engaged in self-harm are not going to die,” said Mills, who has litigated use of force cases and who serves as executive director of Uptown People’s Law Center in Chicago. “Rather, they are acting out some form of serious mental illness. And, therefore, what they really need is intervention to de-escalate the situation, whereas use of force does exactly the opposite and escalates the situation.”

In Pennsylvania, Caprioli said when officers entered his cell he felt the pain of welts in his flesh and the sting of powdered chemicals in the air, and realized nobody would help him.

“That’s the sick part about it,” Caprioli said. “You can see I’m in distress. You can see I’m not going to try and hurt anyone. I have nothing I can hurt you with.”

Eventually, he was taken to the hospital — where Caprioli said hospital staffers assessed his physical injuries — but he didn’t get help from a mental health professional. Hours later, he was back in jail, where he stayed for five days. He eventually pleaded guilty to a charge of “public drunkenness and similar misconduct” and had to pay a fine.

Caprioli acknowledged that he makes his problems worse when he uses alcohol or drugs, but he said that doesn’t justify how he was treated in jail.

“That’s not something that should be going on at all. All I needed was one person to just be like, ‘Hey, how are you? What’s going on?’ And never got that, even to the last day,” he said.

Monroe County Warden Garry Haidle and Monroe County District Attorney E. David Christine Jr. did not respond to requests for comment.

Some Jails Are Trying New Strategies

Jail is not an appropriate setting for treating serious mental illness, said Dr. Pamela Rollings-Mazza. She works with PrimeCare Medical, which provides medical and behavioral services at about 35 county jails in Pennsylvania.

The problem, Rollings-Mazza said, is that people with serious psychiatric issues don’t get the help they need before they are in crisis. At that point, police can be involved, and people who started off needing mental health care end up in jail.

“So the patients that we’re seeing, you know, a lot of times are very, very, very sick,” Rollings-Mazza said. “So we have adapted our staff to try to address that need.”

PrimeCare psychologists rate prisoners’ mental health on an A-through-D scale. Those with a D rating are the most seriously ill.

Rollings-Mazza said they make up between 10% and 15% of the overall population of jails served by PrimeCare. An additional 40% of people have a C rating, also a sign of significant illness.

She said that rating system helps determine the care psychologists provide, but it has little effect on jail policies.

“There are some jails where they don’t have that understanding or want to necessarily support us,” she said. “Some security officers are not educated about mental health at the level that they should be.”

Rollings-Mazza said her team frequently sees people come to jail who are “not reality-based” due to psychiatric illness and can’t understand or comply with basic orders. They are often kept away from other people behind bars for their own safety and may spend up to 23 hours a day alone.

That isolation virtually guarantees that vulnerable people will spiral into a crisis, said Dr. Mariposa McCall, a California-based psychiatrist who looking at the effects of solitary confinement.

Her work is part of a large body of research showing that keeping a person alone in a small cell all day can cause lasting psychological damage.

McCall worked for several years at state prisons in California and said it’s important to understand that the culture among corrections officers prioritizes security and compliance above all. As a result, staff members may believe that people who are hurting themselves are actually trying to manipulate them.

Many guards also view prisoners with mental health conditions as potentially dangerous.

“And so it creates a certain level of disconnect from people’s suffering or humanity in some ways, because it feeds on that distrust,” McCall said. In that environment, officers feel justified using force whether or not they think the incarcerated person understands them.

To really understand the issue, it helps to examine the decisions made in the hours and days leading up to a use of force incident, said Jamelia Morgan, a professor at Northwestern University Pritzker School of Law.

Morgan researches a growing number of lawsuits centered on use of force incidents that involve people in jail with mental health problems. Lawyers have successfully argued that demanding that a person with mental illness comply with orders they may not understand is a violation of their civil rights. Those suits suggest that jails should instead provide “reasonable accommodations.”

“In some cases, it’s as simple as having medical staff respond, as opposed to security staff,” Morgan said.

Individual cases can be difficult to litigate due to a complex grievance process that those locked up must follow before filing suit, Morgan said. Morgan said to solve the overall problem, wardens will need to redefine what it means to be in jail.

This investigation included right-to-know requests filed with 61 counties across Pennsylvania and the investigative team followed up with wardens in some of the counties that released use of force reports. None agreed to talk about how their officers are trained or whether they could change how they respond to people in crisis.

Some jails are trying new strategies. In Chicago, the Cook County corrections department doesn’t have a warden. Rather, it has an “executive director” who is also a trained psychologist.

