... In 1991, regarding [the] mentally ill in prison, what was coming across your radar screen?

Well, in 1991, it was just a blip on the radar screen. In some instances, it was almost a nuisance that we had to deal with this issue. At that particular time, the Department of Mental Health was the other state agency in Ohio that was performing the clinical work for persons who had a mental illness. And there were a lot of concerns that we had at that time in terms of logistics: Who was on first? Who was really in charge? And as a result, it was an issue that we just had to manage, but it was not something we considered a major problem associated with managing prisons. We just figured it was just yet another thing that we had to do. It didn't really come into focus until several years later.

When does it emerge as an issue, the mentally ill in prison?

When we first started to pay an awful lot of attention to persons in prison with a mental illness was following a major prison riot at the Southern Ohio Correctional Facility [at Lucasville], our maximum-security prison. [It was] one of the biggest riots that the United States had seen at that time, and during that 11-day riot, nine inmates were killed as well as one correction[s] officer.

Following that, as would be the case with anything of that magnitude, the aftermath was pretty intense. We were under a microscope that was unparalleled in our work. And as a result, there were a lot of studies, a lot of reviews, a lot of media scrutiny, a lot of things going on. One of the things that surfaced following that riot was that we had an excessive number of persons in prison who had a mental illness, and they needed to be treated.

And at the same time, our system was challenged months following the riot with a major lawsuit entitled Dunn v. Voinovich. The settlement of that lawsuit is what really put us into the position we are now, to provide quality mental health services to those persons who are diagnosed with a mental illness. Our entire infrastructure changed regarding how we go about managing mental health issues and treating persons with a mental illness. So those two things were the major catalysts for us to develop a modern, effective mental health delivery system.

What first were the key issues that emerged out of the lawsuit?

Well, the one thing that was initially put forth -- and we never agreed to this, but it was decided by the persons suing us -- [was] that our mental health delivery system was unconstitutional. We never agreed to that. I always believed that we met the constitutional minima for health care in our correctional system. But we knew that changes were needed, and we thought that maybe this would be a good opportunity for us to convince the legislature and others that our mental health system needs some reparation.

And as a result, there was a significant number of psychiatrists hired and other clinical staff. We created more residential units in our prisons for persons with a mental illness at varying levels. We transferred the psychiatric hospital that was then operated by the Department of Mental Health to the Department of Corrections in the state of Ohio. So we became both the administrator of the mental health delivery system as well as the clinical agency responsible for mental health. So at that time, in addition to being the director of the Department of Corrections, I became a de facto director of a major mental health system. ...

What happened nationwide that led you to become a de facto psychiatric institution?

Well, there are probably varying philosophies regarding why prisons are such big players now in managing persons with a mental illness. It wasn't always that way. Back in the 1950s, many of the so-called psychiatric hospitals started to reduce significantly in numbers. The whole philosophy of community mental health became the standard for persons who had a mental illness in a community rather than just assuming that they needed to be locked away.

But there was a failure, in my estimation, in society. There was no safety net for all these persons who were no longer being treated by mental health agencies, so many of them became homeless; many of them reverted to crime. And as a result, because there was no space and it was extremely expensive to house these persons in psychiatric hospitals, many of them found their way to the courts, and consequently many of them have found their way to prisons and jails and juvenile facilities throughout the country.

And as a result of the deinstitutionalization -- actually, I call it a transinstitutionalization, because these folks have left psychiatric facilities and ended up in correctional facilities -- our world changed regarding the impact of the mentally ill on correctional operations.

Explain transinstitutionalization. What do you mean by that?

Well, what I mean by transinstitutionalization is that instead of persons being institutionalized in psychiatric hospitals, they're now institutionalized with a felony offense in state and federal prisons and in juvenile facilities and jails throughout the country. Sixteen percent of our prison population in the state of Ohio, which reflects basically a national average, are persons who have been diagnosed with a mental illness, and about half of those persons have been diagnosed with a serious mental illness, or a so-called Axis 1 mental illness, which means that they require an awful lot of attention. Many of them require hospitalization. They require major regimens of psychiatric medications. And they are a population that would be a risk not only in the institutions, but when they leave the confines of our correctional facilities.

