Acad Psychiatry (2014) 38:680–684 DOI 10.1007/s40596-014-0216-6
IN DEPTH ARTICLE: COMMENTARY
General Psychiatric Residents and Corrections: Moving Forensic Education Beyond the Classroom Carl E. Fisher
Received: 17 June 2014 / Accepted: 18 July 2014 / Published online: 15 August 2014 # Academic Psychiatry 2014
Abstract Mental illness in the criminal justice system is one of the most important and underserved public health challenges in psychiatry today, but few general psychiatry residency programs offer clinical education in correctional psychiatry. Developing such rotations might seem intimidating to educational leaders unfamiliar with the criminal justice system, but a variety of potential solutions exist for residency programs to offer this increasingly important clinical training. Keywords Residents: Forensic psychiatry . Subspecialty: Forensic psychiatry When most psychiatrists think about “forensics,” images of courtroom testimony or other non-clinical roles are usually the first to come to mind. Similarly, most psychiatric residency training programs provide forensic education primarily through classroom-based instruction on legal topics such as the insanity defense, and few residents receive clinical exposure to the criminal justice system [1]. This is a missed opportunity for residents to learn about one of the most important and underserved public health challenges in psychiatry today. As a subspecialty, forensic psychiatry is increasingly concerned with the epidemic of psychiatric disorders in the criminal justice system. As the Director of Mental Health Services for the Florida Department of Corrections recently put it, “there is no doubt that our jails and prisons have become America’s major mental health facilities” [2]. As the proportion of mental illness in incarcerated populations continues to rise, it becomes critical to address the criminalization of the mentally ill through policy and clinical and public health C. E. Fisher (*) New York State Psychiatric Institute, New York, NY, USA e-mail: [email protected]
initiatives, and resident education can play an important role in these efforts. The educational opportunities in corrections for residents are rich. Given the increasingly large degree of criminal justice involvement in some communities, any clinician who treats serious mental illnesses or practices community psychiatry will benefit from familiarity with corrections. Furthermore, there are unique educational benefits for psychiatric residents caring for criminal-justice-involved individuals, including exposure to a different range and severity of psychopathology and broader experience with systems-based practice. This overview describes the opportunities for psychiatric residents to receive clinical training with criminaljustice-involved populations. After describing the scope of the problem of the incarcerated mentally ill, I review the current state of forensic education in general psychiatric residency programs, including examples of how residency programs can successfully offer this educational experience. There are some barriers that make implementing such training difficult, but there is also a range of possible solutions that allow residents and programs to work with this underserved population.
Mental Health and the Criminal Justice System: the Scope of the Problem While epidemiologic comparisons between incarcerated populations and the general population should be made cautiously, it is clear that people with mental illness are grossly overrepresented in corrections. The best recent research indicates that the past-month prevalence of a serious mental illness (SMI) diagnosis in jail inmates is approximately 16 %, with the rate among women being much higher (31 %) than among men (14.5 %) [3]. Measuring any mental health problem, the US Bureau of Justice Statistics found that 56 % of state
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prisoners, 45 % of federal prisoners, and 64 % of local jail inmates had some mental health problem in the 12 months prior to a 2005 study [4]. This prevalence of mental health problems is at least five times greater than that of the general population [4]. Inmates with psychiatric disorders are also at substantially increased risk of repeat incarceration, up to three times more likely than the non-mentally ill population to be rearrested within 6 years of release, leading to a “revolving prison door” [5]. Focusing only on the prison and jail populations would grossly underestimate the scope of the problem, however, as more than twice as many people are under community supervision (i.e., probation or parole) than incarcerated. In 2012, about one in 108 adults (0.9 % of the adult population) were incarcerated in the USA, but one in every 35, or 2.9 % of adult residents, was under some form of correctional supervision [6]. These statistics also demonstrate the staggering rate of criminal justice involvement in the USA; even though there are some indications that the incarceration rate is leveling off after years of drastic increases, 6,937,600 total adults were still under correctional supervision in 2012 [6]. Considering the mental illness prevalence rates cited above, it is likely that millions of criminal-justice-involved adults are suffering from mental health problems. Anecdotally, in recent months some correctional facilities have noted increasing management problems related to the mentally ill population, in part due to expanding rosters of people with mental illness that have led to tremendous backlogs of cases [7]. Indeed, for at least a decade, correctional mental health experts have recognized that the incarceration rate for mentally ill offenders is growing [8]. As inpatient psychiatric beds are closed and state mental health budgets continue to be cut across the country, it is likely that the criminal justice system will continue to absorb the overflow. Education is one important way to address this extensive and growing public health problem.
