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Debbie Nixon-Hughes is chief of the Bureau of Mental Health Services within the Ohio Department of Rehabilitation and Correction. In this interview she describes the challenges facing America's prisons in their dual roles as correctional facilities and mental institutions, and the problem of trying to reintegrate the inmates back into the community upon their release. "Unfortunately, sometimes people say they can get getter services in prison than they can get in the community," she says. Pessimistic about society's willingness to fund community mental health services in "an age where no one wants new taxes," she fears inmates will psychologically decompensate and cycle within the criminal justice system. "Are we going to just have a revolving door where they're not going to be able to get those services and end up back in prison?" she asks. This is an edited transcript from an interview conducted on Dec. 10, 2004.

When they get out, they're going to have to be assertive, if not aggressive, to try to get the services they need. And if they don't have the energy and/or the insight to do that, then they're going to ... fall through the cracks.

Describe mental health care [in prisons] before Dunn [v. Voinovich] and now.

Prior [to Dunn], there was a two-parallel system that was going on. The Ohio Department of Mental Health provided psychiatric services, and those services were psychiatry [and] psychiatric nursing, where they would come in and provide, essentially, medication management. And then in addition to that, we had psychology services for the department; however, they primarily dealt with inmates on a more cognitive level, usually the higher-functioning inmates.

Since Dunn, we have gone from having a Department of Psychology to having a Department of Mental Health, which means we have a continuum of services that are offered, from outpatient therapy, crisis services, residential treatment services. We have our own inpatient psychiatric services. Also, [we have] increased staffing: We have psychiatric nurses; we have social workers; we have psychologists, psych assistants. That was the primary problem. There just wasn't enough staff. We had approximately 12 doctors, and now we have 67, which is like 42 full-time equivalent staff.

We've also done a lot with regard to training. We've done a lot with trying to truly weave mental health and security together so that they all work. And mental health staff are seen as corrections professionals as well as mental health professionals. ...

What are your thoughts on the challenges of those two worlds, the clash of cultures?

Well, I think the clash in cultures that you talk about [is] between security staff and mental health staff. Security primarily looks at security, the safety of the institution, and there are protocols that are set up to ensure the safety and security of the staff as well as the inmates. Mental health, they have to take that in consideration, but they also have to look at the provision of mental health services. So one of the challenges has been to take a community mental health model and replicate it in a prison system. And it's a true challenge in trying to do that.

Why?

... Our mission is to eliminate needless suffering by the provision of quality mental health services. When we look at inmates, we look at them different from a treatment perspective: What is it that we have to do to make sure that they have the skills and the knowledge to be able to manage their mental health symptoms, not only now, but when they're released? And security, their primary goal is to secure the institution. So when someone's having a crisis, we want to take the inmate out of the cell; security wants to keep that person secure. We want to have a conversation with that person. And in a treatment setting, you want to be able to engage in a relationship. And so that's problematic. It's part of the whole treatment modality to establish a relationship with the inmate. Sometimes security sees that as developing an improper relationship, and there's a fine line between that.

What resistance do you meet from security?

In the higher security levels, it's definitely been a challenge, because they needed additional corrections officers to move inmates from their cells to a treatment setting. Well, at the higher security levels, that's questionable, because these inmates are in these higher security levels because they've done something in which they've hurt another inmate or have hurt a staff person. So people take great strides in ensuring the safety and security of staff.

So they developed these things called program booths, and they're cells that are placed together in a semicircle, in which the inmates can still be moved out of their cell into this setting and sit in a semicircle in which the staff have the opportunity to continue to provide groups. Prior to Dunn, we didn't do that. If someone needed that kind of treatment, you had to wait until they dropped down to a lower security level. So that was a major change in terms of trying to figure out how to provide treatment to everyone regardless of security levels.

Were there subtler philosophical efforts to bring those worlds together?

