The New Asylums [home]
homewatch onlinefaqsstate-by-statediscussion
fred cohen
photo of cohen

Fred Cohen, an expert in juvenile justice, is professor emeritus of law and criminal justice at the State University in New York, Albany. As the court-appointed monitor in the Dunn v. Voinovich lawsuit, he led a team that investigated conditions for the mentally ill in Ohio prisons; many of the team's recommendations were subsequently enacted. In this interview, Cohen discusses the results of the suit and the limitations prisons face in trying to improve mental health care. "These lawsuits have clearly made it better for these inmates. Better -- I wouldn't say good," he says. "These lawsuits are demonstrably helpful. People are taken out of conditions that were barbaric, uncivilized, unhealthful, harmful. … You could have the best intentions and the best commitment of resources to helping prisoners while they're mentally ill, ... but [prison] will never be the [ideal] place where you want to provide that treatment, and it will never reach sort of idealistic goals." This is an edited transcript of an interview conducted on Dec. 2, 2004.

We spend almost all of our money on the mentally ill that we've been talking about on prison, practically nothing up front, where we should be spending most of it, and practically nothing on the back end. But there's no legal obligation on the front end or on the back end.

What were the key issues of the Dunn v. Voinovich lawsuit?

The overriding issue, of course, was a claim by the plaintiffs that their constitutional right to a minimally adequate level of mental health care was not being provided. ... There were six psychiatrists for the entire system when the Dunn lawsuit was filed. And just to give you a contrast, by the time the case ended, so to speak, there were over 40. ... There wasn't any kind of a basic overall plan for identifying the mentally ill and diagnosing them and putting them into environments which would help rather than hurt. And in every respect, the physical culture, you might say, the physical and human resources weren't there. ... Before Dunn, before this lawsuit, you would have just seen inmates ignored, or most likely you would have seen them locked down in segregation, because no one knew how to deal with them. There wasn't any treatment, and the correctional officers didn't know how to deal with them. And they would have been locked down primarily, or just left alone.

And that would have negative consequences for both the mentally ill and the corrections staff, right?

When you have a situation which I've just described, where inmates aren't treated or they're locked down, it's very dangerous for staff. ... They don't know what to expect. A prison without treatment is very noisy. It's very dangerous: It's dangerous for staff, and it's dispiriting; it's dangerous for fellow inmates. ... It's the noise of the old 19th-century hospital that drives everybody crazy and more. It's inhumane. You have people who are suffering, and the longer they go without treatment, the worse their condition.

Was it your sense before Dunn that [the prison system] inherited a large problem that they hadn't asked for?

... If you want to understand how so many people with such serious mental illness came to prisons and jails, you have to go back to what's called the deinstitutionalization movement, which in turn I trace to California in the '60s during the Reagan [gubernatorial] administration. And for many reasons, he and his administration saw to it that via legislation that the mental hospitals were gradually almost emptied.

And that movement caught on around the country. And once you had hundreds of thousands of people leaving the mental hospitals, they suddenly, obviously, didn't become mentally healthy. They went to the streets. They became homeless, or they began to engage in petty, open criminality on the streets, the homeless, the vagrants, or more serious crimes. And then they eventually began to cycle through the system that can't say no. ...

And are prisons equipped to handle this population?

... I can't imagine any facilities being less equipped than jails and prisons. They simply were not equipped for it -- no training, no education, no physical facilities, no staff, no mental health staff, no training of the correctional staff. [There was a] deep misunderstanding of the behavior that accompanies lots of forms of mental illness and reacting as though somebody who's acting out of hallucinations is trying to cause harm to me as an officer. And those things escalate into charges of misconduct; a charge of misconduct leads to being locked down -- out of sight, out of mind. ...

Jails and prisons have become almost the new mental hospitals of our era. That may be a bit of an overstatement, but it's not very far off. They have become the major confining facilities, receptacles for the poorest and in many cases the most serious of the mentally ill, ... because there's just no other place. ...

What did you find in Ohio?