The Current State of Forensic Education Survey studies examining forensic psychiatry education within general psychiatry residency programs have found limited exposure to incarcerated populations. In 1995, a brief survey of training directors of general psychiatry residency programs found that 82 % of programs offered a rotation in forensic psychiatry, including 35 % that required a forensic rotation [9]. However, only 15 of the 150 programs surveyed had a mandatory rotation in prison or jail, with 34 programs offering an optional correctional rotation. A 2014 survey asked general psychiatry residency training directors to assess their programs’ adherence to the 2007 Accreditation Council for Graduate Medical Education (ACGME) program requirements for forensic psychiatry
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education [1]. The directors reported that forensic topics were covered more extensively through lectures and didactics rather than through clinical exposure. Furthermore, the forensic topics most likely to be covered were issues common to general psychiatric practice, such as involuntary civil commitment and violence risk assessment. Of note, these ACGME topics do not include correctional psychiatry at all. In 2007, the ACGME did broaden its requirements for forensic psychiatry education during general psychiatry residency [10]. Previously, the ACGME only required providing “familiarity with the legal aspects of psychiatric practice” and “experience in forensic and court evaluations” [9], but the revised requirements now list exposure to a variety of topics: “the evaluation of forensic issues such as patients facing criminal charges, establishing competency to stand trial, criminal responsibility, commitment, and an assessment of their potential to harm themselves or others” [10]. The ACGME also notes that the experience “should include writing a forensic report,” and states “giving testimony in court is highly desirable” [10]. Nevertheless, among the topics listed, there is no mention of correctional psychiatry. Forensic psychiatry in certain other countries has stronger connections to correctional systems. For example, in the UK, where the National Health Service has been responsible for prison health care since 2003, the Royal College of Psychiatrists recommends that during general psychiatry training, “experience in forensic aspects of psychiatry should be gained, wherever possible, by direct involvement in the clinical care of patients referred to consultants with a special interest or responsibility in forensic psychiatry” [11]. Even so, a 2004 survey of successful Royal College of Psychiatrists Membership Examination candidates found that only 58 % had done a placement in a forensic psychiatry post, and 66 % of those who had not done such a placement had never visited a prison or jail [11]. There have been few specific proposals in the academic literature regarding the forensic education of general psychiatric residents. In 2004, Lewis suggested a model in which residents are exposed to forensic topics on an ongoing basis throughout other rotations (e.g., discussing civil commitment and informed consent on inpatient rotations, duty to report, and forced medication in the emergency room) [12]. This model does include space for a forensic elective in correctional mental health, but the overall thrust of this proposal is augmenting existing rotations with forensic education, and there is little discussion of the problem of criminaljustice-involved individuals. As a historical note, this general lack of attention to the mentally ill incarcerated population reflects the overall development of US forensic psychiatry. Until recently, forensic psychiatry has focused primarily on expertise for the courts rather than the treatment of incarcerated individuals. In this country, the field has its origins on Isaac Ray, a Maine
682
psychiatrist who rose to prominence in 1838 after publishing a treatise on the jurisprudence of insanity and whose subsequent work focused primarily on legal questions such as responsibility and punishment [13]. The field continued this focus on courtroom expertise for many years; for example, one former president of the American Academy of Psychiatry and the Law stated in 1974 that forensic psychiatry “is concerned primarily with the ends of the legal system, justice, rather than the therapeutic objectives of the medical system” [13]. However, catalyzed in part by the subspecialty recognition of forensic psychiatry in 1992 by the American Board of Medical Specialties (ABMS), the field has recently broadened its ambit to include care for mentally ill incarcerated individuals. The American Academy of Psychiatry and the Law now defines forensic psychiatry as “a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory or legislative matters,” and notes that “when a treatment relationship exists, such as in correctional settings, the usual physician-patient duties apply” [14]. It is time to broaden the focus of forensic education in general psychiatric residency to include criminal-justice-involved populations as well.