Absolutely. We have security in our treatment teams all the time. Security can be our eyes and ears, because mental health [providers] in nonresidential treatment unit institutions are only there eight hours a day. And so security plays a real critical role in becoming the eyes and ears and knowing what's going on 24 hours a day and bringing that information to the table when you have a treatment team, as well as mental health helping security to understand more about mental illness, that someone's just not at times ignoring a direct order, but maybe they have voices going on that makes it difficult for them to interpret what's being said.

So between the two, I think security learned a great deal about mental illness and signs and symptoms and what to do, as well as mental health learned a lot about security and [respect] what security had to bring to the table. ...

"Good treatment equals good security": What does that mean?

Well, our director always says that -- "Good security means good mental health; good mental health means good security" -- because when inmates have the treatment that they need, they're able to manage the symptoms, and when they're able to manage the symptoms, they're able to cooperate within the security environment. That's very important, that they are able to follow directions, and so the ability to do that all centers around being able to get the right medication, being in the right treatment, recognizing your symptoms, recognizing when to ask for help. So it really helps the officers, because the inmates, if they're stable, they're better able to manage within the environment at the prison. ...

What does it mean to take an inmate's mental illness into account?

For instance, did someone just totally disregard a rule? And when they go before the Rules Infraction Board, which we call the RIB board, was it just a deliberate intent to ignore a direct order, or was it the mental illness that was going on that made it difficult for the person to kind of hear and understand the order? And so as a result of that, one of the things we don't want to do is to not give any consequence to behavior. There is consequence to everyone's behavior, but maybe instead of having the person get 14 days in segregation, let's say, they would get [fewer] days in segregation, or they wouldn't even go before the RIB until their mentally ill symptoms were stabilized. ...

What level of illness has to be evident in order for it to be mitigating [in the RIB hearing]?

The role that the mental illness plays in the RIB has more to do with if someone is floridly psychotic and really cannot understand what's going on. And instead of going in segregation, what we would do is refer the person for treatment. Whether that's in our residential treatment unit, whether it's in Oakwood [Correctional Facility for mentally ill prisoners], the primary objective is to stabilize the mental illness prior to handing out any kind of disposition with regard to the rules infraction that happened.

But in more routine infractions, the illness is taken in[to] account, but that doesn't excuse the behavior?

... It's an evolving process every day, trying to figure out the role that the mental illness plays against the rule infraction and how you're going to deal with that. So I don't think that there is one measure. That's what makes it difficult. It's growing constantly. It's security working with mental health, listening to the symptoms. And that's what makes it challenging, because some days we might get it right, and other days we may not get it right.

One of the difficult things is when we had people in some of our highest security levels, and you would have inmates coming back saying, "Ha ha ha," telling security, "I tricked those mental health people; I really wasn't mentally ill at all." Just like people can fake mental illness, they can also fake mental health, because of the stigma. So that's again what makes it complicated, because sometimes there's secondary gains from saying that you're mentally ill. But then at the same time, as we know in the community, mental illness is a big stigma, and that same concept happens in prison.

And so it's those things that constantly make us re-evaluate over and over again how is the mental illness affecting the behavior that's going on, and what should we do about it. And I think we learn all the time.

Why the focus on malingering?

Well, [there is] a lot of the concern with who's malingering in prison: Are people getting privileges that maybe they haven't earned? Many times within the correctional facility, because of the large numbers, we have dormitories. And so why would a person [feign] mental illness? Because maybe they want a single cell or double cell versus being in a dormitory setting. Because some of the movement is more [fluid] in mental health treatment units. They have more out-of-cell time, particularly than in some of the higher security levels. Because some of our treatment units are air-conditioned. There are just many reasons why they would want to feign mental illness.

And what security wants is to make sure that those inmates don't trick the mental health staff. And so one of the things that we have to continually work on is how we can work together so that we don't let inmates outsmart us, so that we are placing people in the areas where they need services. If someone needs to be in segregation ... then they go to segregation. On the other hand, if somebody needs treatment, we need to make sure those people have treatment. And that's an ongoing discussion that we have all the time. ...