... The core of our finding is relatively easy to state. There are three segments to this kind of a finding. You look at: Do inmates have relatively easy access to needed care; are the physical resources in place that are required -- bed space, different kinds of transitional treatment space, hospital space; and do you have the human resources -- the doctors, the nurses, the psychologists -- in place? And in all three of those areas we found the state to be deficient -- not venal, not out to really hurt people. But because the care was so lacking, and when it was given, it was so inadequate, we concluded that it fell far below contemporary community norms or professional standards. ...

Were you surprised by what you found?

I was surprised. ... In reflecting what really was bad about it, I think the most dramatic thing when you go through a prison system is what occurs in a segregation system, because every prison system that I've every seen or studied that has an inadequate mental health system has a very full segregation unit, and they tend to be stuffed with the mentally ill. There are out-of-the-way boxcar doors that are solid, and you can lock them where you don't see them; you don't hear them as much. I think seeing so many people in segregation just wasting away and crying out for some kind of help, that got me in the most human sense.

Why is segregation so difficult for the mentally ill?

Segregation in prison, at the point in time we're talking about, before any mental health comes in, is difficult for anybody. I mean, you're locked away; you're locked away for 23 hours a day, seven days a week. Your food is brought to you. You very often don't get any kind of recreation. You don't get any visits. You might be able to talk to your lawyer. You have no radio; you have no television. You're isolated. That's the point of it.

Now, the mentally ill in isolation [usually] simply fall apart. They have no support; they have no sensory stimulus; their hallucinations get worse. And you can just watch them fall apart. ...

If we're talking about the seriously mentally ill, these are people who are in fact being punished by being deprived of medical care and being put in an environment where I can demonstrate to you that there's a strong causal connection between their environment and them getting worse. It's not even a question of treatment even, of them getting worse. You have no right legally, morally, ethically to take sick people and make them worse. ...

You ask yourself why do so many people end up in segregation, and there's almost a working formula here: The poorer the prison system, the more people with mental illness are ending up in segregation. ... If an inmate spits or refuses to hand back his food tray or curses an officer or doesn't cuff up when an officer says, "Put your hands out; cuff up," if that person was in a hospital setting, that behavior would be considered acting out or symptomatic of the illness. In a prison system, that's considered, "I'm telling you to cuff up, or I'm going to write you up." They write them up. They go before a tribunal, a disciplinary tribunal. They are found guilty, and they're sent to segregation -- probably the worst thing that could happen to them and to the system, but that's what happens. That's what happens. They're being punished for their illness. ...

Is that because there's always going to be a fundamental mismatch between these two cultures, where one has a therapeutic objective and the other punishment?

There is always going to be a fundamental mismatch between a hospital as a therapeutic type of community and the prison as a penal colony, as a penal facility, always. The most you can hope to do is sort of bring them together and have overlapping spheres, to an extent. And that's doable, but I don't know to what extent. And I think we did some of that over time in Ohio.

But that culture conflict can only be reduced. I don't see how it can't be eliminated. You will constantly have the clash between security, the staff saying the main function of a prison is to provide security, [and] the clinicians saying that may be so, but the main task that I have as a doctor, as a nurse, as a psychologist, is to treat these people, to understand their illness and work with them. Well, when their illness gets in my face, whose hand is going to trump? That's the collision that you have, and too often security trumps. Not always, and not in every system, but that's the problem. It's inevitable. You can reduce it. You're not going to eliminate it. ...

Were the [Ohio] findings the first time that anybody had faced this kind of issue before, or in prior years had there been similar reports?

Well, there had been reports nationally, [and] certainly in Ohio there were a couple of reports that were pretty damning about the level of mental health care, and we built on those reports. But ours was certainly the most extensive. It carried with it the most clout because of the quality of the investigators. These were really first-rate people, and they just could not walk away. But most importantly, our report occurs in the context of litigation, and now there's a court involved.

And what difference does that make?

It means that there's an enforcement mechanism. It is not just moral suasion. This is the right thing to do. There is a court involved, and if this report doesn't work -- well, can you imagine if the state of Ohio just tried to walk away from a report that they paid for that condemns the system? ...

The blueprint for the Ohio mental health system of care, what is the model?