What role did the mental hospitals closing have in that population emerging inside your prisons?

I'll give you an example. In Ohio, back in the '60s, I think there were maybe 37 psychiatric hospitals as well as facilities for those persons with retardation. Today, I think in Ohio there are 19 of those facilities. At the same time, we had maybe seven prisons in the '60s, and today we have 32. So the whole notion of state-run institutionalization changed quite dramatically.

And I think along the way -- and maybe there are people who will debate my approach -- but many of those persons who I think would have been in state hospitals are now in state prisons. I've actually had a judge mention to me before that, "Hey, we hate to do this, but we know the person will get treated if we send this person to prison."

The tragic irony is, there's literally nowhere else for them? What's happening in America that the judge is telling you that?

Well, I don't know. I think again, it goes back to maybe there's a failure with the delivery of community mental health treatment along the way. I think an awful lot of things have not happened. I think we're just beginning to train police officers to identify behavior that might be psychiatric in nature. There are jails across this country that have a disproportionate number of persons who are mentally ill when they could have been sent to some crisis intervention center, for example. Many of those persons require significant treatment, and they've been in and out of courts for quite some time.

At some point, a judge must make a decision: Well, what should we do? Should we keep this person on the street, or should we find a venue for them where he or she will get treatment? And I don't think they're being crass or insensitive, because [this person has] committed crimes. And a mental illness should not excuse your criminal behavior, but I don't think that we've developed a system of alternatives that need to be in place in order to prevent the kind of problems that we're dealing with now in prisons and jails across this country. ...

So you start to see the rise incrementally of the mentally ill in jails and prisons for the next 20 years?

I think that might be close. I think, though, that it really didn't resonate with corrections people until maybe the early '90s, when we started to see an extreme rise in the prison population in general, when our populations were a lot less than what they are now. We just thought the idea of managing mental health was not a major part of our business. But as the numbers began to rise in some pretty profound ways, we thought, wow, there's something else going on here. There are a number of things going on here that we have to pay close attention to that [were] not a major part of our daily operations. We always knew, and we have always treated persons with a mental illness, but it began to be something much more than that when we started looking at the numbers and the costs and the crowding and the impact on our work. So I'm sure the deinstitutionalization began a lot earlier, the impact of that on our correctional facilities, but we started paying attention to it maybe 10 to 15 years ago.

In the early '90s, what reality did you face in corrections as that population grew?

Some of the obvious challenges that we faced were the cost of managing this population. But I think philosophically for me, the biggest change that we started to pay attention to, when we looked at certain kinds of behaviors prisoners were demonstrating that may have been psychiatric, but it may not have been, [so] we wanted to understand the theory -- and I'm not trying to be crass here -- the difference between mad and bad. We wanted to know if a behavior that resembled deviant behavior was related to just criminal kinds of activities, or if it was induced by some mental illness. And so we started to pay close attention to training staff to detect unusual behaviors.

We wanted to know, if a prisoner got in trouble, whether or not that was related to a mental illness, especially if that person was already on a mental health caseload in prison. We wanted to know what the sanctions should be for certain kind of behavior. We wanted to know if that person was being properly treated along the way. So this whole notion of "mad versus bad" was a big deal for us in prisons, so that we could know how to govern this particular population and at the same time separate persons who didn't have a mental illness, who may have also been demonstrating certain behaviors that were difficult for us to manage.

So costs of managing those persons was a big deal; understanding and detecting and interpreting behavior of prisoners was a big deal; and then housing of those persons became a big deal. We wanted to make sure that these persons were separated appropriately. We don't believe, just because you have a mental illness, that you need to be segregated, because I don't believe you should be if you're in the community. But certain persons require varying levels of attention, and we wanted to make sure we had all of those levels available when that person was diagnosed. So we spent a lot of attention during assessments and evaluations of persons, beginning at the first time they arrived at prison, at reception, all the way through to release. And now we're at the point where that's not even good enough. We want to know what happens after they're released. So a number of approaches were extremely important, and the whole housing piece is one that I'm really proud of.