Does staff also have to be aware of not seeing malingerers everywhere?

Well, there's a couple things that go on with the mental health staff also. At times I get concerned when mental health staff become hardened by the day-to-day activity that goes on in the prison, and so everyone is seen as malingering. And that's a concern. It's a concern that people won't get the treatment they need. It's a concern that security levels get raised. It's a concern that it could be a suicide risk.

There are a number of things where we have to watch out that we don't have our mental health staff falling in the trap to believing that everybody's malingering. ... [Sometimes] they'll just kind of go along with what security says versus being an advocate. It can be a lonely place to have everybody in security saying, "This guy's malingering," and you, being a single mental health person, trying to stand up and say, "I don't think so; I think this person has some real problems." And how that person fits into the whole institution, and how they're seen by others, is a major concern that we deal with all the time.

Is that an inevitable challenge when you're providing therapy in a prison setting?

The two worlds sometimes clash, because again, security, their primary role is the safety and security of the inmates as well as the staff that are there, and mental health, while that's a major consideration, our goal is to provide quality mental health services within the prison setting and within a safe environment. So it's a secondary goal for us in terms of the safety and security, and yet our primary goal is the provision of mental health. And the challenge is, how do you do those where it doesn't become secondary and primary, that it happens all at the same time? ...

Is there also just something surreal about trying to do both things?

Absolutely. People would be very surprised at all the work that we do in prison and the commitment of the staff and the dedication of the staff and how we go about doing our business. So many, many times, you hear these blanket statements on the radio and in articles, where people don't get good mental health. And one of the things I like to say about the Ohio system is I think we have a fairly good mental health system right in our prison system. Unfortunately, sometimes people say they can get better services in prison than they get in the community, due to lack of resources that are in the community. You hear the whole issue about deinstitutionalization, and part of the downfall of that was that there weren't community resources to support the whole movement of deinstitutionalization.

... In prison we're very inclusive. We have people not only that have a severe mental illness, but we have people that are having adjustment problems living in prison, and we're providing cognitive, group and individual therapy as well as medication for that population. There is no time limit. A lot of times when you're out in the community, you're talking about brief therapy; insurance is paying only a certain amount. And we'll provide services, because our goal is to change the experiences and giving people the tools and the knowledge about how to manage their symptoms when they leave prison. And that's one of the best ways we get. It doesn't have to be time-limited. We don't have a funder, such as Medicaid, telling us we can't do A, B and C. We have services, and we provide services based upon the needs that are presented.

It's tough sometimes. While I'll say to you we have a lot of mental health staff, it's still tough, because they're pulled a number of different ways. Not only do we provide services for people with a serious mental illness, but I think about women that have babies in prison, and they have postpartum depression, and so that's another area. You have people that have gone through post-traumatic stress situations, and they're experiencing post-traumatic stress. We're also providing services for that population.

So it is very complicated working in the prison system. But I think we do a very good job, and people would be very surprised when they see the level of services, the competency of the staff, the integration between security and mental health. They would be very surprised to see that. And yet what I would hope is, [that] they would be very pleased, because again, you want people when they're released, as they re-enter the community, to be in a much better situation than when they came in.

Are jails and prisons the new asylums? Have prisons inherited responsibility for the mentally ill in America?

Every once in a while you'll hear a director talking about [that] he is a de facto mental health director; that the numbers of people that have entered the prison system and in jails that are mentally ill has just increased tremendously. And many people ask why. Was it the whole issue of deinstitutionalization and the lack of services that were available out there to support [the mental health system]? And yes, I do believe that's a primary reason. Mental health centers or mental health systems in the community are supported many times, at least in Ohio, by levies as well as other dollars from the general revenue, and those resources have been flat for the last few years. And as such, when people present for services, they're not able to get all the services that they need. And what has happened is that those people end up in jail, and those people end up in prison, and our numbers continue to grow and grow. [When] the hospitals decreased their numbers, you can see at the same time that the prison numbers went up, and jail numbers continue to go up. It's a phenomenon of the lack of services that are available in the community.

