What I Learned: Part 1

Hello from San Diego and the 44th annual American Academy of Psychiatry and the Law conference. One of the annual traditions associated with this conference is my series of "What I Learned" posts, which preserves little factoids, pieces of trivia and topics for me for future reference, and also tells members a bit about what they missed if they couldn't make the conference. For those interested in a more real-time experience, you can follow live coverage on my Twitter feed @ClinkShrink.

In spite of a three hour time difference and associated jet lag I did make it to the morning poster session. While I didn't get to every single poster, I did enjoy one that looked at the rates of military service for prisoners who committed suicide in New York over several years. One of the interesting things about this study was the fact that it was exempt from IRB review because all of the information was in the public domain as the result of a journalist's FOIA request. Having completed the story, the journalist turned over all the data to the poster's authors. Sweet. I don't recall all the numbers due to jet lag and mawazo mengi (keep reading), but the bottom line was that only three percent of the prisoners who completed suicide had a history of military service. Weird. Are veterans less likely to kill themselves in prison than while on active duty?? The poster wasn't designed to answer that question, but it certainly did raise the question in my mind.

Immigration issues are an emerging area of active forensic work now, and this was reflected again in this year's conference. I attended a panel presentation by psychiatrists from Yale and the Philadelphia program, who talked about the basis for deportation ("removal proceedings") and the common questions asked of forensic psychiatrists. An alien can file to be protected from removal based on a real history of persecution or being members of a group at risk for persecution, by being a victim of torture, or if their life or freedom could be threatened by return to the home country. The respondent's testimony about these issues must be credible. Psychiatrists are sometimes asked to testify as to why an alleged torture victim may have inaccurate recall of details related to their experiences, or why their demeanor or emotional reaction while discussing torture appears to be inconsistent with the experience. (All of this discussion brought to mind the prosecution of rape cases where the victim is "put on trial.") A psychiatrist might be asked to testify about a respondent's diagnosis and treatment needs and whether those treatment needs can be met in the home country. One panelist talked about transference and counter-transference issues in immigration evaluations, particularly about her own discomfort about testifying about deficits in her own country of origin's mental health system. I also learned it's good to know about culture-bound syndromes for these evaluations, like "mawazo mengi" ("brain fag"---yes, that's "fag" not "fog") or racing thoughts with headaches.

I was quite pleased to attend a panel presentation about the Goldwater Rule. As regular readers know, this is a persistent interest of mine that I've blogged, podcasted and written about before (here, here, here, here, and here). Now, the Shrink Rappers are finally not the only ones talking about this. The AAPL ethics and peer review committee put on a joint presentation in which they played several television interviews with psychiatrists commenting on criminal defendants in the news as well as on the President. There was vigorous and unanimous agreement about where the talking heads "crossed the line" of professional ethics, how the interviews could have been handled better and what recourse our profession had to address the offenders. Complaints have been filed within the APA against media consultants who violated our ethical rules, and in some states this may also be the basis for a licensing board complaint. Interestingly, social media was not even mentioned. I suspected this may be due to an inherent fear and suspiciousness about the use of social media by forensic psychiatrists. On a side note, but one I plan to track, is that the role of psychiatrists in national security issues and consultation to covert agencies was presented as a "grey area" of ethics. (Oh, I'd say it was a darker shade of grey myself.)

Finally, I attended a panel presentation on the management and reduction of inpatient violence put on by some of my Maryland colleagues. There was a review of the literature on risk factors related to inpatient violence (staffing levels, patients with a history of substance abuse and/or violence, an overstimulating---noisy---environment) and also a presentation of one inpatient unit's plan to reduce inpatient violence. The unit set up a designated "milieu manager" who did hourly rounds on the unit to touch bases with all the patients and keep an ear out for emerging tensions. They did patient-specific limited and targeted observation (a change from the usual practice of continuous, 24/7 observation). I forget the numbers on the assault rate, but what stood out in my mind was that the scores on the patient satisfaction survey I think tripled. The unit got the hospital award for the most improved patient satisfaction. Very cool project, and it was all set up, designed and run by the nursing staff.

Finally, the evening entertainment was a showing of the 1938 film "The Amazing Dr. Clitterhouse." Definitely worth watching even if you only watch the insanity trial at the end of the film. I may need to track down a clip of the "expert" testimony in that case. For peer review, of course.

The conference runs through Sunday and you can follow my coverage today and tomorrow @ClinkShrink. Thanks for attending with me.

Your Patient Died. Who Cares?

 

 

I thought I'd share what I saw on my Twitter feed as soon as I got up this morning. I immediately felt a blog post coming on, particularly after reading the Twitter comments as they rolled in. I felt a bit sick, knowing what some of my colleagues in Ohio must be going through right now. This post is for you.

When it comes to patient suicide, correctional psychiatry is probably one of the higher risk subspecialties within psychiatry. The average prisoner has three risk factors for suicide before he even steps into the facility: he's male, young, and has an active substance abuse problem. There's even a recent study to suggest that being charged with a crime increases one's risk of suicide, even if that person is never incarcerated.

