Yale Psychiatry Grand Rounds: April 16, 2021

April 16, 2021

Information

"Our Role in the Development of Mental Health Services in Corrections"

Raymond F. Patterson, MD, DLFAPA, Faculty, St. Elizabeths Hospital Department of Behavioral Health, Washington, DC

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00:00Special Day for the
00:01Department of Psychiatry every year,
00:03which is the Yochelson
00:05lecture which has been,
00:06I think, one of the Premier.
00:10Lectures in in forensic psychiatry
00:12events in forensic psychiatry.
00:13Certainly in our community,
00:15but I think if you look at the
00:18list of speakers historically.
00:21Uh, an event of national significance.
00:25We're we're thrilled to have
00:27three members of the Yochelson
00:30family with us today to remember
00:33the legacy of Doctor Yochelson in
00:36our Department and in the field.
00:39John Yochelson,
00:41Bonnie Yochelson and Laura Yochelson
00:43representing the. Out with the
00:47original Doctor Yochelson three generations,
00:49which is a very special thing, and.
00:53And we're also thrilled to
00:56have Doctor Raymond Patterson
00:58as the ground round speaker.
01:01I will not try to. Be the introducer.
01:06I will leave that to to Howard and also.
01:15And perhaps others who
01:16might want to comment, but.
01:19John, if you'd like to make just a few
01:22comments about about the legacy of your
01:24father and the significance of this lecture,
01:27and then Howard can introduce
01:29our grand round speaker.
01:30Thank you so much John.
01:33I'm I also see looking at things that
01:36my daughter, Lisa, who is in transit today.
01:39She is is listening.
01:41We can't see her but but she's also very,
01:45very committed to this very, very proud of.
01:50Of the of the lecture and the and
01:53the tremendous work that cowards
01:56and Anna has done over the years,
01:59Dad passed away.
02:01I don't want to go over the material
02:04that Howard is going to go over,
02:08just really to say that that it has been
02:12a source of enormous pride for us to
02:15see of such remarkable practitioners,
02:19researchers, scholars.
02:20Uhm?
02:26Older, older forum of this of this quality
02:29and it never would have taken place without
02:34without doctors amanus of leadership.
02:37This wasn't this was an event that meant
02:40a great deal to my mom Catherine who
02:44participated with Bonnie and me into her 90s.
02:47He passed away in 2005 and I'm wanting
02:50to say that she was that she part that
02:54she was in the audience in the 2000s.
02:57I think Bonnie brought her up
03:01from from New York so.
03:03This means a great deal to our family
03:06and we we greatly look forward to Doctor
03:09Patterson's remarks and and we really
03:12appreciate the it's remarkable looking
03:14at who's on the call and so many familiar
03:18names that we in years past that we've
03:21had the pleasure of meeting weather at
03:24the grand Browns or at the dinner before.
03:27But the spirit is still there and
03:31I would again like to just thank.
03:34Howard, Banana and the team really
03:38is awesome is awesome team.
03:42We always hear from Madeline and from Pat,
03:45who made the arrangements for us.
03:47It's a great group of people and
03:50we're very proud to be part of it.
03:52Thank you.
03:56OK, so maybe I'll jump in here.
04:00And say this. This is something we
04:04look forward to at this point and.
04:07I'm very pleased the history
04:10is goes back almost to 1980 or
04:13so when the family made this
04:15contribution for this lecture.
04:18Started out as a lectureship.
04:22And has helped form and
04:25guide the program in a way.
04:29I think our program in law and
04:32psychiatry is one that is heavily
04:35focused on public sector work.
04:38And that forms the core of what we do,
04:43and we've had a now over 125 fellows
04:46that have graduated from the program
04:49and moved in positions of leadership
04:53around the country as well as
04:56staying on here in Connecticut.
04:58And it's been a joint operation and
05:01apart between our division between
05:04Yale and the State of Connecticut.
05:07Which has been enormously supportive
05:10through the Connecticut Mental Health
05:13Center and in funding four Fellows a year.
05:16Which is a enormous cost for which
05:19they don't get a lot of direct
05:23return in terms of service,
05:25but our program has helped.
05:29The Department of Mental
05:30Health and Addiction.
05:31So I think over 20 of our people
05:34have stayed on in the state system.
05:37For substantial period of time.
05:40So that hopefully is the kind of
05:43payoff that helps both of us and
05:46we both work together with the
05:49Department and legislation and a
05:51variety of other fora for working
05:54on care of the chronically mentally
05:58ill and set up programs in the
06:01Mental Health Center as well.
06:04So let me just say,
06:06certainly at the beginning that the yokels
06:09and story is a very interesting one.
06:12Samuel Yochelson went to Yale and was
06:15in the psychology Department and did
06:18extremely well in that Department.
06:20But he went through at a time when
06:24positions in the Department were
06:26governed or were governed by quota
06:29on the number of Jews it could
06:33be in the Department.
06:35But they offered a support for
06:37him to go to medical school.
06:40Uh,
06:41in lieu of the appointment which he
06:43did and then was in Buffalo for a
06:45while and then went to Saint Elizabeth's
06:47where he did a lot of this work.
06:50Let me share my screen for a minute up.
06:55And.
06:59Hopefully I'm sharing the right
07:02one here. Uh. So as you see,
07:06this is the is the 25th.
07:09A lecture that we have had
07:12over the course of the years.
07:15Yale invested the money,
07:17which in there seemingly.
07:23Sorry, I don't know quite how to put it,
07:26but they get a really good return
07:29for their investments and.
07:31That has allowed us to expand
07:33what was a single lecture.
07:36To inviting a scholar and.
07:40Visiting person to come for
07:42a week and spend time both.
07:44Here in our Department seeing
07:47the the PG two residents in
07:50class and talking with them,
07:52meeting with the psychologists in our
07:55program and having case conferences.
07:58And going up to CVH and doing a case
08:02conference in a grand rounds up there
08:04as well as participating in our other
08:07programs and the grand rounds here.
08:10So that's made for a nice ability
08:13for us to have people to get to
08:16know us a little better and for us
08:19to get to know them and establish
08:22nice connections that that continue.
08:25Uhm?
08:28So Doctor Yochelson was interested in the
08:32criminal personality and first started
08:35with more of a psychoanalytic approach.
08:38And then felt that was not very
08:41useful in thinking about how
08:44to affect people's change. Uhm?
08:49He was started in 1961 and was
08:51joined by a psychologist.
08:54Doctors saying Sam and al.
08:57And they looked at 255 ********
09:00criminals supposedly and the subjects
09:02included both drug users and nonusers.
09:07Went over 17 years and they began to
09:10look at and describe what they thought
09:14were certain kinds of thinking and
09:17patterns of thinking rather than just
09:20psychoanalytic or diagnostic approaches.
09:22The. The work has waxed and waned in terms
09:27of how people have thought about it.
09:30There are, you know,
09:31certainly as John mentioned,
09:32where some problems around.
09:34Some of the things about controls
09:36and other kinds selection, but.
09:39It certainly served as a basis for people to
09:43stimulate other kinds of research as well.
09:46Uh, the family has been involved
09:49since the beginning of this,
09:51and have been enormously supportive.
09:54These are the list of prior scholars
09:58who have come and lectured.
10:00Test. As you can see,
10:03if you know anything about
10:05forensic psychiatry.
10:06These are sort of the leading
10:10lights in the field.
10:13Beginning with the burner Diamond,
10:15Allen Stone, Alan Dershowitz,
10:18Paul Appelbaum and.
10:19All the way down. Uhm?
10:24So let me just say a little
10:26bit about Doctor Patterson.
10:29He's currently a part of the clinical
10:32faculty at Saint Elizabeth Hospital.
10:34Where he's been off and on
10:37throughout the years, he's also,
10:39and it's been associated associate professor.
10:42Whoops little typo at the University,
10:45Howard University, and Georgetown University,
10:47and the University of Maryland.
10:50Uh.
10:51And certainly been at Saint
10:55Elizabeths for a substantial period.
10:59And also in private practice.
11:04He went to northwestern and
11:06went to Howard University,
11:07College of Medicine and did an
11:09insurance turn ship in his first
11:12year residency and then went
11:14to Saint Elizabeth Hospital.
11:16I say Elizabeth has a
11:18long interesting history,
11:19which he gave up for awhile for
11:22initially involved a lot of the
11:25Federal 6 center and dealt with
11:27the military and then became back
11:30and forth with with DC and varying
11:33political things that I'll let
11:35Ray talk about if he needs to.
11:38But it was an interesting talk
11:40and I think they recorded it.
11:43I don't know will have access to it.
11:47He's currently on the AP, a council,
11:50and psychiatry in the law.
11:52Been president of the Washington DC
11:55Psychiatric Society for the AP A.
11:58Several times is done a number of
12:01invited lectures and we're enormously
12:03happy to have him and I like to
12:06leave the rest of the time for him.
12:08If we can.
12:11So thank you Ray. The floor is yours.
12:16Thank you so much, Howard.
12:18I appreciate that very much and and
12:20Doctor Crystal and John Yochelson
12:22and and Doctor Buchanan and I could
12:25just go on and on Doctor Banowski.
