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dr. gary beven
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Dr. Gary Beven is a psychiatrist inside Ohio's maximum-security Lucasville prison. Here, he explains what it's like to try to provide effective psychiatric treatment inside a prison. "We receive the failures of the community mental health system very often," he says, " … inmates that are sentenced for short periods of time for common crimes, that fell through the cracks, that were perhaps homeless, actively psychotic, based in a lower-security prison and then filtered down to Lucasville because they just can't cope with prison life." Beven also discusses the ethics of working with people who have committed terrible crimes; the issue of malingerers; the dangers of placing mentally ill inmates in segregation; and the tensions between his job and corrections officers' jobs. "… The prison doesn't exist to provide mental health treatment, and because the prison exists to provide security and safety to the community, that's a natural barrier for somebody like myself to come in and want to interject myself into that setting and assume or believe that my medical judgment might supersede what corrections professionals and security would think would be the right thing to do," he tells FRONTLINE. This is an edited transcript of two interviews conducted on Oct. 20 and Oct. 25, 2004.

We get the worst, sickest patients in the entire state of Ohio, and we see it as a challenge to try to not only prevent further acts of violence and aggression, but also to bring about some form of a cure, if you can call it that, even for the most seriously ill patients.

... Tell me what it is for you actually to try to provide therapy and treatment [inside a prison]. ...

Providing any type of psychotherapy is very different in a prison setting. [In] private practice, it would just be you and your patient. There's no one else around you, no corrections officers, patient can come or go. There's a level of trust. You don't have the expectation that you could get assaulted.

In prison it's very different, and you have to be realistic in that. I think the key and the reason we've been so successful is that we work with patients on such an intensive, long-term basis that over time, perhaps several years, they begin to trust you, and they can show you that they have earned some trust that they've never had before. And in that setting, you can have some genuine success. And there's been some miracle cures for patients that other people have believed in the past -- even their own families, school systems, private psychiatric agencies have thought this person's completely hopeless. And then when they come here, they turn around entirely, and it's almost a miracle.

Why?

Well, it's taking somebody at their very worst. We get the worst, sickest patients in the entire state of Ohio, and we see it as a challenge to try to not only prevent further acts of violence and aggression, but also to bring about some form of a cure, if you can call it that, even for the most seriously ill patients. And when that happens, there's a real sense of self-satisfaction and professionalism that you don't tend to get in other settings.

What do you do here that's different, then?

Different than they're doing elsewhere? I just think that perhaps compared to other places, over time we've learned that what we were doing in the past was just futile and silly, and we have the resources here and the dedicated staff and the camaraderie and the relationship between mental health and security that's taken 10 years to develop. But I think it's been a great success.

And what was futile and silly? Give me a sense of what the before was.

Well, taking somebody with a serious, chronic mental illness who's also perhaps mentally retarded with a seizure disorder who has been traumatically abused throughout childhood, and then putting them in a really strict, tough setting and expecting them to have some improvement to their behavior and perhaps expecting them not to decline or get worse.

I think that in the past, we just really didn't know any better. And corrections, I think, has really changed over the last decade, at least in the United States. And Ohio, I think, is at the forefront of how seriously mentally ill and aggressive prison inmates should be treated in an effective way. ...

Do you see what's happening here also [as] reflective of America's interesting and troubling and confusing sort of view of what to do with the mentally ill? Are you experiencing that in bold relief here?

The way I look at it is that we receive the failures of the community mental health system very often. And I'm not talking about the inmates that we treated, for instance, who have committed murder, but inmates that are sentenced for short periods of time for common crimes that fell through the cracks, that were perhaps homeless, actively psychotic, based in a lower-security prison and then filtered down to Lucasville [Southern Ohio Correctional Facility, or SOCF] because they just can't cope with prison life. And sometimes I see patients like this, and I think to myself, why is this person here, [and] what good is this doing, especially when somebody's in for a nonviolent offense.

And so at some point, I'd hope that the community mental health system would be fixed so we don't have to do what we have to do as often and as intensively as we're currently providing care. ...

What [has been the] difference since the Dunn [consent] decree? What are you doing now that [is] different? ...

