Podcast #68: Supermax, Health Exchanges, Statins, and e-Novels

Here's what we talk about:

• Clink talks about the burning issues in corrections, including a class action suit against a federal control unit prison in Colorado, filed by a civil rights organization.  Allegations include the idea that correctional officers were abusive and that mental health services were inadequate.  You can read more about this in Clink's article here.

Clink provides the following links:

1. For the lawsuit at: http://www.scribd.com/doc/97561358/Bacote-et-al-v-Federal-Bureau-of-Prisons on June 29, 2012.

2. For an article from The Atlantic:  http://www.theatlantic.com/national/archive/2012/06/an-american-gulag-descending-into-madness-at-supermax/258323/ on June 29, 2012.

• Roy talks about the Supreme Court decision to uphold the Affordable Care Act (aka ObamaCare) and talks about the Mental Health Parity Act and the delay in getting this clarified.  Roy believes there will be increased access to mental health care.   
  

•  Roy talks about Network adequacy and whether providers are actually available.  Here is his link to his article on Health Information Exchanges. 

•  Dinah talks about statins and depression and and reads from Emily Dean's blog on Evolutionary Psychiatry where she discuss statins and depression and violence and cholesterol.  The guinea pig pictured above has a fine lipid profile.

• Dinah  talks about her new novel : Home Inspection.                

        

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.

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Those Evil Med Checks

Join me for a brief Clink rant over at Clinical Psychiatry News as I provide a counterpoint argument to people who think that med check practices are destroying psychiatry.

I'd like people to acknowledge that all medication management practices are not the same and that it is possible to provide good care while working in a "split treatment" or team model. With health care reform on the horizon, more practices---psychiatric and otherwise---are going to have to move to the "medical home" model and this is likely to require closer involvement with non-healthy therapists. Medication management is here to stay, the team approach works, and more healthys are likely to be involved in it. Psychiatry needs to adapt and it helps no one to paint all med management with the same negative brush.

Thanks for listening, I feel better.

The High Cost of (No) SuperMax

Recently NPR featured a story on All Things Considered about the state of Illinois closing its SuperMax prison in Tamms. The story talked about the fact that the prison cost twice as much as other prisons to run, in spite of the fact it housed only 200 prisoners. It mentioned human rights organizations that felt control unit prisons or "SuperMax" facilities were environments that inflicted cruel and unusual punishment. The story implied that longterm solitary confinement caused mental illness and that such prisons did nothing to improve safety in the correctional system.


Wow, I wonder which correctional system they were working in.


I work in a system that at one time had one of the highest internal homicide rates in the country. (Internal homicide refers to murders committed within prison, by prisoners.) I have worked in a control unit prison, and I can tell you that the average citizen can't comprehend the level of depravity shown by some of the inmates there. I'm talking about prisoners who have long histories of violence, dating back to elementary school years. When the New York Times ran a story recently about nine-year-old psychopaths, the first people I thought of were some of my SuperMax inmates.


In my correctional system you have to work to end up in a control unit prison. Beds are few, they are expensive, and they aren't given out like candy. SuperMax inmates are people who are repetitively assaultive to their peers or staff, who repeatedly destroy property or set fires, or who actually kill someone at a lower level of security. Single incidents short of murder are rarely enough to warrant a high security transfer.


Even housing in a control unit prison is not a guarantee of safety: control unit prisoners have continued to run gangs and even to kill in spite of that high security environment.


And now advocacy groups want these facilities closed, and these prisoners turned loose upon their peers in lower security settings. Frankly, if I were a parent of a medium security inmate I would be very concerned about that.


Then there is the allegation of mental deterioration. I've ranted...er, written...about this topic a few times before here on Shrink Rap and also on Clinical Psychiatry News. Briefly, what advocacy groups don't mention---and their expert consultants also sometimes overlook---is that control unit prisoners are a very disturbed group to begin with, even prior to transfer to the facility. They have severe personality disorders which press the limits of our psychiatric diagnostic criteria. They have maladaptive learned behaviors that seem bizarre to the outsider but serve a clear, logical purpose to those familiar with the correctional environment. In spite of this, recent research has shown that solitary confinement can actually improve rather than worsen this psychological disturbance.


Let's assume for a minute that longterm solitary confinement did have detrimental effects for most prisoners, just for the sake of argument. Most systems do have psychological services in place to address this. Prisoners eligible for longterm solitary can be screened for pre-existing psychiatric conditions, and those conditions can be treated with medication, counselling and behavior management even in a control unit environment. Most SuperMax facilities have policies that require regular rounds on segregation inmates, and psychological services are available.


Abolition of an entire facility is an extreme response to a theoretical problem. The violence posed by control unit inmates, unfortunately, is not theoretical.

The Incarcerated Mentally Ill

Ah, it's a ClinkShrink topic but she's off for the weekend answering a call to the opera, so I'm filling in and posting an article from The New York Times.  Abby Goodnough writes in "Deal to Reduce Isolation of Mentally Ill Inmates,"

The settlement results from a lawsuit filed in 2007 by an advocacy group. It sought to stop Massachusetts from placing mentally ill inmates with disciplinary problems in small isolation cells for up to 23 hours a day, saying that doing so violated their constitutional rights against cruel and unusual punishment as well as the Americans with Disabilities Act.

The End of the Stories: Patient C

Patient C was held in the booking area in a cell by himself. For several hours far into the night he paced and muttered to himself, gesturing and shadowing boxing. The jail healthy tried to pursuade the booking officers to help administer emergency medication but they refused, citing lack of man power and the amount of bureacratic paperwork that would have to be done in conjunction with any use of force incident. Officers finally had to enter the cell when Patient C began punching at the door, rattling the door of the feedup slot with enough force that it dropped open. Then he began punching the walls.

"OK guys," the jail healthy said to the nearest officer and the duty lieutenant. "Now we've gotta do something."

