David Stephens

A: So, first I just wanted to start off with a brief introduction for you—your upbringing, how you got into mental health, and how you got into the line of work that you do today.

D: So, I grew up in Phoenix. My dad was a high school physics teacher, and my mom was an elementary ed. She had a degree in elementary education, but she didn’t really use it; she mostly was a stay-at-home mom. So, I guess in junior high and high school, I played a lot of sports. I was involved in band, and I was involved in choir. I did a lot of extracurricular activities. Then, I took an Intro to Psych class, the first semester of college. I was already interested in the brain and fascinated with the brain, and that Intro to Psych class just reinforced that. It was pretty much at that time that I decided that I wanted to pursue a career in psychology. I got an undergraduate degree in psychology, then I got a Master’s degree in counseling. Then, I got a doctorate in clinical psychology, with a neuropsychology emphasis.

Other background information—I don’t know if this matters, but I’m married, I have three grown kids. My oldest is a girl, and she just finished her doctorate in clinical psychology two years ago.

A: Wow!

D: So, that's kind of fun. Kind of a funny story—when she was a kid, I would always tease her and say, “Honey, I know when you grow up, you’re going to be a psychologist.” And she’d say, “Dad, if I ever say I’m even thinking about going into psychology, just shoot me in the head.”

A: And here we are!

D: Yeah! So, I remind her of that every now and then. She took an AP Psych class in high school, and she fell in love with it at that point.

A: I go to Berkeley right now, and my first exposure to psychology and the brain was also through an AP Psych course, and I went to Berkeley originally as neurobiology. I switched since then, but it’s still something that’s really interesting to me.

D: So what do you study now?

A: I study biochemistry now! So, what made you have a particular interest in correctional mental health?

D: When I finished my doctorate, the first job I had out of grad school—I worked out of a state mental hospital here in Colorado and worked on the unit for people with chemical dependence and mental illness. A high percentage of our patients had either been to jail or prison, or sometimes ended up there after leaving our program. We really took the worst of the worst—we wouldn’t even take somebody or consider somebody for our program if they hadn’t failed multiple other treatment attempts. So, many of our patients were homeless people from Downtown Denver and also around the state.

I started getting interested in correctional mental health in my work as a psychologist at the state hospital. We had a forensic unit, and I had friends who were forensic psychologists, so then I had an opportunity to go and become the Director of Mental Health for the Wyoming Department of Corrections. Like I said, then I got much more interested in correctional mental health, while I was at the state hospital. Then, I kind of jumped over into the correctional realm.

A: What differences do you see with correctional mental health?

D: It used to be, people would say there’s very little overlap between the populations. As you may well be aware, more and more of the mentally ill are being arrested and are finding their way into jail and prison, so now, there’s really not much difference in the populations. Probably the biggest difference at this point is how patient treatment continues to be what it’s always been—somebody will come to an office and do the stereotypical 50-minute to an hour, and do individual treatment. Obviously, you can’t do that in jail or prison.

It’s kind of a myth that you can’t do individual psychotherapy in a jail or prison—you can. But it may be a 20-minute session, and very often, it’s in a multi-purpose room on a prison pod. It’s not like they come to your “office.” But depending on the facility and depending on the system, that happens sometimes, but more often than not, it’s in the unit and it’s in the multi-purpose room, so it’s confidential. But, it could be 10 minutes, 5 minutes, 20 minutes—very rarely would it be the stereotypical 50 minutes or hour.

A: How come the first sessions in prison are so short?

D: A lot of different reasons. Often, other case managers or physicians or attorneys or educators need that multi-purpose room. You have to do a count, almost every hour, throughout the day—meaning, all of the people who are incarcerated have to go into their cell, so they can be counted to make sure everybody’s still there, which is kind of important. So, you have to work your sessions in around those parameters and those realities of a correctional facility.

A: With only 20 or 10 minutes, do you think that it is still effective in what you want to accomplish? What things do you think are missing when you don’t have as much time?

D: It’s probably a little harder for multiple reasons, but it’s harder to develop trust in that amount of time. That’s probably the biggest obstacle, but trust is hard to develop in a prison in a jail setting anyway. People who are incarcerated really aren’t used to people being trustworthy; there’s usually at least some element of an expectation that—if you’re not a fellow inmate, that you can’t be trusted. As anybody affiliated with the operation and the facility, you may tell people things you shouldn’t tell them. You don’t really care about the offender. You’re really just there for a paycheck, etcetera, etcetera.

A: So then, for someone who is incarcerated, how do you go about getting their trust?

D: Really, it’s just a process pretty similar to any mental health treatment. It’s demonstrating interest in them, asking questions about them, being able to reflect back to them their experience that you understand it, and that you’re not judging them. Even in a short amount of time, you can develop that—meaning a short amount of session time—but it may take more sessions to get there for somebody who’s incarcerated.

A: When you have mental health sessions inside of a prison, how do you determine who is going to be a patient?

D: When somebody first comes into a jail, they’re assessed by a mental health professional within 24-48 hours. It’s called a mental health screening. You get information about prior mental health treatment, current mental health symptoms—are they on psychotropic medications? So, when someone comes into the jail, you get that information. I don’t know if you’re aware, but there are accrediting entities for mental health and medical treatment in jails and prisons. So, those standards require that you do an initial screening within the first 24-28 hours, and then you have 14 days to do a comprehensive mental health assessment. That includes things like IQ, brief psychological testing, more in-depth interviews. Then, if somebody goes from jail to prison, when they get to prison, they go to what’s called a reception and diagnostic center. They may spend three months there getting testing or all different kinds of things, which includes mental health testing, more IQ testing. By that point, either in a jail or prison, you have a pretty good sense of their mental health history and their mental health needs.

A: If some of the tests determine that someone has a mental health condition, what levels of care will they receive? What are the different levels to that?

D: Many systems, not all of them, have what’s called a mental health classification system. Most of the time, somebody’s assigned, what’s called, a P-Level, which means a psychiatric level. Usually, 1 is the least intense, so that [would be] somebody with very little mental health history. Those are getting more and more and more rare; when we factor in trauma, psychological trauma, physical abuse, sexual abuse, verbal abuse, and head trauma in the form of concussive injuries or traumatic brain injuries, hardly anybody comes into a jail or prison without a history of one or both of those things. So, very few meet that P1 level of care, which is basically none.

Then, it usually goes to a P5, which is somebody who’s actively and/or acutely psychotic, paranoid, so depressed that they’re on the verge of suicide, may be having an active manic episode and they need to go either to the jail or prison infirmary. Depending on the jail or the prison system, they may have actual mental health treatment units within the jail or prison. So, the 4’s and 5’s typically would go there. A P3 would be more of your traditional outpatient. Even in a jail or prison setting, we talk about outpatient treatment vs. inpatient treatment.

A: Would you mind going a little further about outpatient treatment and inpatient treatment? Often, is the medical treatment provided at the actual facility or is it somewhere else?

D: Always at the facility. I guess, unless a prison system—I was Director of Mental Health for the Colorado Department of Corrections, and we have a prison that was devoted to the mentally ill. If anybody had a severe enough mental illness, they would go to that prison. And that would be their housing assignment.

For jails, it’s much more rare, although it’s becoming more common to have an inpatient residential mental health program. Most treatment is what really mirrors outpatient treatment in the community. So, they may have an appointment with a mental health professional every week or once every couple of weeks. They’ll see a psychiatrist anywhere from once a week to once every three months, if they need psychotropic medication. They come from their housing unit, either to a multi-purpose room on that housing unit, or they may come to more of a mental health clinic on the prison grounds or the jail grounds. That’s a little less common, but it does happen sometimes.