Opportunities for Training “Criminal justice” is a broad descriptor that encompasses a variety of settings. Residents can gain experience with correctional populations by working directly in prisons or jails, but other corrections-related settings also provide the opportunity for working with criminal-justice-involved individuals. As noted above, most US general psychiatry residency programs do not provide clinical training in correctional settings, though some have developed educationally rich programs in jails and prisons. For example, at the University of California at Davis’ general psychiatry residency program, first year residents rotate through the Sacramento County Main Jail’s Psychiatric Services (Charles Scott, M.D., personal communication). Psychiatric services within correctional facilities are often organized by various levels of care; residents see patients at an acuity level analogous to outpatientlevel care. Residents’ main roles include new psychiatric evaluations of inmates, ongoing medication management, and consultation to other correctional clinicians. Of course, it is helpful that the UC-Davis forensic psychiatry fellowship supports this rotation with a source of faculty and fellows for supervision. However, residency programs without forensic fellowships have still successfully established correctional rotations for their general psychiatry residents, sometimes by training in non-incarcerated settings that still provide exposure to criminal-justice-involved patients. At Mt. Sinai, first year general psychiatry residents participate in clinical rotations at
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Kirby Forensic Psychiatric Center, a maximum-security forensic psychiatric hospital, as well as a specialized forensic unit at Manhattan Psychiatric Center. The clinical populations at these institutions include individuals charged with serious crimes and inmates transferred from jail or prison. Therefore, even in non-incarcerated settings, there are opportunities for concentrated exposure to correctional populations. There are also a variety of outpatient programs that work with criminal-justice-involved individuals. Diversion programs are intended to limit the detention of persons with mental illness and include pre-booking (i.e., pre-arrest) crisis intervention teams, post-booking mental health courts, forensic assertive community treatment (ACT) teams, and other specialized outpatient services that tailor their care to criminaljustice-involved populations. Likewise, a variety of re-entry programs provide specialized care for recently released mentally ill inmates. The availability of these services depends on the jurisdiction and the local community’s existing investment in such programs, but when present, they provide a useful perspective on community health approaches to the mentally ill and could be easily incorporated into psychiatric residency.
Considerations: Advantages and Barriers to Training in Corrections Barriers Residency programs often do have to manage significant barriers for trainees to work in correctional settings. Procedural issues are sometimes onerous. Jails and prisons are overseen by state departments of corrections, and in order to work within those systems, clinicians must often participate in extensive training programs over which they have little control. Hypothetically, a required 1-week orientation program might seem like too high a cost for a 1-month clinical rotation. On the other hand, if the educational value of such programs is maximized for residents, they become useful teaching opportunities rather than onerous bureaucratic hurdles. Topics such as the roles of peace officers and other staff in incarcerated settings, protections for victimized populations, and even the organizational and physical structures of correctional institutions are all useful for clinicians in training to encounter. Caseloads for correctional settings are usually higher compared to the community, and especially in jail or intake facilities, rapid patient turnover is the norm. Clinicians can face pressure to see large volumes of patients, and supervisors, themselves pressured for time, might have limited time to guide trainees. However, adequate preparation, coordination, and commitment allow residents to take on a helpful portion of the institution’s clinical responsibilities, thus freeing supervisory clinicians for educational activities. This solution, however, requires identifying supervisors committed to teaching,
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not to mention well-coordinated management of resident workloads. An increasing number of correctional institutions are becoming managed by for-profit entities. The ethical and policy issues related to the privatization of correctional mental health services are controversial, and a review of this topic is beyond the scope of this commentary. Suffice to say, prison and jail privatization is rapidly increasing in the USA, and while most studies indicate that privatized institutions function similarly to publicly operated ones, without adequate oversight, privatization can also lead to mismanagement and a lower standard of clinical care [15]. At the level of individual institutions, program directors should be mindful of management issues such as resident caseloads and the adequacy of supervision. Of course, these cautions hold true for all correctional settings, not only privatized institutions. One final risk bears mentioning: are correctional settings more dangerous? Prisons and jails are managed with a strong focus on staff safety, and other clinical settings that have a high incidence of workplace violence, such as emergency departments, unfortunately are sometimes just as (if not more) risky [16]. Safety considerations should not be cavalierly dismissed, of course, and individual institutions vary with respect to safety and security. For example, stability in prisons (i.e., for felony convictions, longer than 1 year) and jails (i.e., for shorter lengths of incarceration) can differ significantly because of their relative rates of turnover. Similarly, intake and reception units are sometimes more volatile because staff are less familiar with inmates. The structure of the institution, the nature of the residents’ specific roles in the institution, and even the character or “personality” of the institution are all important to consider when assessing safety. Ultimately, the specific circumstances of the possible rotation must be considered on a case-by-case basis.
Advantages The educational benefits of working with criminaljustice-involved populations are manifold. There are rich opportunities for systems-based learning; working in corrections gives a direct insight into the culture and environment of jail and prison. There is no substitute for seeing firsthand the impact of incarceration on individuals, including the loss of control of one’s environment, loss of social contacts, vulnerability, gang influence, and subjugation to authority. Clinicians with a richer knowledge of this experience will better understand and serve criminal-justice-involved patientsas well as patients who live in communities in which incarceration is endemic. In some communities, the experience and effects of incarceration are pervasive; if current trends continue, one of every three black American males born today will go to prison at some point in his lifetime [17].