Well, before the litigation, the mental health services were rudimentary. When I started working here, for some time it was just me. I was the only psychiatrist, and I was only part-time, and there was only one psychiatric nurse. And there was a psychology staff, but they were beleaguered and overburdened, and I recall back then the feeling that you're just here plugging one hole in the dike, another one erupts, you run to the next crisis and you feel like you're not getting anywhere. You're on a treadmill going nowhere.

Now we have the staffing, we have the support from central office, from the director's office, the training, fortunately the budget to provide a good infrastructure of care that really is effective. ...

What is it actually like to try to provide mental health treatment inside a correctional facility?

Providing effective psychiatric care in a maximum-security prison is extraordinarily difficult. The work can be very frightening at times because of the inherent danger, and it can also be somewhat demoralizing because of the circumstances which the patients and the staff find themselves in. I think it takes a tremendous amount more concentration, perseverance and dedication than in a community setting, because there's so many obstacles and barriers to treatment and because you're working with the sickest patients that many times don't really want your help. But at the same time, as a mental health professional, you're not on top of the hierarchy in terms of who's important in the prison. Security runs the prison, and we have to work within those constraints. So I'd say it's a very, very difficult, demanding job.

So let's really unpack that in some depth.

OK. I think the first thing that people should realize is that the prison doesn't exist to provide mental health treatment, and because the prison exists to provide security and safety to the community, that's a natural barrier for somebody like myself to come in and want to interject myself into that setting and assume or believe that my medical judgment might supersede what corrections professionals and security would think would be the right thing to do.

So where would we see an example of that?

Well, an example would be somebody who has perhaps been aggressive or violent in another setting, another prison perhaps. And then, upon examination of the incident, one might find out that a great deal or perhaps the entire incident was the direct result of somebody's mental illness. For me to say that we shouldn't punish this person in traditional corrections manner, that mental health treatment is actually the proper way to resolve the issue and prevent further acts of aggression, sometimes that's looked at with a doubtful view, and sometimes your views might be disdained or disparaged.

And on top of that, the corrections professionals, especially the corrections officers who might be the victims of assault or attack by some of these inmates, they're the ones I depend on for protection in this environment. And it's difficult to maintain your own professionalism, your own ethics as a physician, to strongly recommend or insist that mental health treatment be the option provided rather than strict punishment, such as isolation. Those issues can get real difficult, real testy, and they can cause a lot of disagreement and conflict among staff. I think if you can get through that and you can gain some respect from the security staff, then you can use your authority in a real helpful manner. And I think we've been able to do that here, but it's taken a long time. You can't do that overnight. ...

Are [corrections officers] being asked to be social workers as well as corrections officers?

Corrections officers have probably the hardest job in the country. They're for the most part relatively unarmed and outnumbered in a setting where convicted felons have nothing to do all day except plot how they can perhaps escape or perhaps cause problems. Many don't; most don't, but quite a few do. And so I think it's difficult to be a corrections officer in a setting where you're providing services to mentally ill inmates when at the same time you're trying to maintain a secure environment to prevent escapes, prevent murders of other inmates, murders of staff, hostage takings, prevent riots and at the same time be compassionate to the point where you're able to know whether or not you should use disciplinary technique or you should contact a mental health person or use your own personal skills because you're dealing with somebody with perhaps mental retardation and schizophrenia.

So the officers, they work with mental health and work with us in a positive way. Most of them are extraordinarily professional. We couldn't do our job without their protection, and we couldn't do our job without their willingness to be open-minded, to listen to us so that we can have our mission accomplished. ...

If you stand from the corrections point of view, does providing mental health care inside the prison inevitably kind of disrupt if not [their] orders, at least [their] routine? Are they right that providing care, however necessary, ultimately makes their jobs harder in some way if you're in corrections?

Well, it is taxing and expensive, and you can look at it [as] annoying, perhaps, to provide effective mental health treatment. But so is providing food to 2,000 inmates; so is providing dental care to making sure that everyone has a flu shot and a TB test. I think if you look at it, providing mental health treatment from that standpoint, that yeah, it's hard, but if you have to do all these other things, let's do this, too. If you ignore that, you're just making your life a lot harder, not only from the standpoint of there being a lot more injuries, a lot more suffering, a lot less peace and contentment in the prison, or eventually there's going to be litigation. ...