12:27There's a lot of folks that I would
12:29like to say thanks to an an my
12:32appreciation for being invited and at
12:34long list that you just put up Howard.
12:37It's it's. It's pretty compelling
12:38when you see the folks listed there.
12:41I'm I'm very happy to be included
12:43in that list.
12:44I will say just a couple of things
12:47and then we'll go to the slides but.
12:50In fact, I'll put up the slide 1st
12:52and make sure that I've got it right,
12:54because if I don't then I know that
12:56there will be efforts to make sure that
12:59my being challenged is handled well.
13:01So let's see if we can make that happen
13:05first. And assuming that we can.
13:09Here we are, whoops.
13:12That looks great.
13:13Are you seeing that looks great?
13:16Outstanding thank you so much.
13:18I wanna make sure and I somehow
13:21I'm not being able to advance the.
13:25Slide that's not helpful.
13:27Let me make sure I'm not.
13:30Read, make sure your cursor
13:32is on the the
13:34slide presentation, yes.
13:40Rather than the zoom screen.
13:48Well, I actually thought that it was made,
13:50but I'm gonna stop for a minute.
13:51And let's do this again.
13:53Oh, there you are. It says OK.
14:11How's that, no? OK can you see what
14:15I see, yeah. Oh no, that's not good.
14:34You still don't have it.
14:35Did you hit the share screen?
14:37I did, but let's make sure I do
14:40it again and do it right. OK.
14:51Erekose good.
14:55And. When last comma.
15:01How's that that's
15:02good now. Can you advance it?
15:05I can't excellent
15:06thank you so
15:08much. I have several
15:09skills. This is not one of them,
15:11so thank you for bearing with me,
15:14but let me just say a little bit about
15:16today and you can see the evolution
15:19of correctional mental health care.
15:21Actually, it's our role in the evolution
15:24of correctional mental health care,
15:25but modified the slide
15:27because it's not just us.
15:28Meaning mental health
15:29professionals and psychiatrists,
15:30but a lot of other professions as well.
15:33They get involved in this,
15:35so I want to make sure we include everyone.
15:39But let's talk for a minute
15:42about why me and why now.
15:44The 1st 20 years I joined the Saint
15:47Elizabeth System as a resident.
15:49As Howard mentioned in 1979,
15:51so I missed the Samuel Yochelson years
15:54as Doctor Yochelson passed away in 1976.
15:57But just before we started presentation
15:59had a moment to talk about having talked
16:03with people who knew him when he was there,
16:06not only some of the staff,
16:08but some of the patients that were still with
16:11us and the division of forensic programs.
16:15So I say that to say that the 1st
16:1820 plus years of my career were
16:21spent an public mental health.
16:24Meaning mental hospitals both in
16:26Saint Elizabeth's and in Maryland,
16:28and particularly in forensic services.
16:31In both of those states that
16:33Commissioner in mental health in
16:35DC and Superintendent equipment.
16:37Perkins Hospital,
16:38which is our Maryland sister
16:40forensic Hospital in Maryland.
16:42So that was my beginnings.
16:45And as time went on,
16:47as as some of you may know,
16:50Saint Elizabeth also served as
16:52a receiving hospital for the DC
16:54jail and then Lord in prison,
16:56DC no longer has a prison so that
17:00anyone who is convicted of a felony.
17:04DC goes to the federal system, which,
17:06as those of you who are focused on aftercare,
17:10planning and reintegration into
17:12the community,
17:13makes it particularly difficult.
17:14But that is reality.
17:16So during the course of my
17:18being at Saint Elizabeth's,
17:20that became more and more involved with
17:23corrections and learn things that looking
17:25back at it seem pretty simplistic,
17:28but I never quite understood them until
17:31I was working behind the walls now.
17:34Give you one quick example.
17:36The example is how is it that
17:38someone shows up at the Community
17:40Mental Health Center or hospital
17:43emergency room having been charged,
17:45released from prison and having been
17:48involved in mental health care or
17:50released from the jail and just showed up?
17:53How does that happen?
17:55Why is there not a connection?
17:58Why is there not in an effort to try
18:01to make sure they receive aftercare?
18:04And I learned that with jails
18:06sometimes they don't know when
18:08someone is going to be released,
18:10and therefore that individual
18:11just doesn't come back from court
18:13and they don't know that that's
18:15going to happen with prisons.
18:16I thought that if someone
18:18had a 10 year sentence,
18:20that meant that they served 10 years
18:22and I had. And so how hard is that?
18:25You know what date they came in?
18:27You know what day is 10 years.
18:29So how can you not know when
18:32they're leaving except there?
18:33Such things as good time, credits, and.
18:35Other things that happen behind the
18:38walls that those of us who have not been
18:41there don't know or don't understand.
18:43So I am giving this presentation
18:45largely to take it look what is
18:48happened within corrections that has
18:49to do with mental health care and
18:52this also extends to medical care.
18:54But obviously my focus is going
18:57to be more on mental health.
18:59So historically.
19:03How were the mentally ill housed?
19:07Before the mid 19th century,
19:09and there's some interesting
19:11documents and and history to read
19:14through that has to do with when a.
19:16I think one of the quotes has to do
19:19with a colonial soldier who became ill
19:22and it was the responsibility of the
19:25family to provide housing to erect a
19:29structure on the family property in
19:31order to house the mentally ill person.
19:34So it was largely up to the family.
19:38And whoever may have been in that community,
19:42if you will,
19:43using a term loosely to try to
19:46provide something for someone who
19:49was not acting appropriately,
19:51not behaving appropriately before
19:53all of the diagnostic categories
19:56that we think about.
19:58So if home not available, what was?
20:03The arms, houses and prisons.
20:06This is a photograph of Eastern
20:10State Penitentiary in Philadelphia,
20:12and strikingly,
20:14this penitentiary was constructed
20:17and opened in 1829.
20:20And it functioned for a very long time,
20:23but if you notice in the photo
20:25right in front of the penitentiary
20:28is a sign that says open for tours.
20:32Is for tourist because it is alleged
20:34that the penitentiary is haunted
20:36and therefore there is interest in
20:39touring it from that perspective.
20:41But those of us who have been in
20:44institutions and institutional
20:46practice tend to look at it in
20:49a different way like this.
20:51Those who are typical units
20:53or wards within that war.
20:56It's been units within the prison
20:58and the housing of the mentally
21:01ill or those who might have been
21:05disruptive was essentially no
21:07different than it was for else.
21:10And it was,
21:11excuse me,
21:12the determination of who was housed where,
21:16and such correctional terms as
21:18the whole meaning segregation
21:20or somewhere out of sight,
21:23out of mind where disruptive behavior
21:26could be managed and not as impacting
21:29on the operations of the institution
21:32was indeed part of the process.
21:35And in that process many times people were
21:38placed in various forms of segregation,
21:42etc.
21:42Based on what one their
21:45behaviors and attitudes.
21:46But I raise that question
21:49with the of at the end.
21:52Behaviors and attitudes of
21:53who of whom was it the inmate?
21:57Or was it the staff?
22:00Who decided what behaviors were
22:02inappropriate and needed to be
22:05managed in a way that was different
22:08than every other inmate within
22:11the facility and the attitudes,
22:13the stigma mental illness has never
22:17gone away continues with us not,
22:19but consider this that if someone
22:23is locked up and
22:25I hear this from inmates
22:28frequently when I am.
22:30I'm involved in my current activities now.
22:32I'll say a little bit about
22:34that in just a moment, but the.
22:37Report or information coming back is
22:40that they treat us badly differently
22:43because they don't understand us.
22:46They don't understand what we're
22:48doing or how we're thinking,
22:51or how we're acting,
22:53or why we don't do the things
22:56that they think we should do.
22:59And throughout history of reviewing
23:02some of the interactions between
23:04staff and inmates that I'm
23:07talking about corrections now.
23:09You'll see quotes of things like they
23:12expect us to behave like adults,
23:14but they treat us like children.
23:17They don't allow us to be adults.
23:19They don't expect that we're humans,
23:22and that's when someone is
23:24lucid enough to talk about it.
23:26But let's consider someone who may
23:28not be very lucid who indeed may
23:31be responding to hallucinations
23:33or too delusional beliefs and
23:35therefore is not In Sync.
23:37With what is going on scuse me within
23:40the environment and the environment
23:42is a correctional environment.
23:44Uh,
23:45I I started to say a bit about what I do
23:48now and that has been impacted by covid.
23:51Just as almost every part
23:53of our lives has been.
23:55And for the virtual process as
23:58we experience it right now,
24:00consider what it's like for someone
24:03like me who is a court appointed
24:07monitor to attempt to do a virtual
24:10on site visit to a jail or prison.
24:14It almost sounds oxymoronic on its face,
24:17because part of the evaluation assessment
24:20process has to do with talking to
24:24not only the system meaning the policy's,
24:27the procedures,
24:28the actual documentation of
24:30what is supposed to happen,
24:33or what is proposed to happen,
24:36but also to the individuals
24:38who carry that out.
24:41That means talking to officers,
24:43to deputies to people who are involved with
24:46clinical care and how that's being provided.
24:49How does that work?
24:51That also means talking
24:53to detainees or inmates,
24:55whether their own health caseload or not,
24:58and particularly if they are in
25:01segregation or isolation because of
25:03the impact that that has on mental health.