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Working in corrections also provides practical experience with the issue of dual agency. Clinicians in correctional roles have a responsibility not only to the individual patient but also to the safety of the institution, so correctional psychiatry presents a particularly salient way to grapple with this important element of professional ethics [18]. Recent legislation has evoked dual agency issues for all psychiatrists, as, for example, reporting requirements for dangerous patients is enacted as part of firearms legislation. As psychiatrists continue to face dual agency issues in their daily practice, experience addressing this issue in residency across different settings is valuable. Finally, there are unique opportunities to develop clinical skills by working with this population. Incarcerated populations experience a range of pathology, and trainees working in corrections gain exposure to levels of serious mental illness and trauma not commonly encountered in the community. For example, in female incarcerated populations in particular, the scope, severity, and pervasiveness of physical and sexual trauma are profound. Aside from seeing unique psychopathology, residents would gain valuable experience in the assessment of malingering, as some incarcerated individuals pursue mental health treatment to avoid retribution, seek a change in housing status, or simply obtain quasi-recreational medications. More straightforwardly, working with a diverse range of staff on shared management issues provides unique practice in collaborative care.
Conclusions There is an urgent need to train psychiatrists who have an interest in serving the criminal-justice-involved population. The mental health needs of incarcerated individuals are extensive and inadequately addressed, and even though there are some indications that the rapid growth in US incarceration is slowing, the proportion of people with mental illnesses in corrections continues to rise. Still, many general psychiatric training programs miss opportunities to give their residents clinical exposure to correctional populations. Identifying and developing these opportunities might be intimidating to those unfamiliar with the criminal justice system, but a variety of solutions exist for residency programs to offer clinical training in correctional facilities for their residents, ranging from direct clinical care inside prisons and jails to outpatient experiences that enable work with criminal-justice-involved individuals. Regarding educational policy, the current ACGME requirements for forensic education during general psychiatry residency simply do not mention correctional psychiatry. The ACGME should encourage correctional psychiatry exposure as one possible component of the required forensic experience in general psychiatry. It would be unrealistic to require all residency programs to offer clinical training in correctional
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psychiatry, given the barriers some programs might encounter. However, because the criminal-justice-involved population is so dramatically underserved, there is a public health imperative to attempt to introduce these important issues into psychiatric residency education wherever possible. Implications for Educators & There is an epidemic of psychiatric disorders in the US correctional system. & Most general psychiatric residency programs, however, do not include clinical experiences in these settings. & There are unique educational opportunities for residents working in correctional settings, ranging from clinical skill building to systemsbased practice. & There are many ways for psychiatric residents to work with criminaljustice-involved individuals, and residency programs that find prison and jail rotations difficult to establish have several other options to pursue.
Acknowledgments Many thanks to Paul Appelbaum, Charles Scott, Alec Buchanan, Rusty Reeves, David Spagnolo, and Jeffrey Janofsky for helpful comments on this topic. Disclosures The author states that there is no conflict of interest.
References 1. Williams J, Elbogen E, Kuroski-Mazzei A. Training directors’ selfassessment of forensic education within residency training. Acad Psychiatry. 2014. 2. Aufderheide D. Mental illness in America’s jails and prisons: toward a public safety/public health model. Health Affairs Blog. 2014 April 1. http://healthaffairs.org/blog/2014/04/01/mental-illness-inamericas-jails-and-prisons-toward-a-public-safetypublic-healthmodel/. Accessed 17 June 2014. 3. Steadman HJ, Osher FC, Robbins PC, Case B, Samuels S. Prevalence of serious mental illness among jail inmates. Psychiatr Serv. 2009;60(6):761–5.
