Lockup Doc

The below YouTube video is a decent overview of how, since the deinstitutionalization movement of the 70’s, the prisons and jails in the U.S. have been housing a large percentage of people who previously would have been in mental insitutions. It explains some of the challenges of providing mental health treatment behind bars. What it does not address, though, is the significant problem many mentally ill inmates face continuing their psychiatric treatment in the community after they are released. Read more…

How many times do we condemn or agree before hearing the other side of a story? How many times do we stand accused of not listening carefully? How many times do we misinterpret or misunderstand a gesture, a word, an intention? Why do we assume that we know so much about other people’s lives even though we clearly do not? And, even if we did, why do we think we know what’s best when it comes to how others should live their lives?

Through our cumulative experiences in life, the figurative spectacles through which we see the world become tainted. We, unlike small children, lose the ability to see all things as they are. Instead, we see things through our tainted lenses and think we know best. Read more…

I used to have a more “normal” job.

Early in my career I worked in a large medical center and hospital and rotated through a call schedule. I got called into the ER regularly. I covered the inpatient unit and performed consultations on the medical and surgical units. I did all of the typical work tasks associated with a traditional practice.

Then I left it all.

I started working half-time in correctional psychiatry. I have worked in various other less traditional settings to fill the other half of my schedule over the years, but most of it has been spent working with people with developmental disabilities.

My work life is Read more…

Many non-correctional health care providers will also treat inmates from time to time. This may occur in the office or hospital. How can one best approach the challenges of working with the incarcerated in order to deliver the best possible care while simultaneously managing risk?

1. Treat the patient with respect. Not submissive respect, but mutual respect — the way we all want to be treated. I believe that this principle alone goes a long way towards helping one to establish a therapeutic alliance and to minimize interpersonal conflict and hostility. Inmates are people, too. Those who do not agree with this statement should steer clear of treating them.

2. Listen attentively. It may be tempting to get this shackled person (who you may secretly be embarrassed to have in your office) out as expediently as possible. Squelch that temptation, and listen actively as you would to any patient. All patients want their concerns taken seriously. Inmates are no exception. I believe you minimize problems for yourself in the long run (and provide better care) if you ensure that  patients’ concerns are heard, especially if they seem to have more challenging personality styles.

3. Be honest. If there is a particular reason why you think something the patient is requesting is inappropriate, then politely tell them so. If you believe they have a particular diagnosis, psychiatric or not, then Read more…

To be effective and enjoy working as a psychiatrist in any setting requires unique personality traits. Likewise, to be effective and enjoy any type of work in corrections requires unique personality traits. But, working as a psychiatrist AND doing so in jails and prisons narrows down the field even further.

For the right candidate it can be a very rewarding career. For others, frustration and ultimately burnout may result.

Here are a few personality traits that I believe are important:

1. Having a Strong Sense of Independence: One needs to be able to organize and prioritize many different tasks without having to ask for advice and reassurance often.

2. Having Patience: Prisons and jails work on their own schedules. The primary priority is always security. Health care is an ancillary service in corrections, not the primary mission. There will be frequent delays and inconveniences that arise. One must be able to shift gears, adapt, and still make the best use of the time available.

3. Having a Sense of Humility: Psychiatrists make more money than most workers in correctional settings and also must work hard to earn the respect of other staff since those providing “help” in corrections are often seen as enablers. Walking in with an attitude will assure a psychiatrist even higher doses of resentment and passive-aggressive behavior from Read more…

You may be surprised to hear that despite being a physician tech enthusiast who has a blog, Twitter and Facebook accounts, and a MacBook, I do not own a smartphone. I’ll tell you why.

I’ve previously described the challenges and rewards of working as a correctional psychiatrist, but I did not go into any detail about electronics in correctional settings. Since the overriding objective of jails and prisons is to maintain a secure environment, all staff members give up certain conveniences that we’ve all grown accustomed to on the outside.

Today, so many electronic gadgets are capable of making phone calls and connecting to the internet. In the hands of  inmates, such devices could allow escapes to be planned, the coordination of gang activity, and the running of illegal businesses from within the prison walls. Because either careless or corrupt actions of staff can result in electronics being possessed by prisoners, staff cannot bring in their own devices.

Cell phones of all types are very high on this list of banned items. In fact, cell phones have become one of the major contraband items in prisons around the world. In “shakedowns” where surprise searches of inmate property are conducted, Read more…

It may surprise some people to hear that not all inmates, not even the ones who see psychiatrists, have difficulty coping with incarceration. Certainly some do, but many others are more stressed about family/relationship issues, financial problems, or the prospect of being unemployed felons upon release. Some inmates have found positive approaches to incarceration that make it less stressful and more productive while others struggle and often find themselves in undesirable situations.

Since I regularly see prisoners with a wide variety of effective and ineffective approaches to their incarcerations, I decided to compile a list of suggestions for how one could make prison or jail time more palatable. This list is not all-inclusive and is in no particular order. I offer no guarantees and hope that you will never seriously need a list such as this!

1. Stay busy and healthy: Some inmates do virtually nothing in prison, and I believe this is a mistake. Although freedoms are limited, there are still many things inmates can do to make the time pass more quickly, stay physically and mentally healthy, and better themselves. Go to the prison library regularly and read lots of books. Earn your HSED/GED or take college classes if they are available. Do not pass up the opportunity to go to recreation. As your health permits, work out regularly. You’ll feel better, be less likely to be a target, sleep better, and you’ll likely be healthier.

2. Don’t draw attention to yourself: “Lay low” is good advice. Try not to come up on the radar Read more…

This is a more personal post than most for me, but it seems right during the holiday season. I’ve written before about the field of correctional psychiatry. In that particular post, I mentioned some of the appealing factors of working as a correctional psychiatrist. I realize that some people find it difficult to believe that there are intrinsic rewards to working with inmates. If there weren’t, though,  none of us would do what we do. There is no doubt that there are also many challenges. Many inmates, for various reasons, test even the most seasoned clinicians’ patience.

However, one does not need to be a health care professional in corrections to work with difficult people. In fact, one does not have to be working at all. Everyone must deal with rude, aggressive, demanding, or irrational people to varying degrees in different life situations.

I do believe, though, that Read more…

Malingering, which means to feign or exaggerate symptoms for secondary gain, occurs in all medical settings but is especially prevalent in jails and prisons. While it essential for all health care professionals working in corrections to become proficient in detecting malingering, even those working in non-correctional environments will be better clinicians if they learn this skill.

In the December 2009 issue of Current Psychiatry, Lawrence Reccoppa, MD, a correctional psychiatrist from Florida, wrote a brief article entitled, “Mentally ill or malingering? 3 clues cast doubt.”

The “3 D’s,” as he calls them: Read more…

Recently I diagnosed a man with borderline personality disorder (BPD). As I was working with him, it dawned on me how much more comfortable I had become over the years not just in identifying BPD but in working with patients who have it and in discussing the diagnosis with them.

I recall how differently I felt about anything to do with BPD during my residency training and in my first few years of practice. Most mental health and medical professionals can attest to the fact that the term “borderline” is one of the most loaded mental health terms that exists. Unfortunately it is often used perjoratively toward hateful or challenging patients, thereby perpetuating the stigma. Probably out of my own fear, I was hesitant to bring up the diagnosis with patients. I just did not want to say the “B” word to them.

Over my career, though, I’ve realized a few things about BPD.

First, I haven’t met a person yet who Read more…