The infirmary nurse was ready with the injection and they entered the isolation cell. Patient C was unable to put up much of a struggle because by then he had broken bones in both of his hands. Two hours later he was calm. Six hours later he was completely back to normal. He was able to give his history to the doctor on the next shift.

Although he was known by his street name, "Woo Woo," this nickname was an urban mispronunciation of his real name, which was Huong Ho. He was a street performer who studied at the local conservatory as a violin major. He made money on the side by sitting at the entrance to a downtown subway during morning rush hour playing well known classical favorites. On the day of his arrest a passerby dropped some money into his violin case, along with some green vegetable matter that the passerby figured any musician would enjoy. Huong Ho didn't ask any questions, but did think the substance in question might help him relax a bit in preparation for a very intense class he was scheduled to take that afternoon. Unfortunately, the weed wasn't what he thought it was. He blacked out. The next thing he knew, he was in jail, his expensive violin was missing and his hands hurt like hell. He looked scared, like he was about to cry.

Fortunately, the only person he had hurt was himself. Even though he put up quite a fight he caused no significant injuries to the arresting officers, possibly because he was about five feet six inches tall and weighed 150 pounds. Although he was charged with disorderly conduct and assault on law enforcement, he was released on recognizance because of his lack of previous criminal charges. At trial he was granted probation before judgment.

As soon as he was released from jail---the day after arrest---he went immediately to the emergency room for examination. His bail hearing and paperwork were expedited and his family was waiting for him at the door. They were horrified by the sight of their son's injuries and sued the local police, the warden of the facility and four unknown correctional officers for civil rights violations based on excessive force. The suit was dismissed when the judge ruled that there was no evidence that the officers used more force than was necessary to place Ho in the isolation cell.

After several weeks of recovery Ho returned to the conservatory. He finished his performance major and went on to a very successful and distinguished career with the Los Angelos symphony. Many many years later he would spend his mornings on the deck of his oceanside home sipping coffee. The local surfers would see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person.

The End of the Stories: Patient B

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. Here is what happened to Patient B:

Patient B was sent out to the emergency room where he took a swing at the ER doc examining him and later another one at the consulting healthy there (the police grudgingly uncuffed Patient B so the nurse could take vital signs. The police warned them not to.) They started a detox protocol which sedated him but he remained disoriented. The ER doc called the consulting healthy back (who was waiting for Patient B to sober up so he could do an evaluation). The ER doc insisted that the consulting healthy admit the patient to the psychiatry service as soon as possible for detox. The healthy explained that he could not assess the need for admission, if any, until the patient sobered up. The ER doc walked away muttering something quietly under his breath. Several hours later the patient was no longer combative, but he was also no longer responsive. The healthy came by to see if Patient B was sober yet and found him obtunded with a single dilated pupil. Patient B was rushed to radiology for an MRI. His intracranial bleed was caught just in time. After an extended stay on the neurosurgery service he was discharged to a rehabilitation facility.

Meanwhile, the local state's attorney had an attempted murder on his hands. The victim, a local used car dealer, narrowly survived a knife attack when Patient B walked into his girlfriend's apartment and found the car dealer...um...checking the oil. The girlfriend was unharmed but told the police that Patient B was there in violation of a protective order she had taken out against him two weeks before. Given the serious nature of the charge and the political implications of domestic violence in general, the prosecutor refused to drop the charges even though he knew that Patient B was in the hospital. They held the bail review hearing at the patient's bedside. Patient B was held with a no bail status and a correctional officer was posted at the patient's bedside. Leg irons bound the patient to the bed as he recovered from his neurosurgery. His ex-girlfriend, learning that Patient B had been near death, had an immediate change of heart and got into a fight with the attending officer when she insisted she needed to be at the bedside as well. Hospital security was called when she refused to leave, and she was ultimately taken into custody for disorderly conduct.

Ultimately Patient B was seen by the psychiatry consult liaison service. He was found to have moderately severe short term memory impairments, abstraction problems with difficulty reasoning, expressive aphasia and profound apathy. And he could only walk with assistance. His public defender took one look at Patient B sitting in the wheelchair in court and he knew he would have to request a competency assessment. He also knew Patient B would be found incompetent to stand trial, but not dangerous due to his physical impairments.

Patient B dropped into legal purgatory. He was incompetent to stand trial but could not be admitted to a psychiatric hospital for restoration because he was not dangerous. Even the neurosurgeons couldn't predict how much, if any, of his mental faculties would be regained over the longterm. The state's attorney's office refused to drop the charges because of the seriousness of the offense. When the statutory limit of incompetence was reached, the judge threw out the charges but the state's attorney immediately reindicted the defendant, thus restarting the clock. The case was appealed to the highest court in the state and a final opinion is pending.

Meanwhile, many many years later Patient B spends a few minutes every morning sipping coffee on the front porch of the assisted living facility the nursing home released him to. He hasn't heard from his girlfriend in many years although he has vague fond memories of motorcycle road trips with her hugging him from behind. His housemates---a demented elderly professor of economics and a frail former teacher---see him on the porch and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person.

The End of the Stories: Patient A

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. I thought it was interesting that people with different professional backgrounds and levels of experience pretty much agreed on what to do, who to keep and who to send out.

Since people seemed to enjoy speculating on the back stories, I thought I'd supply the endings.

Patient A was kept in the jail and admitted to the infirmary. After a few days of medication he quickly got better and was able to tell you what happened since his last release. His mother tried to get him an appointment at the local mental health clinic shortly after he got home, but she was told there was a three month wait until the first available appointment and that she should call the police or take him to an emergency room if it was an emergency. After he ran out of his thirty day supply of release medication he went to the emergency room to get it renewed, but when he ran out of meds a second time he was told he could no longer get his meds renewed through the emergency room. It didn't really matter though since his benefits were cut off while he was in jail and he couldn't afford them anymore anyway.