That change was one part of a total reimagining of jail operations after a 2008 found widespread violations of prisoners’ civil rights.

In recent years, Cook County’s jail system has gotten rid of solitary confinement, opting instead to put problematic prisoners in common areas, but with additional security measures whenever possible, Cook County Sheriff Tom Dart said.

The jail includes a mental health transition center that offers alternative housing — a “college setting of Quonset huts and gardens,” as Dart described it. There, prisoners have access to art, photography, and gardening classes. There’s also job training, and case managers work with local community agencies, planning for what will happen once someone leaves the jail.

Just as important, Dart said, jail leadership has worked to change the training and norms around when it’s appropriate to use tools such as pepper spray.

“Our role is to keep people safe, and if you have someone with a mental illness, I just don’t see how Tasers and [pepper] spray can do anything other than aggravate issues, and can only be used as the last conceivable option,” Dart said.

Cook County’s reforms show that change is possible, but there are thousands of local jails across the U.S., and they depend on the local and state governments that set correctional policies and that fund — or fail to fund — the mental health services that could keep vulnerable people out of jail in the first place.

In Pennsylvania’s Dauphin County, where Ishmail Thompson died, officials said that the problem — and solutions — extend beyond jail walls. County spokesperson Hambright said funding has remained stagnant amid an increase in people needing mental health services. That’s led to an over-reliance on jails, where the “lights are always on.”

“We would certainly like to see some of these individuals treated and housed in locations better equipped to treat the specificity of their conditions,” Hambright added. “But we must play the hands we are dealt by the existing system as best we can with the resources that we have.”

This story is part of a partnership that includes , , and .

Brett Sholtis received a 2021-22 , and this investigation received additional support from , in with the Carter Center and Reveal from the Center for Investigative Reporting.

To learn more about how WITF reported this article, check out this .

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Colluccio, 38, said he knows what it’s like to be on the other end of one of those calls.

“So, I had a suicide attempt when I was about 10, 11 years old,” Colluccio said. “And we do get callers who are about that age, or quite young, and they are going through similar stressors.”

For people experiencing a mental health crisis, calling 988 can be a lifesaving decision. But what happens after they call depends on where they are. The new , and said calls went up 45% nationally during the first week.

With calls likely to increase as more people learn about the helpline, some call centers said there are limits to what they can accomplish without boosting local resources.

Colluccio said callers in his service area — Bucks County, just north of Philadelphia — have access to more services than in many other parts of Pennsylvania. His job with the Family Service Association of Bucks County, which runs the hotline locally, sometimes involves connecting callers with services such as homeless shelters, therapists, or drug and alcohol counselors.

More than anything, his job is to listen.

Colluccio’s first call of the evening was from a woman who sounded panicked. Her partner had been using drugs and started making violent threats.

Colluccio spent a lot more time listening than talking. He said that by listening closely to what a caller has to say, he offers relief, validation, and human connection.

When he does talk, he usually asks questions — gently searching for specific ways to help. In this case, his questions led him to connect the caller with local domestic abuse services and a social worker.

One service he rarely turns to is 911. Part of the idea behind 988 is to offer an alternative to involving police or an ambulance in a mental health crisis. Colluccio said he would typically use 911 only if someone was an immediate threat to themselves or others. Some people who’ve had poor experiences with the mental health system have voiced concerns and warned others about the possibility of a brush with law enforcement if they call 988.

After talking with the woman for a half-hour, Colluccio asked her key questions to determine whether she felt suicidal. It is an important step to make sure each caller is safe after they hang up, he said.

At the start of the call, it seemed the woman wanted help for her partner. But when Colluccio asked her directly on a scale of 1 to 5 how suicidal she was, she said that she was a 2 or maybe a 3 — and that she had attempted suicide before.

Before they ended the call, Colluccio asked her if she would like a call back the next day. She said yes, so he scheduled one.

Colluccio had just enough time for a sip of tea before another call came in. It was a young man in college, overwhelmed by stress. They talked for over an hour.

This was a pretty typical evening, he said.

“Sometimes it’s more of an immediate intervention because sometimes people call with pills in hand and are actively considering ending their lives,” Colluccio said. “There are people who have called and said, ‘If you did not pick up, I’d have killed myself.’”

Nationwide, there are more than 200 call centers like this one. Calls are tied to area codes. If nobody picks up locally, the call gets kicked to somewhere else. The promise is to always have someone pick up the phone.