25:06So doing it virtually makes that
25:09component very difficult to capture.
25:11And it's also what I think most of us
25:15who do clinical practice to check.
25:19Who had any institutional environment can
25:22can sense and I hate to say it that way,
25:25but it's a feeling.
25:27It's when you're walking on a unit.
25:29You can sometimes feel the
25:31temperature of the level,
25:33the interaction, what's going on there,
25:35and I'll give you 2 extremes.
25:37You're welcome to segregation
25:39unit and it is loud.
25:41People are screaming their banging there.
25:43There's all kinds of what
25:45would best be to Scott.
25:47There's described as
25:48noise and sometimes chaos.
25:50And sometimes that's expected,
25:52depending on how kind,
25:53how the operations are running.
25:55I'll give you the other extreme.
25:58When I walk on a juvenile unit.
26:01If that's quiet, I get really concerned.
26:05Because juveniles aren't quiet,
26:07they aren't just sitting in the
26:09cell doing nothing or not making noise.
26:11If they don't come up to the cell door or
26:14to the window and start asking who's this,
26:17who's in the suit?
26:18Who's who's out here? Then?
26:20I expect that that's something that's going.
26:23No, regularly they are interacting,
26:26but if it's absolutely quiet
26:28and you hear crickets chirping,
26:30that raises concerns,
26:32so that's kind of an extra sense if you will,
26:36of trying to take a read of what's
26:39going on in that environment.
26:42But what happened in the early years
26:45of mental health or mental mentally
26:48ill people being placed in jails
26:51and prisons more times than not?
26:54If their behaviors or attitudes did
26:56not match with what was necessary
26:59to maintain control,
27:00such things as the rule of silence,
27:03not talking, standing up for count,
27:06if you hallucinate ING,
27:08don't stand up for count,
27:10you get a write up, you get a disciplinary.
27:14Those kinds of things that don't take
27:17into account mental health factors.
27:19So what happens when there is
27:22not an understanding?
27:24Or appreciation of the impact of mental
27:28illness on behaviors and attitudes.
27:31Usually the default position is isolation.
27:35Segregation restraints,
27:36use
27:37of force and punishment.
27:40And that has been historically
27:42the default position for quote,
27:45bad or mad behavior behind
27:47the walls. Now, saying
27:49a little bit about how that this
27:53or doesn't fit into correctional
27:55goals and practices because we
27:58have to keep in mind, we come from
28:02a different. It's a different place
28:05in terms of clinical practice,
28:08particularly, and I'm
28:10not really other folks,
28:12but particularly docs,
28:14physicians, psychologists,
28:15social workers, psychiatric nurses.
28:17We are trained to look at the individual.
28:21How is the individual doing?
28:25How do we provide individualized treatments?
28:28How do we structure what we're doing
28:31to reflect our information and
28:33knowledge of the individual? Then you
28:37switch that over to a
28:39correctional environment and it's
28:40not about the individual.
28:41One of the things that is striking for
28:44many of us, when you first walk
28:46into corrections is that people
28:48don't have names. Inmates sometimes
28:51may have a last name.
28:54Smith, Jones, whoever.
28:57But many times it's numbers.
29:00The identity issue of who you are
29:04starts to get lossed in the process
29:08of maintaining order control.
29:11An in some instances safety,
29:14but if those things are
29:16not adequately achieved, these what's on the
29:20slide right now. Isolation
29:22slash segregation restraints
29:24use of force and punishment tend
29:27to be the default positions,
29:29and therefore people who are
29:32engaging in mad or bad behavior.
29:35And I use those terms purposely rather
29:38than to get into diagnostic categories.
29:43Are more likely than
29:44not to have these kinds of interventions.
29:48So what happened? Why did it
29:51change what, what? What made a
29:54difference within corrections
29:56and when I started going into
29:59correctional facilities regularly?
30:01At first it was very clear that both
30:05administrative folks as well as line staff,
30:08officers, deputies you notice,
30:10I say officers and deputies, not guards.
30:14I say that because just as we pride
30:19ourselves in our achievements,
30:21correctional professionals also see
30:23how we refer to them as important.
30:27So when we say, well,
30:29the guarded isn't a good idea,
30:32that if you're involved in
30:33that particular system, you
30:35can pretty much count on not having
30:38a great deal of respect because
30:40you're not showing a great deal
30:42of respect to counterparts who,
30:44quite frankly have more contact
30:46with the individual than we do.
30:49So that rather than setting
30:51up an unnecessary barrier.
30:53It is important to try to set
30:56up a collaborative relationship
30:57is difficult as that may be,
31:00particularly when you're in
31:01a system where there is not
31:04adequate resource in various
31:05areas and therefore things are not
31:08happening in the way that you
31:10would think or want them to happen.
31:13So what happened to change
31:16that perspective of lock him up,
31:18lock him down, get him
31:20out of our sight so that we
31:23don't have to deal with them several
31:27things first. Go back to before
31:30this time period a little bit, but
31:33it still be Gamble 1976 landmark
31:36case not involving someone
31:38with mental illness but is
31:40frequently cited as the case that.
31:43Brought out the issues of
31:46constitutional requirements,
31:478th and 14th Amendments.
31:50And the term deliberative
31:52indifferent subsequently.
31:53But I also mentioned here Bow
31:56Ring versus Godwin 1977,
31:58because that is a mental health case,
32:02a mental health counterpart if you will,
32:05to a stab Estelle V Gamble that requires.
32:10That individuals who are in correctional
32:13institutions and not just there and
32:15will expand on that in a moment.
32:19Are required to have adequate health care.
32:24And when I talk with folks
32:26outside of Corrections, an ask,
32:28particularly when it's mental health
32:30providers or sometimes in in school systems
32:32or colleges who's entitled to health care,
32:34who's entitled to see a Doctor Who's
32:36entitled to get medications if you need it.
32:39Who is that?
32:40And I get all kinds of answers like,
32:42well, kids. Certainly kids.
32:44Well, you know,
32:45old people certainly owe people when they
32:48look at me when they say that nice smile.
32:51Or, you know,
32:52somebody who's who's got a mental illness or.
32:54Or maybe you know there there are
32:57and I'll use the old term because
32:59that's how it usually comes to me.
33:02Well, they're they're mentally
33:03******** so they they don't know much.
33:05You know,
33:06they can't rather intellectually disabled,
33:08but rarely do I hear prisoners.
33:13And when I say no, it's not any of
33:16the categories you just mentioned.
33:17It's prisoners as people who are
33:19locked up and I get. Why is that?
33:22Wait a minute, hold it.
33:24Those are criminals are bad people.
33:25They how do they deserve something that I
33:28can't get that I can't get from my kids etc.
33:31And the basics of this have to do
33:34and that's why the slide is up with.
33:37The prisoner has no option.
33:40When the state has declared that this
33:44person cannot leave that they are
33:47involuntarily retained in this environment,
33:50they cannot leave.
33:52Then it is on the state to
33:55provide health care,
33:57and that includes mental health care.
33:59So that is how that breaks down an it is
34:03important to be able to articulate that,
34:06particularly to some of our counterparts
34:09who just don't understand why they have
34:12to do this and why they have to do this
34:16was not a part of the job description.
34:18I've had so many officers,
34:20and sometimes administrators say to me Doc,
34:23I didn't get into this to be.
34:26A social worker.
34:27I'm not here to hold hands.
34:29That's not what I do.
34:30That's not what I trained for.
34:33And they reinforce that
34:35correctional's environments,
34:36meaning jails and prisons were typically
34:39not constructed for the kinds of
34:42activities that those of us in mental health.
34:46Want to try to implement?
34:49They are not constructed
34:51for sound confidentiality.
34:53That is where the officers pardon me,
34:57can see you and the inmate
35:01or group of inmates.
35:04But they can't hear you,
35:06so it's sound confidential.
35:09But it also allows that there is visual
35:13site monitoring so that everything
35:16can remain under control and safe so
35:20they weren't constructed for that.
35:22And the idea of retrofitting
35:25and sometimes in installing
35:28glass etc to be able to see into
35:32particular rooms all that becomes.
35:35Apart of attempting to accommodate
35:38those kinds of interventions that
35:41we feel are so important but within
35:45beyond the constitutional requirements,
35:47of course are legal actions
35:50and illegal actions.
35:52Individual and class action lawsuits.
35:57And the number one
35:59legal action that has
36:01historically been filed against
36:03psychiatrists and mental health.
36:06Are suicide, or or preventable suicides,
36:09but suicides in any in any case
36:12that is shifted in corrections to
36:15be more focused on isolation and
36:18segregation because of the impacts
36:20of isolation and segregation.
36:22And I am, I guess,
36:25senior now I remember the days at Saint
36:29Elizabeth and in other hospitals that
36:32I had been to where you could write
36:35a 24 hours occlusion.
36:38Restraining order 24 hours.
36:40Today, that would be unheard of.
36:43Today without there being monitoring
36:45and specific requirements of someone,
36:47for example, was in restraints to have
36:50motion exercises to have nursing check
36:53on them every two hours at minimum
36:56to have a hand free to eat those
36:59kinds of things were not a
37:01part of parcel of how it used
37:04to be, so it's important to have
37:07some sense of where it was.