The [Dunn] consent decree had a model that resembled, as close as we could, a community mental health model. And by that I mean you try to identify the general population of the community as sort of the counterpart of the open community. And the idea was to build the system -- if I could draw it for you, it would look like a triangle. And at the base of that triangle would be activity therapists, people who are trained to do structured recreation with the inmates and talk with them and be around; nurses, social workers, psychologists; on up to the doctors, the psychiatrists.

We intentionally built a bottom-heavy, early-detection, early-prevention model, thinking it was cheaper and more effective. The most effective people in that scheme, of course, are the doctors. You need the doctors, but they rarely provide the direct care. They do medication management. You want people at the base who are interacting and throwing a ball around with these people, talking to them about their medication, talking to them about their families, helping them out. They have programs where they bring dogs in, for example, where the mentally ill inmates can help train a guide dog or help train a dog for adoption, programs like that. ...

So community mental health meant trying to identify people as their illnesses are emerging and before they get much worse; give them treatment in that community. But if that doesn't work, [and] they're not so sick that they have to be hospitalized, create mental health units which are kind of protected environments, where there's more nursing care than is available in the general population, where there's programmed activities and structured recreation, safety, trained officers.

And if that doesn't work, then you have Oakwood [Correctional Facility], a hospital, 110 or [1]12 beds, not very many beds. [It's] very expensive to send somebody to Oakwood. And it ought to be as a last resort, and it ought to be for a reasonably short time. ... And the ultimate goal is to prepare the person who has the illness to go back to the community. Unfortunately, that person's community is [the] general population, living with other inmates. And that sometimes is difficult, especially if they know you've been labeled mentally ill. You have to know how to deal with that. You'll get called names. They'll avoid you, avoid sitting with you, for example, in the dining hall.

There's a lot of things you have to work out in the general population, but we all thought that that was the worthiest goal, not just wrap somebody up in some kind of a protected cocoon, but get them into the general population, and hopefully that would help prepare them for their ultimate release into the free community. ...

How were those reforms viewed internally by corrections and mental health staff? What were the obstacles, if any, to implementing them?

There weren't that many obstacles, but there certainly were some. There's a general expression you'll hear from some security people about medical and mental health care or classes: "I can't believe it. This guy did such-and-such, did that kind of a crime, and then they get medical care and dental care and mental health care. They get classes. My kid wants to go to school; I have to pay for it. If I need medical care, I either have insurance, [or] I have to pay for it. I don't get it." And that would probably be actually a fairly sophisticated kind of resistance. Some of them just didn't like the idea that these bad guys or bad women are getting any kind of help. A lot of the COs [correctional officers], then and now, think that inmates fake mental illness. ... So you have that kind of resistance.

But we were prepared for that. We put together and worked very hard as a monitoring team with Ohio staff on a training program. And we started to bring in officers, line officers, with the cooperation of the union, sergeants, lieutenants, on up the line, for weeklong sessions on: What is mental illness? How is mental illness different than mental retardation? They don't know. What is psychotropic medication? What happens to a person when they take medication? What happens to them when they don't? Eventually you found some officers who wouldn't have dreamed of walking by a mental health unit, volunteering for it and wanting to be there. They knew they could do some good. ...

Why do the mentally ill get into so much difficulty in prison?

Well, one of the reasons you see the mentally ill repeatedly charged with infractions and repeatedly punished, and therefore spiraling down and ending up in segregation, is they really can't control their behavior. Many of them, they cannot control it. They don't take their medication. They have paranoid tendencies, and they think they're being attacked. They hear voices, command hallucinations: "You will do such-and-such." So there are a lot of reasons why this happens. And if you continue as security staff to write up as a disciplinary event that [which] is in fact a symptom of the illness, you're never going to change it.

The mentally ill typically serve longer sentences. How do they come in with a minor offense and end up in maximum security?

Persons who are convicted of crime, typically -- certainly in Ohio -- are not sentenced to a particular prison. They're classified in a reception prison based on the nature of the offense and where family is. And most prisoners, a great majority of prisoners, do not begin serving their terms in a maximum or supermaximum facility. As they say in the prison world, you have to work your way to a place like Lucasville [Southern Ohio Correctional Facility, or SOCF]. And the mentally ill have a way of working their way there, for the same reasons they tend to work their way into segregation once there. Their behavior is such that there's infraction after infraction. There may not be the adequate care to deal with their mental illness in these other facilities: lack of understanding; lack of either will or resources to do anything about it.