In some places, like Bucks County, additional resources are available for callers who need more help than counselors can offer on the phone. Colluccio can dispatch a mobile crew of mental health workers to visit someone at home. But in Hanover, Pennsylvania, a town a few hours west, the 988 call center doesn’t have that option.

Jayne Wildasin runs that center and said workers sometimes have to put down their headsets, get in their cars, and go meet with a caller who might live as far as an hour away.

“So right now, if there’s a crisis at someone’s house, we could potentially go there,” Wildasin said.

In another part of the state — rural Centre County — the local 988 call center relies on volunteers — mostly college students from Penn State. Denise Herr McCann runs the operation and said that her team can call in mobile mental health experts, but more of them are needed.

There is also a need for additional mental health professionals who can help once a crisis has passed.

“Sometimes those resources are other counseling services, and they don’t have capacity,” Herr McCann said. “People are calling, and providers are six weeks out if they’re lucky. That’s not any good.”

For decades, suicide prevention call centers have scraped together funding from local, state, and federal sources. With the switch to 988, they now must meet new federal regulations, such as data collecting and licensure requirements, said Julie Dees, who oversees the call center in Bucks County. That all costs money.

“There are increased responsibilities that are being put on the call centers, but there’s really no additional funding being put on that,” Dees said.

It’s an issue around the U.S., according to a from the Pew Charitable Trusts. The polling and research organization noted that states are largely left to foot the bill for the change to 988 — and many of the crisis centers doing the work have been underfunded for years. It recommended that state policymakers evaluate funding needs to ensure that crisis services connected to 988 will be sustainable and seamless.

The Biden administration invested $432 million toward building the capacity of local and backup call centers and providing associated services. But the expectation is that states will come up with the main funding streams.

The also allows states to pass legislation to add a fee to cellphone bills as a permanent source of funds for 988 and associated mental health services.

Pennsylvania’s outgoing Democratic governor has proposed a funding fee model but it hasn’t yet gained traction in the Republican-controlled legislature. The lack of a funding mechanism worries Kevin Boozel, who heads the County Commissioners Association of Pennsylvania.

“This is life or death,” Boozel said. “And you can’t halfway do it.”

Fearing that too many calls could flood the system, Pennsylvania has decided to hold back on publicizing the new 988 number until next year. Counties need more time to set up funding, hire workers, and build capacity for things like those mobile crisis teams.

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Colluccio, de 38 años, dijo que sabe lo que es estar del otro lado de la línea.

“Intenté suicidarme cuando tenía 10 u 11 años”, contó. “Y ahora recibimos llamadas de personas de esa edad, muy jóvenes, que están pasando por situaciones de estrés similares”.

Para las personas que sufren una crisis de salud mental, llamar al 988 puede ser una decisión que les salve la vida. Pero lo que ocurra después de la llamada depende de en donde vivan. y, según , las llamadas aumentaron un 45% a nivel nacional durante la primera semana.

Aunque es probable que las llamadas aumenten a medida que se conozca la línea de ayuda, en algunos centros de llamadas sienten que la falta de recursos locales limita su trabajo.

Colluccio afirmó que las personas que llaman en su área —el condado de Bucks, al norte de Philadelphia— tienen acceso a más servicios que en otras partes de Pennsylvania. Su trabajo en la Asociación de Servicios para la Familia del condado de Bucks, que gestiona la línea telefónica a nivel local, implica a veces poner en contacto a quienes llaman con servicios como refugios, terapeutas o consejeros sobre drogas y alcohol.

Pero, sobre todo, su trabajo consiste en escuchar.

La primera llamada que Colluccio atendió aquella tarde fue de una mujer que parecía aterrada. Su pareja había estado consumiendo drogas y había empezado a amenazarla violentamente.

Colluccio pasó mucho más tiempo escuchando que hablando. Aseguró que al escuchar atentamente a la persona que llama, ofrece alivio, empatía y conexión humana.

Cuando habla suele hacer preguntas para buscar, con delicadeza, formas concretas de ayuda. En este caso, sus preguntas le llevaron a poner a la persona que llamaba en contacto con los servicios locales de maltrato doméstico y con un trabajador social.

Un servicio al que rara vez recurre es el 911. Parte de la idea del 988 es ofrecer una alternativa a la intervención de la policía o la ambulancia en una crisis de salud mental. Colluccio afirmó que solo utilizaría el 911 si alguien fuera una amenaza inmediata para sí mismo o para otros. Quienes han tenido malas experiencias con el sistema de salud mental han expresado su preocupación y han advertido que si se llamaba al 988 acudiría la policía.

