Monday, November 19, 2007

Is This Forensic Psychiatry?

In my post Is This Psychiatry? janye made the following observation:

And, just how are mental health issues different in correctional institutions? Aren't the same medications being used? I'm just trying to understand how psychiatry in a criminal setting is different from the general population settings besides the obvious of the patients being locked up? It doesn't appear to be a speciality when you get down to it!

There are two parts to this question. The first part is, how are correctional and general psychiatry different (if at all)? And the second part is, is correctional psychiatry truly forensic psychiatry?

Both great questions.

Correctional and general psychiatry have similarities but also some huge differences. As janye noted, the medications are the same (yes, I have access to modern medications in prison). You still take a history, do a mental status examination, do lab work, gather outside history when indicated and provide treatment using the same general pharmacologic approach as in free society. I have access to an infirmary, seclusion rooms, and observation procedures when needed just like in free society.

But there are major differences. The patients may be the same if you work in a public mental health clinic, but if you are in a private hospital or private practice they will definitely not be the same. Correctional patients have loads of comorbidity including personality disorders, substance abuse, learned maladaptive behaviors, head trauma, chronic medical diseases etc. By the time they get to my clinic they have often been treated with the gamut of medications.

The other major difference is the environment. This is not a minor thing ("besides being locked up") and it has an effect on how you can practice. The inmates don't hold their own meds. They must report to a pharmacy window (see also my post Pill Line) or a nurse must bring medication to them. Certain medications are valuable in the institutional economy so you must be judicious about how much and what you prescribe. On the positive side, inmates are usually (not always, but a lot of the time) free of drugs and alcohol so you can use lower doses than what they get in free society. There are lots of other differences but these are a few.

Your own personal practice environment is radically different than what you would experience as a general practitioner in free society. You may or may not have an office, a desk or a telephone. You may or may not have heat and/or air conditioning. (My personal record: 100 plus heat index in a bare cell with no ventilation.)

Big differences. Differences that not everyone is cut out for. Fortunately, I like a challenge. Correctional psychiatrists tend to be laid back, not easily flustered and have a high tolerance for chaos. There is a difference between general psychiatry and correctional psychiatry.

And now the second question: is correctional work considered the practice of forensic psychiatry?

In a nutshell, yes. In the late 1990's the American Council for Graduate Medical Education (ACGME) officially recognized forensic psychiatry as a subspecialty of psychiatry. When fellowship accreditation standards were set up, they required fellowships to provide at least six months experience in a correctional facility. In order to become a forensic psychiatrist you have to spend time working with prisoners.

Now, most correctional psychiatrists currently are not forensic psychiatrists mainly because there just aren't that many forensic psychiatrists. And you don't have to have forensic training to work in a correctional facility. But it really does help. Forensic training exposes you to the correctional environment in a supervised fashion. It gives you an understanding of criminal procedure and mental health law. It gives you experience working with violent offenders and potentially dangerous seriously mentally ill patients. All of this comes in useful in prison. As in all psychiatric practice, patients want to be understood. If you understand their culture, their problems and predicaments, you will be better able to treat them. If you have no clue what the legal issues are that they're facing it would be hard for them to feel understood.

So there it is. This is forensic psychiatry.