How, institutionally, did you deal with the culture clash between therapeutic versus punitive institutions?

Well, 20 years ago in this business, the whole idea of treatment and security was like oil and water, and they just did not mix very well. So we changed our approach to how we structure managing correctional facilities and actually put much of the treatment programming and the custody under the same table of organization inside our correctional facilities. So in essence, we forced our uniformed staff and our clinical staff to work together through different types of team approaches, different types of case management approaches, and subliminally over the years, we said that there's really no difference. Good security is good treatment, and good treatment is good security. And we've more or less drilled that into staff. So now I believe -- and maybe it's Pollyannish of me to think this -- but I really do believe that much of our custody staff are big believers in treatment and clinical approaches to managing a prisoner population.

How is that true, that good treatment is good security?

Well, if a person, for example, is mentally ill, that person may be weaker in terms of that person's ability to survive in prison. If we know that that's the case -- take a person with retardation. These people can be preyed upon by more predatory personalities in our correctional facilities. So when we know the propensities of certain persons in our correctional facilities, we're better able to manage that population. So we'll know better where to house certain persons. We'll know what kind of supervision a person might require that might be different than just a person who does not exhibit certain kinds of problem traits or medical problems that might be associated with a mental illness or being elderly in prison or having just other infirmities.

We have developed this idea of making sure, through assessment, that we can make informed decisions, clinical decisions, security decisions about how that person should be best supervised and what the best housing arrangements ought to be, what programming should be available for that person. And I think as a result of training and a number of other kinds of arrangements that we've put into place that we've been somewhat successful. We're not totally comfortable, but I think we're somewhat successful.

When did Dunn come across your desk, and what happened?

Well, the Dunn v. Voinovich lawsuit [was] filed [after] the Southern Ohio Correction[al] Facility riot, which took place on Easter Sunday in 1993 and lasted for 11 days after that. A number of months later, at the end of 1993 or early 1994, the lawsuit was filed. And at that time ... it didn't appear to be a big deal. [But] then we knew that this was not just your average frivolous lawsuit that is being filed in the state corrections agency. And it was certified as a class-action lawsuit. It was one that we agreed upon, that would terminate after a five-year period. It is terminated now. It terminated back in 2000.

But the one thing that I think that was unique about this lawsuit is that it was not a contentious process. We did not fight in the way we have with some other lawsuits, because we knew that in addition to some of the problems that we knew existed, we knew that it was an opportunity to help repair the mental health system in the state. And that's exactly what happened. We worked very closely with the court monitors, the plaintiffs' counsel, our attorney general's office, our staff, to craft something that we thought would exceed constitutional requirements and at the same time provide the needed psychiatric care for persons who were in our correctional facilities. ...

Is it the power of a class action, practically?

We aren't afraid of a class-action lawsuit, because there have been a number of those over the years. Just because it's certified as a class action doesn't automatically make our hair stand on end. But we also knew that we needed to improve. So instead of us assuming the position that it's going to be do-or-die here, we just said, "Well, OK, let's talk." And we did talk. And so we erred on the side of doing what I thought was the right thing, more so than just fighting for the sake of fighting, because we could have fought it and lost big time, and still wouldn't have gotten what we wanted, and would have paid more money along the way. So I think we did the right thing.

So many states do fight, sometimes for decades. Why did you resist that?

Well, I can't speak for the other states. I don't know the political dynamics and the fiscal constraints of their attorneys general offices across the country. But in keeping with what we thought our treatment and clinical philosophies were at the time, we actually wanted to have a state-of-the-art mental health delivery system, because we already were very familiar with the Oakwood Forensics Center that was operated by the Department of Mental Health at that time. And we wanted that to improve, because we thought that we were actually losing money by not having the right kinds of treatment options in place.

So it was more or less something we wanted to do. We wanted to have a state-of-the-art mental health delivery system, rather than just thinking we can continue to put Band-Aids on problems associated with psychiatric treatment. So again, I don't know why certain states do what they do, but here in Ohio we thought it was a good mix. And if it were to happen today, I would recommend doing it exactly the same way.

What role did the riots play in galvanizing political or public support for reforms?