Tras hablar con la mujer durante media hora, Colluccio le hizo preguntas clave para determinar si tenía ideas suicidas. Es un paso importante para asegurarnos de que cada persona que llama está segura después de colgar, señaló.

Al principio de la llamada, parecía que la mujer quería ayuda para su pareja. Pero cuando Colluccio le preguntó directamente, en una escala del 1 al 5, cómo sentía la posibilidad del suicidio, dijo que era un 2 o quizá 3, y que ya había intentado suicidarse.

Antes de colgar, Colluccio le preguntó si quería que la llamaran al día siguiente. Ella dijo que sí, así que programó una llamada.

Colluccio tuvo el tiempo justo para tomar un sorbo de té antes de que entrara otra llamada. Era un joven universitario, agobiado por el estrés. Hablaron durante más de una hora.

Fue una tarde bastante típica, afirmó.

“A veces se trata de hacer una intervención inmediata porque hay quien llama con pastillas en la mano, pensando claramente en acabar con su vida”, expresó Colluccio. “Hay personas que han llamado y han dicho: ‘Si no respondes, me habría suicidado'”.

En todo el país hay más de 200 centros como éste. Las llamadas están vinculadas a códigos de área. Si nadie responde la llamada a nivel local, se envía a otro lugar. La promesa es que siempre habrá alguien al otro lado del teléfono.

En algunos lugares, como el condado de Bucks, hay recursos adicionales para quienes llaman y necesitan más ayuda de la que pueden ofrecer por teléfono. Colluccio puede enviar un equipo de trabajadores de salud mental para visitar a alguien en su casa. Pero en Hanover, Pennsylvania, una ciudad a unas horas al oeste, el centro de llamadas 988 no tiene esa opción.

Jayne Wildasin dirige ese centro y dice que los trabajadores a veces tienen que dejar los auriculares, subirse a sus autos e ir a a ver a la persona que llama, que puede vivir hasta a una hora de distancia.

“Así que ahora mismo, si hay una crisis en la casa de alguien, tendríamos que ir allí”, indicó Wildasin.

En otra parte del estado —el condado rural de Centre— el centro de llamadas local 988 depende de voluntarios, en su mayoría estudiantes universitarios de Penn State. Denise Herr McCann dirige el centro y dijo que su equipo puede llamar a expertos en salud mental, pero que se necesitan más.

Durante décadas, los centros de llamadas para la prevención del suicidio han reunido fondos de fuentes locales, estatales y federales. Con el cambio al 988, ahora deben cumplir con nuevas regulaciones federales, como la recopilación de datos y los requisitos de licencias, puntualizó Julie Dees, que supervisa el centro de llamadas en el condado de Bucks. Todo eso cuesta dinero.

“Los centros de llamadas tienen más responsabilidades, pero no hay fondos adicionales para ello”, añadió Dees.

Se trata de un problema en todo Estados Unidos, según de Pew Charitable Trusts. La organización de encuestas e investigación señaló que los estados tienen que pagar la factura del cambio al 988, y que muchos de los centros de crisis que realizan esta labor llevan años sin recibir fondos suficientes. Recomendó que los responsables políticos estatales evalúen las necesidades de financiación para garantizar que los servicios de crisis conectados al 988 sean sostenibles y eficientes.

El gobierno de Biden invirtió $432 millones para el desarrollo de la capacidad de los centros de llamadas locales y de refuerzo, así como para servicios asociados. Pero la expectativa es que los estados aporten las principales fuentes de financiación.

La también permite a los estados aprobar una legislación para añadir una tasa a las facturas de los teléfonos móviles, como fuente permanente de fondos para el 988 y los servicios de salud mental asociados.

Por temor a que un exceso de llamadas inunden el sistema, Pennsylvania ha decidido no publicitar el nuevo número 988 hasta el próximo año. Los condados necesitan más tiempo para establecer la financiación, contratar trabajadores y crear capacidad para cosas como los equipos móviles de crisis.

Esta historia es parte de una alianza que incluye ,Ìý, y .

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Su carpa y botas de trekking están en el porche donde las dejó por última vez. El césped que solía cortar ha crecido. Y en la mesada de la cocina todavía hay frascos del medicamento para la tos de venta libre que tomó para tratar de aliviar sus síntomas en casa cuando covid-19 comenzó a destruir sus pulmones.

Dixon era guardia en una prisión estatal cercana en el condado rural y conservador de Clearfield, Pennsylvania. Murió en enero a causa del virus, a los 27 años. A su hermana mayor, Stephanie Rimel, la abrumó la emoción mientras caminaba por la casa de Dixon y lo recordaba.

