There is a natural conflict of interest that occurs when a psychiatrist who is providing treatment to a patient agrees to perform an evaluation or render an opinion about something of a legal nature regarding the same patient.

In treating patients in the community, I’ve turned down requests from attorneys on several occasions when they wanted me to provide expert opinions about my own patients. I simply did not feel comfortable doing so as I believed that it was going to interfere with my treatment relationship with them.

This viewpoint is endorsed by the American Academy of Psychiatry and the Law in their Ethics Guidelines for the Practice of Forensic Psychiatry (PDF).

Here’s an excerpt:

Psychiatrists who take on a forensic role for patients they are treating may adversely affect the therapeutic relationship with them. Forensic evaluations usually require interviewing corroborative sources, exposing information to public scrutiny, or subjecting evaluees and the treatment itself to potentially damaging cross-examination. The forensic evaluation and the credibility of the practitioner may also be undermined by conflicts inherent in the differing clinical and forensic roles. Treating psychiatrists should therefore generally avoid acting as an expert witness for their patients or performing evaluations of their patients for legal purposes.

Psychiatrists can be compelled to testify in court as fact witnesses regarding their own patients, but not as expert witnesses. Fact witnesses can verify the dates of treatment, the diagnoses made at those visits, statements that patients made, and the treatment rendered, but they cannot be asked to speculate or render opinions.

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While correctional health care workers may be sued for malpractice, the most common type of lawsuit filed by inmates about health care in the U.S. involves allegations of “deliberate indifference.”

According to US Legal, Inc., “deliberate indifference” is “the conscious or reckless disregard of the consequences of one’s acts or omissions.” To be found guilty of deliberate indifference, prison employees must know that they are creating a substantial risk of bodily harm. So, knowingly ignoring an inmate’s serious medical complaint would be one possible example of this concept. Deliberate indifference violates the inmate’s Eighth Amendment right that prohibits cruel or unusual punishment.

What can you do both to minimize your risk of having lawsuits or other complaints filed against you, and increase the odds that any frivolous complaints that do get filed are dismissed as expediently as possible? Here are a few ideas. This list is by no means comprehensive.

1. Do your best to provide quality care. Regardless of the crimes that an inmate has committed and how much you like him, your job is to provide the same quality of care that you would provide to a patient in the community.

Stay current in your field. Use evidence-based approaches whenever appropriate.

Focus on treatment, not placation. Some inmates will persistently request inappropriate medical interventions. Provide them with what is medically indicated, not with something inappropriate simply to satisfy them.

2. Don’t ignore or minimize inmate health complaints. (Inmates write their concerns on forms that they submit to health care providers.) One of the challenges in correctional health care can be picking up on the clinically significant complaints in the midst of the “noise” generated by the small percentage of inmates who frequently write inappropriate requests. When in doubt, error on the side of assessing someone. If an inmate requests to be seen, but you decide not to grant the request because you do not believe it’s necessary, then be sure to document why. Be sure to follow your institution’s policies and procedures on handling inmate health requests.

3. Document thoroughly. Lawyers usually say that “if it isn’t documented, it didn’t happen.” Be extra-comprehensive if a particular inmate is known to be litigious or if you believe you’re being set up. Stick to the facts in your charting, and appear emotionally neutral. Expect that your patients and their lawyers will read what you write, and you’ll be more careful about what you say and how you say it.

4. Be mindful of boundary issues and professionalism. Yes, it’s two human beings interacting with each other, but there is a significant power differential in the relationship. You’re not friends with each other even if you know the patient well.

I should mention that boundaries vary depending on specialty and practice setting. A small town family doc may very appropriately be friends with some of his or her patients. But, in a correctional setting, the relationship is necessarily much more formal. Titles (Dr., Mr., Ms., Captain, Sergeant, etc.), not first names, are used for both staff and inmates.

Disclosure about oneself to inmates should be minimal. You can admit that you like a certain sports team, but don’t discuss your relationship problems, marital status, kids, or personal history of depression treatment. Don’t discuss with coworkers your weekend escapades within earshot of prisoners: You probably wouldn’t do that in a community setting, so why would you do that in a jail or prison?

Don’t do anything “extra” for inmates that you wouldn’t feel comfortable telling your supervisor about. This principle will help you decide if what you’re thinking of doing is appropriate.

Consider reading the book Games Criminals Play.