Does it reflect [public] ambivalence about keeping this population invisible?

I think it's a lack of understanding more than just an attitude. Way back when, there was the whole attitude when state hospitals were first being built, they were like warehouses for people, and we kind of stashed these folks away. And then there was a recognition that maybe these people need to go into the community. But more than anything else, I think it's a lack of understanding, and I also think it's a lack of money.

You have organizations like NAMI [the National Alliance for the Mentally Ill] that are true advocates out there, but you need the resources in the community to be able to provide the services. Without those services, people are slipping through and ending up in jail and ending up in prison. ...

What's missing?

... I just think that there's a population that's not at times desirable, and it's expensive to provide services [for them] in the community. When you think about downtowns and cities trying to clean up their downtowns and looking at people that may have some mental illness, where they're talking to themselves or eating out of trash cans or doing things, cities don't want to see that anymore as they market themselves throughout the country. Cities market themselves to get people to move into their area. You kind of try to get rid of those people sometimes. …

There's no secret: This is the age where no one wants new taxes, and it's going to cost money to provide the level of services to decrease the prison and jail population.

We've even had discussions about what's cheaper: Is it cheaper to really provide services to people while they're in prison, or is it cheaper to provide services to people while they're in the community? Because again, when you're in prison, we're talking about housing and food, not only services. I just believe more than anything it's about money, it's about taxes and people not wanting to pay those at this particular point. ...

I also sit on a board of a community mental health center right here in the Columbus area, so I see both sides of it. I continue to keep my hand in that community side, and I know our agency is struggling with being all things to all people. And that's pretty difficult to do. And yet then I'm on the other side of ensuring that we have services for people when they're in prison, because I want, for the safety of our community, when people get out that they have those tools. There is that whole issue and a concern that when people come out, is there going to be a system out there to be able to support them? And if not, are we going to just have a revolving door where they're not going to be able to get those services and then end up back in prison?

[Do the mentally ill have very high recidivism rates?]

Well, there has been a belief that people that have a mental illness have a very high recidivism rate. And that is, again, [an issue of] whether the system out there has the ability to support [them upon their release]. You also have a community mental health system that doesn't have a lot of money. ... So you have some dynamics that are going on [where] you're having people come out [who are not] able to engage in services because of long waiting lists, because of limited services, and then they begin to decompensate and fall back into behaviors that could be criminal intent. And then we end up back with those people in prison. So there's limited funds in the community to continue to support people that are coming out of prison, and as a result, those people don't get the services, and then they end up back in prison again.

Re-entry [into the community] -- what are the challenges and realities?

Re-entry is a philosophy; it's not a program. And so re-entry starts at the point of admission into the prison. But probably the most difficult time is when the person gets ready to walk out the door. And what makes it difficult? You're looking for people that have supports in the community, and many people don't have supports. You're looking for housing. You're going to have somebody that's released from prison, that has minimal money, and how are they going to support themselves when they walk out of the door? What kind of housing are we going to find for people? Housing is limited. When you have someone who is mentally ill and who's also been an arsonist, there are not too many people that want you in their program. And so that's difficult.

Working is not something that we shouldn't strive for, but it's also difficult to find people who want to give someone with a mental illness a job. There's a perception that that person isn't going to do a good job. And yet there's some research that says people with a mental illness are some of your best workers.

Looking at public housing developments -- and sometimes there's a rule that if you have a felony, you're not eligible for public housing. Yet these are the folks that come out, that don't have the resources, that probably need public housing more than or just as much as other people need it. So it's the whole issue around kind of discrimination with your criminal record. All of those things.