What are the kind of invaluable qualities that a corrections officer has to have to do this well with the mentally ill?

A corrections officer that works with mentally ill inmates has to have patience; there has to be a level of compassion; and I believe they have to be very professional in terms of being able to overlook insignificant insults or behaviors that ordinarily might make one angry, and be able to understand that because they're working with a different set of inmates, a different population of inmates, [they] can't use cardinal or traditional correctional methods on these people the way I would with inmates that didn't have mental illness. ...

What are the areas of vulnerability, however well intentioned one is, as a professional? Where might the red flags be if there's that kind of overlap?

... Red flags, in terms of a mental health professional losing their mental health identity and overidentifying with security staff, usually happen when you're dealing with inmates that others, maybe people in the general public, would [view] as despicable. And it's very easy to fall into the trap of thinking that because somebody is in prison for a terrible offense that you don't need to provide them with the level of professionalism that you would to an inmate who is in prison for, for instance, a nonviolent crime or somebody that you might see in the street in another setting. And you have to be very aware of that, be self-aware of that. Otherwise you get on the slippery slope where in the end you might be endangering somebody's life inadvertently.

... Is it also areas of malingering and kind of that? ...

Sure. Anyone who works in a prison, in a jail, in a juvenile detention center, is going to see malingering. There's a variety of labels for malingerers -- fakes, manipulators -- and simply what that means is somebody who's either exaggerating a problem that they do have intentionally, or fabricating a problem. I've seen a tremendous amount of malingerers in my day here, and I can understand why. If you look more at the reason for why somebody is malingering, it's much easier to address it.

For instance, we often are asked by inmates to send them to the psychiatric hospital, and I think everyone understands it certainly would be better to be in a hospital than it is in a maximum-security prison. And so we've had people claim to hear voices when they haven't heard voices, claim to be suicidal when they really haven't been suicidal, fake acts of self-harm such as stage an overdose or have a noose or something tied around their neck and then call attention to themselves when the corrections officer is walking by.

I think the risk of malingering is, for the inmates, is that if you cry wolf one too many times, eventually when you're sick you're probably just going to be ignored. And that can happen just to an inmate who claims to have a toothache to get pain medication. Well, one day they're going to have a real toothache; they're just not going to get any help. So it's the same thing in mental health.

Another risk of malingering is that staff get desensitized and they think that everyone's faking. And when you do that, then you have to ask yourself, well, why am I even here? What am I doing in prison? So you really have to look at it thoughtfully. And I would say to other mental health professionals in other prisons, the worst thing you could do is to assume everyone is a malingerer. That's the worst thing you can do, because eventually you're going to ignore somebody who's very, very sick. It's always good to be skeptical, but to use professional judgment.

And another thing, many people that are malingerers sometimes are so desperate that they are willing to risk their lives to get what they want. We've had people at times deeply cut themselves, or, even though they weren't technically sick, they would intentionally take an overdose in front of somebody else, take an overdose of potentially lethal medication in order to force us to send them to the hospital. And we've always had to struggle with that, and at times we've said: "Well, if the person's willing to die, what are we doing? Let's send them to the hospital. They'll address it, they'll come back, and we'll move on from there." Those are some of the most difficult cases. ...

And please don't be sort of falsely modest on this, but self-aware. Why are you good at this?

... A long time ago when I started working here, I really had to confront whether or not this was going to be worthwhile. I remember before the litigation in the mid-1990s being confronted with the fact that I was for a time the only physician here, working part-time with a much higher population of inmates, one mental health nurse and no system of care, no RTU [residential treatment unit] to speak of. There was more or less of a warehousing area, but no group programs, no individual counseling. I remember one day the nurses brought in stacks of charts, maybe 30 or 40 patients that I'd never seen before, and they asked me to renew their medications, and they had patients that were taking anti-psychotic medication. I didn't even know who these patients were, and I had to ask myself, what should I do? Should I just quit and say no, this is ridiculous, why do this, or should I reorder all their medications thinking perhaps that if I didn't that perhaps they would get worse, and stick it out, see all the patients when I could, and work to make the system of care better?