A: For the prison that is specifically devoted to those with a mental illness, how does that facility look different? How are the services provided different from a regular prison?

D: For the services, they are quite different in that they may have four or six hours a day of mental health groups. They may have educational either groups or training, so that they can get a GED if they don’t have that. They may have a recreational therapist that does leisurely activities with them altogether. But it really is, very often, a therapeutic treatment program that’s implemented on that housing unit. Many of them are run in a way that’s called a therapeutic community—I don’t know if you’re familiar with those. The therapeutic community originated with the Tavistock Clinic in London in the late 1950’s, early 1960’s. They say that community is therapy. They’re encouraged to make note when a fellow resident or fellow participant does well. They have a community meeting every morning, where they note positive behaviors and then problematic behaviors. If you had a problematic behavior, you might have to write an essay for the next day on what you did and how you can do something differently. You may have an exercise that you need to do, but those are called pull-ups and push-ups. They document those. You very often progress through a level system by having progressively more positive behaviors, more mental health stability. Many programs are run that way in jails and prisons.

A: This level system—how is that tracked? How do you measure progress?

D: Depends on the system. Some are pretty formal, and they will even have like a points system, that you get x number of points for following the rules, doing your homework assignments, taking your medications, and all of those sorts of things. And if you break rules, then you lose points, and you have to earn x number of points to get to the next level. Others, and I would say this is more common, are less structured and less formal for that; they have a group of patients that have been in the program quite a while, that have demonstrated a little bit of leadership ability and an ability to be responsible. And so, they will kind of run those meetings with staff present. Those people will make decisions about increases in levels or not.

A: Do most of the people who participate in these groups show a significant amount of progress?

D: Yeah, I would say most of them do. Typically, you don’t graduate from that program until you’ve shown enough progress to get to the top of the level system and meet all of your treatment goals.

Some people are not capable of that. They’re more for just maintenance because they’re so severely mentally ill, or so cognitively impaired, or intellectually impaired, that they really can’t progress through. But they are included on the unit for monitoring and safety, and to make sure their needs are met.

A: This idea that community is therapy—why do you think this idea is so effective?

D: “So effective” is a little bit of, perhaps, a misnomer. People graduate from those programs—their success when they return to the community or their success even when they return to general population in the jail or prison, I would say, is mixed. The reason people are able to do well is that community provides a lot of psychological structure that they may not possess internally. So, there’s a lot of support, there’s a lot of guidance, clear expectations typically, and people can adapt to that structure. Many times they do fairly well while they’re in the structure; the challenge becomes when they leave that structure and go back either to the general population unit or community—they haven’t, for a variety of reasons, internalized that structure or maybe don’t even have the capability on their own, due to their trauma or injury history, to implement consistent change.

A: People in the general population—do you think they also have this sense of community or support that they can rely on?

D: No.

A: Haha, can you explain more about that?

D: So, like I said, the short answer is no. There really is no external structure in a general population unit that helps build camaraderie. It’s really just more making sure that everybody’s safe, and doesn’t escape, doesn’t hurt each other. That’s really the bar for functioning in the general population unit.

And it’s not to say—let’s say somebody comes into jail or prison, and this would be more prison, and they don’t have a GED or a high school diploma, for example, there is a lot of encouragement for them to get their diploma while they’re still incarcerated. Many of them are required or certainly encouraged to get a job while they’re in the facility. And so, they may do janitorial work, or they may do landscaping, or they may do—there’s a lot of prison industries. They may help—fish farming is a pretty common thing in prisons now. They will grow fish and sell them to restaurants. Actual farming of crops, cattle management, being on a fire prevention crew—there’s a lot of different jobs inmates can get. So, they go to work from their housing unit and then come back at night and are back in the prison. But I would say, that’s probably the majority of people who are incarcerated—that they kind of live their lives like people do out in the community. It’s just in the context or the confines of the prison.

A: Do you think people in the general population and the prison system as a whole would benefit if there were added systems of camaraderie, for example? Or just systems of support in general? Do you think those should be added?

D: Yes, and that is happening in Europe. The US is starting to adopt that. I work with a group of consultants, and we just finished a project in a large metropolitan city, where their entire jail is really now structured as a therapeutic unit—a therapeutic community. The whole focus is to have people recover and for people to have that support and camaraderie throughout their time in the jail. Like I said, that’s becoming more and more common.

A: To make that change, what needs to happen, going from a stereotypical prison in the US to that sort of therapeutic community?

D: Well, I think some of the biggest change is education of the staff and the officers. People typically stay in a position working as an officer in a jail or prison for a long time, if, for no other reason than, getting state retirement, almost always. So, there’s motivation for them to stay there. If people have been working in a jail or prison, even for 5 years at this point, the culture is—the inmates can’t be trusted, we’re here to monitor them, we need to be tough on them, we’re not here to be supportive, we’re not here to coddle them. That’s been the correctional mindset forever. So, changing that mindset is a big challenge.

Another thing I do in the context of working in corrections is, I do what’s called architectural neuroscience—designing new facilities from a neuroscience perspective and designing them to reduce neurological symptoms, but also to reduce psychological symptoms for both the inmates and the staff. And so, as an example, very very few people who are incarcerated have very many positive experiences in any kind of building. So, whether it’s a mobile home, an apartment, a condo, or a house, 75%+ of people who are incarcerated have experienced childhood, physical, or sexual abuse. It’s probably a higher number than 75, but at minimum that number. Seventy-five percent or more have had concussions or traumatic brain injuries. So, whether, again it’s a living dwelling or a school building or a youth detention center, or a courthouse, or a prison, every building they’ve been in has been traumatic for them. They have not done well. They’ve not done well, they’ve been ridiculed, they’ve been ostracized, they’ve been punished, etcetera, etcetera. So, I work with architects, and the plan is to make the outside of the building look almost more like a hotel, which many of them don’t have much experience with. So, they won’t have those negative associations.

Inside the facilities now, there’s much more natural light, there are plants, there is greenery, there are not complicated lines of sight. People who have had concussive injuries and traumatic brain injuries—very often their visual processing is compromised. So, complex lines of sight can be very difficult for them to process and can result in headaches and that sort of thing. So, I think that’s the other part that’s changing, the design of facilities. It’s now happening with a lot of attention and care being put to—let’s make sure this building is supportive. Let’s make sure it doesn’t make symptoms worse. Let’s create, as much as you can, a welcoming warm environment.

A: I think that the idea of putting this scientific and neuropsychological lens in designing it is really, really important. It shouldn’t even be innovative—it makes a lot of sense to do it that way. The way that facilities are right now and from that same lens, neurologically or socially, what is dangerous about the design?

D: Nearly everything. So, there’s the way that facilities were built, even 10-15 years ago, there are multiple places that inmates can attach a sheet or a shoelace, or some kind of string to and hang themselves. There has not been, historically, any consideration of natural light, any consideration of the space necessary. It’s been harsh, it’s been sterile, it’s been institutional. Noise—nobody considered the impact of noise. Many people with concussive and traumatic brain injuries have light and sound sensitivity. So, the louder it is—they get more agitated, they get more anxious, they get more aggressive. So, again, facilities built even probably within the last 10 years didn’t put a lot of stock into or take account of the noise and sound and light sensitivity.

The complex lines of sight, even complex patterns of carpet or tile, or the combination of [light]—if light came in, it would create shadows that overlapped with different carpet patterns and was very visually demanding and visually confusing. I could keep going, but there just wasn’t much consideration or even understanding that the building could increase stress or decrease stress.

