Raymond F. Patterson, MD: Forensic Psychiatry in Extreme Environments

The Early Years

I consider first Patterson's early years spent on the Southside of Chicago. He was born in 1952 and by 1954, his parents (Frederick and Vinita Patterson) were divorced. His memories begin to solidify around age five years, when his mother moved with him and an older half-sister, Madalyn, to live with their maternal grandparents in a house that faced Washington Park. That park was a haven for all sorts of amusement. Ray lived at that address until he went off to the university. The grandparents' home was an occasional and temporary respite for other family members down on their luck. The neighborhoods on both sides of the park were controlled by Black gangs. Latino and White gangs operated a bit farther away. Both high schools in his neighborhood were under gang influence. Patterson explained how he developed techniques to protect himself from them and to stay in school and do well academically. Central to his plan was remaining a nonmember, staying busy with parttime jobs, and attending summer school to take advanced courses. He also found time to develop into an outstanding softball and football athlete.

An additional dimension of the effort rested on the roles played by family members. They talked to him frankly about avoiding trouble with gang members and the police. Uncle Mac served as a strategic advisor. He was a high school principal who understood the potential problems of the adolescent years for Black males in urban communities. He introduced Ray to jazz and to Count Basie's artistry. Mac pushed Ray to take the test for a magnet school outside the neighborhood. He also guided Ray through the college application process and helped him gain admission to prestigious Northwestern University. One important principle was to avoid attraction to athletic schools that promise fame and only deliver it to a small fraction of Black candidates.

There was also the unshakeable presence of Grandfather, Joseph McBurnett Smith, and his wife Madalyn. He loved classical music and opera's Caruso. He knew how to keep an eye on things without being intrusive and hovering annoyingly. He was a Cajun from Baton Rouge, Louisiana, who married a kindred spirit from Mississippi. He taught his grandson all the rudiments of Cajun cooking. Patterson talked to me at length about the art of preparing a roux, the base of Cajun cuisine. I know now about Ray's favorite dish, Seafood Avery, full of shrimp and crab meat (no shells). One starts with a “light roux” made of flour, olive oil, a bit of oregano, white pepper, and a little salt; then stir with a wooden spoon. Metal changes the flavor. The other ingredients are added once the roux reaches a “working boil.”

His father was a civil rights advocate who worked as a welder in Chicago steel mills and later was employed at the Chicago public library. He also served as a labor organizer and marched with Martin Luther King, Jr., and Jesse Jackson's Rainbow Coalition. His mother was a licensed vocational nurse at a nearby hospital. She worked the nightshift so she could keep a close eye on her son and his half-sister. Mother was deeply religious. Patterson recalls having to accompany her to church, where he watched the ritual spirit possession in full expression. Once he finished high school and went off to university, she completed her own college studies. She earned a bachelor's degree and then went to teach high-school science in Louisiana. It was she who urged her son to do his best in school while she prayed hard that God would bless him. The advice was rooted in one of her favorite sayings: “You work as if it's up to you, and I'll pray as if it's up to God.” Prayers and parental efforts were necessary to make sure he was not “caught up in stuff” while “growing up in the Chicago streets.” Meanwhile, during Patterson's high school years, his father stepped back into his life, notably as a faithful fan at high school football games when his son would show off his skills on defense. Father also introduced him to half-brothers and sisters from the father's first marriage.

Growing up in Chicago and attending Northwestern University represented an extended seminar in racialized experiences. Learning about the task of driving while Black, contending with occasional interactions with police and different gangs at school and in the community, all taught him about that part of Black life. Negotiating territorial sovereignty enforced by gangs was a necessary skill. The 1960s and 1970s community discourse on race, taking place in Chicago, was influenced by representatives of the Nation of Islam, the Black Panthers, and the Rainbow Coalition of the Rev. Jesse Jackson.

