Reginald A. Wilkinson, Ed.D., Director
Ohio Department of Rehabilitation and Correction

Correctional Mental Health Report, January/February 2000

American Correctional Association

ASCA President's Corner

Community Justice

Diversity

International Corrections

Lucasville Disturbance

Management

Offender Programming

Offender Reentry

Prison Health Care

Prison Life

Technology

The daily challenges that confront a correctional agency are wide-ranging and formidable. The Ohio Department of Rehabilitation and Correction (DRC), the nation’s fifth largest state corrections system, is no exception. In addition to operating 31 prisons, the agency is responsible for parole supervision statewide and probation supervision in 50 of Ohio’s 88 counties. One of the monumental challenges facing DRC is health service delivery system for these offenders.

The demographics of prison populations in Ohio, and elsewhere, are changing so that those with mental illness are with us in large and growing numbers. The recent Bureau of Justice Statistics (BJS) Report (July 1999) estimated that about 16% of all prison inmates were reported as mentally ill. That is an estimated 283,800 inmates and consequently make those in my position de facto "mental health directors" as well as corrections directors, like it or not.

There is a long history in our quest to address mental illness in Ohio’s prisons. However, the lofty goal of providing a holistic mental health system became increasingly compromised by evolving budget limitations. Ohio has traditionally been one of the most crowded prison systems in the nation, and security issues came to the forefront. Thus, state appropriations for mental health services, while not ignored, were insufficient given the large and growing percentage of incarcerants with serious mental illnesses.

DRC’s Renaissance in Mental Care.  Two major events took place, which gave rise to DRC’s renaissance in prison mental health care. First, in 1993, Ohio experienced a prison riot at the Southern Ohio Correctional Facility in Lucasville. Nine inmates and one employee were killed. This event put the Department under the public microscope. No single facet of our operations was left unexplored, including mental health services. Second, on October 6, 1993, the Dunn v. Voinovich lawsuit was filed in federal court in Cincinnati, claiming that care for prisoners with serious mental illness was constitutionally inadequate, This litigation was settled and resulted in a five-year consent decree, which is expected to terminate in the year 2000. It’s important to state that DRC realized that changes were needed, and this litigation from inception to resolution to implementation was seldom contentious.

Fred Cohen, the court- appointed Monitor, was very candid about needed changes as well as amenable to taking our positions on issues into consideration. (See Fred Cohen & Sharon Aungst, "Prison Mental Health Care: Dispute Resolution and Monitoring in Ohio," 33 Crim L. Bull. 299 (1997), for a thorough discussion of the dynamics of the lawsuit and the relationship between monitoring and achieving organizational change and, ultimately, decision-making autonomy.)

In conjunction with the decree, DRC assumed all clinical health care responsibilities for the inmate population. Previously, this was a function of the Ohio Department of Mental Health (DMH). DRC also assumed control of the state’s hospital for mentally ill prisoners. The Oakwood Forensic Center (formerly for the "criminally insane") was recommissioned as the Oakwood Correctional Facility (OCF). Subsequently, the OCF earned a Joint Commission on Accreditation of Healthcare Organizations and American Correctional Association accreditation. With these changes, I was well on my way to what I described as a de facto mental health director, and I was determined to use the consent decree as a wedge in the creation of the best possible correctional mental health system. I became increasingly convinced that good mental health was also good security and that spending early, so to speak, meant spending less later, and, ultimately, good mental health care in prisons means better protection for the community. Our inmates do eventually leave our facilities, and we envision them leaving better prepared to adjust in the community. We envision the community a safer place/

Effective treatment also makes our prisons safer and easier to manage. Prison wardens will be the first to admit that inmates acting out from mental illnesses can cause unrest and tension in the general population. As a Regional Director of Prisons, I was often called upon to conduct reviews of prisoners in administrative segregation. It was obvious to me and to others that a good proportion of those inmates would have had better control over their actions if they had received proactive treatment for their illnesses.

The litigation, the decree, and the assumption of expanded mental health care duties were the sparks that stimulated the present state of mental health care for DRC prisoners. The end result is that I have seen a metamorphosis from a marginal correctional mental health system, at best, to one that I would now characterize as among the best in the nation.