And a lot of staff at Lucasville will tell you, maybe off the record, that they see themselves as a dumping ground. The people whose mental illness causes them to act in such a way that they're the difficult prisoners, they're the ones that end up in Lucasville, because the other prison people either won't or can't deal with them. So it's their behavior and conduct reports and infractions and rule infraction violations that get them moving there sort of in a lateral way, and then get them spiraling down once there. ...

They're cycling not only into prisons, but then cycling within the prison system.

It is a cycle, unless you work very hard. And we've done some things to interrupt that cycle. And there are ways to do it. There are ways to do it. Without being pie in the sky, there are ways to do that.

And those are?

Well, for example, at Lucasville there's a high-security unit for people who are seriously mentally ill, who do not need to be hospitalized; they're not that sick, but whose behavior is such that they can't safely be kept in a mental health unit, a more open kind of a unit, and who need intensive care, but they also need intensive supervision and security. So this new unit that was developed at Lucasville serves that purpose. Perhaps 40 inmates end up being placed there. And from the data that I've seen and the discussions I've had, what some predicted would simply be a long-term, kind of a chronic care facility has in fact for many, many inmates become an opportunity to get stabilized. They have very good care there; they have terrific officers working there, and doctors. And then ideally, they would work back to the residential treatment unit, have an unlocked cell for most of the day, be able to interrelate with other inmates, back in the general population. And in many cases we've seen, they could go from this lockdown unit to another prison, and in fact have a lower security status.

So it can be done, [with] intensive care, understanding, training of the security officers. And Lucasville is a prime example. I think that that's going to be a model that's going to be emulated. ...

What role does Oakwood play within the Ohio prison system?

... It meets the same standards as any civil mental hospital. And where a person is deemed by professional judgment, by doctors, to be, for want of a better way to describe this, virtually subject to civil commitment -- if they'd been on the street, they would be seriously mentally ill and an imminent danger to themselves or others -- then they will be sent to Oakwood for acute care. It's not chronic care. It's for acute episodes. It's not chronic in the sense that the chronic care unit is for long-term care for an illness that's not likely to go away very easily. So I don't know the average number of days that are spent there, but it's not very high. Ninety days would be a lot. It's very expensive care. There's very rich staffing. There's 24-hour nursing. It is a hospital setting.

Some of the inmates really like to go there. I know inmates who work very hard to look a lot sicker than they are to get to Oakwood, as they tell me off the record, for respite care: "I need to get out of this place. I can play basketball, and I could move around, and I have freedom. I'm not locked up." And so, how ironic. ...

Most of the mentally ill inmates will be released eventually. Assess the quality of care they're given inside Ohio prisons, and compare it to what they're likely to find in communities when they're returned.

Well, once an inmate is discharged or paroled, what is waiting for him or her is bleak indeed. There are a couple new initiatives in Ohio that I recently found out about, called a wraparound type of program, where the authorities are going to try to provide counseling and residential placement, continuing medication, I think, and the like. But these are very new. The law, unfortunately, is that the only time you're constitutionally entitled to care -- medical, dental or mental health -- is while you are in actual physical custody of the state. So the minute your foot enters the door, you're now a prisoner of the state; you're entitled to care. The minute your foot hits the pavement -- and I'm somewhat overdrawing it -- you are not entitled to any care. So whatever the state is extending is because of a moral or ethical or community sort of judgment. With very few exceptions, it is not legally driven. ...

Recidivism rates for the mentally ill are exceptionally high. What's so bleak, and what's likely to happen to inmates who leave prison?

I think the real scenario is that the best they can hope for is they'll get maybe a 30-day supply, or more likely a 15-day supply, of the psychotropic medication that they were taking. And as they documented in some jurisdictions, as soon as they get off the bus, so to speak, some of them will go trade those pills for another, more welcoming drug if they could. So there will be nothing there for them, typically. There will be no placement. There won't even be anybody to assist them to a place where they might get a referral. Some places, you might find that. And of course I'm speaking very generally. I know of some exceptions. But for the most part, you step out of the prison, and you have a little medication, and there's nothing waiting for you. ...