37:10And where it is to have an idea
37:13of where you going, the PLRA,
37:16the prison Litigation Reform Act.
37:19Is an act that essentially
37:23requires that prisoners try to.
37:27Achieve their resolution of their
37:31complaints or concerns through the.
37:34Process that is available within the system,
37:37so that usually means a grievance process.
37:41It means appealing various things
37:43that may be inappropriate within the
37:46system and in part it was also to cut
37:50down on what were considered quote,
37:53frivolous lawsuits, unquote.
37:54I'll give you an example,
37:56one that I've used when inmate filed
37:59a suit because they said that they
38:03only could eat chicken breasts.
38:05But could not eat chicken legs
38:07and therefore the system was
38:09discriminating against them.
38:10So there are some that are just out
38:13of bounds and there are others that
38:15are right on point and right on target
38:18and then become class action lawsuits
38:21which may result in monitoring,
38:23which we'll talk about in a little bit.
38:27The other.
38:29Listing on the slide is prior.
38:32The Prison **** Elimination Act and
38:34that is largely to protect prisoners
38:37from other prisoners and from anyone
38:40else within the institutional setting.
38:43And that doesn't mean staff.
38:46And that can be correctional staff.
38:49They can be clinical staff or visitors,
38:51volunteers, whoever is there to
38:53protect them from being assaulted.
38:55So there are legal actions that
38:58certainly are there but but why?
39:00Why so much emphasis on
39:02important corrections?
39:03Why jails and prisons?
39:05Uh,
39:06in in one of our earlier talks this
39:09week in talking about single is
39:11this hospital and how at one point.
39:14There were over 7000 inpatients
39:17at Saint Elizabeth Hospital.
39:20This is a little before my time,
39:22but while I was there was still
39:25him between 3 and 4000.
39:27And today,
39:28Saint Louis Miss is a 291 bed hospital.
39:32So it has decreased in size greatly,
39:36and in part because of the emphasis
39:40on community based care and attempting
39:44to reduce the size of hospitals
39:47and particularly the inappropriate.
39:51Retention of individuals in hospitals
39:54that could function with the right supports.
39:58In a community.
40:00During my early early years in Chinese,
40:03when I was in fact before I was
40:05there and moonlighting as an intern
40:08as a medical officer,
40:10I wasn't trained as a psychiatrist yet,
40:13but I was assigned to sleep
40:15overnight and on call essentially.
40:17But in the building for what was
40:20the asylum division and the Asylum
40:22division that was operated by Fuller,
40:25Torrey had within it.
40:28Probably about 120 or so patients
40:30and it no one was under the age of
40:3360 and I was able to read patient
40:36records during the time that I didn't
40:38see patients and I would stay overnight.
40:41So I had a fair amount of time to do that.
40:45And I would read records that had such
40:48things as the annual progress note.
40:51Now for those of us who are aware
40:55of documentation
40:56requirements to have quote the annual
40:58progress note is quite striking,
41:01but the information was very valuable
41:04to me because it allowed me to see in
41:08actual people what I had read about
41:11or continue to read about and would
41:15read about in the future in textbooks
41:18about various forms of treatment,
41:20insulin shock, hydro therapy,
41:22various medications, barbiturates, etc.
41:24Used before thorazine.
41:26Those are things that I learned from those
41:29records in addition to the literature,
41:31but why the shift well with the reduction?
41:35In hospital population,
41:37state hospital populations,
41:38particularly, there was the expectation
41:41that the communities would step up.
41:44They would provide the resources
41:46they would be able to manage.
41:49Individuals coming from these
41:51hospitals an it wasn't only NIMBY,
41:54not in my backyard that got
41:57in the way of that,
41:59but was also funding,
42:01essentially funding for the other supports,
42:04not just.
42:05Coming to the mental health
42:08clinic once or twice a week,
42:11or once or twice a month,
42:15but also housing and vocational
42:17activities and other kinds of activities
42:20to occupy the individuals time.
42:23So with the decrease of the state
42:27hospitals and the lack of resources
42:31and acceptance within communities.
42:33Many people consider the
42:35institutionalization to be more
42:37of a trans institutionalization
42:40from hospitals to homelessness,
42:43and jails and prisons,
42:46so looking at jails and prisons.
42:50A bit of statistical information
42:51and I want to I may move through
42:54these a little bit quickly because
42:56I wanna make sure we had time
42:58for questions and discussion,
43:00so I don't want to go too fast.
43:03But I also want to make sure
43:05that we're able to do that.
43:07This data is a little bit dated,
43:09but the trends are continuing and consistent.
43:12The population of Prisons as of 2014 and now,
43:16this outdated data from
43:18the Department of Justice,
43:20Bureau of Justice Statistics
43:22that will update this.
43:23But at that point,
43:251.5 million people in prisons
43:27and 800,000 in jails.
43:29And I put the big but because when
43:32DOJ and and the rest of us research
43:36community look at jails and prisons,
43:39we tend to look at them based on
43:42the average daily population.
43:45How many people are living in
43:48the jail or the prison today?
43:51And that's what that 800 means for the jails.
43:55But 11.9 million admissions.
43:57That's how many folks come through the jails.
44:00Some who are bonded out within 24 hours,
44:04some who are released at hearing,
44:07some where the families pick
44:09them up and take them home.
44:12But a lot that can't make Bill that
44:15can't that don't have supported families.
44:18And the mentally ill are overrepresented.
44:22And the number of people who can't.
44:24Make the necessary agreement with
44:27the court to return and to be able
44:32to leave so that 11.9 is striking
44:36and the reason I place it.
44:39Yes,
44:39because.
44:40It emphasizes the need for
44:43jails to be front in loaded.
44:47Jails really require clinical staff at
44:49the front door and in the first few days,
44:53two weeks a great deal more
44:55than prisons to prisons.
44:57Most of the time are receiving individuals
45:00who have been convicted and who have
45:03already been in a jail most of the time,
45:06sometimes not, but most of the time,
45:09and therefore there is some information.
45:11There's some record.
45:12There may be some history in terms of
45:16mental health and medications and.
45:18Other interventions or not, and therefore
45:21that is an important distinction.
45:24The distinction by race,
45:26the 47% Caucasian that is
45:29true or wise at that point.
45:31Certainly that the number, the numbers,
45:34the real numbers are that there are
45:37more white people locked up than
45:40African American or Hispanic people.
45:42But when you look at the percentages
45:46compared to the population.
45:48Meaning that if Blacks comprise
45:5012% of the population,
45:52but 34% of the prison population,
45:55or if there is indeed a much greater
45:58chance that a black person or
46:01Hispanic person will be arrested,
46:03than a white person,
46:05then that starts to tilt those
46:08numbers in the direction to reflect
46:10reality rather than the raw numbers.
46:13It's like saying the jails only
46:16serve 800 people a year.
46:18That is not true.
46:20They serve over 11 to 12 million
46:24people a year and you've got to
46:28understand how those numbers work.
46:31Males dominate 86% with females 14%,
46:35but continuing increases since 1999,
46:38and part of that relates to
46:41mental health because prisons,
46:43particularly in jails as well,
46:46are not set up.
46:48In such a way that there is
46:51necessarily equality of treatment
46:54availability an resources.
46:56What do I mean by that?
46:59Let's say you have two women's
47:02units in an institution.
47:04They each hold 50 beds.
47:07You have only 60 women in the institution.
47:12So 50 or one unit,
47:13perhaps an 10 or any other?
47:16Or even if you split them up 30 and
47:1930 it means it looks like you have.
47:2340 beds that are vacant.
47:26And the folks who cut the dollars.
47:28That means the prison or the
47:31jail has available beds.
47:32The reality is that those beds can
47:35only be used for women or women.
47:37So there may be overcrowding
47:40on the men's units.
47:42But under utilization on the women's
47:44and for those institutions that hold
47:46juveniles that cannot be housed with adults,
47:49the same thing applies.
47:51Small numbers of juveniles.
47:53That make it seem that there
47:55may be some empty beds,
47:57when in fact the empty beds cannot be
48:00occupied by anyone other than juveniles.
48:03That also translates to treatment.
48:05If you have 500 military than five juveniles,
48:08it would seem the five juveniles
48:10would be much easier,
48:12but not necessarily depending on
48:14how the resources are allocated.
48:16So all of those things factor in that
48:19at my point is that the basic number.
48:23Rarely tells the whole story.
48:27Only before estimates range between
48:2915% to 60 plus percent, and that.
48:36Filed in court monitoring for.
48:40I even hate to say it.
48:4225 years, let's be conservative,
48:44and I was a court monitor in California
48:47for 18 years and it still continues.
48:50I left that monitor ship that was the
48:52court suicide expert and after writing
48:55an annual suicide report every year.
48:57Frankly I needed a break because there are
49:01things that just needed to be improved.
49:03But the estimates of how the
49:06percentages of people that are mentally
49:08ill within corrections frequently
49:10years ago we would hear well.
49:12Two percent 5%.
49:13And it would be a question how
49:16how do you derive those numbers?
49:19And most of the time it was an
49:22inadequate methodology to determine
49:23who actually is mentally ill.
49:25And in some instances,
49:27those determinations were not even
49:29made by mentali mental health staff.