So, do you have to be an emotionless robot? Absolutely not. There is an appropriate way to make small talk, joke a little, and be friendly and caring without crossing boundaries.

5. Don’t show favoritism. You’ll naturally like some patients more than others. But don’t fall into the trap of going out of your way to help some patients but not others. Inmates talk. A lot. They’ll quickly notice if you treat some people differently from others. Inmates will be more likely to complain about you if they believe you treated someone else with the same concerns better.

6. Treat all inmates respectfully, even if they don’t treat you this way. This doesn’t mean that you should accept rude or hostile behavior from others–you shouldn’t. But, I believe that many correctional employees, regardless of their roles, would have far fewer problems with inmates if they simply treated them the way they’d want to be treated. An inmate’s “punishment” was coming to prison; it’s not the role of prison staff to dole out punishment.

7. Don’t hesitate to expand the field to get more information. If you need additional information about an inmate’s medical history, don’t hesitate to ask him to sign a release so that you may obtain records from community providers. In very complicated cases and in cases where you believe an inmate may be litigious, this can be a smart move. You might end up with helpful information, but even if you don’t, the record will reflect that you tried.

What do you think? If you work in correctional health care, do you have any other tips to share?

(Disclaimer: I am a physician, not an attorney. The information in this article should not be considered legal advice. The opinions in the article are my own.)

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I recently published a post asking for readers to submit questions to me that they might have (primarily about my profession). I’ve paraphrased when necessary:

1. “Why do people who truly do have mental issues despise taking their medicine-often times going off of it and landing themselves back into the hospital due their condition? They say they don’t need the medicine-but obviously they do. And those who fake an illness love their medicines and will fight, steal and lie to have these medications.”

A: Most people do not actually want to have a mental illness. For various reasons they resist it and can be in some degree of denial. One aspect of some mental illnesses is also a lack of insight (or varying insight depending on how sick they are). People who fake illnesses for secondary gain (entitlements, attention, etc.) have a large incentive to stay in the illness role to obtain what they seek. The better they play the part, the less likely their cover will be blown.

2. “Do you have any risk management tips? What are some practical things correctional medical and mental health providers can do to minimize lawsuits by inmates?”

A: Excellent questions. And they require answers too lengthy to write here. Therefore I’m going to do a post on risk management issues in the next week or so.

3. One reader recently sent me an e-mail expressing frustration that I do not publish posts on transference issues. Specifically she was interested in material about patients who have romantic feelings toward their psychiatrists.

A: As a male psychiatrist who currently spends much of his professional time treating male inmates and who is not formally practicing psychotherapy, you’re not likely to find articles about patients and psychiatrists having romantic feelings for each other. I’m just one person doing what I do here for free (actually I pay money for my blog; I spend hours each week writing for free). I simply can’t and am not interested in covering everything. Readers interested more in psychotherapy issues with psychiatrists may want to check out Shrink Rap, a psychiatrist blog by 3 psychiatrists (2 females and 1 male). Dinah, one of the psychiatrists there, has a psychotherapy practice and often posts about therapy issues.

4. How could a librarian (presumably in a correctional facility) help inmates to better understand their health conditions?

A: That’s a tough one. I’m vaguely familiar with the library resources that have been available to inmates in the institutions in which I’ve worked–what’s available seems to vary quite a bit from one place to another. Given the less than high school education that many inmates have, I would say that helping them to find books that would be appropriate to their reading levels would be most helpful.

5. “How do you keep from getting frustrated with recalcitrant/dense/reluctant to take your suggestions types, and how do you keep your cool at the times you’d really just like to reach across the table or whatever and shake your patient and say “WHY AREN’T YOU GETTING THIS?!?!!?”

A: I do get frustrated at times. I wouldn’t be human if I didn’t!  But,  I guess that over the years I’ve learned to be more patient with patients, even difficult ones. What helps me is that I see myself as a consultant to my patients. I’m not there to rescue them or save them from themselves. I do my best to establish rapport with them, assess them, educate them, and provide my opinions and recommendations. If they choose to ignore my recommendations, then I document everything and move on. If they change their minds down the road and  want to work with me, then I’ll gladly do it. I don’t take it personally. It’s about them, not about me. As far as patients “getting it,” some people never will. But I believe that establishing a good therapeutic alliance is one of the keys to being able to make a difference. Patients care much less about what you have to say until they know they can trust you.