Deinstitutionalization 30 to 40 years ago: The promise was of community support and funding. Wasn't that part of the blueprint that was never delivered?

Yes. ... That legislation, it's really about funding studies, programs. It's about mental health courts, which may be good for diversion purposes. Better to keep a person out than to worry about aftercare. But if you can't keep them out, then at least you should have some continuing aftercare for them. ... So on the front end you want to divert, and on the back end you want to provide continuing or better treatment even.

The irony is, I think we'd all probably agree, it's better to keep people out of an institution, which generally becomes part of the conditions you have to work around. We spend almost all of our money on the mentally ill that we've been talking about on prison, practically nothing up front, where we should be spending most of it, and practically nothing on the back end. But there's no legal obligation on the front end or on the back end. ...

And the reason you get mental health care at all in prisons is because of all of these lawsuits that have been brought and won. Nobody suddenly stood up and said, "We've got to bring mental health care to these inmates, and it's the right thing to do, Mr. Governor." It's when Judge Jones said, "I find that you've violated the Constitution, and you will," which has happened in state after state. So no legal obligation. The money doesn't get spent. And like we do in so many things, we spend money in the wrong place in the same process. We spend more money on colleges than on kindergartens. Isn't that the place to spend the money?

Without lawsuits, where would we be?

I'll tell you where they'd be. They'd still be in dungeons. ... These lawsuits have clearly made it better for these inmates. Better -- I wouldn't say good. These lawsuits are demonstrably helpful. People are taken out of conditions that were barbaric, uncivilized, unhealthful, harmful. ...

I think Ohio's handling of the Dunn case, and then the subsequent positive effect it had in prisons, is unique. Not that other states haven't done good things and been sued successfully and pushed and pulled into the arena of getting better, but beginning with the way the lawsuit was handled, it was handled and resolved in a way that a climate for change was created around the litigation. It didn't have to be grown from scratch, so to speak, the way it had to be in states like California, where there was a very contentious litigation; the way it will be in New York now, year after year, fighting over the similar issues as Dunn.

So there was a climate receptive to change that was dictated by the way the state and the plaintiffs and maybe our people handled the factual investigation, the settlement and then the implementation of the consent decree. And because resources were made available, good doctors were brought in, and security people were trained and modified their attitudes and behaviors in many cases, the lives of those inmates are better. I don't think it's any accident that when you go around the country, you talk to people, they talk about the Ohio model. Now, some of that may be overblown, but the model of providing services, the model of resolving a major class-action lawsuit, I think Ohio should be proud of that. ...

Is the idea just to keep improving mental health care inside prisons, or is there another important question that's not being asked?

I think the same question of how it's being handled in Ohio is, where does it all take us? The prison is simply not a place of first choice in which to provide mental health care. And with a certain irony, I would say we shouldn't devote ourselves to continually raising the level of mental health care in prisons as a matter of social policy. We should be devoting ourselves to the larger questions, research questions, action plans, on keeping people out and keeping other people from getting hurt because we don't identify and treat people with mental illness. But failing to keep them out, it's so obvious. You can't just drop them into the community and say, "Do the best you can." And that's what many states, and until very recently Ohio, have been doing. It's "We'll drive you to the bus, you get on the bus, here's your meds, and there's a clinic somewhere between 2nd and 3rd Street. Hope you get there, and good luck." ...

Ohio obviously isn't perfect. What now? What are the areas of concern?

... I think there is a certain amount of slippage. Not deterioration. I want to pick the right word. Certain amount of slippage. I have detected it because I'm doing other work in the prison system on medical [issues]. I have brought it to the attention of the director and his staff. They seemed surprised by it, but they also seemed willing to address it. And I know of at least one instance where I said, "You're really one doctor shy," and the next day, there was another doctor. There has to be more oversight from central office. With funds so tight, with the revenue so tight, everybody's competing for limited dollars in a way that [they weren't] in 1995, so you have to fight your fight for your constituency. And since I'm still in Ohio in one form or another, I do it.

But there is slippage. It can go away. Quality assurance is one of the first things that suffer[s]. Just like when prison money gets tough, the first thing that suffers [is] the teachers and the library. They go; they don't affect security. So in a mental health program, quality assurance, oversight and accountability is one of the first things that suffered in mental health care in Ohio. ...