49:31They were sometimes made by medical staff,
49:34sometimes made by corrections.
49:36So it was a number that didn't
49:39make a lot of sense,
49:41and I hope those of you who are in training
49:44finishing your training early career,
49:47and even some of the senior folks
49:50are hearing between the lines.
49:52My plea to you that we need you
49:55within correctional practice as.
49:57We have always needed you in hospital
49:59practice as well as community,
50:01but in corrections.
50:03You are the boots on the ground.
50:08Frontline folks who can inform the actual
50:11administrators and your colleagues
50:14in corrections, meaning officers.
50:16Deputies of wet mental illnesses.
50:20'cause they don't get it.
50:21A lot of the time.
50:22That's up to us to try to help
50:24them understand that and also help
50:26them understand what it's not.
50:28That if someone is essentially
50:30threatening and misbehavior and
50:32doing all kinds of bad things,
50:34that does not necessarily mean
50:36their mental eel,
50:37but it certainly means that someone
50:39ought to give an opinion or try
50:42to assess if mental health or
50:44mental illness has something to
50:46do with the behavior.
50:47Those numbers of 15 or 60%.
50:50The 60%'s are particularly relevant to women.
50:53That women incarcerated women,
50:55which is much higher of those who
50:58have serious mental illness or who
51:01have mental illness that might not
51:04qualify under the definition of SMI.
51:07But then again,
51:08it very well might,
51:10and PTSD is a major concern within the
51:14female populations of many jails and prisons.
51:17But in terms of mental illness and impact.
51:21Jail deaths the number one cause of
51:24jail deaths in the country is by suicide.
51:32Jails are different than prisons
51:34in many ways, but one way.
51:38Is that individuals coming into the
51:41jail are coming from the street?
51:44They're coming from the community.
51:47Individuals coming into the prison may
51:49most of the time, as I've mentioned,
51:52be coming from an institution of some type,
51:54usually a jail.
51:56So when someone's coming from the street,
51:59that means the head originality and
52:02I genetically of that population
52:04is quite striking.
52:06You have people who.
52:07It's their first time of being incarcerated,
52:11and that sometimes it is irrelevant of age.
52:14Mean. Think of yourself if you've never been
52:19locked up and you suddenly wake up in a jail.
52:24It may or may not remember how you got there.
52:26It may or may not have been justifiable,
52:28but there you are.
52:30And you not been there before and maybe
52:33you haven't worked in a such a place.
52:35So it has an impact on how you feel and
52:38what is going on with you, and you could be.
52:4318 and you could be 58.
52:46And it could be the first time
52:49and it make a major impact on
52:52your desire to continue to live.
52:54So you have jail suicides as
52:57the number one cause of death.
52:59And that means that jails really
53:01have to be intensive in their
53:04screening and referral processes
53:05at the front door starts with the
53:08officer with the booking officer
53:10and in fact it should start before
53:13that with the arresting officer.
53:16Most booking screening forms have a
53:19question on them that has something to
53:22do with the arresting officer Reportes.
53:26That the individual arrestee was
53:28behaving bizarrely or did this,
53:31or did that or something.
53:34That gives the booking officer
53:37some idea that something was going
53:39on before this man or woman or
53:42juvenile came into the facility.
53:44But after that then medical has a
53:47role in screening and identifying what
53:49kinds of issues may be of concern,
53:52both from a medical Anna Dental Anna
53:55mental health perspective and that's
53:57where the triggers both of the booking
54:00officer and the medical screening begin
54:03the process of involving mental health.
54:05And that's where we come in.
54:08So we need you.
54:09You'll notice the number 240%
54:11within the first seven days.
54:13That's funny and loaded.
54:14That's adjustment,
54:15that's how am I gonna make it
54:18through this situation that I'm in.
54:20And if you already come in.
54:22Compromised in some way,
54:24you have a mental illness.
54:26Perhaps you were not on prescribed
54:28medication that you haven't been
54:30taking it for awhile and therefore the
54:33impact or effects of not taking it.
54:35Are impacting you now.
54:37Perhaps it was a substance or alcohol
54:40use issue an you are still intoxicated
54:44or withdrawing from a substance,
54:47so all of those things are happening
54:50in the first days of incarceration.
54:54Suicide deaths,
54:55almost half and general housing
54:58or population.
54:59That's where people sometimes
55:01get lossed because in population
55:04we don't have eyes on them as we
55:07would in a mental health unit.
55:09And some places don't have
55:11mental health units, so it's not
55:14something that has the attention.
55:16Or attentiveness that we would hope to
55:19have for someone we've identified with a
55:22serious mental health issue or problem.
55:25Suicide rate in jails increased.
55:29And it contains, as in,
55:31can't continue to increase,
55:32and as you see at the end to 50 per 100,000,
55:36that's where the jail population versus
55:39the jail admissions comes into play.
55:42Because those numbers are based
55:44on the average daily population.
55:47So if you have a jail of 100 people.
55:50And you have one suicide in that jail.
55:54That would give you a rate.
55:56Up 10 or I'm sorry.
55:59100 per 100,000.
56:02So you would be way up there with one
56:05suicide because you have such a small jail,
56:08so many of the folks who look at
56:11jails and who manage jails are
56:13concerned that little jails like that
56:16back are compared to mega jails,
56:18where there are thousands of inmates.
56:21I believe it was Doctor Tori and Company
56:24who published data that the largest
56:27mental health facility in the country
56:29at that time was the Ellee County Jail.
56:32Because if 10% of a 17,000
56:36population jail is mentally ill.
56:401700 that's bigger than most,
56:42if not all of the inpatient
56:45psychiatric facilities in the country.
56:48So that's why the suicide rates
56:51are measured in per 100,000.
56:54But with jails you gotta be careful that
56:58it represents the actual volume of an of.
57:03Of intakes and individuals coming into.
57:08You don't have to be as you can see
57:12from the slide in a jail for very long,
57:15and things can really happen badly.
57:18The suicide rate by race.
57:20The rates have been fairly consistent
57:22in that sense of who is got the
57:26highest rates in lower rates
57:27with the exception of Hispanics.
57:30Hispanic rates have been increasing.
57:32Over the years and the questions
57:35have largely to do with whether or
57:37not adequate treatment an assessment
57:40is happening for individuals who
57:42may not speak English or may not be
57:45able to communicate their issues
57:47as clearly as others.
57:50It's important to look at I mentioned
57:52earlier our training as mental health
57:55professionals an looking at the
57:57individual and then we come together
58:00as a treatment team treatment in
58:02mental health or different than
58:04the rest of medicine.
58:05Medicine generally works on a doctor patient.
58:08I'm sorry the doctor, Nurse,
58:10patient model.
58:12And the consultants an other kinds
58:15of information that comes through
58:17various testing etc are part
58:19of that model in mental health,
58:22which talking about a multidisciplinary
58:25team where everyone has expertise in
58:28their areas to bring to the table.
58:30That's how we generally are trained
58:33interest in the individual.
58:35But what about corrections?
58:37What are their mission statements?
58:39What are their visions?
58:41And these are representations
58:43of my own views, certainly,
58:46and reviews of various jails and
58:48prisons who typically had their mission
58:51and goal statements posted in their
58:54lobbies of administrative building,
58:56sometimes in their outline
58:58housing facilities as well,
59:00so that everyone has an idea
59:03of what they are about,
59:06what their purpose is,
59:08and I compiled some of this I.
59:12As I mentioned,
59:13I have been monitoring different places.
59:15Sometimes that means long flights
59:16and on one of those long flights
59:19I started counting just writing
59:20down 'cause I couldn't get to sleep
59:23when it was out it was one of those
59:26red eyes night.
59:27Just decide here,
59:28let me occupy my mind and what I
59:31did was started writing down the
59:32jails and prisons that I had
59:34personally been to at least once.
59:36And when I got to 100 I stopped.
59:39But in looking at what they state.
59:43As their purpose, number one custody,
59:45and confinement that when someone is
59:48committed to them, their primary purpose,
59:51in addition to some of the others,
59:54is to maintain custody and to
59:57maintain confinement that is, in part,
59:59why there's so many counts every
01:00:01day in any correctional system,
01:00:04there are counts,
01:00:06multiple counts.
01:00:06How many inmates everybody has
01:00:09to be accounted for.
01:00:10And if the count is off by 1.
01:00:15Many places shut down right now until we
01:00:18figure out where that one inmate it is,
01:00:21and I an if it is an escape,
01:00:25then the whole community becomes aware.
01:00:27An enterprise that something is
01:00:30going on the system.
01:00:33Turns on to find the missing
01:00:36inmate and I had the unfortunate.
01:00:39Situation to be in an institution
01:00:41where the count was off once
01:00:43and I happen to be there at the
01:00:46time. And the couple's off at lock down.
01:00:49And there was a meeting.
01:00:51Kind of a control meeting,
01:00:53and the representative from
01:00:54the unit was saying, well,
01:00:56yeah, we're off by one.
01:00:58And the deputy was there too.
01:01:00And the deputy said, yeah,
01:01:02yeah, well, you know, I.
01:01:04I made the account and without that one
01:01:08there was a dummy in one cell hanging.
01:01:12Wasn't a dummy.