We release people with two weeks' worth of medication, yet it appears that it's taking three months for people to actually get an appointment in the community to continue their services. So the dynamics that you're having ... means people repeatedly have to get services and emergency services. And in some counties, that might mean going back on a daily basis. On some people that might be going back on a weekly basis. But if you look at some of the symptoms that are associated with a mental illness, particularly schizophrenia, those people aren't real good at continuing to always go back on a daily basis to get the medication. If it becomes that difficult, then there's some question about whether or not people have the energy to continue to take medication. And without the medication, then people begin to decompensate on you, and the police end up picking them up, and we might end up with those people right back on our doorstep soon. ...

[Is part of the reason they return to prison that they have difficulty staying on their meds?]

Yeah. There are two primary reasons that make it difficult. I always say that for some inmates/offenders that are released, one of the first independent decisions that they make is whether or not to take medication. You have persons who just say: "I am feeling good. I don't need medication. Sometimes the medication might make my mouth dry." Or there are a number of other components that are going on, that the person says, "I don't want to take the medication anymore." And so they don't take their medication, and as a consequence, they end up decompensating and needing some kind of crisis service or hospital services, and more times than not. But a lot has to do with them making an independent decision and not having the insight -- which is a symptom of schizophrenia -- that taking the medication reduces the symptoms. What they see is, they're taking the medication when they leave, they're stable, and they decide for themselves that they don't need the medication anymore, and they don't take it.

The other component they have is that a lot of times, many people have burned their bridges prior to coming into prison. And some haven't. So we're doing a better job in prison, trying to engage families early on, because without some kind of support, people just don't make it. You and I have support, whether it's family, husband, wife, friend. Many of our folks don't have that, [because] … a number of the people in prison are in there because of drugs. They need a different kind of support system than the system that they had when they came in. If they don't change that, they might pick up some of the same habits and end up back in prison. ...

Is there another irony, that the expectation of community care is not going to happen based on what they've received in prison?

... I do think that they're surprised when they get out that the level of support [is not the same as it is in prison], because again, like I said, we have a fairly solid correctional mental health services that we have supported people with. And when they go out, they're going to have to be assertive, if not aggressive, to try to get the services that they need. And if they don't have the energy and/or the insight to do that, they're going to … fall through the cracks and end up back in some kind of criminal activity that ends up with them going back to jail and possibly coming back to prison. ...

Why do some seriously mentally ill end up in maximum security after coming in with a relatively minor offense, cycling within the system?

Now, I would like to believe that we've done a lot to decrease that phenomenon. That was what the whole Dunn lawsuit was based upon, that people weren't getting the services that they needed, and as a result, instead of getting services, were being sent to segregation. I believe that we have impacted that some. With early identification for every inmate that's admitted into our system, we go through two initial screening processes to identify if a person has a mental illness. And then we also have the whole issue of training with staff, to be able to determine if someone needs mental illness or trained staff so that inmates always have access to mental health care. And then we also have the Rules Infraction Board. The belief is that if in fact all those things happen, we shouldn't have people that are just climbing up in terms of security. We ought to be able to stop that. So I would like to believe that we are stopping some of that, although the reality is, we do have a number of people at our highest security level that have a mental illness. ...

It's nationwide, the issue of what to do with the mentally ill. What have you done in the face of those challenges?

One of the lessons learned as a result of [the incident] at Lucasville [Southern Ohio Correctional Facility], [where you had inmates who] were continuing to act out, that continued to have a mental illness, the key was: What do you do with those people? Do you send them to a supermax [prison]? And if you send them to a supermax, what is that going to do? How is that going to impact their mental illness? Well, Ohio made the decision that people with a serious mental illness would not go to supermax. But yet there was a need to develop a program for higher-security-risk people, higher-security-level inmates in which you could still provide treatment.

So at the Southern Ohio Correction[al] Facility, we developed another level of service within that same prison. So not only did we have the residential treatment unit, but we developed something called the intensive mental health treatment unit, and that was for the higher-level-security inmates that still had mental health needs and that we had to address their mental health needs prior to ever thinking about sending any inmate that was experiencing those symptoms on to a supermax prison.

Before Dunn, people languished in solitary. How did that happen?