[Segregation] is still a problem. Not of the same dimension. I still think that the segregation is being used too often to no affirmative end, in Ohio and elsewhere. ... It's used less, and there is treatment available when it is used, when in the past there wasn't. There are rounds that are being made. There is some opportunity. But I think it is still being used, and too often, and it's an outgrowth of the continuing turf battle between treatment staff and security staff. ...

Is suicide a problem in Ohio?

Well, I know there have been something like 10 suicides to date, not all limited to patients who are on the caseload. They were investigated internally, and no pattern has emerged, as I understand it, from that study that would suggest they're doing something structurally wrong. ...

If your goal is zero tolerance for suicides in prison, you will always fail, because there will be suicides. Your goal has to be to reduce the number of suicides, accept that some will happen, and learn by a kind of a psychological autopsy what may have contributed to the suicide and try to prevent [others]. There are suicides in the outside world, some of which are explainable, some of which are not. There are a high number of suicides among the military in Iraq now. These are stressful places. ...

But the rates for the mentally ill are higher even within the prison population. So what do you do?

What do you do? Well, of course you take a suicide threat very seriously. You have to have special environments, suicide-proof rooms. You have observation. They have a routine in Ohio that's as good as anyplace. One of our monitoring techniques was we made them change all of the beds that they use in these suicide observation rooms. They used to have metal beds, and they sometimes strapped them down, and the metal beds had raw edges on the side. They use what are called ModuForm beds now that are reasonably comfortable when they have to strap somebody down. They changed all their windows so that there's direct observation. There's no reliance on TV. The staff doesn't fake the logs, as they do in a lot of systems, the 15-minute checks. And even with that -- I mean, if you're doing 15-minute checks, how long does it take to strangle yourself even? So you do the best you can. ...

Even more important, in a sense, than actual suicides are the suicide attempts, dealing with those, and how do you distinguish a serious attempt from the effort to mutilate, to just get attention, or just because the pain of the mutilation takes away the pain of the psychological suffering. They're just as important. Sometimes people end up dying when it was just an effort to make a statement and get some help, or have a nurse come down and hold a guy's hand because he wanted contact with a female. There are dozens and dozens of reasons. And inmates learn that in a society without money, so to speak, one of the tokens of exchange is your body. It's one of the few things you have to barter with. And once you cut, they have to pay attention. That's how you buy attention. That's how you buy a change. ...

What's happening in jails [as opposed to prison] with the mentally ill across America?

Well, jails typically are funded and in effect governed at the county level or the city level. There's a cliché that the biggest mental hospital in California is the Los Angeles County Jail. So of course they're not governed by statewide prison mental health cases, because it's a different jurisdiction, but there have been any number of successful lawsuits involving medical and mental health care in jails. Typically, most of the people in jail are there in turnstile fashion. They've been arrested, they couldn't make bail, and they're being held until trial. So they're pretrial detainees. And then there's another population who have been sentenced, typically as misdemeanors, to a year or less.

Jails have one set of problems that prisons don't have, and it's very tough. Jails have to do crisis stabilization and detoxification. By the time a prisoner goes through the jail, trial process or what have you and ends up in prison, they have been detoxified. And 70 [percent] or 80 percent of the folks who come through that system have serious drug abuse or drug addiction problems. And so you have a lot of interesting case law here. The courts have consistently said that for the purposes of mandated treatment, drug addiction is not an illness, so they're not entitled to treatment in the jail for their illness, but they have to be treated for their DTs, that sort of thing. The problem in jails increases as the size of the jail decreases. The smaller the jail, the less likely it is you're going to have any kind of medical or mental health care. They don't tend to do regional care and collaborate as they could. And yet if the prisons have become hospitals, the jails are the emergency room. And it's a general proposition that jails are even less prepared with money, people, clinicians and places to help these people. ...

Why is what you've done in Ohio important to anybody outside of Ohio?