01:01:14It's those kinds of things that sober
01:01:18you when you are doing this kind of
01:01:22work and how important it is for us
01:01:26to be a part of the training and
01:01:29part of the reality that people who
01:01:32are charged with monitoring and and
01:01:35having control custody confinement.
01:01:38What they understand about the role of
01:01:40mental health and why it's important
01:01:42that we're involved with them.
01:01:44As I mentioned when I first
01:01:46started doing this, lots of times,
01:01:48people didn't want to see me.
01:01:50I finally realized that it was
01:01:52important for me to try to
01:01:54understand what they want it.
01:01:56And I found myself asking instead of when
01:01:59going on a segregation unit for example,
01:02:02instead of going there and
01:02:03saying I'm doctor Patterson,
01:02:05I'm gonna make rounds.
01:02:06I wanna see what's going on.
01:02:08I would go there and ask the duty officer,
01:02:12whichever it might be who your problem
01:02:14guys who give you the most trouble.
01:02:17And if I started it with that,
01:02:19I get responses like oh the guy up
01:02:21there on the second tier and cell
01:02:23number 12 he floods every night.
01:02:25He's banging on the door.
01:02:26The other inmates hate him because
01:02:28he's keeping him awake at night.
01:02:29It's it.
01:02:30That is valuable information for
01:02:32me to try to figure out what's
01:02:36going on with that guy,
01:02:38but it also establishes with that officer
01:02:41that what they're experiencing is important.
01:02:44And maybe there's something I can
01:02:46do to help with that disruption.
01:02:49And it's not locking him down.
01:02:52It's not putting him in restraints.
01:02:54It's let's seeing what's going on.
01:02:57Second issue,
01:02:58public safety and the public safety
01:03:00has expanded the public safety,
01:03:02largely applied to keeping
01:03:03the community safe.
01:03:04This is what we're here for,
01:03:06and you find this,
01:03:08or at least I found this.
01:03:11Uh,
01:03:11particularly important and prominent
01:03:14in some of the rural prisons
01:03:17because that prison maybe the
01:03:20the great the highest employer.
01:03:24Our people in that particular community,
01:03:26so it's not just that I work at the prison.
01:03:30My uncle works at the prison.
01:03:32My sister works in the prison at the prison.
01:03:35My Gran father used to work at the prison.
01:03:39My son's gonna work at the prison.
01:03:41It's that kind of investment and involvement,
01:03:44but it also comes with what can
01:03:46be the old way of doing business.
01:03:49We do it this way,
01:03:51'cause we've always done it this way.
01:03:55And we don't understand mental illness,
01:03:57but we really don't want to because
01:04:00we already know what to do with them.
01:04:03It's that kind of stigma that
01:04:05sometimes gets in the
01:04:06way of trying to have a reasonable dialogue.
01:04:10The public safety issue more often the
01:04:12safety for staff and inmates safety
01:04:14for inmates was not a high priority,
01:04:17and some of the legal actions we've
01:04:20already taken a quick look at alright
01:04:22in the service of trying to assure.
01:04:25That both staff and inmates are safe.
01:04:29In many systems.
01:04:30When I again 1st of this punishment
01:04:33was a part of the mission statement.
01:04:36It was not hidden,
01:04:37it was simply a part.
01:04:39This is what we do in most places,
01:04:42has been replaced by rehabilitation.
01:04:43The questions, largely for folks like us,
01:04:46is what does that actually mean?
01:04:48What do you mean by rehabilitation?
01:04:51Does it mean that you have a a work
01:04:54program and that you have some training?
01:04:57Now one of the women's prisons I went
01:04:59to had a women's welding training.
01:05:02Ann is one of the most fascinating
01:05:05things to walk into a workshop with
01:05:07women wearing these helmets that
01:05:10welders helmet San with torches
01:05:11in their hands doing work and
01:05:14there were no problems with it.
01:05:16There were no issues with it and
01:05:19it was very well managed so.
01:05:21There are ways to make this happen.
01:05:24Is that rehabilitation or do
01:05:26you mean something else and
01:05:28it is particularly striking?
01:05:30Sometimes the exclusions,
01:05:31people who are on the mental
01:05:34health caseload can have jobs.
01:05:36Well,
01:05:36people who are the middle or
01:05:39medication where they can make
01:05:40they can't go to a camp a level one
01:05:43meaning minimum security facility
01:05:45because you know they they they
01:05:48might not get their medication.
01:05:50We don't have a nurse out there
01:05:53so they can go out to a camp.
01:05:55So their actual placement within
01:05:57the security system of the prison
01:06:00may be influenced by the lack of
01:06:02staff to actually do treatment,
01:06:04rehabilitation etc.
01:06:05Humane and rehabilitative environment.
01:06:07Changing the environment.
01:06:08The prison that I showed you
01:06:11a little while ago.
01:06:13Philadelphia that prison model can be
01:06:15seen across the country just as state
01:06:18hospital models are similar in various
01:06:21places depending on when they were built.
01:06:24Were looking at Saint Elizabeths and
01:06:27compared to Connecticut Valley Hospital,
01:06:29they have similar kinds of histories,
01:06:32but they also have different histories,
01:06:34but in terms of the construction.
01:06:37And the way that the buildings are
01:06:40made sometimes they don't promote
01:06:42or rehabilitative environment.
01:06:44Sometimes they don't promote
01:06:46a Humane environment.
01:06:47Many new facilities replace
01:06:49bars with solid doors,
01:06:51their pluses and minuses to that.
01:06:54And if the solid door has a vision panel,
01:06:58a window that's.
01:07:004 by 4 inches.
01:07:03That's not helpful to anyone
01:07:04because you can't see in it an.
01:07:07The occupant really can't see much out of
01:07:09it except what's right in front of them.
01:07:12So if you're talking about perhaps
01:07:14having someone on a suicide precaution
01:07:16and you can't see in the cell or
01:07:19it's being done by camera watch,
01:07:21which is one of my particular.
01:07:24Problematic areas because sometimes
01:07:26people aren't watching the monitors
01:07:28or the monitors are broken or
01:07:31there are 20 cameras that
01:07:32someone is supposed to watch for
01:07:34six or eight hours at a time.
01:07:39Difficult. For people to do so,
01:07:41I have really issues with that
01:07:42which we can come back to.
01:07:44And Lastly, a positive reentry of offenders.
01:07:48Even the concept.
01:07:49That the jail or prison has anything to do
01:07:54with what happens after someone leaves.
01:07:57Is something that has been
01:07:59a hard sell in many places.
01:08:01Dot that's not our problem.
01:08:03We are responsible for when they
01:08:06hear what happens after they leave.
01:08:08Has nothing to do with us.
01:08:11There are some facilities and systems
01:08:13who have undertaken certain things
01:08:15that seem to make a lot of sense,
01:08:17like not releasing inmates in the middle
01:08:19of night at 12:00 or 2:12 o'clock in
01:08:22the morning 1:00 o'clock in the morning.
01:08:24What clinic is open if someone supposed
01:08:27to show up at a clinic and say here
01:08:30I've got this piece of paper from the
01:08:32jail or from the prison and says,
01:08:34look I I've used that I need some
01:08:37help and here's the person to call
01:08:39if you want some more information
01:08:42or the number itself.
01:08:43What time are they open?
01:08:45They're not open at one or two
01:08:46in the morning.
01:08:47What is open that wanted to in the morning?
01:08:49Well, most places the liquor store is open.
01:08:52Most places the pharmaceutical
01:08:55representative on the corner is open.
01:08:59But the treatment environments are not,
01:09:01so some systems have said no,
01:09:04we're not going to do that,
01:09:06will just release people
01:09:08during normal business hours,
01:09:09so that maybe they can complete
01:09:12some normal business.
01:09:13There are others that will not take
01:09:15people off of suicide precautions
01:09:18or watch on a Friday.
01:09:20Because they are short staffed,
01:09:22not just them,
01:09:23but corrections on Saturday and Sunday,
01:09:25so they know their monitoring
01:09:27of individuals is going to be
01:09:30less during the weekend.
01:09:31So sometimes they think
01:09:33it through and decide.
01:09:34We really shouldn't do that.
01:09:36Let's wait until our team is actually
01:09:39here rather than having to be an on call.
01:09:42Someone calling the on call Doctor Who
01:09:45doesn't know the person and saying what
01:09:47should we do so the actual integration.
01:09:50With the community both within the system,
01:09:54the prison system itself or the jail
01:09:56and the External Committee has advanced.
01:10:00But all these things.
01:10:02Have,
01:10:03for my perspective,
01:10:04kind of landmark things that happen
01:10:07along the way that made a difference
01:10:10in people getting adequate care within
01:10:13correctional correctional environments
01:10:15and remember it started with.
01:10:18If you didn't have someone to support
01:10:21you at home or in your community,
01:10:25you're more likely than not to
01:10:28be incarcerated by virtue of your
01:10:32mental illness and behavior.
01:10:34From that illness and the attitudes of
01:10:37whomever are observing that behavior.
01:10:40So what happened with that?
01:10:42Well in the free world?
01:10:45There was a free World Hospital
01:10:47movement that is a virtue that
01:10:50Dorothea Dix and I that is there
01:10:53largely because Dorothea Dix had a
01:10:55great deal to do with the establishment
01:10:58of Saint Elizabeth Hospital.