No windows in the individuals’ cells, hard, concrete bunks, bunks they could jump off of, no privacy, because of the way the cells were situated in the housing unit, no opportunity to talk in private to them. If you talked to an inmate, the rest of the population was basically hearing what they were saying, and they were hearing what you were saying. So, just many, many, many factors that were negative in terms of supporting mental health, supporting trust building, supporting recovery.

A: I also wanted to talk about solitary confinement. What happens to our minds, to our brains, to our bodies when we are put in solitary confinement? Why is it so dangerous?

D: Well that’s a great question with not a clear-cut answer. You would assume that solitary confinement is always destructive, and that’s not the case. Now, the new term is “restrictive housing.” People have gone away from “solitary confinement” or “segregation.” and the new term is “restrictive housing.” I’m right now working on a project with a mid-sized state department of corrections, and we’re reviewing all of their—what used to be called solitary confinement, now called—restrictive housing for ways to make it less destructive and less harmful, and actually to be used less, and less, and less.

The guy that was executive director of the Colorado Department of Corrections until, may have been 2 years ago now—he came shortly after I left that position. He’s really a national leader in reducing the use of segregation or restrictive housing. His name is Rick Raemisch. In Colorado, he got to where nobody would be in solitary confinement or restrictive housing for longer than 15 days. That may sound like a very long time, but there are people who are in segregation or restrictive housing for years—5 years, 10 years, 20 years. Some people are released from restrictive housing—which has meant lockdown, 23 hours a day, 7 days a week—onto the street, which is a very difficult adjustment, but now, we’re recognizing that how you do restrictive housing has a significant effect on people’s mental health. It used to be—I don’t know if you’ve seen movies, but movies mirrored reality—that people would be put in kind of like a cave. No light, no stimulation, no human contact. They may be in that for days, or weeks, or months. Now, sometimes because of the danger of being in the prison, or because they have enemies, or because they don’t want to interact with anybody, people do things to make sure they get into restrictive housing. They get to have their own cell, which is perceived to be a benefit. Typically, people get less of their own property in a segregation or restrictive housing unit, so that’s a negative, but they still get some property. They communicate back and forth—it’s called fishing. They get dental floss, and they will tie it on something. They can share messages, they can share food items, they can share a lot of things with their fishing line or their dental floss; they slide it across the floor to somebody in a different cell. So, there is some opportunity for communication.

When people are cut off from all human contact, they can become more depressed. They can become more anxious. They can become more paranoid. They can become more psychotic. But, it isn’t just—anybody in segregation or restrictive housing is going to decompensate. Some people actually do better there.

There’s a mental illness called social anxiety disorder, where people are embarrassed or humiliated by interacting with others. Those people actually do better in restrictive housing. And there’s a personality disorder called schizotypal personality, where those people really don’t want to develop a relationship with anybody. So, they also do better in restrictive housing.

A: How do we reimagine what this restrictive housing looks like so that it can promote more healthy behaviors and stay away from the idea of the cave?

D: I think it’s kind of what I already said, but reducing the amount of time that people are in that unit. What’s happening now in this state that I’m talking about and working with, is they’ve changed restrictive housing from being a place to being a status. So, you could be in the general population unit, and yet, restricted to your cell 20 hours a day. You still are interacting with other people. You’re in a general housing unit. It often is quieter in general housing units than it is in restrictive housing, where restrictive housing is a place. So, that’s another big part of it—turning it from a place into a status.

What I predict—this hasn’t happened yet—in the next 5 years, we’re going to recognize that the people who have found their way into segregation or restrictive housing, which is often referred to as the jail within the jail—when you break a rule, that’s when you end up in restrictive housing—are the ones that are most injured. They’re the ones that have had the worst histories of concussion or traumatic brain injury or even brain illness. They’re the ones that have had the worst physical and sexual and emotional abuse. So, I think it’s actually going to turn more into an intensive treatment unit than anything else. I think that’s what needs to happen.

When people have concussive injuries, their brain is not able to process information in the same way. They’re literally not able to control their behavior.

A: So, what you have been saying is that the people who have been harmed the most—you can bring them into the status where instead of seeing it as a punishment, it’s more a place of healing, is that correct?

D: Right, yes.

A: Do you support restrictive housing as a form of punishment at all?

D: Well, it’s an interesting question because in my opinion, we don’t really do anybody any favors if there’s not consequences for their behavior. Then, they don’t learn. So, to say that nobody should have consequences for their behavior—I don’t agree with that. More serious infractions—and there is a subset of people who are incarcerated who cannot safely be with anybody else; they are so violent that they’re going to assault or kill whomever they’re with. So, restrictive housing isn’t necessarily the answer to that. But, being in a single cell, or again, being in a very intensive treatment unit, I think is the answer to that.

So, I think restrictive housing or segregation has been definitely dramatically overused. I think, as a status, where you lose some privileges... In many jails and prisons, there’s what’s called an honors unit or an honors pod. If you don’t have disciplinary infractions, you go there. There are more televisions, there are more activities, there is more freedom, more opportunity, and so, moving from that, to a general population unit with a restrictive status I think is a good idea. The restrictive housing unit maybe will have to be continued for the most dangerous and the most violent, but even that, I think it will move to more of a high-structure high-intensity treatment unit, than a behavior management—be locked in your cell 23-hours a day—kind of scenario.

A: How many prisons across the US, do you think, have this mindset of coming away from the ideas of solitary confinement and toward a place of treatment?

D: Well, it’s interesting. I am involved with a group that’s called the Correctional Leaders or Leadership Association. It consists of all of the executive directors of every prison in the country. Many of them are taking trips to Europe to see what Europe and some Scandinavian countries are doing. Their countries are much, much, much less restrictive than ours. Part of the reason they can do that is because they have much higher staff to incarcerated person ratio. The ratios in the US are often 1 officer to 20 or 30 offenders. In Europe, it’s more like 1 to 5. But, this is really a ballpark, but maybe 30 or 50% see the benefit and are working towards limiting restrictive housing and changing how it’s done.

A: Do you think such a change is possible, given this ratio like you mentioned, of officers to the prison population? As well as the fact that a lot of prisons are overcrowded?

D: Yes, I do. The overcrowding is becoming less and less of a problem. There’s been a movement across the country to parole less violent offenders because through the 90’s and even through probably 2010 or 2012, every state was spending a lot of money on building more and more and more prisons. I think people finally saw that madness, that the solution isn’t just to keep building prisons and building prisons. So, now, like I said, many states, if not all states, are releasing non-violent offenders. So, the overcrowding is becoming less and less and less of a problem.

I think even with the staffing ratios, you can implement restrictive housing as a status and even [reduce] its use period. A significant part of that is recognizing the neuroscience and recognizing the injury status of these offenders. I don’t know if you’re aware, but psychological trauma has the exact same effect on the brain as a concussion or a TBI does. So, people’s cognitive function is just not what it should be. So recognizing that and being able to rehabilitate it, I think, will make a big difference in how prisons and jails are run.

A: So, I also understand that you have a part in training correctional administrators to implement successful correctional health care systems. What does this training look like?

D: Well, kind of like what you read implies—healthcare administrators many times don’t have a correctional background. Many times, they don’t have a mental health background either. So, [it’s] understanding the dynamics of—”who’s the person coming through the door?” and to include officers [in that]. Officer wellness is a hugely important thing. And the PTSD rate amongst correctional officers is higher than that of military veterans returning from combat. So, helping them to understand their staff may be compromised in some ways. [It’s] understanding what are the medical and mental health needs of offenders and helping them design systems to meet those needs.

A: Do you think that the mental health of officers comes after all of the changes that will be made? Which one will come first?

D: In terms of addressing officer mental health?

A: Yes.