Why should we care about what happened in Ohio? Well, a lot of people won't care. But if you care about people who have no advocates, who are least able to defend themselves, who are least able to make a claim on anybody's resources or speak for themselves, who are among the lowest of the low, despised, who are human beings, who are in great pain, are suffering greatly, if you care about that group and you feel called to help them with whatever skills you have -- it's a human thing. I think a society is measured by what it does with, what somebody once said, the least among us. And I don't want to sound too pious about that, but it gives me a much better feeling to walk away with having moved that system a bit and brought some change to people's lives than work for a corporation and get them a tax refund.

You said that prisons are the new asylums. What does that tell us?

It's loaded with irony, because the better you make an institution that shouldn't be used for the purpose you're improving, the more you're ensuring its use. And that's always troubled me. I don't know how to get around that. That's quite a dilemma. ...

If I improve the conditions, even though it's possible that I'm continuing the longevity of an institution that you think is itself flawed, I still think I'm doing the right thing. It's the liberal versus the radical-change position. And that's where you are. Do you wait till you overthrow a society or you come in with a whole new political regimen that you believe in and that may never come, or do you try to clean it up and soften it where you can? ...

Tell us more about the distinction between patients and inmates.

... Being an inmate, for example, allows people who confine you to do a lot of things to you, not necessarily for you. Being a patient, you're in an environment where it's expected -- the culture, unspoken. You don't even have to say it; you just analyze it. The culture is, I'm here because you need to do things for me, not to me. You need to do things for me; I'm a patient. ... They're inherently incompatible, treatment versus punishment, treatment regimens and cultures and punishment regimens and cultures. ...

Are we asking prisons to do something impossible?

... You could have the best intentions and the best commitment of resources to helping prisoners while they're mentally ill, ... but it will never be the [ideal] place where you want to provide that treatment, and it will never reach sort of idealistic goals. I don't think anybody can say specifically what the limits are, but if you're in a swimming pool that's 50 yards long, you're never going to be able to swim 60. And if that's your goal, you can't get there. And so -- and I don't mean this to sound resigned -- you do the best you can, because the best you can can really impact on a number of lives. And if you begin to improve the aftercare and stabilize people and bring them into a way where they can survive and maybe thrive in the community, and if those two aspects of that three-part system -- front end, inside, back door -- can be aligned, then it's worthy. Without thinking of perfection, it's a worthy goal.

Prisons and jails are hospitals by default. By default. And does that mean that the job now should be to redesign the prison and jail so that they now serve that purpose as a matter of express social policy or as a matter of default social policy? I wouldn't design them so that it's a matter of "Now we've found the right answer: prisons and jails." No. We have now discovered that institutions are being used in ways they've never been designed for. Let's help these people while they're there, but let's carry the ball a bit further and find other solutions, institutional and process, community and otherwise, for the hundreds of thousands of people that need this kind of attention. …

Group therapy at Lucasville -- how did it begin, and why is it important?

Group therapy or group counseling is preferred in the prison setting, high-maximum security or elsewhere, because it's more economical. No one knows if it's more effective or not, but if one treatment person can work with seven or eight or 10 people, there's certain obvious economic advantages to it. I think it works in Lucasville pretty well in that you're not only able to start to get some insight into your own problems, but you're also able to interact with people who can be supportive or questioning, who are sharing similar dilemmas. There's a socialization aspect to it. A therapist is watching how you relate one to another, as opposed to a one-way street, and I think that has a certain amount of value. A lot of these fellows come from an environment where it's not cool or hip or smart to talk about things that bother you, and especially to talk about your mental illness. ...

At a minimum, it doesn't cause any harm, and no one gets hurt, and I think it's a good event. In addition to the medication, which is all they would get otherwise -- there is no individual therapy in prison -- it's the closest thing you can have to something that resembles a psychodynamic activity. ...

 

home » introduction » watch online » some faqs » state-by-state » special reports » join the discussion
special video » making of the film » interviews » producers' chat » inmate profiles
readings & resources » tapes & transcript » press reaction » credits » privacy policy
FRONTLINE » wgbh » pbs

posted may 10, 2005

FRONTLINE is a registered trademark of wgbh educational foundation.
background photo copyright ©2005 corbis
web site copyright 1995-2014 WGBH educational foundation

 

SUPPORT PROVIDED BY

NEXT ON FRONTLINE

Solitary NationApril 22nd

FRONTLINE on

ShopPBS