And at that time, thank God, the Dunn v. Voinovich lawsuit was just getting off the ground. ... National experts came in -- a mentor of mine from Colorado, Dr. Jeff Metzner, and also now a friend and mentor, Fred Cohen. They revolutionized the care here, and I decided I was just going to stay. And I saw it through, and now, fortunately, I'm reaping the fruits of all the hard work that we've had together here over the last 10 years. ...

Could you have ever done that without the Dunn decree, ironically?

I seriously doubt it. I seriously doubt it, because there just wouldn't have been the money to do it. Without the weight of the federal court saying you need to do this, I doubt that anybody would have said, "Well, we're going to give these millions of dollars to form the Bureau of Mental Health Services and hire all these staff." And without that system in place, we just wouldn't have been able to do anything.

The litigation was crucial; it was very helpful. And what it has done is to build a model of care that other systems can emulate, perhaps, hopefully, without litigation. Another state that's struggling can look at Ohio and say, "How do you do it?" You know, Ohio's a big state, 12 million people; [it's] struggled over the last few years economically. The state budget has gone down; the state employees haven't gotten a raise for a few years. And so if we can do it, especially in a prison like this, where there has been a horrible riot [in 1993], where we've had very serious problems with violent, mentally ill inmates, if we can do it here, then I don't think any other system has an excuse of why they can't do it also.

How difficult was it actually to forge the changes in mental health care, because as you know, it comes in the wake of the worst tragedy here, the riots, officers killed. Was there even more resentment than there might be otherwise for mental health care treatment for inmates named in the suit? Did that make the perception of the work even more difficult?

Yeah. Early on in the litigation, there certainly was a more adversarial relationship, a noncollaborative relationship between custody staff and mental health staff. Plus, there was the federal monitors coming in, and they were trying to do their job. We were trying to defend what we were doing because we were doing the best we could, even though we didn't really have the resources or the knowledge to do it. And there were definitely times where nobody agreed and there was a lot of dissension, and if we hadn't fought through that, and if certain core staff hadn't decided to stay, myself included, I just don't know if things would have been as successful.

In terms of now the level of care that you're providing, what can your therapeutic objective actually be within this setting? Give me a sense as a professional. How does that change?

Our targets for effective treatment I think are very high. First of all, this is a setting where, for better or for worse, we have total control of the patients, and so we, for the first time in these patients' lives perhaps, we can expect complete and total sobriety -- no crack cocaine, no marijuana, no alcohol. For the first time, we expect complete adherence to medication regimens, 100 percent, where[as] in the community, the person goes to their shelter or goes home and takes their medication whenever they want to [and] at the same time might be using drugs or alcohol. So those are two things.

We also see the patients very often, and so there's a daily interaction with the most severely and mentally ill inpatients, especially among the activity therapy staff, the psychology assistant staff and the nursing staff. We also have a variety of groups. It still amazes me that even in a maximum-security mental health unit, we run 25 -- I think it's 25; it's more now -- group programs, where[as] in the community, I just don't think those resources exist. And we have the tools and techniques to essentially force or encourage, with a lot of help from security, to get these people to comply with the treatment plan. And when we have that happen, it's my opinion, even though I haven't worked with these people in the community, it's my opinion that many of the patients we see probably have the best therapeutic outcome they've ever had, perhaps after years of severe and chronic mental illness.

So is the answer ultimately that we provide better and better mental health care inside of prisons?

Well, I think that if you have a system that sends you severely mentally ill inmates, you have to provide them with mental health care. You can't deny that; you can't say they don't exist. You have to provide them with a level of care that they would expect in the community. I think that in a setting like this, it's our obligation to supersede what's available in the community, because the setting is so desperate and so dire. If we didn't do that, I don't think we would have as successful an outcome.

But the best thing would be for severely mentally ill inmates not to be sent into a prison like this. There has to be some way, some screening mechanism, to hopefully prevent them from entering the prison system itself. And then I think there must be some better way of preventing them from filtering down to the Southern Ohio Correctional Facility.