Acad Psychiatry (2014) 38:680–684 4. James DJ, Glaze LE. Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report, 2006 September (revised 2006 December 14). http://www.bjs.gov/ content/pub/pdf/mhppji.pdf. Accessed 17 June 2014. 5. Baillargeon J, Binswanger IA, Penn JV, Williams BA, Murray OJ. Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Psychiatry. 2009;166(1):103–9. 6. Glaze LE, Herberman EJ. Correctional populations in the United States, 2012. Bureau of Justice Statistics Bulletin, 2013 December. http://www.bjs.gov/content/pub/pdf/cpus12.pdf. Accessed 17 June 2014. 7. Schwirtz M. Inmate attacks on civilian staff climb at Rikers. New York Times, 21 May 2014. http://www.nytimes.com/2014/05/22/ nyregion/rising-hazard-for-civilian-staff-at-rikers-attacks-bymentally-ill-inmates.html. Accessed 17 June 2014. 8. Aufderheide DH, Brown PH. Crisis in corrections: the mentally ill in America’s prison. Correct Today. 2005;67:30–3. 9. Marrocco MK, Uecker JC, Ciccone JR. Teaching forensic psychiatry to psychiatric residents. Bull Am Acad Psychiatry Law. 1995;23(1): 83–91. 10. ACGME ACGME program requirements for graduate medical education in psychiatry 2007. 11. Reiss D, Famoroti OJ. Experience of prison psychiatry: a gap in psychiatrists’ basic professional training. Psychiatr Bull. 2004;28: 21–2. 12. Lewis CF. Teaching forensic psychiatry to general psychiatry residents. Acad Psychiatry. 2004;28(1):40–6. 13. Candilis P, Weinstock R, Martinez R. Forensic ethics and the expert witness. Springer; 2007. p 10. 14. American Academy of Psychiatry and the Law: Ethics guidelines for the practice of forensic psychiatry, adopted May 2005. http://www. aapl.org/ethics.htm. Accessed 17 June 2014. 15. Austin J, Coventry G. Emerging issues on privatized prisons. Bureau of Justice Assistance monograph, 2001 February. https://www.ncjrs. gov/pdffiles1/bja/181249.pdf. Accessed 17 June 2014. 16. Kowalenko T, Cunningham R, Sachs CJ, et al. Workplace violence in emergency medicine: current knowledge and future directions. J Emerg Med. 2012;43(3):523–31. 17. The Sentencing Project. Report of the Sentencing Project to the United Nations Human Rights Committee Regarding Racial Disparities in the United States Criminal Justice System. http:// sentencingproject.org/doc/publications/rd_ICCPR%20Race% 20and%20Justice%20Shadow%20Report.pdf. Accessed 17 June 2014. 18. Robertson MD, Walter G. Many faces of the dual-role dilemma in psychiatric ethics. Aust NZ J Psychiatry. 2008;42(3):228–35.
IN DEPTH ARTICLE: COMMENTARY
General Psychiatric Residents and Corrections: Moving Forensic Education Beyond the Classroom Carl E. Fisher
Received: 17 June 2014 / Accepted: 18 July 2014 / Published online: 15 August 2014 # Academic Psychiatry 2014
Abstract Mental illness in the criminal justice system is one of the most important and underserved public health challenges in psychiatry today, but few general psychiatry residency programs offer clinical education in correctional psychiatry. Developing such rotations might seem intimidating to educational leaders unfamiliar with the criminal justice system, but a variety of potential solutions exist for residency programs to offer this increasingly important clinical training. Keywords Residents: Forensic psychiatry . Subspecialty: Forensic psychiatry When most psychiatrists think about “forensics,” images of courtroom testimony or other non-clinical roles are usually the first to come to mind. Similarly, most psychiatric residency training programs provide forensic education primarily through classroom-based instruction on legal topics such as the insanity defense, and few residents receive clinical exposure to the criminal justice system [1]. This is a missed opportunity for residents to learn about one of the most important and underserved public health challenges in psychiatry today. As a subspecialty, forensic psychiatry is increasingly concerned with the epidemic of psychiatric disorders in the criminal justice system. As the Director of Mental Health Services for the Florida Department of Corrections recently put it, “there is no doubt that our jails and prisons have become America’s major mental health facilities” [2]. As the proportion of mental illness in incarcerated populations continues to rise, it becomes critical to address the criminalization of the mentally ill through policy and clinical and public health C. E. Fisher (*) New York State Psychiatric Institute, New York, NY, USA e-mail: [email protected]
initiatives, and resident education can play an important role in these efforts. The educational opportunities in corrections for residents are rich. Given the increasingly large degree of criminal justice involvement in some communities, any clinician who treats serious mental illnesses or practices community psychiatry will benefit from familiarity with corrections. Furthermore, there are unique educational benefits for psychiatric residents caring for criminal-justice-involved individuals, including exposure to a different range and severity of psychopathology and broader experience with systems-based practice. This overview describes the opportunities for psychiatric residents to receive clinical training with criminaljustice-involved populations. After describing the scope of the problem of the incarcerated mentally ill, I review the current state of forensic education in general psychiatric residency programs, including examples of how residency programs can successfully offer this educational experience. There are some barriers that make implementing such training difficult, but there is also a range of possible solutions that allow residents and programs to work with this underserved population.