Considering this, if you practice correctional health care for a few years it's pretty likely that at some point you will experience a patient suicide, either as a health care first responder, as an administrator or as a mental health clinician. I feel like I need to write this blog post to warn you about something:

Don't expect your friends, family and colleagues to understand why you're upset that somebody died.

I know that sounds counterintuitive, but that's just the reality of correctional health care. The general public---and even some physicians---are going to instinctively give you a "who cares? He's just a criminal" response even if they don't know the person or what he was locked up for.

Let's consider the responses I've seen just today regarding the suicide of Ariel Castro, the man who kidnapped three women and held them prisoner for several years (comments drawn from a network news site):

• Great news! Seriously, it's great that Ohio taxpayers won't have to pay to house and feed this scum bucket.
• He did society and himself a favor....good thing he's gone!
• Too bad that he didn't live to be locked up and suffer for a few decades.
• Too bad he couldn't have been chained to a wall while the inmates he was being protected from got rewarded for taking turns demonstrating the receiving end of his version of the universe. Can't exactly hang yourself when your chained to a wall. Cruel and unusual? If it's not cruel and unusual, it's not punishment.

Yeah, that could be your patient they're talking about. And all your patients watching the news or reading a newspaper will see this public reaction and know that the rest of the world truly could care less about them. Your job, temporarily, is about to become much harder. Fingers will be pointed, armchair psychologists who have never set foot in your facility will "know" how the system or you as a clinician must have failed, and new redundant policies will be created that will make your health care delivery system less efficient.

This will pass. Eventually, people will grasp the fact that this man who successfully hid multiple felonies for several decades probably also had the skill to hide a planned suicide attempt. Your colleagues in other parts of the country will step up to the plate to remind the media, and the general public, that correctional and forensic psychiatrists are taking an active role to implement suicide prevention policies and training that have dropped the correctional suicide rate substantially in the last twenty years.

And maybe, just maybe, it will lead people to recognize the importance of what you do.

Just a few thoughts from inside the walls, given that next week is National Suicide Prevention Week.

Why Are Inmates Dying?

In yesterday's New York Times there was a story by Erin Banco called Suicides Worry Experts at Big Jail in Capital. The story talks about four deaths at the DC jail this year and the general worrying trend of increasing correctional suicides nationally. The article speculates that the deaths may be attributed to lack of adequate mental health staffing or deficiencies in the jails' observation practices. Some of the people interviewed for the story linked the deaths to cutbacks in state mental health budgets.

Correctional suicide is an area that, as Dinah would put it, is a "Clink" thing---a topic I've been interested in for a number of years. I wrote about this three years ago in an article called Correctional Suicide: Has Progress Ended? In my article I pointed out that nationally we seemed to have hit a "floor" with regard to suicide prevention---rates had been declining consistently over the years until a recent plateau. I wrote about what I thought might be the cause of that plateau: the Prison Litigation Reform Act which limited prisoner access to the courts and circumscribed how far courts could intervene to improve prison and jail conditions,  as well as changes in the profile of the typical correctional suicide, and the increasing problem of gang violence and intimidation in corrections.

What was most striking for me then was the fact that correctional suicide studies are starting to show increasing numbers of inmates who die from suicide without any previous mental health history or history of suicide attempts. I coined the term for this phenomenon a "clean" suicide---one that could not have been picked up or prevented through currently accepted screening methods and referral protocols. The New York Times article didn't address this, but I couldn't help wondering if the deaths in the DC jail might fall into this category.

What I didn't mention in my earlier paper---because the numbers weren't out yet---was that the increase in jail and prison deaths may reflect a larger trend in rising national suicides. According to the CDC, the age-adjusted death rate for suicide has increased by 8.7 percent since 2000. The other new data comes from the recent Department of Justice report on inmate sexual victimization and abuse. According to this national survey, being a sex offender increases the by other inmates. The Washington Post has reported that three of the four DC jail deaths were by detainees who were charged with sex offenses.

The Times may be correct that cutbacks in state mental health budgets have had an effect, but this does not address the fact that for many states the funding for correctional health care comes out of the public safety budget rather than the health and mental hygiene budget. State cutbacks could still play a role, just not through the route the article suggests. States with privitized correctional health budgets would also have to be examined separately to look for contractual budget changes.

So those are my thoughts about the NYT correctional suicide story. I figured I'd better get this post up fast before Dinah nudges me to write about it. (Yeah I know, I'm supposed to be re-reading the book proposal but Dinah you know I had to blog about this.)

Reading While Depressed

I have to get off that suicide topic. Here's something a little more helpful:

In the current issue of the Paris Review, a reader writes in asking what she should read while depressed. Review writer Sadie Stein answers with a number of interesting suggestions, followed by 67 reader comments with additional ideas.

If you need to clean your head out from our last post and discussion, read this:

Life-Affirming Reads