One of the main things we have trouble with are sometimes we receive nonviolent offenders or offenders with very short sentences for minor crimes, perhaps something like robbery. Everything's relative, especially in a prison like this, and they were previously at a minimum- or a medium-security prison. And because those prisons have their own strict rules and guidelines and expectations of compliance with security protocols, those inmates with serious mental illness just can't follow the rules appropriately. They're frightened; they're scared; they're paranoid; they're anxious, pacing; they're restless; they don't take their medication. Sometimes there will be a violent incident, not even maybe a violent incident, but a very disruptive incident, and their security level will be raised, and that might happen two or three times, and finally they end up down here at SOCF. …

... Why are there so many mentally ill incarcerated? Give me your view of where that story begins and how we're here.

I think there's so many mentally ill people in prisons primarily because there's just not adequate community treatment and support systems for people with severe and chronic mental illness. There just aren't. If there were, I just don't think we'd be seeing the level of dysfunction in the prisons. ...

Is there a large percentage of the population that you're serving here at Lucasville who could, in fact, have been served by other mental illness hospitals if they existed these days?

Oh, yes. I hope that some of the inmates that have agreed to be on film will depict the fact that, at least in viewers' minds, there probably would be a better place for these people than a maximum-security prison. We've really had some difficulty treating some of the most hapless, low-functioning inmates that are perhaps functioning at the level of a child, with temper tantrums and crying spells, and they need constant attention and constant reassurance, who can't read or write.

Sometimes it boggles my mind that these people are down here. If you look at it on paper, it all makes sense: Person's in prison for this crime, and at another prison they were aggressive, they were violent; a corrections officer is injured. But when they're down here and you say, "Oh, my God, what happened?" And you have to wonder, something didn't go right; there's got to be a better way to address this. So of course there's certain individuals that I think would be better off somewhere else. ...

Do you feel like Sisyphus sometimes, where you're just rolling the boulder up and it rolls right back down on you, in terms of doing your good work and watching these guys also max out into the community? Tell me what that's like actually in your gut.

It's difficult sometimes to work with somebody for maybe years, and then they leave prison; their prison sentence ends. Of course they don't want to stay; you don't want them to stay. But then you always wonder, what's going to happen to them? We've worked with them for five years; now they're gone. Everyone's happy about that, but you always wonder, well, is that person going to come back? And are they going to come back because the community's not going to accept them because they can't find a job, they can't afford their medication, because they might not be able to be psychiatrically hospitalized because there's no psychiatric hospital beds in the community? It's hard. ...

And in terms of the reality of the inmate population you're dealing with, many of them, it seems to me, that we've talked to haven't been identified early in their lives as having a mental illness of any kind. What role [do] socioeconomic factors play in the population you're dealing with in terms of the missed [diagnoses]?

Yeah. Most of the patients we have down here, you look at their backgrounds, they're from very impoverished environments, either from African American inner-city environments with no father figure, no stable home environment, or a white, Appalachian, rural environment that is very similar -- lack of education, dropping out of school early, not being able to read or write. You ask yourself, well, how did that happen, especially when you do an IQ test and they have a normal IQ, but still they failed academically. Many of the patients we work with have been sexually, physically abused as children. They've been neglected. They haven't been afforded with decent housing. Some of them have been kicked out of their home as a child. And occasionally I'll talk to inmates, they'll tell me that they began drinking and using hard drugs in elementary school. And so when I hear those stories, it's no surprise to me that they've landed here. It's just sad, though.

In what ways can the mental illness be manifested here in prison that either shocked you as you went along in this or you've learned more about it as you've seen it?

Mental illness manifests itself in prison because of the inherent stress of the environment, which brings out the worst in just about everybody. It brings out the worst in staff members who are having a bad day and you lose your temper. It happens to me; it happens to everybody. There's the inherent tension and hierarchy among inmates, the pecking order. Many patients decompensate and become extremely depressed, hopeless, suicidal. Many turn to severe self-mutilation or acts of self-injury which could even be life-threatening or grossly disfiguring. And many inmates that also suffer from severe mental illness become delusional and hallucinate.

Explain to me in some vivid way, if you can imagine it, what is it to be mentally ill and in segregation.

Segregation is a correctional tool that separates disruptive, unruly and aggressive, dangerous inmates from the rest of the institution. It separates inmates from each other and separates the general population of inmates from these inmates. It's a form of isolation, and its goal is to protect staff and to protect other inmates and to also act as a deterrent. ...

