Lockup Doc

Simply stated, correctional psychiatry is the practice of psychiatry in jails and prisons. It is a branch of forensic psychiatry, which according to the American Academy of Psychiatry and the Law (AAPL) is “a medical subspecialty that includes research and clinical practice in the many areas in which psychiatry is applied to legal issues.”

For those not familiar with the educational background of a psychiatrist, a psychiatrist is a medical doctor who has completed a four year medical degree (M.D. or D.O.) followed by what is typically a four year residency in psychiatry. Some psychiatrists then complete another 1-2 year fellowship in a subspecialty such as forensic psychiatry, geriatric psychiatry, or consultation-liaison psychiatry. Child psychiatrists typically complete 3 years of general psychiatry residency followed by 2 years of child psychiatry fellowship.

So, why is correctional psychiatry considered a specialty? Isn’t it just general psychiatry in a correctional environment?

Not really. There are several variables that make the practice of psychiatry different in a prison setting.

First, as anyone who works behind bars will tell you, the number one priority for everyone working there is (or at least should be) security. This means that even non-security personnel also share responsibility for institutional security.

The unfortunate result is that we professionals who provide any type of rehabilitation or treatment must do so in a setting that is anything but therapeutic. The security needs of an institution will invariably collide with the ability of physicians, nurses, psychologists, and others to get their jobs done efficiently and effectively.

For example, an institution may go into “lockdown” status for anywhere from a few minutes to a few hours. During lockdown, movement of inmates is typically stopped or severely restricted, staff are not allowed to enter or leave, and important events such as medical appointments simply do not happen. I recall once during a partial lockdown that my patients were not allowed to come to the primary care clinic at the prison to see me. So, I improvised like any prison psychiatrist would, and I saw my patients in broom closets in one of the housing units. Sometimes you’re lucky to get a chair to sit on!

Rules about confidentiality are also different from the outside. While medical and mental health records are still generally accessible only to those with a “need to know,” treating professionals can and must disclose to Security any information obtained from patients that may affect the safety and security of the institution.

In addition to the inherent challenges of the working environment, the patient population in a correctional setting is much different from that on the outside. Approximately 70% of the inmates have substance abuse problems, and approximately 70% have antisocial personality disorder (strong criminal personality features).

Treating patients with these issues in a setting where security come first presents many challenges. Although there is a risk of physical violence toward psychiatrists in corrections, the more practical daily challenges involve attempts of often angry inmates to intimidate and/or deceive psychiatrists into giving them various controlled substances or special privileges (lower bunk, excuses from work, or a move to a different housing area).

Despite the inherent challenges and stress of practicing psychiatry in a jail or prison environment, there are many rewards. I really feel as though my services are needed. There are always some inmates that I feel I am able to help. I get along well with most of them and never take the occasional hostility personally. Although the secure nature of the work environment can be constraining at times, the structure of it is appealing. The work is also very circumscribed, meaning that when I leave for the day, I’m done. In a twisted sort of way that I cannot really explain, there is a novelty factor of working in a prison setting with offenders that makes it more interesting and less mundane than the typical private outpatient psychiatry practice. For the right candidate, it can be a very rewarding career!