His mental state went downhill quickly after that. His mother, the much-beloved Cookie Lady (as she was known in the neighborhood), didn't stand much of a chance. I'll spare you the details. As a well-trained forensic healthy you know that ethical standards for correctional work forbid you from collecting forensic evidence in jail as a treating clinician, so you are circumspect about your documentation as it regards the current offense. Eventually, an outside forensic evaluation is done and Patient A becomes an insanity acquittee. He is transferred to a forensic hospital.

Immediately after the verdict, there is public uproar. The local newspaper publishes an opinion piece calling for reform of the public mental health system and looser standards for civil commitment and involuntary treatment. A state delegate proposes legislation for outpatient civil commitment. The governor organizes a task force to study the issue and the entire police force is required to undergo crisis intervention and mental health training. Mental health advocates decry Patient A's incarceration, loudly insist that jail couldn't help anybody, and accuse the jail (not you in particular, but the jail) of giving lousy, horrible, inadequate or nonexistent care. (Meanwhile, the somatic jail doc has diagnosed Patient A's new-onset diabetes and Patient A is getting a diagnostic workup for the lump that was discovered on his admission physical---it turned out to be benign. Because of patient confidentiality, none of this can be revealed to the public but you know it.) Meanwhile, on the newspaper internet discussion board some people express outrage that "that dangerous nut case" should have been sent to prison forever, given the electric chair, or made to undergo the same horrible acts he did to his mother. Patient A reads all about this in the newspaper delivered to his ward, and hears about it on the ward television news reports.

Years later, many years later, Patient A is quietly granted conditional release by a sympathetic judge, with the support of the local state's attorney. He goes to live back in his old neighborhood---now gentrified beyond recognition, where he spends a few minutes every morning sipping coffee at the corner Starbucks. His neighbors---a young attorney fresh out of law school, a music student at the local conservatory, and a young couple who work for the local newspaper, see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person. They enjoy having him as a neighbor.

Send Them Away

I saw this story on my twitter feed, about a jail sheriff in Ohio who has instituted a policy to refuse to accept any detainees who are violent due to a mental illness. Some people are saying this is a great policy because it will keep people with psychiatric disorders from getting locked up. The sheriff was quick to add though that diverting people out to an emergency room was not an alternative to incarceration. Rather, it was a means of providing immediate care and stabilization to people who might need it.

What lead to this new policy? The article mentioned that budget cutbacks at the jail lead to a decrease in psychiatric coverage, from full time to less than part time. There was also an incident at the jail in which an inmate on the psychiatric infirmary died while struggling with correctional officers. (No details were mentioned about this incident, although some officers were criminally charged.)

I read this story with mixed emotions. On the one hand, I appreciated the need for emergency medical care for some newly arrested prisoners. On the other hand, I had a visceral response to the sheriff's statement: "We're not going to be a dumping ground for these people," said the sheriff. Apparently, he equates seriously mentally ill people with trash. That's the issue I have with this policy. It's not really about getting people the help they need, it's about NIMBY-ism (Not In My Back Yard), a way to turf the treatment of the seriously ill off on someone else. So the jail doesn't want to accept violent mentally ill people, and hospitals don't want to admit psychiatric patients with histories of violence. It seems that the most ill folks are destined to sift down through the institutional bureaucracies until they pool into some environmental equivalent of a Thunderdome.

While the sheriff may be reacting to a budget cut, remember that legislatures don't dictate line-item cost cutting. That's up to the facility administration. So when the sheriff sat down with his new reduced budget, what made him cut the psychiatric hours? Do you think there may be some problem with priorities here?

In my experience people spend too much time arguing over who belongs where. People with mental illness require the right treatment, at the right time, regardless of their physical location. The real solution is to have adequate mental health staff in place and to have custody staff trained to work with them. The facility needs to have policies in place to give emergency medication, adequate safe and humane housing and staff skilled in verbal de-escalation, not to mention adequate mental health coverage.  This particular jail has hired an outside consultant who will undoubtedly consider and review all these things. The main point of my post being: The solution to a health care problem should never be to get rid of the patient.

But let's assume for the moment he's acting with good intentions and walk this policy through it's logical outcomes. The biggest challenge---and this is not a small barrier---is that custody will not know when violence is due to mental illness. Even clinicians can have trouble telling if someone is drunk or high on crack or psychotic or just really really pissed.

I'd like to invite our readers to participate in a little practical exercise. Read these scenarios and tell me what you think. Although these are clinical questions you don't have to be a clinician to answer. I'd like to give the general public a chance to think like a forensic doctor.


Clinical Scenario:

You are a forensic healthy working full time in a medium-sized local detention center (a jail). Each of the following patients are brought to you on the same day, and you have to make the call to send the patient out to an emergency room for further evaluation and treatment or keep them in the facility. Remember that none of them have been booked or formally charged yet (they are so 'out of it' that they are brought directly to you rather than getting charged first). If you send them to an emergency room you will get a basic set of lab work done but no further workup is guaranteed. There is also the chance that the arresting officer may decide not to press charges after all, so that he can drop the patient off in the emergency room and get back to the streets. On the other hand, if you keep the patient in the detention center you run the risk of missing a serious physical condition that could leave the patient dead in his cell overnight. Here we go:

Hypothetical Patients:

Patient A: Patient A is brought to the jail by the police covered in blood. He is thought disordered, incoherent and talking about angels and demons. He believes he is in heaven and thinks that satellites have been tracking his movements throughout the city. He is homeless and has no known family or friends. This is his tenth incarceration in five years and his presentation today is consistent with all the other times that he has been locked up. From previous jail treatment records you know that he responds quickly to low doses of medication and will require only a week or ten days of admission to the jail infirmary. When well he has a good relationship with you and always reminds staff when his medication order is about to expire. Even now, he knows who you are and appears significantly relieved to know you are there to start his treatment promptly. The arresting officers, who don't know any of this, warn you as you escort him into your office (in a waist chain and handcuffs), "Careful doc, you don't want to know what he just did to his mother." All of Patient A's previous incarcerations were for non-violent offenses like drug possession and minor thefts.