[Before] the Lucasville riot in 1993, I think we were inconsequential as a state agency to our legislature. As long as this corrections agency was quiet, then we were happy. Well, the Lucasville riot changed all that. ... Following the Lucasville riot, the General Assembly appropriated 907 new staff to this agency. We wouldn't have ever gotten that if it were not for the riot. We were one of the most crowded prison systems in the United States. That changed. Our crowding level went down significantly. So as a result of that riot, we became well known. We became more than just a blip on the state government radar screen, and folks started paying attention to us. And we thought we should take advantage of that platform.

What were the challenges that you faced in implementing [the changes from Dunn]?

Implementing the lawsuit was a challenge, and the first challenge was convincing the legislature that we need millions of more dollars to hire psychiatrists and psychiatric social workers and other clinical persons. We had to make sure that training was available for staff persons who worked in the housing units that were available for persons with a mental illness. We wanted to make sure that even laypersons had a good understanding of what we were trying to achieve, even though it was not a part of their daily responsibility. So we did that. ...

And probably one of the biggest things that happened internally that we had to manage was, well, who would do what? How would the medical nurses -- would they now give out psychiatric medications, or would the psychiatric nurses do it? So there were all these things that had to be managed, and somehow or another the culture needed to change regarding what was important. So it wasn't just saying, "Tomorrow this is the way it's got to be."

... I want staff to have input. I want them to own what it's going to look like, so when it's actually out there and operational, then it won't be just me or central office or some other bureaucrat saying, "This is the way it's got to be." So we had to make sure that there was an awful lot of buy-in along the way. And we think we achieved that. ...

What was it like to bring corrections and mental health staff together on this? It's a bridge that's quite unusual.

Well, I think it was. But the way we kind of described it is that even though one's strictly medical, one's strictly mental health, there were concentric circles. And there was a lot of overlap in terms of responsibilities, and the biggest overlap itself was that we still had to run successful correctional institutions. We still had to manage a prison, so that was kind of the baseline, default behavior that we wanted to see. Now we had to work out the details where the overlap was not so obvious. And so we put people in a room; we sequestered folks; we had task groups; we had conferences; we had anything and everything that we needed in order for the right hand to know what the left hand was doing and to get those hands to work together. It's by no means perfect, even today, but I think medical staff, psychiatric staff, security staff understand why it's important. ...

Is it your sense that the mental health care that's now being provided in your prisons may exceed what's available in the communities?

Well, unfortunately I do believe that some of the mental health treatment that we provide in prisons is better than what one might get in the community. Who would you sue in the community to improve the mental health system? We're under a microscope. And I believe that not just about mental health, but a number of other things. A prisoner can get to a physician in prison a lot quicker than I can at home. But we know that to be the standard, so we don't complain about that.

But when you know that the courts are more apt to send a person to prison because they're going to get treated, there's something disconcerting about that. But it's no [aspersion] on the court. It is more so an indictment of not having all we need in the community, and I don't know how you achieve that. Everybody's strapped for money. I think there's some things that aren't as costly, such as training police officers to identify unusual behavior. That's happening now through a number of grants and a number of projects. But I do think we far exceed the constitutional minimum for providing mental health care to a person in prison that may not get that same level of care in the community. ...

How important is Oakwood [Correctional Facility] in your mental health delivery system?

... It's the flagship of how we govern our psychiatric care in Ohio, and we think the level of care that they get is unmatched anywhere, whether it's a state psychiatric hospital or anywhere else in the community. We have a very professional staff. We're pleased that the institution, the numbers are going down, that we're being able to manage that population successfully, and to help prevent relapse and deterioration of their disease. And as a result, it sets the stage for what we do in our cluster mental health units, what we do in our psychiatric counseling, and the overall mental health delivery system in general.

Is it for short-term acute care? What is its mission?