But when a mentally ill inmate is in long-term segregation, there's a combination of social isolation, very loud pandemonium, chaotic noise and a lack of adequate freedom and privileges, such as usually visitation is restricted. They might be restricted from using radios, watching television, having certain reading materials, like hardback books. The stress of all that can really bring out the most severe symptoms of mental illness. ...

But in segregation, the inmates are the most vulnerable, and they're the most vulnerable to acts of self-injury, to potential suicide and explosive acts of aggression. And because there is the physical isolation between the inmates and between the staff and the inmates, sometimes the inmates that lose their composure will resort to animalistic and very vile behavior, the worst of it being throwing human feces or excrement, throwing urine, throwing blood, exposing their genitals to female staff, throwing spoiled milk and other food.

And if that's all happening because an inmate with serious mental illness is decompensating and their behavior is going downhill, that can create a very serious security problem for the institution. And that ends up with perhaps staff injury, with excessive uses of force where staff are intervening because they've been assaulted, and also severe self-mutilation.

[Does that behavior become cyclical?]

When a severely mentally ill inmate is in segregation confinement, isolation, solitary confinement, whatever you'd like to call it, they can fall into a cycle of futility in that perhaps their initial acts may or may not have been related to mental illness. Perhaps they weren't, but perhaps -- for an example, say there's an inmate on medication, doing well, becomes assaultive or violent in the general population of the area of the prison; goes into segregation, and because perhaps the system of care is not in place to ensure that adequate treatment is provided, that person might become noncompliant with their medication and may be placed in an area where there's no psychosocial interventions to treat schizophrenia, and their behavior can get worse. The person can become more disruptive, more loud, more aggressive, less responsive to interaction and direction by mental health and security staff. And then their behavior can generate, through the conduct reports, disciplinary tickets, and that will prolong their stay in segregation even further. ...

So it's always better in those situations to be proactive, acknowledge that this person maybe does deserve some disciplinary consequences of what their behavior is, acknowledge at the same time that they're mentally ill and provide a resource of effective care such as a secure residential treatment unit in the prison where they can receive some punishment for whatever they've done, but at the same time receive the care that will prevent them from going downhill even more. ...

So as you know, often in this setting, there are incidents where one must use force, and there are cell extractions. ... How does that happen? What's going on that it's come to that point?

... I think that anyone who works in a prison, including me, realizes that we are just a few acts or incidents away from a hostage taking, from a riot, from an inmate pulling out a homemade weapon and burying it into the chest of your friend or cutting another patient, and then pandemonium develops. And perhaps just one horrendous incident could bring down everything we've done like a house of cards, because as everybody knows, when there's a dire emergency like a riot, everything gets changed, and people wonder, well, since this happened, what you were doing must not have worked.

And so you have to be realistic. If there's an inmate, even though he's sick, [who] refuses to come out of his cell, refuses to allow officers to inspect the property, refuses to comply with orders and stands fast to that, eventually that inmate is going to do what they're told, whether they want to or not. Well, in the past, I think that when an inmate was sick, force was used because of a legitimate issue -- for instance, somebody refusing to come out of their cell, refusing to give their food tray back which was broken and maybe is going to be used as a weapon. But now we react to uses of force differently in that if an inmate is known to be mentally ill and they're acting irrational, screaming, banging his head, threatening to cut himself, refuses to come out of the cell, mental health staff are always consulted in those incidents, and we'll do our best to try to talk the person out of the cell.

I think most corrections officers are not interested in bursting into an inmate's cell, risking injury to themselves and risking a lawsuit and injuring somebody else. They'd rather not do that. They're trained to do it properly, and I respect them for what they're trained to do, but the way things are working now, it's much better. ...

Have you ever been attacked?

I have not been physically attacked, thank God, while I've worked here. I've been spit on. I've had an inmate fill up a glove with urine and throw it at me. It burst, but it missed me. I have had numerous death threats. I have a very large stack of horrendous death threats, some written in inmates' blood, saying that they're going to find my house through the Internet when they get out; they're going to rig my car to explode when I start the ignition. I've had an inmate tell me that they're going to tie me up and force me to watch while my children and wife are mutilated and raped.