D: Sadly, I think it’s going to come after the other changes. I was a chairman of the board for an entity called Desert Waters Correctional Outreach. That entity or that agency’s mission is to reduce trauma for correctional officers, to reduce suicide on the part of correctional officers, to promote officer wellness. They continue to have a difficult time getting prison systems or even individual jails to allow them to do the training. It’s not perceived as a high budgetary priority. Doing some of these other things enables a system to build fewer prisons, enables the system perhaps to have fewer officers on staff. So from a budgetary perspective, I think those things sadly will come first.

A: So, let’s say someone who is recently coming into the prison for the first time gets their evaluation, and they are level P5? What might care look like for someone who is rated at that level?

D: If there is a mental health unit, they will be in the mental health unit. They might be in that mental health unit or mental health facility their entire incarceration. They may never become mentally stable enough to function in a general population unit. So, they are almost without question, going to be on psychotropics. There’s a process in jails and prisons that allows somebody to be involuntary medicated. The statute, really it’s more of a Supreme Court case—Washington v. Harper—provides for a prison system to be able to involuntarily medicate somebody. That happens fairly regularly if they’re so psychotic they can’t function.

I don’t know how much you know about mental health programming, but there’s a mental health program called the social learning program that came out of UCLA. That is really a very basic token economy behavior management program for people that are acutely mentally ill. So, some facilities have some version of that social learning program for those P5 people. More commonly, the P5 person is there for a short period of time because they have an episode of acute mental illness and once that’s stabilized through medication or through treatment, then they can go back to a general population unit.

A: Going back to the Washington v. Harper case, what are the qualifications needed to invoke something like that? I feel like if there aren’t a lot of regulations, that could be a power that’s abused.

D: So you have to have a committee that includes a treating psychiatrist, an independent psychiatrist, and a prison official of some sort. They review the case, they review the mental health needs of that person and it takes a two out of three vote for doing the involuntary medication in order for that to happen.

In my experience, it’s very seldom, if ever, abused. I don’t know if I can say that I’ve seen a case where it’s been abused. There’s a concept called chemical restraint. So, instead of keeping people shackled, it used to be that people would just be put on such significant anti-psychotic medication or any psychotropic medication, that they were essentially non-functional. Accrediting standards don’t allow that; that just doesn’t happen anymore, but if Washington v. Harper was misused, then it could go in that direction. But, it really just doesn’t happen.

A: If someone needs psychotropic medication, do you think prisons right now are adequately equipped to make sure that they keep getting their medication on time?

D: There’s a lot of variability, and this actually even goes back to the chemical restraint. Depending on the size of the system or the jail, depending on the location, depending on the administration, there probably are some cases of chemical restraint. There are certainly cases where people don’t get adequate psychotropic medication. Accrediting standards make that more difficult, and it’s perceived to be a significant benefit to be accredited by either the National Commission on Correctional Health Care or the American Correctional Association. When you have that accreditation, it protects you in the event of a lawsuit. That’s where a lot of systems see benefit, but there are standards for how often somebody sees a psychiatrist—do they get the medications they need? For the most part in most systems, when somebody needs medication, they get it.

My opinion is that sometimes people get medication when they don’t need it, and not in a chemical restraint kind of way. But, inmates often like to be sedated. In California, and this was maybe 20 years ago, but in the California DOC, there was a paper that circulated not only amongst the inmates in a given facility, but it circulated amongst inmates across facilities of what to say to get a medication—how you need to present your symptoms, this is what you need to talk about—so it will sound credible. And so, there’s motivation on the part of some inmates, for sure, to get medication when they don’t need it. Sometimes, that’s not screened adequately enough, so people are put on medications that they don’t truly need.

A: I’m not sure if this is something that you would also know, but I feel like there are lots of cases where people who have a certain condition or chronic illness get medication that is not suited to that condition. For example, one that I hear about is Tylenol for certain types of cancer. In your experience, do you think that’s something that happens commonly?

D: I assume you mean, with cancers, pain treatment? Is that specifically what you’re referencing—are you talking about chemotherapy?

A: I think just in general, within the health systems in prisons, whenever someone presents with certain types of cancer, that is the only treatment they get.

D: I think that's relatively uncommon. Inmates are very happy to sue anybody affiliated or associated with the jail or prison, and so, most practitioners or clinicians are aware of that. So, in a certain way, that’s a good thing. This is because they’re going to be more motivated to make sure they’re providing appropriate care, so when the inevitable lawsuits come, they’re protected and there’s medical justification.

To say it never happens, that would certainly be incorrect. And, there are certain types and specific medications that have high “street value” in the prison or the jail. Narcotics, opiates, painkillers of any kind have pretty high street value. People can sell them really easily to other inmates. A whole class of medication called benzodiazepines, which are anti-anxiety medications, are chemically very similar to alcohol. Those have a very high street value and are seldom prescribed to any inmate in any jail or prison. Some antidepressants (Wellbutrin is one of them), stimulants like Adderall, or Strattera, or Ritalin—those are hardly ever prescribed because they’re stimulants and have a similar effect to cocaine or meth. So, part of the art of prescribing in a jail or a prison is to meet the person’s medical need but to do so in a way that doesn’t provide much opportunity for abuse, sale, or inappropriate use of that medication.

When I was Head of Mental Health in the Colorado Department of Corrections, we discovered a group of four offenders who—all of them were on multiple psychotropic medications and other medications as well. They were pretty good at being able to cheek their medication, or not take it, and save it up. So, every Friday, one of them would get to take everybody’s weekly medication. And then the next Friday, the next guy would get to take everybody’s weekly—the whole amount of meds they got for the whole week, they would save them up. That one person would take the medications for all four of them. They just rotated, so every week, somebody got to take the whole pile. Those kinds of things are not uncommon, and so, managing appropriate medical needs and appropriate medication needs in a way that protects those people, like I said—that’s part of the art and part of the challenge.

A: Do you think there's any way to change how medicines are administered or anything like that, such that they can still get the care they need with appropriate drugs without having that risk? I feel like it’s hard to justify not giving proper treatment or proper care—

D: Yeah, I don’t think you can justify that. There’s no excuse for somebody not to get their medical needs taken care of; that’s actually illegal to not appropriately care for their medical needs. So, some systems... If a medication can be ground, they will grind them and put them in applesauce. The applesauce doesn’t have a negative effect on whatever the medication is, and there’s no way to save the medicine that way. Almost every jail or every prison has the nurse and an officer monitor and look inside their mouths after they’ve taken it, but some are good enough that they can still hide it. Some medications are done in injection form for that reason.

By in large, most jails, administrators and systems, prison administrators and systems, and clinicians, are committed to the health of the inmates and are wanting to provide good care. They are definitely exceptions, but I would say that that’s the majority of healthcare providers in jails and prisons.

A: What is your opinion on for-profit correctional healthcare organizations? I feel like a name that I hear a lot is Corizon Healthcare who has a lot of lawsuits against it. What is your opinion on companies like that?

D: Another good question. There can be benefits to them, in that they can provide healthcare at lower cost. And one of the big reasons that jails and prisons started going to private healthcare providers is that it allows the state or the jail to get people off their retirement payrolls, so they would become an employee of the private contractor. Then, the state didn’t have to keep paying retirement benefits. Those people weren’t accruing retirement benefits. So, there was significant cost savings.

The other primary motivation has been that the perception is that that private healthcare provider would assume all the legal risk for the healthcare, but that’s not the reality. When there are lawsuits, both the provider and the jail or the prison get sued. So, everybody’s named in the lawsuit.