The Oakwood Correctional Facility is not designed for any long-term stay. It is designed specifically to stabilize persons who may have been demonstrating erratic behavior because of their mental illness. So the persons who end up there are people with a chronic problem. They're acute patients. They're typically seriously mentally ill. They are ones who oftentimes find their way back to Oakwood on multiple occasions. But that's OK [as] long as the mission is to stabilize that person and to not warehouse them in a place just to keep them out of the hair of the other prisons. So I think that facility does a good job of being able to discern the persons who can be stabilized, in some cases pretty quickly, and then reintegrate them back out into the general population or to another mental health housing unit. ...

What will be required to [improve the re-entry process]?

... One of the things that we're doing here in Ohio is going to communities. For years, the state of Ohio has been Big Brother, and the communities have believed that you can't do anything unless we're giving you money to do it. But we're now saying, these persons who are being released from prison are part of your community; it is going to help you and your community to make sure that they're successful. So through Citizen Circles programs and other local re-entry programs, we're now getting citizens to get involved unlike we've ever seen before, for no new money.

Now, that's not to say we don't need money, and we certainly have applied for all the federal grants, and we want to come up with other options, such as our programs -- one in Hamilton County and one in Cuyahoga County, Cleveland and Cincinnati -- where we have programs specifically for persons with a mental illness, called our ACT teams, or we call them Assertive Community Treatment teams, where we specifically have parole officers with a mental health caseload, who work with local mental health providers to provide the right kind of wraparound services to keep that person returning to prison.

[Is] the recidivism rate for the mentally ill higher than for other inmates?

I certainly have heard that, but I really would think that there is a lot more research needed to determine exactly the impact of a person's mental illness on recidivism, or their return to prison. We believe and we've heard anecdotally that a person's mental illness will get you back to prison a lot quicker than a person without a mental health problem, but we need to know why. We need to know what is the behavior that's going on. Is it because a person isn't taking their medication? Is it because of the environment that they're in in the community? Exactly what's happening? Are they not getting family support? Are they not having access to community mental health counseling? And we don't know all the answers to those questions, but we need to know those answers. ...

Once they leave your gates, the rest of us have no obligation?

Unfortunately, there's a finite amount of money in the communities to treat persons with a mental illness. And there is a lot of concern about Medicaid funding and other kinds of resources to provide mental health treatment in the community. And when persons are released from prison who are not only ones with a mental health disease but they're also criminals, somebody's got to make an informed decision: Well, who should get first access to some of the community mental health treatment? And unfortunately, over the years, it has not been persons who have been in prison. It's a tough proposition for our parole officers and others to find the right kind of placement for persons in prison.

We have people in prison who have serious mental illness, who we can't release to the community because we don't have a place to send them. We don't have a proper placement for them. So as a result, some of them stay in prison longer than what their expired sentences or what their indefinite recall [is] for. If they have an expired sentence, we just let them go, because we have to. But for those persons who are parole-eligible and there's an indeterminate sentence, some of those persons are still in prison. ...

Are you worried about backsliding?

Well, certainly. You think about whether staff, because there isn't as much scrutiny, will become complacent. I haven't seen a lot of that. There were some issues here and there. Certainly as a department, it is our mission to conform to and abide by the spirit of the settlement, but it's not something that you can automatically assume is going on. There needs to be regular audits and quality assurance monitoring and inspections of what's actually taking place in our mental health units across the state. And even though I'm mostly pleased, sometimes you worry about backsliding and things going in a direction different than what you like to see. But if that's happening, if it has happened, it's not happened to the level where I think we're being disingenuous. ...

Looking ahead, a century from now, how will imprisonment of the mentally ill look?

Well, hopefully a century from now we'll see more prevention kinds of activities going on in our communities. Mental illness is more treatable than some other diseases in terms of stabilizing them, but it needs to happen at an earlier age. It needs to happen with kids. We need to make sure that the juvenile facilities are paid close attention to, because many of those people graduate to adult prisons. We need to make sure that we have a truly holistic system of managing those prisons.

Hopefully in the next century we'll have a lot fewer people even in prison. And hopefully, proportionately [there will be] a lot fewer people with mental illness [in prison]. Hopefully we'll come to a level of understanding in this country that there are other alternatives rather than prison to manage persons who commit certain types of crimes. And a number of countries have already figured that out already. We've not figured that out to a level that I'm comfortable with.