It was just a lack of understanding about how the mental illness affected the behavior, and the lack of resources. I think lack of resources is a major piece; that you didn't have the resources to have the staff to do the assessment and to understand and to be able to provide the treatment. So it was a combination. It was a lack of understanding, a lack of identification and screening that went on, and then the lack of resources to be able to respond.

Was there also a cultural attitude, an inertia, a numbing?

Well, again, it goes back to one of the first things I said, this lack of understanding. People didn't understand mental illness and how it affected behavior, and that if you provided treatment, you could change that behavior and that that individual inmate would be easier to manage. Not only would that inmate be able to manage himself, but that the officers would be able to manage. So there was a lack of understanding, and as a result of that, it was seen as the behavior being deliberate. They just continued to go up. It was a culture. It was a training.

We [now] have training for every prison employee that's hired. There is an eight-hour training about mental illness. There is a specialized mental health training that we do for correction[s] officers and all staff that work in areas like segregation or the infirmary or in mental health units. And when we have that training, there is a better understanding about what's going on. And [we] have been surprised that people [we] thought were absolutely hopeless, that there was nothing you could do with them but to lock them up more and more. As we provided treatment, you had this "Wow." There was a major difference. …

Oakwood -- what is it, and what is its role?

We have a facility called the Oakwood Correctional Facility up in Lima, Ohio, and it is an inpatient psychiatric hospital, 131-bed facility. It has 120 male beds and 11 female beds. It is certified by the Joint Commission of Accredited Health Care Facilities, as well as [being an] ACA [American Correction Accreditation] facility. It's a hospital like any other hospital in the community. This is a hospital that's available to every prison that we have here in the state of Ohio. So if someone needs that level of service, that's the one place they would go to. ...

When you get to Oakwood, it is probably the highest intensive service program that we have. People go there; they generally stay, I would say, 120 days or less. A lot of times [at] inpatient psychiatric facilities, people are there, like, 15 days, but with the nature of the population that we serve, people are generally staying there longer. They go in, they do assessments, they provide treatment based upon a treatment plan, and there's a number of groups and activities that go on. Their primary intent is to stabilize the mental illness, to be able to return the person to the least restrictive environment. So we see that as probably the most restrictive clinical environment that we have, and that [when] people go there, and if we can stabilize them, we try to return them back to the residential treatment units. ...

How do inmates view Oakwood?

Well, you have a certain group of inmates that enjoy going there. Let me give you an example. If you're an inmate at the Southern Ohio Correctional Facility and you're locked up 23 out of 24 hours a day, and you go to Oakwood, you're probably released 23 [hours a day]. That's an exaggeration, but you have more out-of-cell time. You have more interaction time with other inmates. So you have more treatment time out. So it's a major difference. Sometimes inmates are anxious to go there. ...

[Why?]

You're a patient; you're taken care of, whereas when you're at your parent institution, you're an inmate. And you receive mental health services, but it's a difference than being taken care of all the time. And a lot has to do with, again, kind of the inmate movement and the inmate interaction. You just have a lot more interaction. When you're at Oakwood, you have a track that you can walk around. You have picnic benches that are out there. It's a whole different environment when you're at Oakwood versus when you're at the Southern Ohio Correctional Facility. ...

Because all those things are therapeutic, are in the service of treatment?

Right. The difference is between when you're at SOCF and when you're at Oakwood is that there is a treatment, therapeutic environment that we're trying to maintain there. Every aspect of your life, from eating your meal to recreation to treatment, is all centered around attempting to stabilize the mental illness. So it's a 24-hour treatment environment, whereas at SOCF it's a security environment which you can receive treatment in. ...

If I were at Lucasville, what kind of behavior could get me [sent] to Oakwood?

Well, there's four primary reasons why you would get to Oakwood, and they are that you're either dangerous to yourself, dangerous to others, could benefit from hospitalization, or so gravely ill that you can't take care of yourself. You have to meet one of those four criteria to be able to get into Oakwood.