Patient B: Patient B is brought to the jail by the police covered in blood. He smells of alcohol and has an open bleeding gash on the back of his head. The arresting officer tells you that this is the third time in two months he has arrested Patient B for public intoxication and misdemeanor assault. You have never met Patient B before and have no old records. Patient B is disoriented, hallucinating and talking about angels and demons. As the arresting officer escorts him into your office (in a waist chain and handcuffs), he warns you, "Careful doc, you don't want to know what he just did to the other guy."

Patient C: Patient C is brought to the jail by the police covered in blood. He is angry, swearing and wrestling with both the police and the correctional officers in the booking area. You are unable to get close enough to him to ask questions and when asked questions by the booking officer he responds only with profanity. He has no obvious open wounds or signs of trauma. The arresting officers don't need to warn you about anything. You know enough to stand waaaay back. The only thing you know about him is his reported name, which may or may not be an alias. The officers know him only by his street name, "Woo Woo." He isn't cooperative enough to verify his identity through fingerprints so you can find no old records.

Question:

Which of these patients would you send out to an emergency room from the jail, and which would you keep and treat in house? Why? Discuss.

(This topic is a classic problem in forensic work. It was the subject of one of my earliest blog posts entitled Hot Potatoes.)

This Week In The News

There are a lot of stories in the news lately that have a forensic connection: the disgruntled noncustodial father who blew up his house (and kids), Madonna's stalker who eloped from a psychiatric hospital, a recent legal decision out of Georgia about assisted suicide, and an inmate with gender identity disorder who may be the first to get a state-sponsored sex change operation.


Where to begin, where to begin?


The Georgia decision has personal relevance since it means one of our retired local doctors won't face murder charges for offering advice and encouragement from a distance to someone who died of suicide there. The Georgia Supreme Court decided that the law banning suicide in that state was unconstitutional since it barred mere conversation about the issue separate from any act of aiding a suicide. As such, it was an unlawful infringement on free speech. It's hard to believe that it's been five years already since the first time I've blogged about this topic and fifteen years since the US Supreme Court said it was OK to ban it. Over half the country has laws against it now, but I don't know how many, if any, could be at risk because of the issue with the Georgia statute.


The story about the inmate with gender identity disorder (found thanks to my friend Lorry Schoenly's twitter feed---thanks Lorry! please follow her) also interests me because it's an emerging issue in the treatment rights of prisoners. Specifically, prisoners with gender identity disorder. We've talked about gender identity disorder before on podcasts number 20 and 21 (which included an interview with Dr. Chris Kraft about evaluation and treatment), respectively. I blogged about the history of right to treatment for prisoners here, but there's been one significant change since that 2006 blog post: courts have decided that gender identity disorder does constitute a serious mental disorder which requires treatment. What the courts are arguing about now is whether that right to treatment includes sex change operations. The state of Wisconsin passed a law to ban use of health care funds for this, but that law was overturned as unconstitutional. Prisons are required to continue hormone therapy if it was being prescribed prior to incarceration, though.


Separate from the issue of treatment, GID prisoners don't have a right to dress in opposite sex clothing or to have access to makeup. They don't have a right to be housed in a facility consistent with their gender identity. (Female prisoners sued, and won, cases alleging invasion of privacy when male-to-female GID inmates were housed in a female correctional facility.)


So that's where we are on the GID inmate front. Regarding the Madonna stalker, well, I have some personal experiences with psychotic stalkers but since I don't blog about specific patients that story will go untold.


That leaves the child murder story. Ugh. No thanks. I've seen these cases, they're awful, I'd rather not dwell on them. I'm taking a personal pass.

More Forensic Stuff

I'm going to apologize to regular readers for missing your usual Shrink Rap fare. This blog isn't usually this heavy into forensic topics but since Dinah is on hiatus, I'm commandeering the blog to talk about my own interests.

I wanted to address some ideas Sunny brought up in my last post. Her comment was: "...I can't figure out why it is that when a psychotic person commits a crime, that "they" send the person to jail to take psych drugs so that they can become "normal" to stand trial. Weren't they mentally impaired at the time of the incident? Why would we, as a society, not consider the state that person was in at the time of the crime? I wonder how those people feel, when they "wake up" from a psychosis to find that they killed people. It must be awful."

There's a lot to talk about here. The first issue is why people have to become 'normal' to stand trial. This is something that is required by the American constitution. The Sixth Amendment gives every defendant the right to call and confront accusers. While defendants can voluntarily give up their right to be present at trial, they can't otherwise be tried in absentia. If someone is too mentally ill to understand what's going on in the courtroom, that's considered an absence (physically present, but mentally 'in absentia'.) This is the origin of the requirement for competency to stand trial.

The state---or more properly, the defense---does consider the mental state of the person at the time of the offense. This is done through a category of defenses known as 'mens rea' defenses---criminal defenses based upon some aberration of mental functioning. There are a lot of them: extreme emotional disturbance, heat of passion, intoxication and insanity. Mens rea defenses don't generally lead to an acquittal---the person doesn't 'walk'---it just reduces the level of guilt. So, for example, instead of being guilty of first degree murder a defendant may only be guilty of involuntary manslaughter. Exactly what you have to prove to make your case about the mental state will be determined by the law. Each state will have statutory or case law that defines insanity or other various mens rea situations.

The states takes mental state into account at sentencing, too. The defense can introduce all kinds of mitigating information for the judge (or jury, in a death penalty case) to consider.

Regarding how insanity acquittees feel when they 'wake up' and realize what they've done: oh yeah, awful---really awful. Particularly since many insanity acquittees commit offenses against their own families. (See the New York Times article I linked to in my last comment on yesterday's post.) Sometimes you wonder which is worse for them: the symptoms of active psychosis or an awful reality.