Patterson chose Northwestern because of the scholarship assistance offered and its recognized national standing. Few classmates were Black. This produced its own culture shock. The racial climate led to his conclusion that he did not belong there. In fact, he felt the university managed to develop little meaningful interaction with its minority students. He gave up football after freshman year, limited his extracurricular activities, and attended to his parttime jobs at a gas station and the Chicago post office. With all the civil rights conversations going on around him, he decided he had to concentrate on his studies and solidify decisions about his career. In his junior year, he applied for admission to medical school and was accepted by Howard University. Howard did not require completion of the bachelor's degree.

Medical School Years

Raymond Patterson likes to refer to his medical school as The Howard University College of Medicine, with deliberate emphasis on “The.” This special manner of reference underlines the uniqueness of this educational institution, its traditions and rituals, and the link to Blacks in American medicine as teachers, patients, and researchers. Everybody was aware, too, of the history of the old Freedmen's Hospital, Howard's principal teaching facility. Patterson felt the College of Medicine was leading a natural experiment with its class of about 120 students, 10 or so of whom were White. There was also a small group of Blacks who walked around with attitudes that signified membership in the broader society's upper crust.

For him, biochemistry and anatomy demanded serious attention. He heard his grandfather's voice urging him to focus. He rearranged his priorities and got down to studying. Once settled, he could feel the urging of the professor of surgery to pursue “equanimity under duress.” He tuned into the imperatives of Professors Alyce Gullattee and Frances Welsing that patients be treated as individuals with lives that demanded attention and respect. Patients also had names, these two Black psychiatrists declaimed in unison. They were somebody. One of the six students in his group assigned to dissect a cadaver was White. Another was a member of the Nation of Islam. The differences in politics caused some friction; however, since they all wanted to be doctors, they found a way to work things out. By third year, the call to psychiatry was strong, and the wish to think seriously about the intersection of illness and its social determinants was irresistible. Listening to him talk reminded me that Black males in these situations sooner or later recognize that they are representing family members and others back in their home communities. The success is not singularly Patterson's. It belongs to others who witnessed his voyage.

Raymond Patterson graduated from the Howard University College of Medicine in May 1977. It was an eventful year for him, he remembers. Graduation was followed by his June wedding to his girlfriend, Deborah Carter. He obtained state licensure to practice medicine in July and celebrated his 25th birthday in August. His parents, many relatives, and childhood friends from Chicago attended the graduation ceremony. I was not there but looking at Patterson's face, I could tell how proud he was that he had delivered that gift of pleasure to family and friends. He left Chicago and reached his goal of becoming a doctor. His mother and Uncle Mac were proud leaders of his fans at graduation.

He first met his future wife one day when he went on an errand to the animal section of the College of Medicine. That is where she worked as an administrative assistant. He talked of walking into the office seeking some live animals for a project. He posed a question to Ms. Carter, and she smiled at him in reply. She did provide him the information he was seeking, while also leaving him absolutely smitten in the process. Two years later, they sealed their promises and went on to build a family in Maryland. Their 44-year union produced two sons, one a psychologist and the other an advertising executive. Patterson's wife remains at the center of his life.

Maturing of the Forensic Psychiatrist

The first half of his four years of residency training were spent at Howard. Then he transferred to St. Elizabeths Hospital, where he spent considerable time in their Division of Forensic Programs, treating and performing evaluations of both inpatients and outpatients. He worked with federal courts and the District of Columbia district court. He participated in civil, criminal, and family matters. Once he finished training in 1981, his principal work was in his role as a staff psychiatrist at St. Elizabeths on a pretrial unit. This entailed weekly appearances in court that made him visible to many attorneys. From that exposure, his name became widely known in forensic psychiatry. In addition to his main employment, Patterson also was building a private practice of clinical adult psychiatry where he expanded his experience in psychotherapy and psychopharmacology. Extra work at a nearby community mental health center offered opportunities to do group and family therapy.

He gradually developed a connection to nearby law enforcement agencies such as the U. S. Secret Service, the U. S. Marshal Service, the District of Columbia Police, Baltimore City Police, and the U. S. Capitol Police. These agencies sought consultation about the interaction between psychiatric illness and violence and how to manage those individuals in need of urgent care. In 1985, he was recruited to become a site visitor for the Joint Commission on Accreditation of Hospitals. For over a decade, he made use of this group's administrative criteria to determine excellence in hospital care of patients. He employed his forensic skills in consultation to jails and prisons; secure forensic hospitals; state and federal courts where he served as a monitor for the court; the Department of Justice Civil Rights Division under the Civil Rights of Institutionalized Persons Act; and the local Protection and Advocacy agencies. The invitations augmented recognition of his national identity as an expert witness in cases related especially to the standard of care in different types of hospitals and institutions providing clinical care in a context of custody and rehabilitation.