How do I have to have improved to get out?

Well, what happens is, by law, you have to no longer meet one of those four criteria. You can no longer be dangerous to yourself, no longer be dangerous to others, no longer need that level of service, or that you've increased your level of functioning so that you're able to take care of yourself back in your parent institution.

… Why can't inmates who thrive at Oakwood just stay there?

Well, one, it's just very costly. It's very costly. Plus, again, Oakwood is a treatment facility. Now, one of the things that we try to do is to develop the supports within a residential treatment unit that would support people in that environment. We have developed a residential treatment unit where actually we believe the average length of stay might be six months. But we're aware that maybe 25 [percent] or 30 percent of the population might have to stay in that environment their entire incarceration. It's just like, I would say, in the community: Why do people not stay in hospitals forever and ever? It's costly, and it's not needed. Once you stabilize the condition, you return people back to a less restrictive environment.

Is Oakwood like the old long-term psychiatric hospitals? Does it provide chronic care?

Oakwood's for an acute illness. It's not for chronic mental illness. The chronic mental illness that we talk about is dealt with in our residential treatment unit. Oakwood is to deal with an acute illness that comes up, and to stabilize the condition and to move the person back. …

Is Oakwood operating at full capacity? Is it serving its function as you hoped?

Oakwood is more than serving its function. And in fact, I think we're doing so well that we are looking to probably reduce the number of beds that we have at Oakwood. Probably their average census is running about 80 right now, and so we were in the process of considering to reduce the number of beds there. It won't impact patient care because it's not like we're limiting beds that we've been using, but we're looking to, with limited resources, how to best utilize the resources that we have, and it would be to reduce maybe the number of beds there.

Why is that happening?

I think people are doing a better job in the residential treatment units. We've also changed some policies. At one point we had something called mandated medications, and to get on mandated medications, you used to have to go through the Oakwood facility. Now [we] can initiate mandated medications in our residential treatment units. So people are doing a better job within the residential treatment units, and we've allowed them to do more clinical interventions within those units without having to go through Oakwood. ...

Are there many of the mentally ill in prisons who don't belong there?

There is a small population of people that you might believe don't belong there, people that have consistently gotten picked up on the streets or stealing because they haven't been able to work to support themselves, or lack of family support. But there is a large number of people that I believe are where they need to be because of the dangerousness that they present to the community. And those people I do believe need to be in the prison system.

Again, that's what makes this whole issue about the delivery of mental health services so complicated, because you just have such a range of people. And if I was naive, I could believe we could do everything in the community, and we could prevent people from coming into prison. But that's a naive approach. There are people that have done some pretty dangerous crimes, that I believe need to be in prison, and yet we still need to provide them services. I'm not sure I would agree that those people don't need to be in prison if we had done a better job providing services, that they wouldn't be there. ...

Whether [they committed a] serious crime or not-so-serious crime, most mentally ill inmates will be released.

Absolutely. At one point our fact sheet said [the average stay] was about two years, but now I think we're running three years. The majority of the inmates that comes into our system will all be released back into the community within about a three-year period of time. …

Are we expecting too much of corrections in terms of the mentally ill?

I'm not sure if you're expecting too much. I think if you want to change the life experience of that inmate that's coming in, and you want to make sure that they have the resources that they need, that corrections are going to have to get into the mental health business. We're going to have to provide people with medication, with symptom identification, with counseling, to be able to successfully make it in the community. Unless you're going to have a system that can do that within the community, and not be concerned about the safety and security of your community, someone has to do it. And at this particular point, the way that everything is set up, it's going to be the prison system.

But you've got to give the prison system the resources to be able to do that. You can't expect us to return people back to the community and that the community [will be] safe and secure unless you give us the resources to be able to do that. I think we play a very critical role in the re-entry of offenders with a mental illness. And we've been working with a number of different partnerships -- NAMI, families, the Ohio Department of Mental Health -- to successfully get this done. I do not believe one system independently should bear the responsibility to deal with this population. It is a community partnership that we have to have to be able to address the needs of this population.