In addition to what I have noted above, why is it important to have a good correctional mental health treatment program? Beyond all the legal and practical reasons one might express, above all, it’s the right thing to do! Twenty years ago, many of the mentally ill inmates we house today would not have been in prison at all. They would have been civilly committed to the custody of DMH. As is the case nationally, prison populations have soared in most jurisdictions as state mental health hospital patients have dwindled in number. The philosophy of deinstitutionalization has reduced the number of persons committed to state mental institutions, but the requisite community mental health services are not always there.

Treatment for inmates with mental illness is more than just "the right thing to do"; it is a constitutional requirement and, for DRC, a requirement presently enforceable in federal court. Morris, Steadman, and Veysey correctly remarked that "the provision of mental health services to persons with mental illness who come into contact with the criminal justice system is not an option but a constitutional necessity." S.M. Morris, H.J. Steadman, & B.M. Veysey, "Mental Health Services in United States Jails," 24 Crim. Just. &Behaviors 3-19 (March 1997). Thus, DRC administrators and clinicians are committed to professional health care for all eligible Ohio prisoners.

Dunn Monitor Fred Cohen described the Ohio system as having, "moved, then, from simply obtaining the possibility of mental health care, to assuring access thereto, and now to problems of refinement of quality of care." F. Cohen, Dunn Consent Decree Monitoring Fourth Annual Report (1999). (See also Fred Cohen, The Mentally Disordered Inmate and the Law (CRI, 1998) for a comprehensive discussion of legal mandates.)

Comprehensive, Sound Mental Health Care Is Critical. In addition to my view on "doing the right thing" and judicial mandates, the following is a list of DRC’s overarching reasons why operating a comprehensive and sound correctional mental health service delivery system is critical:

• Nearly 12% of DRC’s 47,000 inmates are diagnosed as "seriously mentally ill." A host of other inmates with a less serious mental illness co-exist as normally as possible in the prisoner population. Good management and effective clinical care are required to resolve this prodigious problem.
• For years, corrections personnel have attempted to discern the difference between prisoners who are "mad" versus those who are "bad." For both security and health reasons, we need to know whether offenders are demonstrating purposeful negative behavior as opposed to those who are "acting out" because of their mental illness. Mental health professionals working closely with security professionals assist in this task.
• Whether the prisoner has an acute psychiatric illness or a personality disorder, correctional staff should be concerned with preventing further deterioration. Suicide, and suicide attempts, are stark examples of the consequences of unknown or unattended deterioration. Accordingly, prevention and amelioration of mental health related problems, from an administrative and clinical perspective, is a conscious, ongoing mission.
• Unfortunately, prisoners with a "weakness," either physical or mental, are at a disadvantage and are sometimes preyed upon by "stronger" inmates. There is, of course, a constitutional duty to protect vulnerable inmates, and the mentally ill and developmentally disabled often fall into that category. (See Farmer v. Brennan, 511 US 825 (1994), on the "duty to protect" inmates. The duty to protect often overlaps with the duty to treat, and DRC officials are aware of that fact.)
• Knowing inmates’ physical and mental limitations allows DRC staff to most appropriately house, classify, assign jobs, and treat prisoners. Good mental health, then, includes screening and evaluations, which provide this crucial information.
• As is the case with 95% of all prisoners, transition to the community is inevitable. For community health and safety reasons, operating a holistic mental health service delivery program for offenders is paramount.

Organizational Structure

The restructuring of the earlier, dual agency administered system into DRC’s Office of Correctional Healthcare (OCHC) in 1995 has had significant, positive impact on the delivery of mental health care. There is a comprehensive structure for achieving a holistic approach to correctional mental health in Ohio. The DRC OCHC is the division primarily responsible for prisoner mental health care, for medical and substance abuse treatment, as well as for prisoners with mental retardation.

Within the OCHC is the Bureau of Mental Health Services (BMHS). This bureau is responsible for the day-to-day clinical care of prisoners with a mental illness, regardless of how slight or profound. I should also note that the Dunn decree is limited to those with serious mental illness, while our voluntarily undertaken mission, as just noted, is broader. Funding for all mental health services is supported centrally by the BMHS. In the past, funding was dispensed separately to each prison. Now, virtually all mental health programs, including the entire budget of the Oakwood Correctional Facility are financed through one mental health line item controlled by the OCHC and the BMHS. This does have an impact on funding equality and in achieving a desirable consistency in treatment policy and programs.

