Doctors, nurses, and other health care professionals often find themselves in situations where they must speak up for their patients. Typically such patients either do not realize what they need, do not know how to ask for what they need, or they lack the authority to obtain what they need.

The circumstances and challenges of advocating for patients vary significantly depending on the practice setting. I’ve previously written about how practicing in correctional settings presents unique challenges. Essentially the main challenge in any jail or prison, regardless of how “treatment-friendly” it may be, is that a correctional facility exists for the primary mission of security, not treatment.

So, if you’re a health care professional in corrections and you have a patient who needs your voice, how can you go about being an effective advocate?

1. Identify what your patient needs as clearly and concisely as you can. Be mindful of the implications of your request on security staff and on the security of the institution. Consider the potential problems it might create with other inmates wanting the same privilege or exception for themselves. Be realistic, and keep it simple. The more complicated the request is, the less likely that security or administration will be to give approval.

2. Rely as much as possible on facts, data, and the science of your profession to state your case. For example, if you are a psychiatrist or psychologist and strongly believe that your patient needs to be moved away from his current cellmate because he is either a dangerous predator likely to kill or a vulnerable, likely victim, then do not base your concern on how the situation makes you feel. You’ll be more effective if you’re seen as rational and logical. In this particular case, if you can cite results from psychopathy testing or IQ testing to bolster your concern, you will have more credibility. It’s much more difficult to argue with facts and science than with emotion.

3. Choose your battles wisely. If you never find yourself speaking up for your patients, then you may be missing opportunities to help them. After all, many patient needs are not self-evident; nor are they obvious to non-health care professionals. But, if you feel as though your are constantly battling for your patients at every turn, then you may have an unrealistic viewpoint of what can be accomplished in a correctional facility. You’ll be more likely to become cynical, burned out, and you may lose favor with administration and security and be seen as a trouble-maker. And the unfortunate end result is that you will be less helpful to your patients. You’ll have much more credibility if you carefully choose your requests.

4. Think win-win. Even though it may require a concerted effort on your part, you are more likely to work collaboratively with those in power if you think of yourself as being on the same team. Follow the chain of command in your system, and do not undermine those with authority in order to promote your cause. For example, e-mailing the world about your concern in an effort to force others to be accountable may help you win the immediate battle for your patient, but you’re sure to lose the war. Administration and Security may not understand your profession, but if you present yourself as professional, organized, rational, mindful of security concerns, and asking for special accommodations only when necessary, you are more likely to become an effective and respected patient advocate.

Photo by Christiana Care

As correctional health care professionals, there may be times when we are tempted to conduct ourselves in a less than professional manner simply because we can.

We may be able to get away with speaking to our patients rudely, using profanity profusely, or wearing inappropriate clothing. After all, we work in jails and prisons. This culture is far from prim and proper. And, our patients are inmates. Many may tolerate misbehavior from us that patients on the outside would not and should not tolerate.

I’ve previously written about how I’ve found the book, Games Criminals Play, to be an invaluable resource. One key point that I learned is that many inmates, especially those trying to set up and manipulate staff, want to know whether each prison worker is a fellow inmate or “the police.” In other words, do we side with the inmates, or are we professional workers who take our jobs seriously?

Inmates study staff and look for clues to answer this question. The more professionally we behave and appear, the less likely we are to become targets for setups. Secondly, conveying a professional image will likely improve our credibility with administration and security staff. It’s difficult enough to provide treatment in a non-treatment setting as it is without us undermining ourselves. Finally, the stigma we all face for working where we do would likely be lessened if we exhibited the same professionalism standards that our colleagues in the community exhibit.

So, how can we improve our professionalism?

First, we should dress appropriately. We shouldn’t be dressing as though we’re getting ready to watch the football game on the family room couch if we’re going to work. Dressing sloppily conveys a lack of attention to detail and a lack of taking our roles seriously. Dressing provocatively says that we may be willing to compromise boundaries.

Several months ago I read an article in Clinical Psychiatry News. It was written by a very experienced psychiatrist who had just started doing some corrections work. He felt sympathetic toward the inmates and began wearing green scrubs to work so that he would be dressed similarly to them. I am sure his intentions were honorable, but I feel strongly that trying to be more like inmates in order to bond with them is a big mistake. By doing so one is more likely to be seen as a sympathetic and easy target. I’ve come to believe that most inmates who are looking for quality health care would much rather receive it from someone who appears successful, polished, and detail-oriented.

Second, we should treat our patients respectfully and use a professional tone and language just as we would if we were working in the community.

There is no denying that treating prisoners can at times be very emotionally exhausting and thankless work. There will undoubtedly be some patients that we frankly don’t like and who behave in very hostile and disrespectful manners toward us. However, we must be certain that we do not lower our professional standards by responding with inappropriate behavior.

Third, we must maintain appropriate boundaries with our patients. This is one area where we need to be even more careful in correctional health care than do our community-practicing colleagues. In corrections, other than discussing our professional credentials, we should not be volunteering personal information or answering personal questions.

But wait, isn’t it more important that we’re caring individuals? Isn’t all of this professionalism talk a bit superficial?

Certainly being caring is one of the most important qualities that we can possess. But, if we lack professionalism, we’re not doing our best. And we’re undermining ourselves. We cannot complain about getting no respect if we do not behave respectably.

However, if we exhibit the above-mentioned traits of professionalism, we’ll likely be more effective at what we do. We’re likely to be more respected by inmates and others, we may feel better about ourselves and what we do, and we’ll be showing the rest of the world that working in correctional health care truly is a worthy and honorable endeavor.