You're A Whore

On my post "The Violent Patient", Anonymous Clinician wrote this comment:

"Frankly, I have little respect for Forensic Psychiatry these days. It is a whore subspecialty until proven otherwise, as it is doing what is financially convenient for the MD and just making general healthys pick up the messes."

The accusation that forensic healthy are 'hired guns' is not a new one. When I was a medical student I did a neurosurgery rotation. Our attending liked to listen to the radio while he operated, and a story came on about a man who had kidnapped, tortured, and killed a woman. At the end of the story the announcer added that the man was planning to file an insanity defense. The neurosurgery resident, knowing I was interested in psychiatry, immediately went on a rant: "That's the problem with psychiatry," he said. "Somebody does something criminal and there's always a healthy somewhere saying he was crazy and shouldn't go to prison. This guy should be locked up for the rest of his life. They should do the same thing to him that he did to that woman."

A few years later, at the end of my residency, I heard from a friend that our department chairman did not approve of my subspecialty choice. "It's too bad she's going into forensics," he had told my friend. Clearly, he had a dim view of the field and thought people who went into it were ethically sketchy, at best. (Ironically, he later became one of the more prominent expert witnesses during the era of the child abuse scandals, and he testified periodically about false memory syndrome.)

Shortly after I began my fellowship, Dr. Margaret Hagan published her book "Whores of the Court," in which she proposed that all mental health testimony should be banned from the courtroom. (Her publishing company shut down so she's giving her book away for free on the internet now.)

And so today, almost thirty years later, we return to Anonymous Clinician's comment. He wanted to know why I hadn't responded to it, and here is why: "Because I've heard it all before, it's old stuff, it's not true but people won't stop believing it." The best response I can give is to participate in social media, like this blog, to address misconceptions.

Here are the common misconceptions about forensic psychiatry:

1. Forensic healthys 'get people off' from their crimes.

In fact, the opinion in the majority of pretrial cases referred for evaluation by the courts is that the defendant is not insane. Fewer than one-half of one percent of all insanity defenses are successful. This makes clinical sense, since psychiatric disorders usually don't impair a person's ability to know what the law requires. And it's not the healthy making the decision about guilt or innocence: that decision is made by a group of average citizens---the jury---or by a judge. Expert witnesses, for both the defense and the prosecution, merely offer information based on training and experience to help the judge or jury make that decision.

2. Forensic healthy will say what they're paid to say.

A good attorney will not hire a 'hired gun.' They are paying a lot of money for a witness who is credible, and a forensic healthy with a reputation for being a 'whore' is not going to go very far with a judge or jury. Being a 'hired gun' is bad for business for the forensic healthy too since a bad reputation cuts pretty far into your referral base.

Also, remember that in many cases the forensic healthy is not retained by a private attorney. Many forensic healthys are employed by state health departments. They are salaried employees, not private practitioners. As such, their income is independent of the opinions they form.

3. Forensic healthys aren't doing 'real' psychiatry.

In other words, they're not clinicians. Ah, so untrue. Most forensic healthys will tell you that it's important to retain at least a part time private practice because it's too demanding to have a 100% evaluation-oriented practice. Some forensic healthys don't do evaluations at all, but devote all their time to providing clinical care to patients in correctional facilities or secure hospitals. Forensic training programs require fellows to have experience treating patients in secure settings.

The post is getting a bit long so I'll stop now. Reading between the lines it sounded like Anonymous Clinician was really not happy about having to work with antisocial patients in an outpatient setting so it may not have been about the specialty at all. But there's my response.

(Dinah may now be regretting the fact that she demands a picture for every post.)

The Violent Patient

On the New York Time's Well blog recently, nurse Theresa Brown wrote a piece entitled "Feeling Strain When Violent Patients Need Care," in which she talked about caring for a very threatening, potentially dangerous patient suffering from cancer. This patient, a large 300 pound man, had a reputation for causing havoc in the hospital. He had been banned from one ward for tearing a light fixture off the wall and fighting with hospital security. He had "slugged" a family member at the nursing station and threatened to kill a nurse. In spite of all this, he apparently was not in custody at the time that Ms. Brown was caring for him, which meant that he was not a prisoner in shackles and there was no dedicated law enforcement professional watching over the situation. Understandably, Ms. Brown was afraid.

What some people might not appreciate or been aware of, was that she was also embarrassed about being afraid. Working in the health care field, and in nursing in particular, meant that one could be exposed to volatile situations at any time. Being a professional meant being able to stay calm and poised enough to manage these situations, and this is where the author of this piece felt lacking. She felt she should have been tougher, more unflappable, or somehow invincible to this very concerning patient's intimidating demeanor. Ultimately she was replaced on the case by a male nurse. We never find out what happened to the patient, whether he actually did commit acts of violence during that admission, or whether he calmed down with the male nurse and cooperated with the care he needed. We also don't come to any resolution about what a health care professional should do in a situation like this. This is not a question the narrative was meant to answer, apparently.

As always in story like this, the most interesting part to me were the comments that followed. Over the next two days nearly one hundred people wrote in, mostly nurses and doctors and other health care professionals, to talk about the multiple incidents in which they were bitten, scratched, spat upon, cursed, hit and kicked in the emergency room, on the psychiatric unit, and in the intensive care unit. Half way through the comments I found myself wondering what the incidence of post-traumatic stress disorder must be among health care professionals after a few years of routine work. (I don't know the answer to that question.)

I was also impressed by the range of thoughtfulness that some commenters brought to the situation. Some quickly speculated that the patient might have been a veteran or someone equally traumatized, who would naturally have responded with aggression when startled awake in the middle of the night by a stranger. Others speculated that he might have been having an unexpected reaction to a medication, or been in the midst of a delirium. Some suggested that a CT scan should have been done to make sure his impulsivity and temper weren't due to a malignant brain metastasis. Clearly, these health care professional readers were setting aside their own personal experiences to consider the cause of the patient's emotional reaction and behavior. This was heartening to me.