I would say there's really a lot of variability, even within a big company like Corizon, in terms of quality of care. I worked for one of the private companies that was part of the two-company merger that became Corizon, called Correctional Medical Services. We actually were able to get one of the states where I worked for them out of a Department of Justice Consent Decree because we demonstrated that the quality of care being provided exceeded that even of hospitals. I would say, the majority of it depends on the quality of two people: the regional manager and the—every jail or prison that has privatized healthcare has what’s called a—Health Services Administrator. Just like the name implies, they’re the ones that are responsible for and coordinate all of the care in that facility. If you have a good Health Services Administrator, then the quality of care, even if it’s from a private company, will be very high. If you don’t have a very good Health Services Administrator, privatized or not, the healthcare in that facility will not be of very good quality. So, it’s not so much whether it’s privatized or not, because I was a state employee when I was the Director of Mental Health with the Colorado Department of Corrections, and there were some Health Services Administrators that honestly were not very good. The health services in those facilities suffered until we replaced that administrator with a different one. So, it’s really, in my opinion, not so much private vs. public or state or county run, it’s the quality of the person at the site and the quality of their supervisor or administrator.

A: Currently, are there a lot of status checks or facility checks? Are there any checks on the Health Services Administrator?

D: It depends on their boss. Sometimes, their bosses hardly ever show up. Other times, they come and do audits, and come and talk to inmates, and review documentation. So I would say it’s very dependent on the quality of their supervisor. When I oversaw state departments of correction, I would go to every facility two or three times a year and do audits, talk to staff, talk to inmates, and I would make sure that the quality of care was there. When you do that, quality improves. It also depends on the quality of the clinician; sometimes if it’s not being monitored, there’s enough going on that some of that systemic quality suffers.

A: Do you think that there’s anything that needs to be improved, in terms of this monitoring system? Are there any things you would implement to improve the overall quality?

D: Yes, there’s quality assurance processes, or something that's called continuous quality improvement. Almost every facility and system does or say they do quality assurance or continuous quality improvement. Many times, it’s just collecting and collating data. And that doesn’t really do anything. If you just have a stack of data and report that data, you could be providing horrible care and still be able to report data. So, I think it takes an understanding of what a healthcare system is and what a true continuous quality improvement process is, which is—the short-ish version—identifying the key quality metrics, doing chart reviews, talking to offenders, looking at outcomes, and then taking all of that data; then, when you find a problem in a system, or a problem in an element of care, [it’s] then providing a fix to that, and then checking and monitoring to see if your solution was successful. And if it’s not, then come up with another solution. But, by doing that, that’s the way to make sure quality healthcare is happening consistently.

A: You mentioned that part of this quality assurance is going out and talking to the people who are incarcerated. Are there any really memorable stories or things that they’ve said that you’ve kept with you?

D: I would say a fairly common one is people expressing surprise and even shock that I would care to show up, that I would care to talk to them, if they made a complaint or had a problem, that I would check back with them to see that it was resolved. That was, I’d say, fairly common.

A pretty powerful story is… even though I was always State Director for whatever mental health system in corrections, some of them I actually provided treatment to, individual inmates. There was this guy—he grew up in a ranch out in the middle of nowhere and was physically and sexually abused throughout his childhood. Then, once he was old enough, he became a cowboy. His pattern would be that he would work 12, 14, 16 hours a day for months and months and months at a time. Eventually [he became] exhausted. And I don't know if you know what a dissociative disorder is? Essentially it’s that you’re not consciously processing information, just kind of going through the motions, but you’re not making conscious choices about what you do. It’s kind of like a blackout when you’ve had too much alcohol. You’re continuing to talk to people, you’re continuing to do things, but your brain isn't really engaged. And that happens with trauma.

So what would happen to him is he would get these jobs, and he would work 12, 14, 16 hours a day, and become exhausted. Eventually, he’d take a break, go into town, get drunk, and then steal things, assault people. This had happened several times, and each time after these incidents, he committed several felonies in the process, and so [he] was imprisoned. He would serve his sentence, and the sentences weren’t that long—a couple years—so he’d get out, do the same thing, wind up back in prison. And so, when I met him, he was actively suicidal. He hated the fact that he hurt people, and he hated the fact that he broke laws. So, the last time he’d had one of these incidents, he asked the judge if he would give him a life sentence. He said, “I don’t want to be out in the community. I can’t trust myself. I’m hurting people.” The judge wouldn’t do it. And so, he decided, “Well, I’ll just kill myself then.” He had multiple suicide attempts in the prison. So, I started working with him, diagnosed the dissociative disorder, and talked about what he was doing and why. I said, and this is probably after 6 months or a year, I would like you to consider getting a prison job, but we’re going to place very strict limits on how many hours you can work and on what you can do. So, we did that and avoided any future or further dissociative episodes. Then, he was able to go to an honor camp or an honor prison. Once again, I kept working with him—strict limits on how many hours he could work and what he could do. He eventually got to where he got paroled, went to school, got a degree, and became a youth wilderness counselor. He talked to me on multiple occasions about saving his life and how he was able to see that he wasn’t just an agent of destruction and harm, and that he could actually meaningfully contribute to the lives of other people.

To have those kinds of stories and that kind of impact is really very powerful.

A: Thank you for sharing that—that’s an amazing story. I can imagine that some of the work you enjoy the most is really just talking to people and having these sessions where you can work with them.

D: Yep.

A: When you’re working with someone who has trauma, who has dealt with a lot of harm and hurt in their lives, what are some things you keep in mind? What are some ways you work with them to deal with their trauma?

D: Probably the biggest thing that I do is spend a lot of time talking about brain function and letting them know that really the effect of the trauma—there’s a chemical cascade that happens when somebody has a concussive injury or psychological trauma. That chemical cascade limits the amount of fuel that their brain gets, and so, then they become incapable of processing and managing emotion appropriately, they become incapable of processing thoughts accurately, and have great difficulty controlling their behavior. So, much of the work I do with people with trauma is helping them be aware—you were injured by this, but it’s something from which you can recover—that we can do some things to get their brain to refuel itself and change the perception they have of who they are and what they’ve done. It’s a fascinating thing that in my experience anyway, [for] everybody who has had a concussive injury, a traumatic brain injury, psychological trauma, their brain misinterprets what has happened and tells them—because there’s a fuel deficit, but the brain doesn’t really realize that—in effect, “You’re deficient. You’re damaged. You’re unworthy. You’re worthless.” It depends on the severity of the injury. Also [it’s] working with them to get the accurate perception that they’re injured; they’re not deficient, they’re not unworthy, they have infinite value in who they are. Their dysfunction and emotional management problems and behavior problems are due to the effects of that injury, and they can completely recover.

A: Do you think that that’s the main thing that leads to a recovery like that?

D: I do.

A: That’s interesting.

D: It’s really the combination of addressing the neurochemical, neurobiological problem and then the misperceptions that come from that.

A: Further than just addressing the problem of that neurological deficit or fuel deficit, what are some of those ways that you enforce that idea?

D: Really it is having them practice, any time they catch themselves saying something along the lines of, “I’m so stupid. I’m an idiot. Nobody cares about me.”—either having those thoughts or making those statements, and having them consciously counter it with, “No, the problem is I’m injured. There’s nothing wrong with me as a person, and I can recover.” Just the fact of practicing that accurate perception and accurate thinking gets… I mean, brains—one of their primary functions is to automate everything as much as possible, so they can be efficient. By practicing that consciously and us talking about it and monitoring how that’s going, we get to where that accurate perception automates. That’s an important part of the recovery process.

A: So I can imagine as they are understanding this new awareness, there may be some changes that you see in them as a patient? What are some other changes you see in them as they continue working with you?