But I also believe that persons should be sanctioned for their behavior. I just don't think we understand that those sanctions can be a lot more creative. Hopefully in the next century, technology will exist that will prevent some of the problems, whether it's through medications or other types of prevention methods that will keep a person from being involved in crime in the first place. I think we need to be astute -- politicians and public officials, educational institutions and others -- about the nature of the impact of mental health in this particular situation, and to not shy away from trying to deal with it, because I think a lot of the attitude has been over the years out of sight, out of mind. You lock people away, then they're no longer a problem. Well, guess what: Ninety-eight percent of everybody who go[es] to the prison get out, and it behooves us all to pay close attention to it when we can, and not to sweep it under the rug. ...

In terms of the mentally ill, unless we divert resources to the front door rather than the back door, what's ahead? If jails and prisons are the new asylums, what's ahead?

Well, I don't see any evidence that things are going to get better before they get worse, unfortunately. I think the notion is that crises [are] what makes people think differently. ...

We are the gatekeepers of a lot of persons who are mentally ill, and that's not something we relish. We don't like that idea. We don't like the idea that we're being charged with fixing a lot of the woes of our communities. And we think we do a good job at what we do, but it needs to be a shared responsibility, and it needs to be one where all the component parts are working together. All the cogs in the machine have to play their roles. And I think that's the approach that public officials need to assume, not just in the near future but now; that this is not something that I think we're talking about four or five years from now. We're talking today that this kind of approach is needed.

Otherwise?

Otherwise we can anticipate more costs; we can anticipate more victimization; we can anticipate more havoc in our communities. I don't think anybody wants that. We all want to feel safe, and we all want persons with any disease, whether it's cancer or polio or anything else, to be treated properly. Why not mental health? Why not a mental illness?

Put Ohio in a national context. What's instructive?

I think jurisdictions around the country have to pay close attention to what particular methodology they want to have in place to manage persons with a mental illness. Some state departments of corrections manage directly those persons, and others have contract services, and even others have their state mental health agency providing that service.

I think the one thing that was a lesson learned for us is that we can achieve our goals without having to fight a whole lot. And through the Dunn v. Voinovich lawsuit, remarkably, we did not have a lot of battles in terms of standing in front of courts and deposing lots of people and spending lots of money defending something that ultimately we may have lost anyway. So I think that's an important part.

I think the other part is, I think if we looked at providing treatment because it's the right thing to do rather than [as] just another obligation, I think that will take us a long way to ensure that persons with a mental illness [are] being treated like other people in prisons who might have hepatitis C or any other kinds of medical problems.

I think the idea of having good modalities to return persons to the community following their stay in prison is going to be absolutely critical. We're paying close attention to the re-entry of persons with a mental illness and trying to be scientific about it and not just trying to find placement. We want to have good assessments. We want to find good placements for those persons, either in halfway houses or in their homes with their families. ...

What does the public most misunderstand about the mentally ill in prison?

Well, I think what the society in general don't understand about mentally ill persons in prison is very much. I don't know that people even think about persons with a mental illness in prison, unless there is something episodic going on that would cause them to do so. ...

But I think the community knows very little about the fact that we're treating thousands of persons in our prison population with mental illness, and serious mental illnesses. These aren't just personality disorders or feelings that you might have that you would see very common occurrences with in depression. It's not just depression and borderline personality and those. We're talking about psychoses. We're talking about problems that govern the behavior of persons that can be very dangerous to themselves and others. So I think very little is understood about what we do. And I personally would like folks to know a lot more. ...

Summarize where we were 30 years ago and how we've ended up.

I started in this work in 1973. We had 7,000 prisoners. Today we have over 44,000. And nationally those numbers parallel what we experienced here in Ohio. But also in 1973, the number of persons in mental health and retardation facilities was a lot greater than what existed in state and federal correctional institutions. So we've seen this transinstitutionalization take place, where persons with a mental illness have grown significantly while living in a prison or a jail or juvenile facility. And hopefully that trend can not revert back to more institutionalization of persons in state hospitals for the mentally ill, but I also don't think it's the right thing to have more persons in state prisons and correctional facilities in the future. ...