01:11:01And in 1855 is when Saint
01:11:05Elizabeth's Hospital opened.
01:11:06And it's 7th patient which I
01:11:09mentioned earlier this week.
01:11:11Was Richard Lawrence,
01:11:13who who had attempted to assassinate
01:11:16President Andrew Jackson.
01:11:17So from its very beginning there
01:11:20was a relationship with the
01:11:23criminal justice system in that way.
01:11:26But Saint Elizabeth was largely a
01:11:29military was for military personnel
01:11:31during its most early days,
01:11:34and all the way through World War Two,
01:11:38and then shifted to actually
01:11:40being responsible for.
01:11:42Mental health care of individuals
01:11:44in the District of Columbia,
01:11:46as well as a number of other territories.
01:11:49And, as I mentioned earlier,
01:11:51or any of us,
01:11:53any citizen of the United States became
01:11:55mentally ill in a foreign country
01:11:58would be brought back to Saint Elizabeth's.
01:12:01Not necessarily to your home state,
01:12:04but to cenis.
01:12:05If you were in need of mental health care,
01:12:09so the Free World Hospital movement took off.
01:12:12In the sense of starting to move
01:12:15people from the incarcerated punitive
01:12:18environment to a hospital environment,
01:12:22that hospital environment was supported,
01:12:25and.
01:12:27Across the country and continue to grow
01:12:31until another important act and this one.
01:12:34The CMHS act.
01:12:36Community Community Mental Health Center
01:12:39community mental Health Systems Act of 19.
01:12:42Services act.
01:12:43I'm sorry in 1963 and that act
01:12:47essentially was enacted to try to
01:12:50reverse some of the atrocities.
01:12:52Some of the ugly or bad that
01:12:56it happened within.
01:12:58Hospital systems for a variety of reasons,
01:13:00but the intent was that there were people
01:13:04who didn't need to be in a state hospital.
01:13:07They had been there for too long.
01:13:10They have been there when
01:13:12they were functioning.
01:13:14When they could be in the community
01:13:16and this act was essentially to
01:13:19try to support the development of
01:13:22community services so that individuals
01:13:24could indeed get to the kinds
01:13:27of services they needed outside
01:13:29of a hospital and the overall.
01:13:34I guess description of that process
01:13:39was the institutionalization.
01:13:41And those of us who have been involved
01:13:44in this work in various capacities.
01:13:47Like myself, may tend to see
01:13:50that as the institutionalization
01:13:51versus trans institutionalization.
01:13:54Did we move people from one
01:13:58institution setting to another one?
01:14:01And the other two that come to
01:14:03mind are the streets, homelessness,
01:14:06the homeless population.
01:14:07And I will tell you there are
01:14:10people there were in my own
01:14:12history with Saint Elizabeth.
01:14:14The police would bring people to our,
01:14:17ER, psychiatric emergency room.
01:14:19And it wasn't until meeting with
01:14:21some of the police administrators
01:14:23that we understood that they did.
01:14:26They didn't want to bring him to the
01:14:29hospital because they had to wait.
01:14:32Four and five and six hours for
01:14:34the individual would be evaluated
01:14:36and whether the hospital was going
01:14:39to keep them so it was easier.
01:14:41For them, the police to take him to the jail.
01:14:45'cause they could drop him off
01:14:46at the jail and get back out on
01:14:49the street and fight crime.
01:14:50So why would they bring them to us?
01:14:53Well,
01:14:53we worked out an agreement that our
01:14:55own security would be responsible for
01:14:57the individual once they came to us
01:15:00and the police could get back out there.
01:15:02And the number of admissions that we got.
01:15:08Increased,
01:15:08I won't say exponentially,
01:15:10but certainly dramatically because
01:15:12we were getting people who indeed
01:15:15were sometimes intoxicated,
01:15:17sometimes were clearly clearly
01:15:19psychotic and in need of our help.
01:15:23And during the PCP epidemic that we
01:15:26had in Washington phencyclidine we
01:15:29were urine testing every admission
01:15:32that came to the hospital because we
01:15:36couldn't tell, was this PCP intoxication.
01:15:39Or delirium? Or was it schizophrenia?
01:15:42Wasn't bipolar disorder back then?
01:15:44Manic depressive disorder we couldn't
01:15:46tell because the behaviors were
01:15:49so similar it was only after a
01:15:51kind of dry out washout period of
01:15:54a few days that we could actually
01:15:56get a sense of who was.
01:15:59Intoxicated or withdrawing,
01:16:01and who was indeed had a primary,
01:16:04serious or persistent mental mental illness.
01:16:08So the homeless population
01:16:10continued to increase,
01:16:12but also the population in our jails.
01:16:15An our prisons.
01:16:18And for the jails.
01:16:21The meter fences, the kinds of things that
01:16:24we sometimes we call ticky, tack crimes.
01:16:26You go into 711 and try to steal.
01:16:29You know a box of Donuts.
01:16:32And get caught with that.
01:16:33Is that a jail offense?
01:16:35Well, yeah, it's breaking a law, it's theft.
01:16:38It's a misdemeanor.
01:16:40How many of those folks ended up in the jail?
01:16:44How many of them got a 711
01:16:46and ended up on the streets?
01:16:49So the trans institutionalization
01:16:50is a reality,
01:16:51but it can't simply replace some
01:16:54of the protections that individuals
01:16:56have about their their freedom.
01:16:58So the.
01:17:00Couple of cases just to keep in mind,
01:17:04but I took the Jones is a 1980
01:17:06case and it basically says that
01:17:09if you are incarcerated the state
01:17:12the system cannot simply send you
01:17:15to a mental hospital
01:17:16without due process without
01:17:18there being a hearing or process.
01:17:21Hopefully before but certainly if not before,
01:17:24within a reasonable time after
01:17:26a transfer to a hospital.
01:17:28So even then it extends prisoners rights too.
01:17:31Their own Freedom,
01:17:33Liberty to say I don't want to be in
01:17:36hospital I don't wanna go to the mental
01:17:38hospital I don't want to to have the
01:17:41guys here think I'm I'm mentally ill.
01:17:44'cause then they'll they'll treat
01:17:45me differently when I come back
01:17:48so the stigma is still there.
01:17:49Kansas V Hendricks gives some.
01:17:53Opportunity for corrections to
01:17:54Medicaid or treat someone when it's
01:17:57in the interest of the institution,
01:17:59so that gets into a fuzzy area.
01:18:02Visited the individual.
01:18:03Or is it the institution?
01:18:05And what does that mean and how is it?
01:18:08How is it in history?
01:18:10So these are again protections
01:18:12that are intended to make sure
01:18:15that someone is in the right place
01:18:17and that they have protections
01:18:19for being in the wrong place.
01:18:24Ray Ray after
01:18:25interrupt for a
01:18:26minute 'cause we're running out of time.
01:18:29People don't usually stay after 11:30 or so,
01:18:32so if they want you want any questions.
01:18:36We're going to only be able to take a couple.
01:18:39OK, that's fine.
01:18:40Let me stop here because the rest
01:18:42of this presentation has largely
01:18:44to do with monitoring and that an
01:18:46outbound ended with this point.
01:18:48However, just to make sure I mentioned,
01:18:50we need to all underground we need
01:18:52you in the institutions we need to
01:18:55actually providing that information.
01:18:56But we also need you in the role that I
01:18:59serve for several courts at this point,
01:19:02monitoring being able to look at the
01:19:04documents that the parties have agreed on.
01:19:07This is what should be happening
01:19:09within an institution.
01:19:10And here's the expert to come in and
01:19:12help the court determined that that
01:19:14indeed is happening or not happening.
01:19:16So I apologize for going so long,
01:19:18but I could spend the rest of
01:19:20the three days with you guys,
01:19:22so I'll stop there.
01:19:23Howard and we can open it.
01:19:30I just wanted to add to that one of
01:19:33the things that has helped us in
01:19:36the Department with the uncles and
01:19:38families they contributed to a prize
01:19:41that we give to some of our graduates
01:19:46who have shown themselves to be.
01:19:49Uh. Excellence in care and either
01:19:53click clinical and forensic work
01:19:56and this year we're awarding it
01:19:59to Doctor Vineeth Carvalho.
01:20:01Who worked in the prison system at
01:20:03the women's prison in Connecticut
01:20:05from 2006 until just a year or two
01:20:08ago when she moved to the state
01:20:10hospital and she made an enormous
01:20:13difference within that setting?
01:20:14She can't be here today.
01:20:16We usually give the award on Thursday night,
01:20:19but will do it a graduation.
01:20:21But I just wanted to take a minute
01:20:24to to let people know about that.
01:20:27Script.
01:20:42I guess we are. Anybody have any questions?
01:20:45Wake up, just unmute yourself.
01:20:56Doctor Patterson Smith and this is a
01:21:01informative and nicer great lecture.
01:21:03I really appreciate your time
01:21:06and talking with us today.
01:21:09I do gotta trained at Saint Elizabeth
01:21:12Hospital from 2002 to about
01:21:152004 and I just psychologist it,
01:21:18Howard Pavilion and really great.