D: Decreased anxiety or eliminated anxiety, decreased or eliminated depression, decreased or eliminated anger management problems, a sense of calm even in stressful situations. They’re able to better manage their behavior. They’re able to engage in relationships. Because if you think you’re worthless, you’re going to have a very hard time communicating with somebody else and certainly developing any level of intimacy with another person. You’re going to hide yourself from them because you believe that if anybody sees you at any depth, they’re going to see all the problems and they’re going to leave you. So, significantly improved relationships is a frequent thing. Even significantly improved trust in the relationship I have with the person. Decreased rule violations in a prison or jail context. Giving respect to other people instead of just demanding it.

A: For the people who are incarcerated, what types of mental illnesses or conditions do you see that are most prevalent in this population?

D: Substance use disorders are probably the most common. Depression is very, very common. Anxiety is very, very common. PTSD is very, very common. ADHD or attentional problems are very, very common. Probably those are the most common.

A: Do you think those are all things that can be addressed with this new awareness that you mentioned?

D: Yes. That, and again paying attention to and changing the fueling of the brain.

A: Doing this type of work, listening to someone, having them develop this awareness and changing the fuel deficiency of their brain—why is this work so important to you?

D: Probably the biggest thing is… I’ve seen the devastation and destruction that comes from trauma, which the vast majority of these people have experienced. I’m sure from your training you’re aware that glucose is the primary fuel for the brain. You may or may not be aware that concussive injuries, traumatic brain injuries, cause the brain to limit how much glucose it lets in from the body. So, by getting more glucose to the brain, that helps the brain recover.

Prior to me focusing more on the fueling of the brain, I would say to inmate groups that I did, I would say to the individual inmates that I worked with, that I could not say that if I had had the same experience as they did, that I wouldn’t be right where they were. There’s nothing different about me than there is about them. So many of them have been so traumatized and believed then that they were less than other people or deficient or damaged. Like the story I told you, to be able to do that for somebody, to give them their life back, is such an important work.

One other quick story if you have time: I worked with a guy on an outpatient basis. He spent the majority of his youth in a state mental hospital due to being diagnosed with autism. He basically matured out of the state hospital system—he was in the juvenile and adolescent units. When he became 18, they released him and he was in the community. He went to a tech school and learned to be a motorcycle mechanic, but also he had an alcohol problem. So, when he was in his state—the state doesn’t matter—he was coming home one day from school, and somebody got too close to him on the road. So, he ran into that car and had an altercation. He got a felony charged from that. So then, he moved back with his parents to Colorado but had to go back to that other state for the adjudication process. That’s about the time that I started seeing him. And so, he also had a bipolar diagnosis and a couple other things, but the autism was the primary problem.

I started working with him, and really, it wasn’t therapy because if I ever tried to say anything, he would talk faster and louder. So, it was really monologues. But, we talked about his alcohol use and I provided some structure for him. He got through his parole and got off parole. Then, he got a job. But then, he was drunk again and driving. He got a little close to somebody, a policeman happened to be nearby, [so they] flipped on their lights to pull him over. He tried to outrun them to get home before they can—which is really not great planning, but that’s another story. So, he raced home, got in his garage, was trying to close the garage door before the policeman could get in. He wasn’t successful, so they got in the garage. He rolled up his power windows, so they couldn’t get him out of the car, but he caught the officer’s hand in the power window. So, he got another felony for that.

So, I went to court and testified. This was after I had been the Director of Mental Health for the Colorado Department of Corrections. I said to the judge, “I’ve overseen the mental health services in Colorado in the prison system, and that is not the place for him. It won’t benefit him. It won’t do any good.” The judge didn’t listen. He got sentenced to, I think, a year, prison term in Colorado. He got out, was on parole, started seeing me again, stopped drinking, and was doing pretty well. But still, therapy—”therapy”—consisted of his monologues. After he got off his parole, he started climbing mountains in Colorado. One Friday, he was headed up to climb some mountains, and somebody in the drive-up bank in front of him was too slow. So, he pushed their car through the drive-up window with his car. The woman got out, and she was understandably not happy about that. He confronted her with a knife. So, another felony. This time, I went to court and I said to the judge, “He’s been to prison before. I don’t think it was helpful then; it wouldn’t be helpful now. My recommendation is that he have the longest possible probation term.” He always does very well when he’s supervised and monitored. So, the judge fortunately agreed to do that. And, it was the summer that he was going to turn 40. He’d been sober and he’d been doing well on parole. He was very, very angry still, though. Probably every second or third word was, “F this and F that. F the police.”

So, he decided to climb another 14,000-foot mountain and drink one last time—this was his last hoorah. He got drunk, drove his truck through somebody’s campsite. The police showed up, and he tried to hit the police with his truck. He got another felony. He was still on probation at this point. So, I had started doing the fueling the brain treatment, along with the other things. So, I went and said to the judge, “I’ve been in this court before. If you look at this court record, you can see that I recommended the longest possible probation term for this guy because he had done well on supervision. I think with the treatment I’m doing, he will be able to recover. What I’m recommending is a year probation and a reconsideration to see how he’s done.” The judge, kind of amazingly, agreed, and so, he did the treatment. We started having conversations like you and I are having—actual conversations. Actual therapy. He might have said the F word once in like 6 months. He complied with all his probation, did the reconsideration, got off probation. He has a job now. He used to be very aggressive towards his parents; that’s completely gone away. That’s another case where he got his life back, and not even back; he got a life for the first time.

He texts me every six months: "Hi, Dr. Stephens! Just wanted to let you know that I’m doing well." Which, again, that’s another reason why I do this.

A: That’s amazing. I also wanted to shift gears a little bit and I wanted to talk about CorrValues. Would you mind telling me the history of CorrValues and how it started?

D: So, it started as a collaboration between me and a person that I had worked with. Most of the goal was to provide consultation and, like you read earlier, training for Health Services Administrators to improve the quality of care, to help counties and states provide healthcare in a much more cost effective way. The goal has been to be the administrators of healthcare services. Then, there can be contracted actual clinicians. That’s a much more cost effective way to do it and helps provide for and ensure the quality of care.

We have enough experience to understand what a CQI process should look like, to help jail administrators know what’s happening—really the healthcare needs of the people who are incarcerated there—as well as, get healthcare systems and processes in place that meet the healthcare needs. I don’t know how much looking you’ve done on the website, but kind of a corollary effort has been to work with churches in not only providing safety and security for the church, but also helping the church address needs of trauma, sexual abuse, and even, relationship abuse, management of staff in a way that’s preventive. So, the more that we can do to prevent injuries, to prevent trauma, to help the church be an advocate for prevention of problems—all of that is designed in a way to reduce incarceration, to reduce the incidents and impact of injuries.

A: What I’m also hearing is that CorrValues has a really strong commitment to community. As a mental health provider, why is it so important for you to also address issues that are directly related to correctional mental health? For example, things like re-entry barriers and barriers, why is it important for you to address those as well?

D: It's kind of back to those stories I told you. To me, it’s a tragic thing that anybody is incarcerated. That has a terrible effect on their life. So, if somebody’s been incarcerated, helping them recover from that and return to living a meaningful life and to have that awareness and understanding of their infinite value, to me is very important. Preventing injury, preventing incarceration, preventing trauma—to kind of summarize it, all of that is mental health. We can treat mental illness, but I think promoting mental health is a much more effective endeavor. Even the architectural neuroscience I do, my primary motivation in that is reducing stress, reducing sympathetic nervous system activation, reducing aggression so that everybody who’s in that facility—staff, officers, people who are incarcerated—improves everybody’s mental health.

So, I probably could’ve said it much shorter, but encouraging, promoting, developing mental health is really probably the thing that’s most important to me.

A: Do you think that other people who provide other mental health services or health services in general have this connection with the community? If not, how can we promote this idea so that we can take care of the entire community?