“Nunca podré estar en su boda”, dijo Rimel. “Nunca lo veré envejecer”.

Sin embargo, sus expresiones de dolor se convirtieron rápidamente en ira. Rimel recordó la desinformación que proliferó el año pasado: las máscaras no funcionan. El virus es un truco demócrata para ganar las elecciones. Solo las personas mayores o las que ya están enfermas están en riesgo.

Rimel dijo que su hermano creía algo de eso. Lo escuchó de otros guardias de la prisión, de familiares y amigos en Facebook, dijo, y del ex presidente, por quien votó dos veces.

Las falsedades y las conspiraciones han fomentado una actitud de desdén sobre el coronavirus entre muchas personas en las zonas rurales de Pennsylvania, donde ella y sus hermanos crecieron, apuntó Rimel. Y, debido a la desinformación, su hermano no siempre usaba una máscara ni practicaba el distanciamiento físico.

Cuando los miembros de la familia expresaban sus opiniones despectivas sobre covid, el dolor de Rimel se volvió aún más fuerte y personal. Rimel recordó un momento particularmente difícil justo después de que su hermano tuviera que ser hospitalizado. Incluso entonces, familiares repetían teorías conspirativas en las redes sociales y se jactaban de no usar máscaras, contó.

Algunas de las personas que asistieron al funeral de Dixon todavía comparten información errónea sobre covid en internet, dijo otra hermana, Jennifer Dixon.

“Ojalá hubieran estado allí sus últimos días y lo hubieran visto sufrir”, dijo. “Observar cómo su corazón todavía podía latir. Sus riñones produciendo orina porque [eran] muy fuertes. Su hígado funcionando. Todo. Fueron sus pulmones los que se habían ido. Sus pulmones. Y eso solo se debió a covid”.

Ambas hermanas quisieron que el no fuera ambiguo sobre lo que lo había matado. Dice: “Kyle tenía mucha más vida para vivir y COVID-19 frenó su brillante futuro”.

Si bien estas hermanas han optado por ser francas sobre lo que sucedió, otras familias han decidido guardar silencio sobre las muertes por covid, según Mike Kuhn, director de una en Reading, Pennsylvania.

El negocio de Kuhn no manejó el funeral de Kyle Dixon, pero en sus tres funerarias ha ayudado a enterrar a cientos de personas que murieron por el coronavirus. Dijo que aproximadamente la mitad de esas familias pidieron que no se mencionara a covid en los obituarios ni en los avisos de defunción.

“He tenido personas que dicen: ‘Mi madre o mi padre Iban a morir, probablemente en el próximo año o dos de todos modos, y estaban en un hogar de adultos mayores, y luego se enfermaron de covid, y ya sabes, yo realmente no quiero darle mucho crédito a covid ‘”, dijo Kuhn.

Algunas familias quisieron que se cambiara el certificado de defunción oficial de su ser querido para que no figurara covid como la causa de la muerte, agregó Kuhn. Los certificados de defunción son documentos oficiales del estado, por lo que Kuhn no podría hacer ese cambio. Pero la solicitud muestra cuánto quieren algunas personas minimizar el papel del coronavirus en la muerte de un familiar.

Negarse a enfrentar la verdad sobre lo que mató a miembro de una familia o una comunidad puede hacer que el duelo sea mucho más difícil, dijo , quien trabaja como experto en cuidados al final de la vida para la y ha escrito libros sobre envejecer, el cuidado al final de la vida, la muerte y el duelo.

Doka dijo que cuando una persona muere por algo controversial, se denomina una “muerte por privación de derechos”. El término se refiere a una muerte de la que la gente no se siente cómoda hablando abiertamente debido a normas sociales.

Doka exploró por primera vez el concepto en la década de 1980, junto con un otro relacionado: “duelo privado de derechos”. Esto ocurre cuando los dolientes sienten que no tienen derecho a expresar su pérdida de manera abierta o completa debido al estigma cultural sobre cómo murió la persona.

Por ejemplo, las muertes por sobredosis de drogas o suicidio se consideran con frecuencia como resultado de un supuesto fracaso “moral”, y los dolientes a menudo temen que otros los juzguen por las elecciones y conductas de la persona fallecida, dijo Doka.

“De hecho, si digo que mi hermano murió de cáncer de pulmón, ¿cuál es la primera pregunta que se va a hacer? ¿Era fumador?”, dijo Doka. “Y de alguna manera, si era fumador, es responsable”.

