Sunday, July 16, 2006

Clinical Judgement And Judicial Clinicians

We've had some discussions on this blog about split-therapy versus single-provider therapy, and over at Trick-Cycling there was a vigorous discussion about the role of nurse-practitioners in mental health care. In the correctional world we have one more practitioner to deal with: the judge.

In most cases the role of the judge is limited to sending the patient to our facility or getting him or her out. We do get referrals for treatment from the court, and for the most part these are appropriate. It can never hurt to have an extra pair of external eyes watching out for my patients. The problem happens when the role of the judge extends beyond identification and referral and into the realm of imposing treatment. I don't mean ordering that the patient participate in treatment, I mean ordering the treatment itself.

The usual way this comes up is at the bail review hearing. Inmate X appears in court and says to the judge, "I'm not getting my (insert sedating psychiatric medication here)." Inmate X does not mention that he was not participating in treatment at the time of arrest, or that the only time he takes medication is when he's locked up. Nevertheless, an order gets written that Inmate X must be evaluated for medication. Well and good, this is appropriate although not totally necessary. Provided that Inmate X was honest with the intake nurse and gave a history of mental health treatment, he would have been referred to see the psychiatrist anyway. We now have two duplicate referrals, one from the court and one from the intake nurse. Subtract one point for inefficiency.

But back to the court-ordered treatment. Occasionally Inmate X will tell the judge that he wants to be on the mental health tier. We do provide some special housing for inmates with chronic mental illnesses who have trouble in general population. No problem. But if the inmate gets into trouble or starts fights or otherwise acts up on this tier, he might not be accepted back there. Thus, the court-ordered jail hospitalization. Not because he needs to be in the hospital, but because the judge wants him out of general population. Subtract one point for losing an inpatient bed.

Some judges order that the inmate "be provided with medication"; usually the implicit understanding is that the medication is provided if clinically indicated. Rarely, you'll get a judge who orders that an inmate should get medication, even if the inmate has already been seen and found to have no Axis I disorder. I've also seen orders specifying the name, dose and frequency of medication to be given. This creates an interesting situation when the patient then tells me he has a history of an adverse reaction to that same medication. Subtract one point for creating a legal conundrum.

So far I haven't heard of any correctional physician who has been found in contempt of court for using sound clinical judgement, or who can document the reasoning behind a clinical decision and can explain it coherently to the court if asked. The real downside is that doing this takes time which could be spent providing clinical care. That's where I see a need for sound judgement.


Disclaimer: The opinions expressed in this blog are my own, expressed while off-duty, and do not represent those of my employer or the state government. Please don't make me listen to Barry Manilow.


Dinah said...

Since I have coffee with a judge every morning, I am posting this disclaimer, aimed to preserve my IRL social life: I am not responsible for any words/thoughts/or feelings expressed by ClinkShrink.
I did, however, add the pic of Judge Judy to the post.

ClinkShrink said...

And a nice pic it is too. Thank you.

MT said...

I guess you psychotherapists heard W's "Axis of Evil" remark as lots richer in connotations than the rest of us. I'd have thought "Evil" equals Axis II from Iran and Iraq, but Korea seems kind of Axis I. That's why we have professionals, I suppose.

Steve & Barb said...

I've never actually evaluated North Korea, so I cannot diagnose at a distance. (If I become a Senator in the future, perhaps I'll be able to render such a diagnosis.)

On the Same Page said...

I sat through a "lecture" on Monday by an assistant warden from a prison "reception center" on the daily madness of the placing of inmates according to custody level scores and needs. The inmate is thoroughly "evaluated" for up to month, and then, using a matrix of issues such as violence, sexual offense registration, drug & alcohol use, disability (visual, speech, mobility), medical status, mental health condition(s), proximity of family (right), gang affiliation, previous escapes, arson, "computer crimes," known enemies, and specific requests for "special needs classification" (formerly referred to as "protective custody"), a decision is made. Once the decision is made as to level of custody and status, a matrix of the facilities that are capable of "serving" the inmate is consulted - changing on a daily basis - and then they are placed. As you can imagine, this can take far too long. If a facility is perfect for you, but say it is in the "high desert," and you're on psych meds: too hot for you. The perfect, protected yard for your wheelchair and meds is available, but so is a man you owe money. On and on and on. Honestly, I don't see the judges having much influence on this particular system, unless you are referring to US District Judges, who seem to have influence of late. And why do prison clinicians get away with just writing incarceration on Axis IV?

Sarebear said...

Because I guess now they are talking about the patient being a prisoner in their own mind, thus, the incarceration dx . . . Incarceration as a State of Mind; It's Not Just For Criminals, Anymore. Article in Journal of Lunacy; founding board meets once in a blue moon.