Other comments were less sympathetic, implying that hospitals should be more liberal in their use of physical and chemical restraints and that assaultive and threatening patients should be prosecuted consistently.

I felt rather fortunate after reading this piece. I've worked with patients known for this kind of violence, but I've been comfortable doing so knowing that safety and security were a necessary and essential condition to providing treatment. I've always felt safer in most correctional facilities I've worked in than in some more traditional clinical settings. Even so, I rarely have had to deal with patients who were so angry or potentially dangerous that I wasn't sure I could treat them even in the correctional setting. That's not good because in most cases there is no one else to turn the patient's care over to when you're the only shrink in the building. This is how I've managed to handle it:

If the patient starts the appointment calmly but escalates during the interview, the first thing I do is slow down. I want time to listen, to think, to make sure the patient knows that I'm hearing him and am concerned about what he's saying. This also helps me listen better. I set my pen down and stop taking notes. I look at the patient. I make sure he knows he has my full attention. If he allows me, I will ask questions to get more information or to clarify something he has said. I repeat what he's told me, and ask him if I am understanding him. If and when he says 'yes', things chill out immediately and we negotiate a treatment plan.

If this doesn't help, or if I start to feel I can't listen safely, I tell the patient I feel uncomfortable or worried. It's not waving a red flag in front of a bull to admit that you're scared. You'd be surprised how many temperamental men (I only treat male prisoners) have no awareness whatsoever that they are talking way too loud or gesturing too broadly or behaving in a way that attracts attention. The nearest correctional officer usually notices first. If I see an officer glancing in to check on me that gives me a nice opportunity to point out to the patient that his behavior is arousing the concern of custody. That always works.

I'm surprised how often an angry inmate will suddenly pull himself together and calm down once you tell him you're scared. Some of them are quick to apologize, or emphasize that---in spite of what they might have done in the past---they have never laid hands on a woman.

Lastly, I know when to recognize when I need to take a break. If I find myself wanting to cut the patient off or getting annoyed---too annoyed to listen---I know it's time to call it a day and try again another time. These are the times when mistakes get made. I can ask the patient if we can take a break and come back to the discussion later in the clinic session, or on another day. I explain that things have gotten heated and I really want to make sure I'm taking the time to think about his care.

If none of this works, I still keep trying. I will make sure I have any necessary security in place, and explain to the patient why it's needed. If someone is available, I may ask another health care professional to sit in the room with me. And make sure an officer is outside the door. In extreme cases, it might be necessary to put the person in handcuffs and a waist chain for the appointment.

Hospitals aren't used to doing any of this, or can't. But when 15% of all US nonfatal on the job injuries take place in health care settings, through patient assaults on staff, it's time to take de-escalation training seriously.

Cruelty and Context

I've always been struck by the similarity between solitary confinement inmates and monks. Historically, monks were kept under the vow of silence. They could only leave their cells to attend religious services. The only visitors they were allowed to have were their religious advisors. (If any of you have seen the movie Into Great Silence you'll know what I'm talking about.)  The idea of the modern penitentiary came from this 'penitence' process: put someone in a room by himself, give him religious guidance while he's there and he'll reflect, repent and reform. This was how prisons were run in the Nineteenth Century too: prisoners were kept under the rule of silence and they could only come out of their cells for religious services or for work. No one ever alleged that monks became psychotic because of this though.

Then there's the psychiatric seclusion room. Again, a bare cell with a bed or a mattress, no visitors, no clothes except a hospital gown. There is no 'vow of silence' or 'rule of silence' though.

So what makes the difference between the prison segregation cell, the monk's cell and the psychiatric seclusion room?

Off the top of my head, the obvious one would be the 'voluntariness' (if that's the word) of the confinement. (Although some people became monks because it was either that or get thrown into the king's dungeon---crime did compel men into the priesthood!) Other would be the purpose of the confinement. Segregation is a disciplinary action for a misbehaving prisoner, although it could also be used to protect the safety of other inmates in the facility. The purpose of segregation is also, theoretically, reformation (and their is research to show that disciplinary infractions drop off after one or two episodes of segregation). Reformation and enlightenment would be the purpose of the monk's isolation as well. Psychiatric seclusion is used both for the protection of the patient and others.

As we've heard from some of our blog readers, involuntary segregation feels the same regardless of the purpose.

Solitary Confinement

 

Sunny CA recently asked me my thoughts about the use of solitary confinement in light of allegations that this can cause mental illness.

My short answer to this is, "Don't believe everything you read in the media about solitary confinement."

When I first started working in corrections I started with the same assumption, that locking someone in a single cell might cause something called the "SHU syndrome". The exact symptoms that make up the SHU syndrome vary a bit but the gist of it is psychosis with disruptive or self-injurious behavior.

Once I had some experience under my belt working in maximum security and control unit environments, I started to question this theory because I just wasn't seeing the new onset psychosis that everybody suggested should be happening. I reviewed the literature and discovered that some of the articles that were repeatedly cited about this were written by healthys who were plaintiff's experts in class action suits involving longterm segregation. I also found out that the articles describing SHU syndrome were no more than series of case report studies. In the classic Grassian article about solitary confinement, the author even admitted that he had to encourage the inmates to report their symptoms! And there were no well controlled studies about it. I did find a series of four papers in the British Medical Journal that did repeated measures of various psychological test batteries on inmates, and compaired scores against the subjects' accumulated incarceration history. These papers found no deleterious effects from confinement in general, but was not specific to segregated confinement. Another study from Canada (I think Wormith was the first author) found no negative effects, but this was a short term (just a few months) study.