01:21:21Great experience for me and one
01:21:24of the things that was concerning
01:21:27to me was when I saw that the age
01:21:31requirements for working in the
01:21:34federal prisons is 30 under 36.
01:21:38Do you know if there will be any
01:21:40change in terms of the age requirements
01:21:42for psychologists to be working?
01:21:44Rather people to be working
01:21:45in the prison system?
01:21:47The federal prison system?
01:21:49Thank you Carolyn.
01:21:50I I I don't know if there's any
01:21:53any proposed change for that,
01:21:55and frankly it it surprises me if
01:21:58there would be any kind of age limit
01:22:01like that on on clinicians to to be
01:22:04involved with programs that that.
01:22:07From my perspective makes no sense,
01:22:09but I don't know if there's any
01:22:11plan to make a change in that so.
01:22:15Amazing. Yeah, thank you.
01:22:18You're welcome, you're welcome.
01:22:25Damn, you had some comments.
01:22:27Yes I am. I have worked in
01:22:31prisons before, not usually.
01:22:32I've never worked but formerly
01:22:35hired by a prison, but I worked.
01:22:38Both as a forensic social worker going
01:22:41into prisons to do evaluations on
01:22:44people and assessments for the court.
01:22:47Or I worked with serious people
01:22:50who were who were identified
01:22:52as serious juvenile offenders.
01:22:55You know they try to help get them out of
01:22:57prison for either for largely for problem,
01:23:00****** behavior.
01:23:01Uhm, and trying to, you know,
01:23:04educate people around risk and how
01:23:07you know the you know the some
01:23:10of the causes of pedophilia and
01:23:13****** abuse are not best remedied
01:23:17by putting people in isolation.
01:23:19Or locking them up,
01:23:21and I mean it's true for most every
01:23:23kind of problem behavior, right?
01:23:27So you know.
01:23:27So a lot of it was training
01:23:30people to do some of the work,
01:23:32but one of the things that I've found,
01:23:34I've also done a lot of reentry work.
01:23:37And in Connecticut,
01:23:38and worked a lot in in all of the
01:23:41different prisons in the state.
01:23:42And one of the biggest issues
01:23:46that I see in terms of.
01:23:49Having mental health professionals
01:23:51be more involved and have really
01:23:54any kind of influence in terms of
01:23:56the treatment that people receive.
01:23:58Is I mean the lack of funding for that,
01:24:01it's just not seeing? Is that important?
01:24:04In less, you know, we're going to put him on,
01:24:07you know,
01:24:07Thorazine or something that's going to,
01:24:09you know, make them. You know, stuporous.
01:24:12And you know, keep them from being at all.
01:24:15In datable,
01:24:16so I mean there needs to be so much
01:24:18education and and real education at
01:24:21the legislative level to increase
01:24:23funding so that we can provide adequate care.
01:24:26But I think quite honestly that
01:24:28you know an I realized that I may
01:24:31be preaching to the choir here,
01:24:33but I feel like we need to do
01:24:36things prior to that.
01:24:38Like we need to really explore and embrace.
01:24:42The idea of an as I said this and
01:24:44some of my comments of putting
01:24:47mental health professionals making
01:24:49as part of policing etc.
01:24:51I mean, I don't think policing is the answer,
01:24:54but you know having some other kind of
01:24:58service like we have services for people.
01:25:01Under the name of it,
01:25:02but where you're active in the community,
01:25:04working with the homeless,
01:25:06trying to engage the homeless.
01:25:08And you know to try to help get them.
01:25:11The mental health care they need
01:25:13before they get arrested for loitering
01:25:15or having you know what I mean.
01:25:17Doing something,
01:25:17disrupting the peace and being incarcerated.
01:25:19And I mean it goes on and on.
01:25:22But there's just so much education
01:25:24and then there needs to be a real
01:25:26commitment to it in terms of funding.
01:25:28Otherwise, it's just not gonna happen.
01:25:31And I think it goes hand in
01:25:33hand with the whole,
01:25:35you know,
01:25:36restructuring of how we think about
01:25:39police and the policing and the.
01:25:41The laws that allow them to you know to why
01:25:44do they have to pull a gun in every instance?
01:25:47Why do they have to?
01:25:48I mean it, it's so much bigger
01:25:50and I I could like the law so,
01:25:52but anyway it's just.
01:25:55It's just a major problem and I
01:25:57think funding and education have to be,
01:25:59you know, education. First,
01:26:01'cause that's how will get the funding,
01:26:03but they're just really needs to be
01:26:05a push if we're gonna see systemic
01:26:07change and less you know less trans
01:26:10institutionalization of people
01:26:11from you know hospitals you know.
01:26:14And making making that,
01:26:15making the prisons,
01:26:16dumping grounds for people that
01:26:18we don't really want to know more
01:26:20about it next society so families
01:26:22know they're great points.
01:26:24And I couldn't agree with you more and.
01:26:27Let me tell you, for for a short time
01:26:29I was Commissioner of Mental Health in
01:26:32DC and I from my Firenze background
01:26:34just as as most of us here on this line
01:26:37and done reviewed records in preparation for
01:26:39going to court and trials and hearings etc.
01:26:41And what do I find those records?
01:26:43A lot of disruption,
01:26:44family disruption, school stuff.
01:26:45So I started going to the schools
01:26:48as Commissioners say look,
01:26:49let me let me find out what's
01:26:51going on with these kids, right?
01:26:53So I went to high schools,
01:26:54realized it was too late so I
01:26:57started going to middle schools.
01:26:58Realize that this is I was.
01:27:01Too late, so when you say education,
01:27:03I agree with you.
01:27:04Educating policy makers,
01:27:05people control powers.
01:27:06I know that's what you mean,
01:27:08but I also expand that to include
01:27:11getting interventions early on before
01:27:12they get to us before they get to
01:27:14forensic before they get to corrections.
01:27:17How about you look at that stuff?
01:27:19But what I've also learned over
01:27:21time is that simply because it might
01:27:23be the right thing to do or good
01:27:26idea or right idea doesn't make
01:27:28it happen and I will give you a.
01:27:31Real life example.
01:27:32Right now Covid right now if you look
01:27:35across the spectrum of how correction
01:27:38institutions have responded to covid,
01:27:40there are some systems that have said,
01:27:43OK,
01:27:43let's get our inmates and our staff vaccinate
01:27:46their others where legislators or ever since.
01:27:49We're not paying for that for those
01:27:52damn criminals you know there we,
01:27:54we gotta get every so the inside
01:27:57of a Correctional Facility where
01:27:59people cannot leave but for age.
01:28:02It's not so different than
01:28:04the inside of a nursing home.
01:28:07Right, so how do we fund one?
01:28:09But we don't fund the other,
01:28:11so I understand what you're
01:28:13saying and part of our role.
01:28:16Is not only to talk about the
01:28:18science and say what we know
01:28:20and what we think we know,
01:28:22but also to talk about impact.
01:28:23And when I talk to folks about fund systems,
01:28:26what I say to them is you know what
01:28:29most of the guys and women in your jail
01:28:31or in your prison are coming home.
01:28:34They coming back here so it happens
01:28:36to them while they're incarcerated
01:28:38has certainly an impact on how they
01:28:41see the world and how they're going
01:28:43to be when they come back to you.
01:28:45So how about?
01:28:46We try to manage what we can manage
01:28:48and connect to the outside world,
01:28:51and there's some systems at
01:28:53Philadelphia's a good example I
01:28:55think where they try very hard and I
01:28:58think successfully to be able to get
01:29:01entitlements reestablished before somebody.
01:29:02What made you cut off all
01:29:04the funding they get out?
01:29:05They got no money.
01:29:08Well, that's happening in Connecticut,
01:29:09but it doesn't happen consistently,
01:29:11and it's a major problem 'cause people
01:29:12end up returning to the neighborhoods
01:29:14they don't have a place to live.
01:29:16There are all kinds of
01:29:18bands and restrictions.
01:29:18They get dropped off at 4:00
01:29:20in the morning or Whaley Ave.
01:29:23You know where there's
01:29:24nothing healthy happening,
01:29:25you know and they get caught right back up,
01:29:28back up and you know so it's just a set up.
01:29:32No, OK, I
01:29:33think we'll have to formally
01:29:36stop at this point and.
01:29:38If they want to take anymore questions,
01:29:41that's OK, but I have to give
01:29:43people permission to leave.
01:29:45I think at this point, so thanks a lot.
01:29:51Thank you everyone that has to go
01:29:53and I will stay here for however long,
01:29:55but thank you all very much.
01:29:57I appreciate it and again,
01:29:59I apologize if we went too far in this
01:30:01guy and not enough time for discussion.
01:30:03But again, that's part of what it
01:30:05is effect impacting by virtual.
01:30:07If we were all in the same place
01:30:09we right now be in the front
01:30:11of an auditorium or somewhere
01:30:13talking together and.
01:30:14Share it so I I regret that too.
01:30:17But again, I want to extend my
01:30:20appreciation once again to yell to
01:30:22everyone who's been involved with
01:30:23this and making sure this happens.
01:30:26Trischen and Company and trying to make
01:30:28sure that I'm not overly challenged.
01:30:30And of course the Yochelson
01:30:32family or making this process.
01:30:34And this this seminar of reality.
01:30:36So my thanks to you for that.