If that support isn't given, if those resources aren't provided?

I'm scared to think about what would happen if those resources aren't available. I certainly would not feel safe if those resources weren't available. And yet I feel that it's a tragedy for the population that we're serving if we can't treat them.

Our mission is to eliminate needless suffering. And we're talking about a population that doesn't intentionally [suffer], but due to their mental illness suffers. And I think that's a responsibility on everybody to eliminate that suffering and helping people to be as productive of a citizen in our community as they can. ...

What's ahead? What are the challenges?

The challenge is [that] for the last four years, we've continued to lose resources. Now, we haven't lost money, but we haven't gotten an increase, so we haven't been able to maintain with inflation. So in some ways, we've lost money. And it's being able to continue to develop this system that addresses the needs of people with a mental illness in the prison system with less resources.

It's continuing to be a challenge to find staff that are dedicated and want to work in this environment, and for me to tell people that it is a rewarding environment and you do see significant changes. You can impact what happens in your community. So resources, both money [and] staffing, that's the biggest challenge. Keeping this whole mental health in the forefront, continuing to train people to talk about what the benefits are to have a correctional mental health system within a prison, that continues to be the challenge, but one that I am very willing to take on because I believe in what we've done. I've seen what the outcomes can be. And I believe that it's very worth the efforts to be able to work in this system and to do the work that I do, as well as all the other mental health professionals and the security personnel out there. ...

[With less money], what would happen to the system?

... [If] we lost money, probably the first thing is, we might look at decreasing the staffing. People would have higher caseloads while they were there. One of the things that at least I wouldn't do, but you would consider to do, one of the knee-jerk reactions is to decrease the amount of training that you would have.

What would be the ultimate outcome? You would slide back into a system where you were before, where you have staff that are going to be burned out; staff that are trying the best they can, but not having the training, you're not going to have time for communication; not having the training, you're not going to have the understanding that you have within the system. And what I think is, you would revert back to a system pre-Dunn.

And what does that mean? You're going to have a higher number of people with a mental illness in higher security levels. And then you're going to have people that are released that you might have a very high recidivism rate for, people with a mental illness. So your recidivism rate's going to be great. And quite honestly, the other thing that we had prior to Dunn is more inmate-on-inmate assaults or inmate-on-staff assaults that occurred. Those are all the possible outcomes of not having an effective mental health system and not being able to maintain it. …

Is it generally surprising to you how much treatment now goes on in prison, and how little there was prior to that?

You know what? As I think about my career, I've been providing mental health services for about 26 years now. And when I first came in, I worked in a community mental health center. And quite honestly, I can tell you that policy has changed. Community responsiveness has changed.

For example, I remember working in the community, and I had a client back then who really physically attacked me, and threw me down and ripped my sleeve off of my jacket. The person ended up in a state hospital first. And then, while the person was in the state hospital, they pretended like they were hanging, and a nurse came in to cut him down, and the inmate grabbed that nurse's hair and pulled out a patch of hair.

And I remember deciding at that point I was going to prosecute. But that was the exception to the rule, because when I came in, having a mental illness was an excuse for bad behavior. But I also saw that change over a period of time, in which there became a time where you made people responsible for their behavior. There were consequences to behavior, regardless of whether you were mentally ill. And the key was that you took mental health services to where the person was. And that was the beginning of taking mental health services to jail, that we follow people to jail. There used to be a time they would go to jail and they would just be gone, and they received no services. But there was more emphasis in taking services to jail.

I think the same thing has happened in the prison. Before, there weren't as many people, when I started 26 years ago, in prison. But I think the whole concept of moving services to prison has been a major change, and one that, quite honestly, I am very surprised about, but pleasingly surprised; pleasingly surprised that people that have a mental illness are still held responsible for their behavior, but that they get the treatment and the services that they need, so that when they're released, they are able to function more effectively in the community. ...

 

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posted may 10, 2005

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