Monday, November 19, 2007

Is This Forensic Psychiatry?

In my post Is This Psychiatry? janye made the following observation:

And, just how are mental health issues different in correctional institutions? Aren't the same medications being used? I'm just trying to understand how psychiatry in a criminal setting is different from the general population settings besides the obvious of the patients being locked up? It doesn't appear to be a speciality when you get down to it!

There are two parts to this question. The first part is, how are correctional and general psychiatry different (if at all)? And the second part is, is correctional psychiatry truly forensic psychiatry?

Both great questions.

Correctional and general psychiatry have similarities but also some huge differences. As janye noted, the medications are the same (yes, I have access to modern medications in prison). You still take a history, do a mental status examination, do lab work, gather outside history when indicated and provide treatment using the same general pharmacologic approach as in free society. I have access to an infirmary, seclusion rooms, and observation procedures when needed just like in free society.

But there are major differences. The patients may be the same if you work in a public mental health clinic, but if you are in a private hospital or private practice they will definitely not be the same. Correctional patients have loads of comorbidity including personality disorders, substance abuse, learned maladaptive behaviors, head trauma, chronic medical diseases etc. By the time they get to my clinic they have often been treated with the gamut of medications.

The other major difference is the environment. This is not a minor thing ("besides being locked up") and it has an effect on how you can practice. The inmates don't hold their own meds. They must report to a pharmacy window (see also my post Pill Line) or a nurse must bring medication to them. Certain medications are valuable in the institutional economy so you must be judicious about how much and what you prescribe. On the positive side, inmates are usually (not always, but a lot of the time) free of drugs and alcohol so you can use lower doses than what they get in free society. There are lots of other differences but these are a few.

Your own personal practice environment is radically different than what you would experience as a general practitioner in free society. You may or may not have an office, a desk or a telephone. You may or may not have heat and/or air conditioning. (My personal record: 100 plus heat index in a bare cell with no ventilation.)

Big differences. Differences that not everyone is cut out for. Fortunately, I like a challenge. Correctional psychiatrists tend to be laid back, not easily flustered and have a high tolerance for chaos. There is a difference between general psychiatry and correctional psychiatry.

And now the second question: is correctional work considered the practice of forensic psychiatry?

In a nutshell, yes. In the late 1990's the American Council for Graduate Medical Education (ACGME) officially recognized forensic psychiatry as a subspecialty of psychiatry. When fellowship accreditation standards were set up, they required fellowships to provide at least six months experience in a correctional facility. In order to become a forensic psychiatrist you have to spend time working with prisoners.

Now, most correctional psychiatrists currently are not forensic psychiatrists mainly because there just aren't that many forensic psychiatrists. And you don't have to have forensic training to work in a correctional facility. But it really does help. Forensic training exposes you to the correctional environment in a supervised fashion. It gives you an understanding of criminal procedure and mental health law. It gives you experience working with violent offenders and potentially dangerous seriously mentally ill patients. All of this comes in useful in prison. As in all psychiatric practice, patients want to be understood. If you understand their culture, their problems and predicaments, you will be better able to treat them. If you have no clue what the legal issues are that they're facing it would be hard for them to feel understood.

So there it is. This is forensic psychiatry.


Dinah said...

you still didn't explain how you're any different from a pharmacist

ClinkShrink said...

Did that really need an answer?

Anonymous said...

Also, if you aren't doing psychotherapy, basically you see a patient for at most 10 minutes at a time (about long enough to write a precription?), how does this provide you with fulling your interests with mental health issues and the law?

ClinkShrink said...

By caring for forensic patients I am fulfilling my interest in forensic psychiatry. Simple enough? Forensic psychiatry is both consultation work (doing evaluations for the legal system) and clinical work (providing care in secure settings).

The idea that I don't do psychotherapy really seems to bother you. Yet in public sector psychiatry the split treatment model is the rule rather than the exception. In private facilities and for-profit mental health care companies it's also a common treatment approach. Only in private practice do patients (if they can pay for it) get meds and therapy from the same person. Is this a good idea? It depends. Split treatment works for a lot of people but doesn't work for some. Regardless, it is going to be the reality for some time to come. You'd better get used to it.