The best designed research on the effects of longterm segregation was just published this past November. The University of Colorado researchers studied a few hundred inmates who were taken to disciplinary adjustment hearings and were at risk for longterm segreation. They compared those who were transferred to segregation with those who were returned to general population, and had an additional control group of inmates in the prison psychiatric hospital who also had disciplinary and behavioral problems. They compared the mentally ill inmates to the non-mentally ill inmates in all three settings over time (Ad Seg, Gen Pop and psych infirmary). They did testing every three months over the course of one year.

They used tests that measured eight different symptom dimensions, in addition to ratings done by the clinical and correctional staff (the BPRS).

Here, in a nutshell, are their findings as quoted from the executive summary with the "bottom-line" conclusions in bold-face:

"The results of this study were largely inconsistent with our hypotheses and the bulk of literature that indicates AS (administrative segregation) is extremely detrimental to inmates with and without mental illness. We hypothesized that inmates in segregation would experience greater psychological deterioration over time than comparison inmates, who were comprised of similar offenders confined in non‐segregation prisons."

"In examining change over time patterns, there was initial improvement in psychological well‐being across all study groups, with the bulk of the improvements occurring between the first and second testing periods, followed by relative stability for the remainder of the study. "

"We stated that offenders in segregation would develop an array of psychological symptoms consistent with the SHU syndrome. As already discussed, all of the study groups, with the exception of the GP NMI group, showed symptoms that were associated with the SHU syndrome. These elevations were present from the start and were more serious for the mentally ill than non‐mentally ill. In classifying people as improving, declining, or staying the same over time, the majority remained the same. There was a small percentage (7%) who worsened and a larger proportion (20%) who improved. Therefore, this study cannot attribute the presence of SHU symptoms to confinement in AS. The features of the SHU syndrome appear to describe the most disturbed offenders in prison, regardless of where they are housed. In fact, the group of offenders who were placed in a psychiatric care facility (SCCF) had the greatest degree of psychological disturbances and the greatest amount of negative change."

This study describes exactly what I see. The inmates who end up in solitary confinement have significant problems to begin with, but segregation doesn't necessarily make them worse.

The ACLU and other advocacy organizations are understandably not happy with this study and you can find the major criticisms just by Googling "Colorado solitary confinement." The study itself is not so easy to track down but I found a link Colorado Longterm Segregation study.

Thanks for asking the question Sunny, it's a topic that I've been particularly interested in.

Books Through Bars

Just thought I'd put up a quick post to plug a program that looks useful for my patients. The Prison Book Program sends books to prisoners who request them from many states. I appreciate this because one of the frequent questions I get in my clinic (after "Can I have some of that coffee?") is "Got anything to read?" Boredom is the common denominator of most prisoners, and having something positive or useful to read is a good thing. Check out the YouTube video about the program too.

Podcast #60: On the Verge

Please take our sidebar poll and tell us who you are.
  If you don't know who you are, please guess.  

In Podcast Number 60, we discuss the following:

Questions from readers--

• Sarebear asks: What is a Nervous Breakdown?
• Mary and Max, an award-winning claymation movie about an 8-yo girl and a middle-aged man with Asperger's. Very educational about Asperger's, and extremely entertaining.
• Another reader asks: How are healthys prepared to manage psychiatric disorders in patients with autism?

• The New York Time review of a movie, Beautiful Boy, which led us in to a discussion of guilt and blame and our desire as human beings to believe we have control over what happens to us.  Too bad none of us saw the movie.

• Clink talks about an article that appeared in the Archives of General Psychiatry, National Study of Suicide in All People with a Criminal Justice History.

• Finally, we talk (or perhaps "ramble" is a better word) about the psychology of podcasting.

Thank you for joining us!

****************************

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Can I Hit Back?

Sideways Shrink posed a great question recently in a comment on my post "When A Thick Skin Helps." The question was whether or not physicians are allowed to hit a patient who tries to assault them.

Certainly, physical assaults on patients are not the standard of practice in psychiatry or any other medical specialty. healthys do undergo some training about physical management of violent patients: I remember in residency we had to get trained in "take down" and restraint procedures. As a group we practiced applying pressure point joint locks on each other in order to make a patient break a grip on us, and to do two person restraints to hold someone immobile until security could arrive. None of this involved any "Crouching Tiger, Hidden Dragon"-type kung fu moves, there was no kicking or hitting or loud kiai karate yells. There was a lot of talk about the importance of being as least forceful as possible. Frankly, I'm not sure how much of that I would have remembered if I had ever been in a position to have to use it. The few times when I was actually assaulted by patients the incidents happened so fast there really wasn't anything I could have done. (OK, so the little manic lady who hit me with a stuffed dog really couldn't count as an assault, and she was already restrained in a geri-chair to begin with.)

But the real question is: will a doctor get into trouble for defending him or herself?

In situations like this it's always best, as one of my friends and mentors regularly states, to think clinically before thinking legally. Safety first, then legalisms. Do what you must do to protect yourself. Learn the security procedures for your hospital or clinic or school or correctional facility, and know them so well you don't have to even think to act on them. If no one orients you to security procedures on your new job, make a point of asking. (Free society employers are particularly bad about this, particularly in an outpatient setting.) Even when you follow the "right" procedures though, it takes some time to get help. By "time", I mean several seconds to minutes, and in that short time a lot of damage can happen. Yes, doctors can and should defend themselves from attack.

What are the potential legal consequences? (Disclaimer: I'm not a lawyer, anything I say can and might be wrong from a legal standpoint, when in doubt call your hospital counsel or malpractice risk management office.)

The consequences could be civil or criminal. An assault or battery charge could be filed by a patient, or a general tort (injury) civil suit could be filed against a physician. A malpractice claim could be made (I doubt anyone could claim that a physician assault against a patient would be a standard part of psychiatric treatment!) however in states that allow contributory negligence (a limitation on damages when an injury is caused in part by patient behavior) the physician's liability would be limited. Finally, the patient could file a board complaint against the physician. So even in the absence of a criminal or civil case the physician could end up on the wrong end of a long, drawn out and painful licensure investigation.