Doka predice que los estadounidenses que han perdido a sus seres queridos a causa de covid en comunidades donde la enfermedad no se toma en serio también pueden encontrar acciones similares, transferir la responsabilidad del virus a la persona que murió.

Las hermanas de Dixon dijeron que esa es la actitud que a menudo perciben en las respuestas de las personas a la noticia de la muerte de su hermano: preguntar si tenía condiciones preexistentes, o sobrepeso, como si él tuviera la culpa.

Es poco probable que quienes critican o rechazan a las víctimas de la pandemia cambien de opinión fácilmente, dijo , socióloga especializada en duelo. Agregó que los comentarios críticos provienen de un concepto psicológico conocido como disonancia cognitiva.

Si la gente cree que la pandemia es un engaño, o que se exagera sobre los peligros del virus, entonces “cualquier cosa, incluida la muerte de un ser querido por esta enfermedad, lo compartimentan”, explicó Prigerson. “No lo van a procesar. Les da demasiado dolor de cabeza tratar de reconciliar”.

Prigerson advierte que las personas cuyas familias o amigos no están dispuestos a reconocer la realidad del covid podrían tener que establecer nuevos límites para esas relaciones.

Mientras Rimel continúa llorando la muerte de su hermano, ha encontrado alivio al unirse a grupos de apoyo para el duelo con otras personas que están de acuerdo con la información sobre covid. En agosto, ella y su madre asistieron a una marcha en recuerdo de las víctimas de covid en el centro de Pittsburgh, organizada por el grupo .

Y en junio, se colocó una lápida sobre la tumba de Dixon.

Cerca de la parte inferior hay un mensaje contundente para el público y para la posteridad: F— COVID-19.

Mucho después de que hayan partido, la familia quiere que la verdad perdure.

“Queremos asegurarnos de que la gente conozca la historia de Kyle y que falleció a causa del virus”, dijo Rimel.

Esta historia es parte de una alianza que incluye a NPR, WITF y KHN.

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Months after Kyle Dixon died, his old house in Lanse, Pennsylvania, is full of reminders of a life cut short.

His tent and hiking boots sit on the porch where he last put them. The grass he used to mow has grown tall in his absence. And on the kitchen counter, there are still bottles of the over-the-counter cough medicine he took to try to ease his symptoms at home as covid-19 began to destroy his lungs.

Dixon was a guard at a nearby state prison in rural, conservative Clearfield County, Pennsylvania. He died of the virus in January at age 27. His older sister Stephanie Rimel was overwhelmed with emotion as she walked through Dixon’s home and talked about him.

“I’ll never get to be at his wedding,” Rimel said. “I’ll never see him old.”

Her expressions of grief, however, quickly turned to anger. Rimel recounted the misinformation that proliferated last year: Masks don’t work. The virus is a Democratic hoax to win the election. Only old people or people who are already sick are at risk.

Rimel said her brother believed some of that. He heard it from other prison guards, from family and friends on Facebook, she said, and from the former president, whom he voted for twice.

Falsehoods and conspiracies have fostered a dismissive attitude about the coronavirus among many people in rural Pennsylvania, where she and her siblings grew up, Rimel said. And, because of the misinformation, her brother didn’t always wear a mask or practice physical distancing.

When family members expressed dismissive beliefs about covid, Rimel’s grief became even more painful and isolating. Rimel recalled a particularly tough time right after her brother had to be hospitalized. Even then, family members were repeating conspiracy theories on social media and bragging about not wearing masks, Rimel said.

Some of the people who attended Dixon’s funeral are still sharing covid misinformation online, said another sister, Jennifer Dixon.

“I wish that they could have been there his last days and watched him suffer,” she said. “Watch his heart still be able to beat. His kidneys still producing urine because [they were] so strong. His liver still working. Everything. It was his lungs that were gone. His lungs. And that was only due to covid.”

Both sisters wanted to be unambiguous about what had killed him. It reads, “Kyle had so much more of life to live and COVID-19 stopped his bright future.”

While these sisters have chosen to be outspoken about what happened, other families have opted to keep quiet about deaths from covid, according to Mike Kuhn, a in Reading, Pennsylvania.

Kuhn’s business did not handle Kyle Dixon’s funeral, but his chain of three funeral homes has helped bury hundreds of people who died from the coronavirus. He said about half of those families asked that covid not be mentioned in obituaries or death notices.