D: I would say it’s there to varying degrees. Most mental health providers or mental health clinicians understand that by treating mental health disorders or mental illness, that has a positive effect on relationships, on families, on marriages, and on the community. But I would say, it’s a little uncommon for people to have the perspective I do of actually working in and with the community and seeing that as part of a mental health clinician’s role and of having an impact. I would say the field is probably geared more toward reducing and hopefully alleviating mental illness. My focus is more on prevention.

I don’t know if you saw my background. I was the dean of an undergraduate school of psychology, and I did that for about 5 years until the school folded. But, training clinicians and giving them that perspective was an important part of my job. I trained master’s level professional counselors, master’s level marriage and family therapists, clinical psychologists, and in this school and with the faculty that worked under me, we would talk about [how] that’s an important part of the role, promoting mental health. I think wider dissemination of that in graduate schools [is important], but even just in community gatherings. One of the things that I started doing, very recently, is what I call, brain forums in the community—just to give people information about brain function about trauma, how to address those things, how to prevent decompensation, and all that, I think is an important thing.

A: To all the people that will read this in the future, what is something you want people to understand and know about the brain?

D: Well, I think we’ve discussed it. In my neuropsychological training, I took neuropsychology courses, I took biological psychology courses in my doctoral program, I took psychopharmacological courses in my doctoral program, and [brain fuel] was hardly ever discussed. So, the critical role of having the brain being fully fueled is a thing that I think is most important for lay people and professionals to understand.

A: Can you go more into the science of this? Maybe more about the glucose processes or the actual treatment and what that looks like?

D: Sure. So, the science is that any time there is sufficient impact or motion of the head such that the brain moves inside the skull, that activates the sympathetic nervous system, which is the fight-or-flight-or-freeze [response]. Or females, it’s been labeled as the tend-and-befriend reaction. That activates the sympathetic nervous system because of the chemical cascade that starts in the brain to deal with the injury. The same is true, like I’ve said before, with psychological trauma. So, if you’re abused, if you’re even just very fearful, if you see somebody seriously injured, whatever, all of that activates the sympathetic nervous system. When that happens, the brain pulls more glucose from the body, so there’s enough fuel for the brain to respond to the danger. So, there’s enough fuel for the brain to either fight or flee or do what it has to do to protect itself. The brain does not store glucose like the body does. So, it’s dependent on a steady flow coming in from the body, but again, in these traumatic situations, more glucose is pulled from the body, so there’s enough fuel for the dangerous situation. That creates a condition called hyperglycolysis. Glycolysis is the process by which the brain gets glucose. Hyperglycolysis is when that process is accelerated. So, the brain is then getting too much glucose too fast. If that continues indefinitely, theoretically, the brain could drain the body of glucose. If you don’t have enough glucose in your body, you won’t survive.

So what the brain does, and we still don’t fully understand the mechanism, is downregulate that glucose coming in from the body to turn off the hyperglycolysis. The problem is that it doesn’t do it only in the moment; it does it permanently. For the next injury or the next trauma, the brain upregulates glucose intake again because there has to be enough to protect you. Hyperglycolysis happens again; the brain downregulates glucose to turn off that hyperglycolysis, but it downregulates it a little more. So you’ve lost a little bit more fuel to your brain on a permanent basis. The next time, same process. That happens for every time there’s enough impact, motion, or trauma to activate the sympathetic nervous system. The brain can accommodate x number of injuries or traumas as long as they’re of minor severity through neuroplasticity—that there are multiple vision centers, attention centers, emotion centers in the brain, etcetera, etcetera. So, when one is limited because of inadequate fuel, then the brain—and the brain will, as an example, completely turn off the processing of one eye. I don’t know if you’ve heard of visual neglect? The brain will actually completely defuel and turn off the processing of one eye.

Several years ago, I treated a guy. He had a car accident and had a concussion. The next day, he was in another car accident. The day after that, he was in another car accident. So, he came in to see me, and on neuropsychological testing, one of the tests was to see a picture in front of him and sit there and copy it. He copied it, told me he was finished, and it was like someone had drawn a line down in the middle, and he didn’t draw the right side of that figure at all. It wasn’t that he wasn’t seeing; when I showed him, he was shocked. Then, he also understood why he kept getting in car accidents. After I treated him, I had him do a different neuropsychological test, also including a drawing task. He did it perfectly. So, the brain had shut off the visual processing of his right visual field. The brain will do that, and for the first several injuries, the first x number of injuries, through neuroplasticity, other parts of the brain can take over the function. Eventually, though, you get to the point where the brain can no longer adapt because there is such fuel limitation that you start having symptoms: headaches, tinnitus, lighter sound sensitivity, balance trouble, anxiety, depression, anger, mania, word-finding problems, losing track of where you are in a conversation, memory difficulties, attention difficulties, all of that.

Have you heard of CTE? Chronic traumatic encephalopathy. Basically, it first came to our attention from NFL football players. A number of them shot themselves in the chest, so their brain would be preserved so somebody could figure out what the problem was. They had horrible memories, not just anger but rage, severe depression; they became non-functional essentially. They had no idea what was happening. What did happen, or what was happening, was because they experienced—even though most of them were minor—so many concussive injuries, their brain was basically starving and non-functional. I discovered this probably about 5 years ago—baseline assessments for athletic participation. It became a thing; it’s actually not quite as popular anymore, but before high school or middle school or even a club sport—before a person could participate in those, they had to have a neuropsych screening, so when they had an injury, it could be determined the severity of the effect of the injury, cognitively. And so, I started doing these baseline screenings and probably did a thousand or more of them. I would always do an interview as a part of it and say, “Have you or has your kid ever had a concussion? Has your kid ever had a traumatic brain injury? Have they ever hit their head?” The answer, 95%-99% of the time, was no, no, no, no problem. Yet, probably 80% of the people, these kids, had clinically significant and statistically significant impairment on neuropsych screening, despite parents denying any history of injury. And so, that’s kind of what led me to dive deeper into the research and discovering this glucose or fueling problem.

A: So the risk factors for having this deficiency are...

D: Bumps on the head and psychological trauma.

A: I see, I see.

D: My opinion now is that probably every person, when they’re learning how to walk, has 1 or 2 or 3 of these injuries. And then, it doesn’t take a lot for it to happen. Certainly with concussive injuries and loss of consciousness and all of that, people have symptoms due to the chemical process that is happening and the lack of fuel, but it can be successfully treated.

A: For the person who got in multiple car accidents, I’m sure his brain was not receiving the proper fuel. What does the treatment process look like?

D: So it’s not a medication, but you can get glucose over the counter. You can buy glucose tablets and gummies. Part of the treatment is having people take glucose as a supplement. Then the other part of it is, like I talked about, changing the thought process and inaccurate perceptions that come from those injuries.

A: That’s a really powerful thing, that that can create that amount of change.

D: It is! It really is.

A: What are some myths that you think you want to dispel about correctional healthcare, mental health in general?

D: With correctional healthcare, I think there are a couple of myths. I’m not actually sure they’re myths. For example, people say that it’s wrong that people who are incarcerated should get healthcare when people in the community don’t get healthcare. What I would like people to know is that those people don’t have an opportunity, period, to go and get healthcare at a public hospital or a public clinic or free clinic or anything else. Their healthcare is really at the mercy of the system. So, providing healthcare to those people is very important.