Several employment posts reinforced the direction that Patterson's career was taking. His technical forensic knowledge was progressing under the supervision of the experts found at St. Elizabeths Hospital. This facility of over 2,000 beds (at that time) offered care to patients with different levels of security needs. Between 1981 and 1983, Patterson was a staff psychiatrist there at its John Howard forensic pavilion. In 1983, he was named its medical director. In 1987, he became Administrator of Forensic Services for the District of Columbia, which was the same year that the District took control of St. Elizabeths from the federal government. In 1992, the Mayor of D.C. named him Commissioner of Mental Health Services, a job he held for just several months because the District's Council invoked a residency requirement for holders of the post. Patterson refused to move into the District from a home he had been occupying nearby in Maryland.

In late 1992, he accepted appointment as Superintendent of the Clifton T. Perkins Hospital Center (Maryland's secure forensic facility) and Director of Forensic Services for the State of Maryland. This position was coterminous with appointment as associate professor of psychiatry at the University of Maryland. The Baltimore Sun newspaper celebrated his appointment,³ noting all the expected challenges that he would encounter. The article also recounted how, when he resigned from the post in Washington, colleagues and patients packed a hospital venue to celebrate his accomplishments at St. Elizabeths. Patterson recalls this event fondly, especially as patients had joined with activists, administrators, and representatives from community and government agencies in Washington to give him the “Our Hero Award.” It left him on the edge of tears. The U. S. Department of Justice presented him the Award for Public Service, and the U.S. Secret Service gave him its Award for Outstanding Assistance and Support to Law Enforcement. This type of stardom had been seen before, when the Washington Post Magazine reported on Patterson's life story.⁴ The celebrity status had appeared, too, when he was the center of attention in an extensive interview about the effect of the verdict on the community in the trial of Washington, D.C. Mayor Marion Barry.⁵

Our discussions about his time at Perkins brought into sharp relief the problem of running a hospital facility whose budget is controlled by a state legislature facing competing demands on the funds available for state-wide activities. Patterson was in a tight corner. He was an experienced surveyor for the Joint Commission, and Perkins was not accredited. Thus, he knew that to achieve accreditation, the hospital would have to improve its staffing levels both for physicians and nurses. Disappointed, he quit his post in mid-1994 and took a senior administrative job in a federal agency for a year.

In September 1995, he was named Chief Psychiatrist for the Department of Public Safety and Correctional Services in the State of Maryland. He was also Senior Psychiatric Consultant to the Patuxent Institution, a specialized treatment prison that catered to individuals who were suffering from serious personality disorders, but not severe psychotic illness. They had been convicted and sentenced for their crimes and had been judged capable of benefiting from psychiatric care and rehabilitation. This was his first excursion into prison administration. His remit was also expanded to include membership on the state's panel that reviewed contracts held by agencies charged with delivering mental health care to prisons. During this time at Patuxent, he served as a court-appointed monitor of care in different institutions. In 1998, St. Elizabeths went into receivership, and the individual serving as the monitor asked Patterson to return to St. Elizabeths and take responsibility for the care in the Division of Forensic Services. Patterson served as Director of Forensic Services from then through 2001. He gave up the appointment at St. Elizabeths when he decided that the consultancies (in prisons and secure hospitals) had become too numerous and time-consuming.