The interesting side to that, though, is most of the time when I receive those threats, the inmates sign it. And then when I confront the inmate, they ordinarily apologize, and sometimes they'll say something almost humorous like: "Oh, you know I'm just kidding. How long have you known me? I would never do that. I just did it because the inmate three cells down was mad because you wouldn't give him Valium, and he paid me a pack of cigarettes to write it. I hope you forgive me." But still, it's hard to get this kind of death threats. And I think everyone working in a maximum-security prison has that risk, especially women working in a male prison. Most people probably have, like I do, an unlisted phone number and are aware that if you do receive a threat, don't ignore it. At least look into it, because it could conceivably be credible. And ordinarily, when I've received a threat, even if the person identifies himself, I'm interested in finding out when that person is getting out of prison, are they going to be paroled, what is the real risk. ...

And all those who say, "Oh, God, it's Dr. Beven and his soft therapy for these felons who don't deserve anything," what do you ultimately say to those critics who sit at home?

Well, I hope that I can speak for other correctional psychiatrists in that I'm not here trying to make a prisoner's life easier; I'm not here trying to make their life more comfortable. I'm here because I'm a physician. There's people here with very serious, chronic, severe mental illnesses that I'm using my medical skill to treat in a professional way, just like the dentist provides professional services, just like the medical doctor here at the prison provides care to people with AIDS and hepatitis C, heart disease. I'm no different. I think people misperceive psychiatry as a soft medical profession when it's a medical subspecialty just like any other, and so they use their misperception of the field of psychiatry to think that I'm here providing programs to ease somebody's life in prison when it's really not like that at all.

I think if the average person saw the level of suffering, some of the severe illnesses … in prison, they would really think twice about having those thoughts, and they would probably realize that not only are we doing the right thing, but perhaps there should be more people doing it.

And ultimately most of them are coming out, yes?

Almost everyone in prison is coming out of prison. Even at this prison, most people are going to be released one day, and in my opinion, the worst thing you can do -- the worst thing you can do -- is to have a seriously mentally ill person, keep them locked away in segregation or solitary confinement, provide them with no care, no rehabilitative services at all, let them out, give them some street clothes, hand them a bus ticket and say, "Have fun in inner-city Cleveland," or wherever they're going to go. And that goes on all across the country. Or at least I'm sure that it has.

Those people are going to live in society. You're going to see them on the streets; you're going to see them whether you know who they are or not. You're going to see them at the mall; they're going to serve your food at the restaurant; they're going to work at McDonald's, whatever.

And so what we're doing here, I think, is also important for society as a whole. If we treat somebody with respect, professionalism, competency in here, keep them sober, treat their mental illness effectively, give them coping skills, provide them with a better education, connect them with the community mental health center, find them a decent place to live, that person, in my opinion, is probably going to be less likely to become violent and to resume a life of crime. ...

What did you think was going to happen with deinstitutionalization? Where were you in that argument intellectually years ago?

Deinstitutionalization happened when I was early in my training, and I didn't see it firsthand. I'm just seeing the repercussions of it. That movement, I believe, was done by people who really believed that what they were doing was proper and ethical, and there were many patients in state hospitals that shouldn't have been there, that had no recourse or release. They were being warehoused. ...

Prisons have become the new asylums, the new state mental hospital facilities. Deinstitutionalization has inadvertently caused a tremendous amount of mentally ill people that have not been provided with adequate community resources to fall into the criminal justice system. We're picking up the pieces which deinstitutionalization has led to. For better, for worse, that's what we're dealing with right now, and I think that the solution would be to improve community mental health systems and for there to be at least a reasonable amount of state psychiatric or public psychiatric beds across the United States, especially in larger states with urban populations whose jails are just flooded with severely mentally ill people who don't have any insurance. If those things aren't addressed, over time the situation is simply just not going to be solved.

We might do a better job in prison of providing mental health care, and we could even raise our level of service to what's in a psychiatric hospital. But it's still a prison, and I still think it's not the right way to address the problem. ...

[Can you give me] your thoughts on some of the inmates we've seen? ... Jakuba Lewis?

Yeah. Jakuba Lewis is interesting from the standpoint of the fact that he has severe treatment-resistant schizophrenia that has failed just about every type of anti-psychotic medication we've had, and he's required placement on Clozaril, which is an excellent medication, but it requires weekly blood studies to prevent the possibility of there being a serious physical reaction or a life-threatening reaction to the medication.