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Bupropion (Wellbutrin, Zyban) is a unique but commonly prescribed antidepressant that inhibits the reuptake of dopamine and norepinephrine. It is FDA approved for the treatment of major depressive disorder, seasonal affective disorder, and smoking cessation. It is commonly used off-label for the treatment of attention deficit hyperactivity disorder (ADHD).

Anecdotally there have long been reports of abuse and diversion of bupropion in jails and prisons. In my own personal experience in these settings, I have not seen much evidence of such misuse. Inmates rarely present to me seeking this medication. By contrast, and about which I have previously written, quetiapine (Seroquel) is highly desired medication in corrections.

I conducted a literature search on this topic and was not able to find many articles. There are a few case reports of bupropion nasal insufflation (snorting). In one description it appears to have caused a “brief buzz” lasting only a few seconds.

In 1983 a study in Psychopharmacology compared bupropion, dextroamphetamine, and placebo in mixed substance abusers. According to the abstract:

Results indicated that the subjective effects of amphetamine as measured by the Addiction Research Center Inventory (ARCI) differed markedly from bupropion and placebo. Bupropion, in contrast to amphetamine, had no peripheral sympathomimetic effects and did not reduce appetite or caloric intake.

In another study comparing the abuse potential of bupropion with that of caffeine, it appeared that caffeine was a more reinforcing substance to ingest. From the abstract:

CAF significantly increased ratings of ‘pleasant effects’ (p = 0.008) and ‘high’ (p = 0.03), whereas BUP produced a ‘high’ of only very moderate size (p = 0.02). In 3 subjects each, BUP or CAF produced ratings of ‘pleasant effects’ that were >9-fold higher than those for PLC.

My opinion at this point, based on my own clinical practice experience and the paucity of available scientific evidence is that bupropion is not likely very amphetamine-like in the subjective effects it produces. In the community, I would guess that some adolescents and young adults experiment with crushing and snorting it but quickly lose interest in doing so because of its lack of reinforcing properties. In prisons and jails where inmates lack ready access to prescription and illicit substances that they might abuse on the streets, there is probably a higher incidence of abuse and diversion of bupropion. However, it does not appear to be nearly as coveted as quetiapine, benzodiazepines, or opioid analgesics.

Since there is little data on the abuse potential of bupropion, I am very interested in hearing from other health care workers who may have experience with or thoughts about this issue.

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 security staff as well as hostile, adversarial relationships with inmates. Working conditions can be far from ideal. One may need to evaluate inmates in noisy and almost always Spartan environments. Life will be difficult for those who think they are special!

4. Having an Ability to Work Alone: Professional isolation is a reality in corrections. I once spent a couple of years working in an HMO setting with a group of psychiatrists. While there were many things about HMO life I didn’t like, at least I spent a lot of time around colleagues. In prison, though, one often needs to work alone.

5. Displaying a Secure, Confident, Relatively Calm Demeanor: A psychiatrist who comes across as indecisive or not self-confident will be taken advantage of by inmates. The reality is that all of us who work in correctional health care are taken advantage of by inmates to some degree, but life will be more challenging for the meek in prison. One must also be able to be in the midst of chaos or hostility and not lose ones temper or appear excessively anxious.

6. Having a Good Poker Face: One needs to be able to deal with seeing and hearing the bizarre, outrageous, and vulgar without reacting to it. Likewise, although most inmates are not malingerers, when a psychiatrist suspects malingering, it is crucial not to show any emotional reaction. (Please see this recent post on malingering for details.)

7. Having the Ability to Set Limits and Maintain Professional Boundaries: Those unable to set limits with patients probably shouldn’t practice clinical medicine and definitely should not work in corrections. Patients everywhere, but especially in jails and prisons, will tell their psychiatrist what they want. What they want may or may not be what they need or what is appropriate. Likewise, those who tend to want to rescue others and easily become overly-friendly with patients will be the guaranteed victims of numerous setups. (Read the post on the book about this, Games Criminals Play, for more information.)

8. Being Thick-Skinned: Not callous, just not overly-sensitive. Psychiatrists need to be able to have inmates yell names and threats to them on a segregation unit without it getting to them. I remember in my early days several inmates on a segregation unit were angry because I wouldn’t drop what I was doing and go talk to them that minute. One was yelling out at me that I was a “fucking white-ass bitch” and that he was going to “kick my ass” as soon as he got out of prison. Such threats are not a part of everyday work for me and have diminished considerably over the years. Most inmates actually are reasonably polite, but on a daily basis I see the more subtle attempts at manipulation where inmates attempt to make the psychiatrist feel guilty or inadequate for not giving them what they want. Fortunately most patient encounters go quite smoothly without any such issues.

9. Being Kind and Compassionate: Please note that one can be thick-skinned, skilled at setting limits and professional boundaries, AND still be kind and compassionate. Sadistic people don’t make good correctional psychiatrists! But, those who care about their fellow human beings, take seriously their professional duty as physicians, and at the same time can set limits and not take things personally are likely to do well.

10. Having a Sense of Adventure and a Sense of Humor! Much of it actually is fun, if one has the right attitude. Taking things too seriously (prisons and jails are serious places) will increase the likelihood of burnout. Laughter at the appropriate times is good and necessary!  Being curious about life and humanity and being able to focus on the positive all make the job more interesting and enjoyable.

Do I do all of the above all the time? Of course not. These are the ideal traits, not the ones that every successful correctional psychiatrist will have. And certainly some days are better than others.