Mental Health and the Criminal Justice System: the Scope of the Problem While epidemiologic comparisons between incarcerated populations and the general population should be made cautiously, it is clear that people with mental illness are grossly overrepresented in corrections. The best recent research indicates that the past-month prevalence of a serious mental illness (SMI) diagnosis in jail inmates is approximately 16 %, with the rate among women being much higher (31 %) than among men (14.5 %) [3]. Measuring any mental health problem, the US Bureau of Justice Statistics found that 56 % of state
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prisoners, 45 % of federal prisoners, and 64 % of local jail inmates had some mental health problem in the 12 months prior to a 2005 study [4]. This prevalence of mental health problems is at least five times greater than that of the general population [4]. Inmates with psychiatric disorders are also at substantially increased risk of repeat incarceration, up to three times more likely than the non-mentally ill population to be rearrested within 6 years of release, leading to a “revolving prison door” [5]. Focusing only on the prison and jail populations would grossly underestimate the scope of the problem, however, as more than twice as many people are under community supervision (i.e., probation or parole) than incarcerated. In 2012, about one in 108 adults (0.9 % of the adult population) were incarcerated in the USA, but one in every 35, or 2.9 % of adult residents, was under some form of correctional supervision [6]. These statistics also demonstrate the staggering rate of criminal justice involvement in the USA; even though there are some indications that the incarceration rate is leveling off after years of drastic increases, 6,937,600 total adults were still under correctional supervision in 2012 [6]. Considering the mental illness prevalence rates cited above, it is likely that millions of criminal-justice-involved adults are suffering from mental health problems. Anecdotally, in recent months some correctional facilities have noted increasing management problems related to the mentally ill population, in part due to expanding rosters of people with mental illness that have led to tremendous backlogs of cases [7]. Indeed, for at least a decade, correctional mental health experts have recognized that the incarceration rate for mentally ill offenders is growing [8]. As inpatient psychiatric beds are closed and state mental health budgets continue to be cut across the country, it is likely that the criminal justice system will continue to absorb the overflow. Education is one important way to address this extensive and growing public health problem.
The Current State of Forensic Education Survey studies examining forensic psychiatry education within general psychiatry residency programs have found limited exposure to incarcerated populations. In 1995, a brief survey of training directors of general psychiatry residency programs found that 82 % of programs offered a rotation in forensic psychiatry, including 35 % that required a forensic rotation [9]. However, only 15 of the 150 programs surveyed had a mandatory rotation in prison or jail, with 34 programs offering an optional correctional rotation. A 2014 survey asked general psychiatry residency training directors to assess their programs’ adherence to the 2007 Accreditation Council for Graduate Medical Education (ACGME) program requirements for forensic psychiatry
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education [1]. The directors reported that forensic topics were covered more extensively through lectures and didactics rather than through clinical exposure. Furthermore, the forensic topics most likely to be covered were issues common to general psychiatric practice, such as involuntary civil commitment and violence risk assessment. Of note, these ACGME topics do not include correctional psychiatry at all. In 2007, the ACGME did broaden its requirements for forensic psychiatry education during general psychiatry residency [10]. Previously, the ACGME only required providing “familiarity with the legal aspects of psychiatric practice” and “experience in forensic and court evaluations” [9], but the revised requirements now list exposure to a variety of topics: “the evaluation of forensic issues such as patients facing criminal charges, establishing competency to stand trial, criminal responsibility, commitment, and an assessment of their potential to harm themselves or others” [10]. The ACGME also notes that the experience “should include writing a forensic report,” and states “giving testimony in court is highly desirable” [10]. Nevertheless, among the topics listed, there is no mention of correctional psychiatry. Forensic psychiatry in certain other countries has stronger connections to correctional systems. For example, in the UK, where the National Health Service has been responsible for prison health care since 2003, the Royal College of Psychiatrists recommends that during general psychiatry training, “experience in forensic aspects of psychiatry should be gained, wherever possible, by direct involvement in the clinical care of patients referred to consultants with a special interest or responsibility in forensic psychiatry” [11]. Even so, a 2004 survey of successful Royal College of Psychiatrists Membership Examination candidates found that only 58 % had done a placement in a forensic psychiatry post, and 66 % of those who had not done such a placement had never visited a prison or jail [11]. There have been few specific proposals in the academic literature regarding the forensic education of general psychiatric residents. In 2004, Lewis suggested a model in which residents are exposed to forensic topics on an ongoing basis throughout other rotations (e.g., discussing civil commitment and informed consent on inpatient rotations, duty to report, and forced medication in the emergency room) [12]. This model does include space for a forensic elective in correctional mental health, but the overall thrust of this proposal is augmenting existing rotations with forensic education, and there is little discussion of the problem of criminaljustice-involved individuals. As a historical note, this general lack of attention to the mentally ill incarcerated population reflects the overall development of US forensic psychiatry. Until recently, forensic psychiatry has focused primarily on expertise for the courts rather than the treatment of incarcerated individuals. In this country, the field has its origins on Isaac Ray, a Maine
682
psychiatrist who rose to prominence in 1838 after publishing a treatise on the jurisprudence of insanity and whose subsequent work focused primarily on legal questions such as responsibility and punishment [13]. The field continued this focus on courtroom expertise for many years; for example, one former president of the American Academy of Psychiatry and the Law stated in 1974 that forensic psychiatry “is concerned primarily with the ends of the legal system, justice, rather than the therapeutic objectives of the medical system” [13]. However, catalyzed in part by the subspecialty recognition of forensic psychiatry in 1992 by the American Board of Medical Specialties (ABMS), the field has recently broadened its ambit to include care for mentally ill incarcerated individuals. The American Academy of Psychiatry and the Law now defines forensic psychiatry as “a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory or legislative matters,” and notes that “when a treatment relationship exists, such as in correctional settings, the usual physician-patient duties apply” [14]. It is time to broaden the focus of forensic education in general psychiatric residency to include criminal-justice-involved populations as well.