Then, I think secondarily, in corrections, for probably—I don’t know—20 years or more, there has been this debate about: are people mad—meaning crazy—or are they bad—as in they just want to be criminals? I think either is a myth. The real thing is, like we’ve been talking about, that people are injured and traumatized. So, in most cases, they didn’t just decide one day—I want to be a criminal. And, in many cases, they're not mad or crazy, it’s the effect of the trauma and the glucose limitation. So, injured I think is a much better word. People still, in my opinion, need to be accountable for their behavior. There needs to be consequences to violating the rules of society, but I’m not sure we’re doing it in the best way and using the best science to do that.

And I think maybe the myth about mental illness is that you can’t recover; you can recover. People do recover.

A: Right now, for mental health in prisons, what do you think are the most alarming issues or the most important things to address?

D: Well, suicide continues to be probably the most alarming issue. Jails are the highest risk environment for suicide in the country. The suicide rate ranges from 37 per 100,000 to 177 per 100,000. So, suicide really continues to be… It’s an interesting thing. I’m in the middle of doing a series of suicide prevention training for a large midwestern jail, and I told them just the other day, because it’s true, that right now, the total numbers of death from COVID is exactly the same number as happens every year from suicide in jails. So, that gives a little perspective or context.

A: What’s part of that suicide prevention training that you think is important for people to know?

D: I think for officers and staff in jail to know: it’s a high risk environment. People are in crisis when they’re in a jail or a prison. Like we’ve talked about already, at least as historically constructed, the facility itself raises the risk of suicide. They need to be aware, and that’s part of the training. A big part of the training is the risk factors for suicide and strategies for preventing it. As an example, the most recent meta-analytic study of suicide in jails was in 2012, but that study had identified that 69% of people who killed themselves in a prison did so within 24 hours of a court appearance. So, they need to know that kind of information. I think suicide is probably the biggest danger and the most alarming issue.

Secondarily, for a long time, I would do training at universities and other places, and say that the common pathway to jail or prison was psychological trauma, early substance abuse, and school failure. I don’t disagree with things I said before, but I think now, I would also include and probably make it an even bigger issue, that trauma—again whether it’s a head injury or psychological trauma—that’s who’s in jail; that’s who’s in prison: people who are traumatized. It’s kind of tragic that our societal response to trauma has been to incarcerate. And not knowingly, but now we know and now we can do something about and do something different.

A: In your work, where do you see race and racism fitting in? How does it impact your work?

D: I think it’s pretty prevalent in correctional settings. There are gangs—a huge issue, particularly in prisons. It’s a significant issue, even often in jails. Gangs are very often organized around issues of race. So whether it’s white supremacy or in some jurisdictions, Native Americans, African Americans, Latinos or Latinas—that’s often the composition of gangs; it’s often ethnically driven.

And so, addressing that issue is very important, but I would say there’s a fair amount of racial stereotypes, certainly. Just kind of day in and day out in a jail or a prison. Addressing that and really affirming the significance and worth of every person regardless of their crime, regardless of their race, regardless of their behavior is something that needs to happen.

A: Something that I also saw on the website was this quote: “Racism… frequently derives from brain dysfunction.” Could you explain this further?

D: Sure. Like we’ve talked about earlier, the brain dysfunction or brain injury results in the individual’s brain interpreting that, “You’re deficient. You’re insufficient.” The brain then also tries to identify the source of that insufficiency or defect or deficiency because it doesn’t know it’s a glucose problem. So, it can identify, “Well, I didn’t do well in school, so that’s the problem. This ethnic group is trying to vy for my position in society or trying to supplant me or trying to say that they’re as good as me.” That then threatens that person’s sense of self-esteem and self-concept.

James Baldwin and Martin Luther King, were very different politically and very different philosophically. I don’t know that James Baldwin is really known for theology, but he certainly grew up in a church and had a lot of theological musings and themes in his writing. He and MLK were pretty divergent, but both of them talked about discrimination com[ing] from a deep fear on the part of the person who discriminates, and that discrimination and racism are very much individual problems and individual issues. Both of them said that in many ways, the life situation was worse for the racist than the victim of racism.

Their interpretation, which makes a lot of sense to me, is that it’s that deep seeded fear of being supplanted or proven to be less than, and so, if they can point to a group in society that is less important or less worthy, then that kind of staves off the personal insecurities.

A: Right now, I’m having some conflict about the explanations for racism, being with a scientific basis or a structural and social basis. With a scientific basis, it implies that if children grew up in a society that wasn’t racist, and they had some sort of brain injury or trauma, then they would have this propensity of being racist on their own. How do you compare those explanations and how do those interact?

D: My daughter and I have these conversations. Her opinion, I think, has been more of the social constructivist position and a societal position. I don’t know if you’ve seen the research about the brain, [that it] almost instantaneously detects difference—it can be faces that are differently ethnically or racially. It can be a pattern of things, and when a different thing, that’s not consistent with the pattern, is shown, the brain very quickly identifies that and reacts to it. There have been some very good imaging studies that support that. I think that there is very much a biological neurochemical brain component. In my opinion, social constructions, societal explanations derive from groups of individuals who have come together. I don’t think it has to be either or; I think it can be both. I think we probably have—at least in my opinion and you may not agree with this and my daughter doesn’t necessarily either—not enough credence or research or scientific explanation given for discrimination. In my view, it seems like it’s been more of the social construct explanations. In my opinion, we need both.

A: I think it is important to at least have more research in that area. That’s a new perspective for me that I really appreciate, even if I don’t agree with it! It’s important to explore.

D: I don’t know if you’ve heard in philosophy, there’s a perspective called the problem of unrecognized alternatives. I always try to keep that in mind. I have a perspective. I do a lot of research. I read pretty extensively. It doesn’t mean that I know all the answers; it doesn’t mean my perspective is the right one. One of the values often of educators and certainly was for me as the dean, is the principle of lifelong learning. I hope that I’m continuing to learn. I hope I’m continuing to grow. I hope my opinions are continuing to evolve based on new information and credible information. Who knows? Right now, I don’t know [that] I’ll ever be convinced that racism isn’t both an individual neurological brain function, certainly [with] societal influences and effects as well.

A: My last question for you is: what is your message to people? What is something that you want people to take away?

D: Probably—and I say this to everybody I treat, I say it when I do presentations and trainings—that everybody has infinite and equal worth. Related to that and in my opinion—this is somewhat controversial to people that I talk to—but to me, there is zero correlation between behavior and value. Or between behavior and worth.

A: I can see why it’s controversial, haha.

D: Haha yep!

A: What do you say to people who disagree?

D: Hm… you disagree! Haha, I’ll give an explanation. So, I've worked with people on death row. I’ve worked with people who have killed healthcare workers in the system where I work. I’ve worked with sexual sadists, and their behavior due to injury is what gets them where they are. There’s a study done—I don’t remember the authors off the top of my head—[that shows that] 75% of people who are diagnosed with psychopathy had a history of 4 or more traumatic brain injuries with loss of consciousness. That was the most common theme, and that’s what explained most of the variants in their histories. These people I’ve worked with—they as a person still have, in my opinion, infinite value and worth. Not to say that what they did wasn’t horrific. Not to say that they shouldn’t be separated from society for what they did. But, they’re no less worthy as a person. Maybe a common example for somebody my age: Mother Teresa isn’t any more valuable than anybody else. She sacrificed her life for the poor in India, but she’s not more valuable than the guy on death row. The essence of her humanity isn’t any better or any more than the other person’s.

A: Yeah, it’s hard for people to understand because there’s this obsession of placing value on people based on their achievements and what they’ve done. I think it’s a fundamental idea that will take time for people to get used to.

D: And some people will just plain disagree, and that’s okay!

A: That’s okay! That’s all the questions I have for you. I appreciate your time so much, knowing how busy you are! I learned so much, and I had new perspectives, so that’s a great gift for me.

D: You’re welcome! I’m glad.