In addition to Oakwood, DRC has divided the state’s 31 prisons into 12 separate "clusters," or catchment areas. Each cluster has a designated Residual Treatment Unit (RTU) or easy access to one. Assignment to one of the nine RTUs is for appropriate care and never a disciplinary action.

RTUs provide care and supervision for inmates who require special housing on a graduated basis; that is, as mental disability improves or stabilizes, generally via psychopharmacology more privileges and movement are permitted. For instance, in the least restrictive RTU environment, mentally ill inmates may be permitted to work in the general population and eat in the prison-dining hall with the other inmates.

Treatment plans are developed for each prisoner housed in a RTU. The basic mission of the RTU is to reintegrate the offender back into the general population. Similarly, the OCF’s mission is to stabilize the inmate and to return the inmate back to his or her RTU or parent prison. Currently, there are 730 inmates housed in RTUs, while the OCF population averages 95.

Thus, the structure of mental health services in DRC resembles a triangle, with OCF at the top, treating the most seriously ill who need hospital care; the RTUs as intermediate, or chronic care, facilities; and the broadbased outpatient population, treated yet able to function in the prison community.

In striving to understand and deal with the differences between those inmates who are so-called "mad" versus those who are "bad," numerous fail-safes exist. Although mentally ill inmates will demonstrate criminal behavior, the line is often blurred as to whether the behavior stems from the sickness or is willfully deviant in nature. For mentally ill prisoners who are assigned to disciplinary segregation units, clinical staff routinely monitor their physical and mental conditions. Regardless of the cause, criminal-type behavior is not tolerated in a prison setting. An inmate’s mental condition is taken into account at a disciplinary hearing, not as an excuse but as a way to fashion a disposition consistent with security and treatment needs.

The Ohio State Penitentiary (OSP), Ohio’s "super-max" prison, as a matter of policy does not house prisoners who require acute psychiatric per se. However, if a mentally ill inmate’s condition is in remission (i.e., he’s not showing any outward signs of a mental disorder), OSP is a disciplinary option.

Mental Health Staffing

The recruitment, training, and deployment of trained personnel are ongoing challenges. Enhanced care means an enhanced staff, and recruitment is now a perpetual process. Overall, mental health staff has increased dramatically over the past four years. For example, the number of psychiatrists expanded to 41 full-time- equivalents from nine. DRC mental health staff salaries are now commensurate with those of other local and state mental health agencies. Nevertheless, in order to maintain adequate staffing tables, diligence in recruitment must be maintained.

Staff training is a time-consuming necessity. New employees must complete a five-week pre-service training program: three weeks at the Corrections Training Academy and two weeks of on-the-job training (corrections officers complete a seven-week program). Annual in-service training also is required. For many mental health clinical and administrative staff, working in corrections is a new career choice. DRC must ensure that the clinical staff adapt to the correctional environment, regardless of a staff member’s credentials. Specialized mental health training is provided for non-mental-health staff, such as corrections officers and clerical workers. This is a three-day program designed to increase knowledge about mental illness., support appropriate attitudes and behaviors, and better integrate security and mental health concerns. There is ongoing evaluation of this training and preliminary results are quite positive.

Administration

DRC, through its version of Total Quality Management dubbed "Ohio Quality Corrections" has adopted the use of employee teams to improve work processes. The mental health environment is no exception. Multi-skilled teams are consistently deployed to tackle specific and more general tasks. For example, employee teams that planned the transition of services from the DMH to DRC greatly assisted in achieving positive results. Staff teams also are responsible for quality assurance of mental health practices as well as compliance with the terms and conditions of the Dunn court order.

Partnering with the appropriate organizations augments DRC’s ability to provide state-of-the-art services to offenders with mental disabilities. For example, an ongoing relationship with the DMH has proven very beneficial. Working closely with community mental health agencies and boards has additionally provided assurances of quality mental health care health care for offenders, especially those who are being supervised in the community.