In a prison, it's really hard to have consistent labs drawn to get the results and to ensure that the patient is getting the proper dosage. And we've been able to get his blood drawn effectively and every week have the nurses monitor him real closely. And as a result, he's able to benefit from the medication, and he's now at a lower-security prison. So it's been a success story.

Surprised everyone, would you say?

Well, considering where he is, I think it's a real surprise. If you had seen Jakuba Lewis several years ago, when he was incessantly hallucinating and really struggling, one would think, there's really no hope for this person. But thankfully, even though we're here, we've been able to treat him very effectively, and hopefully he'll never, ever come back to a prison like this again. ... I think it's remarkable in the fact that he was, one, so ill and having so much trouble that his behavior stabilized to the point where he was able to be conduct report-free I believe for over a year, which is really remarkable in a real strict environment where you're expected to follow the rules, essentially irrespective of what your limitations are. ...

And Carl McEachron?

Carl was once thought of as a person that was hopelessly aggressive, disruptive and violent. He was the type of individual who was very difficult to work with because in the past, he had been very aggressive towards staff, including, I believe, by spitting on staff members and throwing body waste. And so there wasn't a lot of empathy for him; there wasn't a lot of people going to bat for him, and people weren't saying, "We really need to help this person." The tendency would be for somebody like that to just -- "Let's lock him away. If this person's going to behave like that, let's just not have anything to do with him."

The fortunate thing with Carl was getting him into treatment, even though he didn't want it. He didn't believe there was anything wrong, and so he was transferred to Oakwood, the prison psychiatric hospital, and he was placed on medication that essentially turned his life around completely, where he was once viewed as a primitive, angry, disruptive, violent, sociopathic person to somebody with a sense of humor, somebody who could communicate decently, who was nonviolent, who may not agree with the medication he's taking or agree with all the treatment he's received, but who you can have a cordial relationship with. So I think he's another success story.

Years ago, before we had the system in place that we do now, that type of individual would still be in segregation, and they would probably never get out of segregation.

Spend his entire life there?

It's possible -- spend his entire life, or worse, in my opinion, [be] released into society in the state that he was in, given some clothes and a shower, bus ticket, and then the next thing you hear about is you read about him in the paper, or the next time they come back, if they've done something horrendous. …

Oakwood -- what role does it play in the work you do here?

Oakwood Correctional Facility is vital to the success of the mission we have in ODRC [Ohio Department of Rehabilitation and Correction]. It's a genuine accredited psychiatric hospital, but it's run by the prison system. If we didn't have it, this would be the last stop for all of these inmates. For instance, a violent, psychotic inmate sent down here, and somebody that was either too physically sick … or somebody … who is just not able to cope with the demands of a maximum-security prison, we wouldn't have anywhere to send them. So we'd be forced to use probably just correctional techniques to control their behavior rather than to allow them to disrupt the workings of the entire institution and do the best we could with the medical care given the fact that it's a maximum-security prison and it's not a hospital. If Oakwood didn't exist, I really feel that it would be a detriment in the care we could give to these inmates. It's vital. ...

So for somebody like McEachron, how is he ultimately going to do when he comes out?

When somebody like Carl leaves prison, the outcome, I believe, depends almost entirely on the level of community support that's available. If he is simply let out and not provided with some system that he can fit into as a mentally ill person who's been in prison for a number of years, it's likely that he's going to deteriorate, because he probably won't be encouraged to take his medication; he may not show up for mental health clinic appointments to see a psychiatrist; he may resort to using drugs or alcohol. And eventually, his behavior may deteriorate to the point where you might see in a community [what] we saw here in prison, kind of an unsocialized, aggressive, paranoid, delusional individual that would probably break the law and deteriorate even further when they were reincarcerated.

And what's happening with someone like Carl, as he came in for I think a fairly minor theft, and then he had a parole violation with another theft?

Many severely mentally ill inmates have come into prison either on minor violations of the law or on parole violations. And when they enter the system, if the care they're receiving is deficient, their behavior can worsen. They can become more disruptive, and then they filter down to a prison like this, which is kind of like the basement for the severely mentally ill in Ohio. ...

 

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posted may 10, 2005

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