What Life Is Like for the 'Criminally Insane' at a Maximum-Security Psychiatric Hospital

While on sabbatical from her job as a college professor, Mikita Brottman volunteered to run a book club for patients at the Clifton T. Perkins Hospital Center, a state-run, maximum-security forensic psychiatric hospital in Maryland.

There, she met Brian Bechtold, who in February 1992 admitted to shooting and killing both of his parents in the family's home in Silver Spring, Maryland. A state psychiatrist diagnosed the 23-year-old with paranoid schizophrenia, and a judge ruled that he was not criminally responsible for the murders on the grounds of insanity. This meant that instead of going to prison, Bechtold was sent to Perkins—indefinitely— for psychiatric care and treatment.

As the book club continued, Brottman was struck by Bechtold's intelligence and articulateness; she wondered why, after 27 long years at the hospital, Bechtold was still being held there. Piecing together interviews with Bechtold, his medical records and legal documents involving the case, Brottman offers an insider's view of what it's like inside the country's forensic psych wards in the book "Couple Found Slain: After a Family Murder."

Brottman spoke with A&E about the grim daily reality of patients in forensic psychiatric hospitals and why the hardest part is often not knowing if they'll ever get out.

How and why do people end up in forensic psychiatric hospitals?

All the patients have committed crimes and have been sent there by a judge, but they're not actually criminals—they've been judged not responsible for their crimes.

Some are there because they've committed serious felonies and are being held for competency evaluations, to see if they have the capacity to stand trial. Some are inmates who come from other state psychiatric facilities because their behavior has been violent or aggressive and they meet the criteria for involuntary commitment. Most, however, have been found incompetent to stand trial or convicted of a crime that was committed when they were under the influence of a mental illness, like Brian.

Can they ever get out?

They're sent there until they have recovered or are considered stable enough to gradually return to the community—no matter how long that takes. For some of them, this never happens, and they stay in the hospital until they die. There's no federal agency charged with monitoring them and no registry or organization that tracks how long they've been incarcerated or why.

What's a typical day like for Brian and other patients in these facilities?

Generally, the patients have to get up early for breakfast and there's a lot of waiting around. The food is better than [in] prison, although they can't have silverware—everything is eaten with a spoon. There are a lot of groups—therapy groups, daily function groups. There are some groups run by volunteers, like yoga or book clubs or  debate groups. And then there's a lot of downtime where they have to be on the ward but they can't go back into their rooms. They have to mix with other people.

Usually, there are people just sitting around, watching TV or playing cards. They have a certain amount of time where they can go outside into a little courtyard and play basketball or hang out. Many of the patients have jobs [within the facility], so Brian's currently working as a medical assistant, taking records from office to office, but he's also worked as a janitor and in the gardens. He gets paid for that work, too.

And then he'll see his psychiatrist probably once a week. He doesn't really have visitors at the moment—because of COVID-19, they're on Skype—but patients can have visitors a couple of times a week. And they can get parcels, including certain amounts of food and books and things like that, which is better than prison. Basically, it's pretty monotonous and there's a lot of downtime with nothing in particular to do.

What has life been like for Brian in the hospital?

At first, he got help, attended lots of therapy groups, and did pretty well. But the psychiatrists wanted him to take medication, and he got into conflicts about that. Over time, he felt as if he'd recovered his sanity, but his psychiatrists disagreed. The medication made him impotent and incontinent. He started to believe he'd never get out.

At one point, he took a hostage, tried to escape, and got shot by the police. Another time he attacked a social worker. He's witnessed three patient-on-patient murders. At one time, he had a doctor who was declared criminally insane. He was diagnosed with cancer and recovered. He represented himself in court twice, trying to argue for his release.

By now, he's been there longer than almost anyone else, including many of the doctors. He's had a very interesting and traumatic life.

How are forensic psychiatric hospitals similar to or different from prisons?