6.”Particularly in the setting you work in, how do you manage to avoid coming down with, for lack of a better term, secondary PTSD? It’s got to suck to sit and listen to what are undoubtedly some pretty horrible stories for hours on end and I can’t imagine it’s possible not to be affected by what you hear.”

A: Honestly, it’s very draining at times. For me personally, having variety in my schedule (I don’t just work in corrections) is key. I do think I’ve learned to cope with it better over time. However, I’ll have to say that I also think it’s something that some people can naturally do more easily than others. It may sound like an oxymoron to be able to be a sincerely caring person and at the same time realize that you need to do your little part each day to try to help others and then forget about it when you walk out the door, but that’s what I try to do. You can’t save the world. I’ve come across some very caring health care professionals in non-correctional settings who could never survive working in a jail or prison. They would get so emotionally wrapped-up in all the drama and trauma that they would lose their ability to objectively assess their patients. They’d run into boundary issues (they’d become enmeshed) because they’d want to rescue all the unfortunate patients they treated. And that’ s just not healthy for the patients or health care workers. I know that may be difficult for some people to understand, but it’s so true. And these would be the ones, in my opinion, most likely to be traumatized from their work.

Thanks for your questions. I hope some of my answers made sense! Feel free to leave your comments.

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I’m getting tired of hearing myself talk. You’re probably getting tired of it, too. So, it’s your turn!

Seriously, I really want to hear from you.

Ask me whatever you want about my profession, and I’ll do my best to answer (as long as the questions aren’t too personal or about my employers!).

You may leave your question(s) as comments to this post, or you may e-mail them to me (click on Contact at the top of the page to quickly send me a message).

I look forward to your questions and appreciate the time you take writing them. Please help me make this interesting! Thanks.

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“Hey Doc, this guy needs some help.”

I’ve heard that statement from countless correctional officers over the years. Its meaning is very simple: Someone is exhibiting thoughts or behaviors that the officers find disturbing and “not normal.”

I appreciate the officers expressing concern. Without their input I often would not be aware of cases where I might be able to be of assistance.

But, one of the questions that always pops into my head is whether the situation is one in which I can actually help. I certainly would not expect officers to make this decision, but it’s a point I must consider.

Some inmates could potentially benefit from our help; they might be suicidal, manic, psychotic, or depressed. But unfortunately they might repeatedly refuse to meet with mental health professionals. In such cases we can help assure that they won’t harm themselves, but there’s often little else we can do.

Others may be angry, assaultive and even homicidal. Maybe they have repeatedly destroyed property, have flooded their cells, or have threatened to go on a hunger strike. Such problem behaviors may be present when there is an exacerbation of a treatable mental illness, but more often they occur in the context of a personality disorder that is not likely to be treatable. Antisocial personality disorder or even psychopathy are a couple of common examples.

But some bad behaviors do not have any clinical labels–nor should they. The range of possible disturbing thoughts and behaviors is endless.

It’s quite understandable that lay persons who observe others exhibiting troubling thoughts or behaviors naturally want them to get “help.” Many of these inmates are under stress and may have psychological issues. They absolutely deserve to be evaluated by mental health professionals. It’s important that we not miss potentially treatable conditions.

But the point I want to emphasize is that not all of them have treatable psychiatric illnesses.

It’s often challenging to explain to security staff how a mental health professional cannot do much in some cases.

But it would be quite presumptuous and potentially dangerous if mental health professionals believed that they had the answers in all cases where people were having disturbing thoughts or behaviors.

Not only would such an approach be  dishonest and filled with false promises, but it would lead down the path of medicalizing the human condition. Anything that’s not “normal” or desirable would become a medical problem. I do worry that my profession is veering too far in this direction already.

For example, some psychiatrists have argued that pathological lying should be labeled a mental disorder and added to the DSM (the textbook of psychiatric diagnoses). That’s ludicrous!

And then there are unusual behaviors or beliefs that may not be harmful but may bother others. The question is, where do we draw the line? We’re at risk of psychiatry becoming the social police.

Is your kid’s hair orange? Are you a little “abnormally” interested in UFO’s? Oh, you don’t really care about socializing with others and never have but would prefer to read books instead? Maybe you’d better call a psychiatrist.

What do you think? Is society moving too far in the direction of medicalizing all bad or “different” behavior?

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