Dinah said...

Funny, I'm the blog psychotherapy voice, I always say "I don't do med checks." I mean in my private practice. Since I also work in clinic settings, was once the medical director of a clinic, and consider myself a 'community' psychiatrist (meaning I work in CMHCs), I do do med checks (should I write a post about my other face?)-- in clinics split treatment is the rule. My patients don't get the same time or attention that they do in private practice, they get juggled around a bit --in one of the clinics I work at the patients are attached to the therapist who has time with a psychiatrist, if the therapist leaves, the patient gets reassigned and may get a new psychiatrist as well-- really ridiculous but a quirk of how this clinic operates, I didn't make the rules, I do obey them. Also, I'm not available to the clinic patients when I'm not in the clinic, they get a covering doc for emergencies, and I don't always remember either my patients or the details of their lives the way I do when I sit with people for long periods of time.

That said, I generally see 2 patients an hour for "med checks" --this is enough time to hear some of what is happening in their lives, to listen (the key element in psychotherapy), to provide some degree of connection and comfort. It's not psychoanalysis. It's not weekly or biweekly psychotherapy (most of my private patients come every other week once they are stabilized), it's not an hour, but I'm not sure what the exact line of how much exactly constitutes psychotherapy. A lot, I think, depends on the patient, on how they look at the session, on what they try to get out of it-- really, if someone comes in with an agenda, I don't say after 10 minutes "gotta go" though after a bit I may gently help them wind up. If someone comes in with a careprovider, says "uh-huh" to every question, and my main source of information is the care-provider's reports of how they are doing, it's definitely NOT psychotherapy.
I will tell you that I've seen people make remarkable changes without the traditional weekly therapy.
And then again, I don't quite know what Clink does in jail, or how she can love any job that doesn't entail A/C in the Baltimore summers, or how she doesn't get really anxious being away from her cell phone for so long.
So how's your mood?

ClinkShrink said...

My mood is good because of great friends (with or without cellphones), a job I love (even without A/C) and an upcoming holiday. Life is good.

Anonymous said...

My problem is, what i'm not understanding is, without spending time, getting to know and understand a patient, talking to a patient about how or why, what led up too being imprisoned,how is your speciality any different than a clinical shrink? I'm not judging whether or not psychotherapy is right or wrong or whether or not a patient needs or wants talk therapy, I'm just trying to figure out how a criminal who is mentally ill is any different than a mentally ill individual who has never been in prison. Maybe the question is, where is the law in this? Is writting a report for the courts instead of insurance companies or walking into a prison instead of a clinic for work everyday fulfilling your interest in the law. I understand you irrated with my questions and I am doubtful I will get an answer here, but I truely do not understand the difference. If there is no talk in a office visit regarding someones criminal behavior relating to mental illness, how is it different than than a non-criminal?

ClinkShrink said...

OK, I think I can give a clinical illustration that answers your question:

A patient comes into my office and says, "The judge ordered an 8-505." I know that his lawyer (who has even more cases than I have) has not explained this. I'm able to tell the patient during his med check that Health-General 8-505 is a Maryland-specific statute that allows judges to commit a defendant to a substance abuse rehabilitation program. I'm able to explain the legal procedure to him and to tell him what to expect.

Similarly, I keep up with changes in the law because these laws affect my patients. I've reviewed proposed legislation that would give emergency petition powers to correctional officers, and also legislation to create involuntary medication panels for prisoners.

This is how forensic psychiatrists working in corrections are able to provide enhanced care compared to general practitioners. Keeping up with the law is interesting and satisfying.

Did that help? I think that was more on point with your question.

Anonymous said...

Thats gives me a much better understanding!

FooFoo5 said...

You Clink, therefore you are. Enough said.

ClinkShrink said...

Aw...thanks Foo.

Anonymous said...

Garry Kasparov sentenced to 5 days in jail. Good thing you don't have to keep up with those laws.