In theory, they're very different from prisons. Most are co-ed. The patients are called patients, not inmates. They don't have numbers. They can dress in ordinary clothes. They get therapy and treatment from doctors. They're given medication, sometimes against their will. They're being treated, not punished. There are more amenities. The food is a lot better. They can have visits from friends and family, and can actually sit with them and give them a hug. They're usually released into the community gradually, over a year or so.

In other ways, they're very similar to prisons. They're surrounded by fences, patrolled by guards, the patients are put in solitary confinement, and other punishments are used. The difference is that patients don't have sentences—they stay there until someone decides they're well. Brian and many other patients have tried to get sent to prison, and those who have succeeded say it's much better. They're treated with more dignity.

How so?

You're not being judged all the time and you're not seen as a patient, but just an ordinary person. With Brian, the problem is that everything he does is seen as a symptom instead of a rational choice that anyone might make. In prison, you can stay in your room, you can choose not to go to meals, you can choose not to go out into the yard, and it's not jotted down in your file as a symptom of an illness—it's just a choice.

The other thing is that in prison, even if you're doing a life sentence, you've got a determined time. What's really ground Brian down is this constant hope that if he does this or if he does that, maybe he'll get out or maybe another doctor will let him out. It's this constant not knowing and not having any sense of making progress toward a goal.

How often are people ruled not criminally responsible because of a mental illness and sent to forensic psychiatric hospitals in the U.S.?

Contrary to popular opinion, the 'insanity' defense is rarely used, and it definitely isn't an easy way to get out of going to prison. According to an eight-state study, it's used in less than 1 percent of all court cases and, when it's used, it has only a 26 percent success rate. And of those cases that are successful, 90 percent of the defendants have been previously diagnosed with a mental illness.

There are about 250 state psych hospitals in the U.S., and most states have two or three.

What are the biggest misconceptions you hear about forensic psychiatric hospitals and their patients?

A lot of people picture these places as full of crazy, dangerous people, but many of the patients are intelligent, articulate people with the same needs, desires and fears as anyone else. The secrecy that surrounds them really feeds into the 'us versus them' mentality, which is really stigmatizing. It's just too easy to see it as evil people doing evil things. There's less of a line between the perpetrator and victims than most people think. Perpetrators can be victims, too.

It's much more complicated than it seems and there are lots of grey areas when it comes to crime.

In your research, did you come across evidence of abuse in these facilities?

There's some abuse in all psychiatric hospitals and I've included some statistics in the book about guards being fired for mistreating patients. But there are those acts of abuse that are very overt and then there are more subtle kinds that may not necessarily fall into the category of abuse.

The psychiatrists are really overworked and have big caseloads and can get ground down and frustrated and… they just lose empathy. It's that kind of abuse that can be almost more insidious than acts of violence.

The staff know [the patients have] done this dreadful thing that's often very high-profile, and part of the treatment regime is learning how to behave like everyone else in a normal, regular way, so unusual behavior is usually condemned and sometimes punished. People who are unruly are put in restraints and drugged and it's not considered punishment, it's considered treatment, but it's not clear how helpful that is. But there are acts of violence, too. The patients are violent with each other, and the staff are sometimes violent to the patients.

The type of crime that Brian committed—a child killing his parents—has been called a 'schizophrenic crime.' What are the typical characteristics of this crime?

There's been a lot of work done by psychiatrists on children who kill their parents and it's always in situations like Brian's, where the parents are in their mid-50s, the child has suffered years of abuse.

They're often mostly white, middle-class families. The child is mentally ill and the parents are mentally ill. It's like a hothouse. If the child was in a different situation, the crime might not have occurred, but that kind of situation is a breeding ground for violence, especially when there's mental illness. The crime is unpremeditated and it's usually when the parents are going about their ordinary business, like cooking dinner or something. It's almost always a surprise [to everyone else] because it's often families who keep to themselves and everyone in the community thinks of them as a perfect family. There's a lot of horror surrounding it.