Relinquishing the position at St. Elizabeths left him settled with an office practice that was divided between clinical outpatient work and an extensive practice responding to assignments requested by attorneys and judges. The latter work drew him to high-profile forensic psychiatry cases having to do with serial killers, terrorists, and the White House. (Our discussion of several of these assignments illustrated how carefully he proceeded in this work, examining his own potential to be biased, seeking relevant information widely, scrupulously avoiding involvement with media, and attending to the dignity of examinees and others.) This latter work was separate from the time-consuming attention demanded by commitments to improving care in forensic hospitals and prisons. Of course, he still accepted speaking engagements all over the country, participated in professional meetings, and supervised trainees in medical school forensic programs in the Washington, D.C., area (St. Elizabeths Hospital, Howard University, Georgetown University, and the University of Maryland).

Reflections on His Career

Thinking about his activity in the facilities serving this unique population, he recognized that the work had been hard. He was pleased, however, that he had received recognition for it. He saw that in two prestigious “Keys” that had been awarded to him from the Directors of two prisons: The Angola State Penitentiary in Louisiana, and the Patuxent Institution in Maryland. The “Key” to a prison facility is a distinctive honor that carries with it compliments from the facility's leadership that the individual being cited has contributed substantively to the well-being of the institution. Those awards have been enhanced by his being named the 2019 Seymour Pollack awardee by the American Academy of Psychiatry and the Law and the 2021 Yochelson Visiting Professor of Psychiatry and the Law at the Yale School of Medicine. Patterson also notes, as we review his accomplishments, that he has published several scholarly accounts of his contributions to the evolution of mental health care in correctional facilities.^6,–,8

He held my attention in an informal disquisition about the culture in these two types of institutions, especially the prisons. He reminded me of their emphasis on control, both of people and the intense regimentation of activity. He noted the preoccupation with security and safety and the constant struggle to maintain equilibrium with the task of caregiving. He found it his life's work to preserve the access of inmates and patients to psychiatric and medical care. He regretted having to mention that some of these institutions are still not equipped to provide care for substance users. In his opinion, however, that is not the only group being underserved. Women and juveniles also do not enjoy equitable access to treatment.

Patterson reminded me of language commonly associated with prison culture, such as: the use of derogatory terminology referring to women; the wearing of pairs of pants without belts, causing the pants to drop way below the waist; the constant glorification of “being bad,” and “taking no shit from nobody;” and carrying weapons and constantly seeking ways of referring to self-pride. There is the claim, too, that one is not just a man, but a Black one and armed. This “jailin culture” is antithetical to the idea that those responsible for the inmates and their future should keep an eye on what is necessary to ensure success in community life. As I argued elsewhere, “short lengths of stay are usually linked to minimal degradation of skills required for living in the community. Longer lengths of stay require an emphasis on guarding against deterioration of these skills and implementing rehabilitation techniques that offer amelioration of skills required for community living” (Ref. 1, p 181).

We contemplated together the possible effects of sustained isolation on the average human being. Patterson pointed out the lack of connection between these punishment decisions and the overall mission of the institution. He described the apparent incongruity between caregiving and the organizational and political emphasis on punishment of aberrant and criminal behaviors. Here, I recalled the concept, enunciated by Jacob and Foth,⁹ of the “a-potential” individual found in prisons and forensic facilities. Those in charge of these institutions determine that the patient or prisoner demonstrates no potential for recovery and improvement, with eventual return to the community. These individuals are often excluded from access to care and rehabilitation and essentially placed in a zone of invisibility. Patterson rails against such inhumane treatment. These values cement his identity and purpose in forensic tasks.

Patterson insists that the specialist who wants to work in prisons and forensic psychiatric hospitals must develop a habit of repeated self-examination and thoughtful interaction with others. The hope is for the development of a quiet self-confidence, a respectful curiosity about others, and a distinctive professional style reflecting commitment to justice and fairness for all. These attributes are demanded by life in these institutions: the predominant presence of minority faces; caste elements built into the organizational structures; social groupings like gangs; the chasm between correction officers and prisoners; and the caregiver/patient dichotomy.

It has been a privilege to follow Patterson's movement from a Chicago community to leadership positions in the medical subspecialty of forensic psychiatry. Navigating extreme environments is, for him, practically an art form. He has done it, though, with the words of the surgery professor still audible: “equanimity under duress.” And with Gullattee and Welsing, his psychiatry teachers, insisting that every encounter in extreme forensic environments must be with an individual who has a name.