“You know, I’ve had people say, ‘My mother or my father was going to die, probably in the next year or two anyway, and they were in a nursing home, and then they got covid, and you know, I don’t really want to give a lot of credence to covid,'” Kuhn said.

Some families wanted to have their loved one’s official death certificate changed so that covid was not listed as the cause of death, Kuhn added. Death certificates are official state documents, so Kuhn could not make that change even if he wanted to. But the request shows how badly some people want to minimize the role of the coronavirus in a loved one’s death.

Refusing to face the truth about what killed a family or community member can make the grieving process much harder, said , who works as an expert in end-of-life care for the and has written books about aging, dying, grief and end-of-life care.

When a person dies from something controversial, Doka said, that’s called a “disenfranchising death.” The term refers to a death that people don’t feel comfortable talking about openly because of social norms.

So, for instance, if I say my brother died of lung cancer, what’s the first question you’re going to ask — was he a smoker? And somehow, if he was a smoker, he’s responsible.”

Ken Doka, an expert in end-of-life care for the Hospice Foundation of America

Doka first explored the concept in the 1980s, along with a related concept: “disenfranchised grief.” This occurs when mourners feel they don’t have the right to express their loss openly or fully because of the cultural stigma about how the person died. For example, deaths from drug overdoses or suicide are frequently viewed as stemming from a supposed “moral” failure, and those left behind to mourn often fear others are judging them or the dead person’s choices and behaviors, Doka said.

“So, for instance, if I say my brother died of lung cancer, what’s the first question you’re going to ask — was he a smoker?” Doka said. “And somehow, if he was a smoker, he’s responsible.”

Doka predicts that Americans who have lost loved ones to covid in communities where the disease isn’t taken seriously may also encounter similar efforts to shift responsibility — from the virus to the person who died.

Dixon’s sisters said that’s the attitude they often perceive in people’s responses to the news of their brother’s death — asking whether he had preexisting conditions or if he was overweight, as if he were to blame.

Those who criticize or dismiss victims of the pandemic are unlikely to change their minds easily, said , a sociologist specializing in grief. She said judgmental comments stem from a psychological concept known as cognitive dissonance.

If people believe the pandemic is a hoax, or that the dangers of the virus are overblown, then “anything, including the death of a loved one from this disease … they compartmentalize it,” Prigerson said. “They’re not going to process it. It gives them too much of a headache to try to reconcile.”

She advises that people whose families or friends aren’t willing to acknowledge the reality of covid might have to set new boundaries for those relationships.

As Rimel continues to mourn her brother’s death, she has found relief by joining bereavement support groups with others who agree on the facts about covid. In August, she and her mother attended a remembrance march for covid victims in downtown Pittsburgh, organized by the group .

And in June, a headstone was placed on Dixon’s grave.

Near the bottom is a blunt message for the public, and for posterity: F— COVID-19.

Long after they are gone, the family wants the truth to endure.

“We want to make sure that people know Kyle’s story, and that he passed away from the virus,” Rimel said.

This story is from a partnership that includes , and .

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Within an hour, Ricardo Muñoz, 27, was dead. Muñoz, who had a knife, was killed by a police officer in Lancaster, Pennsylvania. The incident has striking similarities to the . in Philadelphia six weeks later but has received far less national attention.

According to a Washington Post , as of Nov. 18, police had killed 987 people in the U.S. in the past 12 months. Like Muñoz and Wallace, almost a quarter of those people  of a serious mental illness.

Two Sisters, Two Different Calls for Help

Ricardo Muñoz lived with his mother in Lancaster, but earlier on that September Sunday he had been across town at his sister Rulennis Muñoz’s house. Rulennis recalled that her brother had been having what she calls “an episode” that morning. Ricardo became agitated because his phone charger was missing. When she found it for him, he insisted it wasn’t the same one.

Rulennis knew her brother was in crisis and needed psychiatric care. But she also knew from experience that there were few emergency resources available for Ricardo unless a judge deemed him a threat to himself or others.

After talking with her mom, Rulennis called  to see if Ricardo could be committed for inpatient care. It was Sunday afternoon. The crisis worker told her to call the police to see if the officers could petition a judge to force Ricardo to go to the hospital for psychiatric treatment, an . Reluctant to call 911, and wanting more information, Rulennis dialed the nonemergency police number.

Meanwhile, her mother, Miguelina Peña, was back in her own neighborhood. Her other daughter, Deborah, lives a few doors down. Peña started telling Deborah what was going on. Ricardo was becoming aggressive; he had punched the inside of the car. Back on their block, he was still yelling and upset and couldn’t be calmed. Deborah called 911 to get help for Ricardo. She didn’t know her sister was trying the nonemergency line.