Maximizing communication between DRC central office staff and prison/community corrections personnel is viewed as one of the keys to good health care services. Regularly scheduled meetings for field staff allow concerns to be addressed and issues resolved. Personnel at these meetings typically represent a combination of clinical workers and administrators. Hence, good management of mental health care is directly correlated with good clinical services and vice versa.

Quality Assurance

An important, if not our most critical, administrative responsibility is the quality assurance (QA) function. The QA Program is authorized by DRC Policy No. 321-01, which became effective on June 28, 1998. It operates through Standard Operational Procedures, which were put into effect on September 15, 1998. The confidentiality of DRC QA activities is protected by the Ohio Revised Code, as are independent hospitals’ QA activities.

Directly overseeing the QA duties is the DRC Quality Assurance Transition Team (QATT). The QATT will spend considerable time with the Dunn monitoring team in preparation for assuming for DRC the role of self-monitoring following the termination of the consent decree. This process will ultimately encompass the existing QA process. Team members include a psychologist, a psychiatrist, and two nurse administrators. The monitoring/QA process will initially concentrate on Dunn compliance issues and segue into continuous quality improvement efforts.

Community Reintegration

If DRC, or any correctional agency, is to have a positive impact on minimizing the problems associated with the reintegration of mentally ill offenders to the community, the process must be well coordinated. Within DRC, the Division of Parole and Community Services (DP&CS) is responsible for the supervision of released offenders , including those with a mental illness. The DP&CS operates the Offender Services Network (OSN), whose staff is charged with ensuring offender access to appropriate community treatment services.

The division works closely with central office mental health administrators and prison staff to optimize the exchange of critical information involving released offenders. OSN staff also works hand-in-hand with other mental health service providers.

Additionally, in 1997, DRC and DMH signed an inter-agency agreement regarding the transition of seriously mentally ill inmates into the community. DMH currently has 12 community linkage social workers assigned to state prisons who, along with DRC mental health staff, coordinate and link mental health services for prisoners released to Ohio communities.

Conclusion

Articulating that it’s the "right thing to do" by providing the delivery of quality mental health care services is easier said than done. As noted, the numbers alone make this a daunting task. Even without the benefit of empirical research data, one can certainly extrapolate that there are persons now being sentenced to prison who in the not-so-distant past would have been committed to state mental health hospitals. In 1965, there were six Ohio prisons and 26 state mental health and mental retardation facilities. Today, by contrast, there are 31 prisons and 21 mental health and mental retardation institutions. We estimate that on any given day there are over 6,000 inmates on the caseload of those for serious mental illnesses. Our average daily census in the RTUs and OCF is about 700 mental health patients. That number is expected to grow as more and more mentally ill people move from the streets into the criminal justice system.

If current public policy dictates that correctional systems are now catch-all agencies for many persons with mental disabilities, then correctional administrators and other stakeholders must be prepared to address the complexities of providing health care to offenders who suffer from such disabilities.

To reiterate an earlier point, this does not suggest that persons who commit crimes should not be punished for their voluntary misdeeds. I do suggest that the process of prescribing the proper treatment in conjunction with the appropriate sanction for mentally ill offenders is in need of careful study. In the meantime, the Ohio Department of Rehabilitation and Correction believes in the "Rehabilitation" portion of its name. That is, over and above the admonition to do the right thing, no one benefits when prisoners who have a mental illness recidivate.

From my perspective, it is clear that comprehensive mental health care for offenders yields positive results: Offenders are better able to cope with the prison environment; releasees stand a better chance of not recidivating; staff feel safer as they perform their duties in calmer environments; and, fewer citizens are victimized, thereby improving public safety. In order to quantify that impression, we look forward to working with Fred Cohen and his associates as they conduct an empirical longitudinal study of 50 inmates and other studies designed to further test my impressions.

Our joint objective in working together to address this significant challenge is to assist inmates with mental disorders, as well as other inmates, in successfully reintegrating into their respective communities. Although our mission is far from complete, tremendous strides have been made. As the director of DRC, I rest better these days knowing that we have created an infrastructure for mental health service delivery that is actually both defensible and professional. Actually, there is nothing mystical associated with providing good mental health care for offenders, just a lot of commitment and a lot of hard work. We think we have both.