Opportunities for Training “Criminal justice” is a broad descriptor that encompasses a variety of settings. Residents can gain experience with correctional populations by working directly in prisons or jails, but other corrections-related settings also provide the opportunity for working with criminal-justice-involved individuals. As noted above, most US general psychiatry residency programs do not provide clinical training in correctional settings, though some have developed educationally rich programs in jails and prisons. For example, at the University of California at Davis’ general psychiatry residency program, first year residents rotate through the Sacramento County Main Jail’s Psychiatric Services (Charles Scott, M.D., personal communication). Psychiatric services within correctional facilities are often organized by various levels of care; residents see patients at an acuity level analogous to outpatientlevel care. Residents’ main roles include new psychiatric evaluations of inmates, ongoing medication management, and consultation to other correctional clinicians. Of course, it is helpful that the UC-Davis forensic psychiatry fellowship supports this rotation with a source of faculty and fellows for supervision. However, residency programs without forensic fellowships have still successfully established correctional rotations for their general psychiatry residents, sometimes by training in non-incarcerated settings that still provide exposure to criminal-justice-involved patients. At Mt. Sinai, first year general psychiatry residents participate in clinical rotations at
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Kirby Forensic Psychiatric Center, a maximum-security forensic psychiatric hospital, as well as a specialized forensic unit at Manhattan Psychiatric Center. The clinical populations at these institutions include individuals charged with serious crimes and inmates transferred from jail or prison. Therefore, even in non-incarcerated settings, there are opportunities for concentrated exposure to correctional populations. There are also a variety of outpatient programs that work with criminal-justice-involved individuals. Diversion programs are intended to limit the detention of persons with mental illness and include pre-booking (i.e., pre-arrest) crisis intervention teams, post-booking mental health courts, forensic assertive community treatment (ACT) teams, and other specialized outpatient services that tailor their care to criminaljustice-involved populations. Likewise, a variety of re-entry programs provide specialized care for recently released mentally ill inmates. The availability of these services depends on the jurisdiction and the local community’s existing investment in such programs, but when present, they provide a useful perspective on community health approaches to the mentally ill and could be easily incorporated into psychiatric residency.
Considerations: Advantages and Barriers to Training in Corrections Barriers Residency programs often do have to manage significant barriers for trainees to work in correctional settings. Procedural issues are sometimes onerous. Jails and prisons are overseen by state departments of corrections, and in order to work within those systems, clinicians must often participate in extensive training programs over which they have little control. Hypothetically, a required 1-week orientation program might seem like too high a cost for a 1-month clinical rotation. On the other hand, if the educational value of such programs is maximized for residents, they become useful teaching opportunities rather than onerous bureaucratic hurdles. Topics such as the roles of peace officers and other staff in incarcerated settings, protections for victimized populations, and even the organizational and physical structures of correctional institutions are all useful for clinicians in training to encounter. Caseloads for correctional settings are usually higher compared to the community, and especially in jail or intake facilities, rapid patient turnover is the norm. Clinicians can face pressure to see large volumes of patients, and supervisors, themselves pressured for time, might have limited time to guide trainees. However, adequate preparation, coordination, and commitment allow residents to take on a helpful portion of the institution’s clinical responsibilities, thus freeing supervisory clinicians for educational activities. This solution, however, requires identifying supervisors committed to teaching,
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not to mention well-coordinated management of resident workloads. An increasing number of correctional institutions are becoming managed by for-profit entities. The ethical and policy issues related to the privatization of correctional mental health services are controversial, and a review of this topic is beyond the scope of this commentary. Suffice to say, prison and jail privatization is rapidly increasing in the USA, and while most studies indicate that privatized institutions function similarly to publicly operated ones, without adequate oversight, privatization can also lead to mismanagement and a lower standard of clinical care [15]. At the level of individual institutions, program directors should be mindful of management issues such as resident caseloads and the adequacy of supervision. Of course, these cautions hold true for all correctional settings, not only privatized institutions. One final risk bears mentioning: are correctional settings more dangerous? Prisons and jails are managed with a strong focus on staff safety, and other clinical settings that have a high incidence of workplace violence, such as emergency departments, unfortunately are sometimes just as (if not more) risky [16]. Safety considerations should not be cavalierly dismissed, of course, and individual institutions vary with respect to safety and security. For example, stability in prisons (i.e., for felony convictions, longer than 1 year) and jails (i.e., for shorter lengths of incarceration) can differ significantly because of their relative rates of turnover. Similarly, intake and reception units are sometimes more volatile because staff are less familiar with inmates. The structure of the institution, the nature of the residents’ specific roles in the institution, and even the character or “personality” of the institution are all important to consider when assessing safety. Ultimately, the specific circumstances of the possible rotation must be considered on a case-by-case basis.