The 911 Call

´¡Ìý of the 911 call show that the dispatcher gave Deborah three options: police, fire or ambulance. Deborah wasn’t sure, so she said “police.” Then she went on to explain that Ricardo was being aggressive, had a mental illness and needed to go to the hospital.

Meanwhile, Ricardo walked up the street to where he and his mother lived. When the dispatcher questioned Deborah further, she mentioned that Ricardo was trying “to break into” his mom’s house. She didn’t mention that Ricardo also lived in that house. She did mention that her mother “was afraid” to go back home with him.

The Muñoz family has since emphasized that Ricardo was never a threat to them. However, by the time police got the message, they believed they were responding to a domestic disturbance.

“Within minutes of … that phone call, he was dead,” Rulennis said.

Ricardo’s mom, Miguelina Peña, recalls what she saw that day. A Lancaster police officer walked toward the house. Ricardo saw the officer approach through the living room window, and he ran upstairs to his bedroom. When he came back down, he had a hunting knife in his hand.

In video from a police body camera, an unidentified officer walks toward the Muñoz residence. Ricardo steps outside, and shouts “Get the f–k back.” Ricardo comes down the stairs of the stoop and runs toward the officer. The officer starts running down the sidewalk, but after a few steps, he turns back toward Ricardo, gun in hand, and shoots him several times. Within minutes, Ricardo is dead.

After Ricardo crumples to the sidewalk, his mother’s screams can be heard, off-camera. Police made the body camera video public a few hours after Ricardo’s death, in an effort to dispel rumors about Ricardo’s death and quell rioting in the city. The county district attorney has since deemed the shooting justified, and the officer’s name was never made public.

Spotty Care, Dangerous Crises

Across the U.S., people with mental illnesses are 16 times more likely than the overall population to be killed by police, according to  from the mental health nonprofit .

Miguelina Peña said she tried for years to get help for her son.

Among the problems, the family couldn’t find a psychiatrist who was taking new patients, she said. Additionally, Peña speaks little English, and that made it difficult to help Ricardo enroll in health insurance, or for her to understand what treatments he was receiving. Ricardo got his prescriptions through a local nonprofit clinic for Latino men, .

Instead of consistent medical care and a trusted therapeutic relationship, Ricardo got treatment that was sporadic and fueled by crisis: He often ended up in the hospital for a few days, then would be discharged back home with little or no follow-up care. This happened more times than his mother and sisters can recall.

“There was an occasion where a judge was involved, and the judge determined that he should be released home,” Peña said. “And my question is, why would the judge allow him to go home if he wasn’t doing well?”

Immediate Threats and Escalation

Laws in Pennsylvania and many other states make it difficult for a family to get psychiatric care for someone who doesn’t want it; it can be imposed on the person only if he or she poses an immediate threat, said , advocacy and public policy director at the National Alliance on Mental illness. By that point, it’s often law enforcement, rather than mental health professionals, who are called in to help.

“Law enforcement comes in and exerts a threatening posture,” Kimball said. “For most people, that causes them to be subdued. But if you’re experiencing a mental illness, that only escalates the situation.”

People who have a family member with mental illness should learn what local resources are available and plan for a crisis, Kimball advised. But she acknowledged that many of the services she frequently recommends, such as crisis hotlines or special response teams for mental health, aren’t available in most parts of the country.

If 911 is the only option, calling it can be a difficult decision, Kimball said.

“Dialing 911 will accelerate a response by emergency personnel, most often police,” she said. “This option should be used for extreme crisis situations that require immediate intervention. These first responders may or may not be appropriately trained and experienced in de-escalating psychiatric emergencies.”

°Õ³ó±ðÌý continues to advocate for more resources for families dealing with a mental health crisis. The group says more cities should create crisis response teams that can respond at all hours, without involving armed police officers in most situations.

There has been progress on the federal level, as well. Kimball was happy when President Donald Trump signed a bipartisan congressional bill, on Oct. 17, to implement a three-digit national suicide prevention hotline. The summon help when dialed anywhere in the country. But it could take a few years before the system is up and running.

Rulennis Muñoz said the family never got to see how Ricardo would have responded to someone other than a police officer.

“And instead of a cop just being there, there should have been other responders,” Rulennis said. “There should have been someone that knew how to deal with this type of situation.”

This story comes from a reporting partnership with , Ìý²¹²Ô»åÌýKHN.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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