Advantages The educational benefits of working with criminaljustice-involved populations are manifold. There are rich opportunities for systems-based learning; working in corrections gives a direct insight into the culture and environment of jail and prison. There is no substitute for seeing firsthand the impact of incarceration on individuals, including the loss of control of one’s environment, loss of social contacts, vulnerability, gang influence, and subjugation to authority. Clinicians with a richer knowledge of this experience will better understand and serve criminal-justice-involved patientsas well as patients who live in communities in which incarceration is endemic. In some communities, the experience and effects of incarceration are pervasive; if current trends continue, one of every three black American males born today will go to prison at some point in his lifetime [17].
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Working in corrections also provides practical experience with the issue of dual agency. Clinicians in correctional roles have a responsibility not only to the individual patient but also to the safety of the institution, so correctional psychiatry presents a particularly salient way to grapple with this important element of professional ethics [18]. Recent legislation has evoked dual agency issues for all psychiatrists, as, for example, reporting requirements for dangerous patients is enacted as part of firearms legislation. As psychiatrists continue to face dual agency issues in their daily practice, experience addressing this issue in residency across different settings is valuable. Finally, there are unique opportunities to develop clinical skills by working with this population. Incarcerated populations experience a range of pathology, and trainees working in corrections gain exposure to levels of serious mental illness and trauma not commonly encountered in the community. For example, in female incarcerated populations in particular, the scope, severity, and pervasiveness of physical and sexual trauma are profound. Aside from seeing unique psychopathology, residents would gain valuable experience in the assessment of malingering, as some incarcerated individuals pursue mental health treatment to avoid retribution, seek a change in housing status, or simply obtain quasi-recreational medications. More straightforwardly, working with a diverse range of staff on shared management issues provides unique practice in collaborative care.
Conclusions There is an urgent need to train psychiatrists who have an interest in serving the criminal-justice-involved population. The mental health needs of incarcerated individuals are extensive and inadequately addressed, and even though there are some indications that the rapid growth in US incarceration is slowing, the proportion of people with mental illnesses in corrections continues to rise. Still, many general psychiatric training programs miss opportunities to give their residents clinical exposure to correctional populations. Identifying and developing these opportunities might be intimidating to those unfamiliar with the criminal justice system, but a variety of solutions exist for residency programs to offer clinical training in correctional facilities for their residents, ranging from direct clinical care inside prisons and jails to outpatient experiences that enable work with criminal-justice-involved individuals. Regarding educational policy, the current ACGME requirements for forensic education during general psychiatry residency simply do not mention correctional psychiatry. The ACGME should encourage correctional psychiatry exposure as one possible component of the required forensic experience in general psychiatry. It would be unrealistic to require all residency programs to offer clinical training in correctional
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psychiatry, given the barriers some programs might encounter. However, because the criminal-justice-involved population is so dramatically underserved, there is a public health imperative to attempt to introduce these important issues into psychiatric residency education wherever possible. Implications for Educators & There is an epidemic of psychiatric disorders in the US correctional system. & Most general psychiatric residency programs, however, do not include clinical experiences in these settings. & There are unique educational opportunities for residents working in correctional settings, ranging from clinical skill building to systemsbased practice. & There are many ways for psychiatric residents to work with criminaljustice-involved individuals, and residency programs that find prison and jail rotations difficult to establish have several other options to pursue.
Acknowledgments Many thanks to Paul Appelbaum, Charles Scott, Alec Buchanan, Rusty Reeves, David Spagnolo, and Jeffrey Janofsky for helpful comments on this topic. Disclosures The author states that there is no conflict of interest.
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