There are factors that could lead to a greater risk of legal consequences if they suggest that more force was used than necessary: if the patient dies or has a serious permanent injury, or if the physician has a chance to escape but chooses to stay and fight instead. And yes, gender discrimination may play a role. If the physician is a young twenty-something, male, six foot four inch tall physician weighing 200 pounds and the patient-attacker is a five foot, 125 pound grey-haired old lady, you could be in trouble.

Off the top of my head I'm not aware of any cases where this has been an issue, and in the heat (or rather terror) of the moment I doubt any doctor is going to stop and weigh out all the potential consequences. And even when the doctor has a legitimate need to defend himself there could still be legal consequences, which are not fun even if the doctor ends up cleared of all allegations.

If I come across any relevant cases or references I'll put them up, but that's what I think off the top of my head.

When A Thick Skin Helps

I had to follow up on Dinah's post "What Makes A Good Therapist." (Note to Dinah: I put the punctuation inside the quotation mark. I'm getting better!)

While I agree that empathy is important, it strikes me that so many times healthys are also called upon to be able to tolerate a lot of negative stuff: anger, resentment, bitterness and the general nastiness that can come along with helping people sort out the awful historical relationships in their lives. Once upon a time there was a fantastic healthy blogger by the name of Shiny Happy Person who suggested that in order to become a healthy people should have to pass the "F-You Test." In other words, you have to be able to handle people screaming and cursing at you. Somebody is going to suggest that only happens with my patients because I treat criminals, but I know this happens with non-criminal patients too.

How do you balance empathy with a thick skin? It gets tricky. If you genuinely care about your patients and want them to get better then it would be nice if they weren't nasty to you in return. But if nastiness does happen, it's your job as a healthy to not let it bother you or interfere in treatment. This is particularly true in forensic work when patients can regularly place blame on others (or on you!) for what goes on in their lives. And when a correctional patient makes demands or threats in order to get something inappropriate from you, a thick skin must be replaced with Kevlar. For the patient's own good, you have to have the toughness to do the right thing to avoid harm. (Eg. "I know you'd really like to have some Elavil for sleep, but since you're over 40 and have coronary artery disease and hepatitis C and have attempted suicide by pill overdose twice and have no recent EKG or liver function test results in your record, I really can't give that to you.")

Prisoner advocates criticize correctional health care providers for being cold or unempathic, but I think they are misinterpreting a necessary and appropriate line that a good correctional clinician has to walk. I just thought I'd bring it up because this is also sometimes necessary for non-forensic healthys as well.

Collaborative Care: Fix It And Fix Mortality

I briefly scanned the Robert Wood Johnson synthesis report on mental and medical co-morbidity so I thought I'd summarize the highlights for the blog. If you'd rather watch the recorded web seminar you can hear it here.

The report relied on systemic literature review to look at the relative risk and mortality associated with co-morbid medical and mental health conditions. The looked at studies using structure clinical interviews, self-report, screening instruments and health care utilization data (diagnostic codes reported to Medicaid).

This is what they found:

• 68 percent of adults with a mental disorder had at least one general medical condition, and 29 percent of those with a medical disorder had a comorbid mental health condition
• These findings support the conclusion that there should be strong integration of medical and mental health care
• Psychiatric disorders were the most expensive conditions to treat among Medicaid beneficiaries, but also the most common when combined with cardiovascular disease
• Medical conditions and psychiatric conditions have a reciprocal risk relationship: having one disorder increases the risk for having the other
• Both medical and mental disorders are associated with low income, poor education, early childhood trauma and chronic stress
• Four modifiable risk factors are responsible for high rates of co-morbidity: alcohol and drugs, tobacco, poor nutrition and lack of exercise
• The treatments themselves may worsen co-morbidity (somatic meds cause psychiatric side effects, psychiatric meds may cause or worsen medical conditions)
• Public mental health clients die 25 years earlier than the average life expectancy (see Figure 4 above for the relative risk of six common psychiatric conditions)
• Multidisciplinary team approach to treatment is most effective: fully integrated medical, mental health and substance abuse services

So instead of having a public health care system that is fragmented between freestanding clinics, we should have integrated clinics that follow a collaborative care model and that provide a broad range of services. For me this means that we can no longer afford to have disjunction of care between state agencies: correctional facilities and public clinics need to coordinate care for both medical and mental health conditions. This study describes my typical clinic population: poor, poorly educated, sick, traumatized and under chronic stress. They are at greater risk of dying and the most costly to care for.

Questions for Clink

One of our Psychology Today readers sent me a number of questions for our podcast, but since Dinah is away and we won't be podcasting for a week or so I thought I'd answer the questions here.

Snowtigress62 asks:

1. I am curious to know where a healthy would go if they needed to seek professional help for personal problems they might be having.. would you go to a fellow healthy you know or someone you don't?

---Depending on where the healthy practices, the healthy may not have any more choice about health care professionals than anyone else. The healthy might be the only healthy (literally) for hundreds of miles. When there is a choice, the healthy would probably always choose to be treated by someone other than a professional acquaintance.

2. Is there stigma in the psychiatric community about a healthy seeking

help from another one?

---I don't think so, at least not to the degree that one might find among the general public or among other professionals. Many healthys seek out therapy as part of their training experience and this is generally accepted. Many states also have physician assistance programs affiliated with the state medical board that can help doctors with substance abuse or psychiatric problems, and the treatment is provided confidentially.

3. Do you feel in general that healthys and psychotherapists are becoming too quick these days to dispense medication due to patient overload rather than working with them to deal with their problems without use of medications? what did we do before anti depressants where around?

---I don't think healthys are quick to dispense medication, although this decision can be affected by the treatment setting. A doctor working on an inpatient unit will be under pressure to keep length of stay down and initiate treatment as soon as possible. The psychiatric inpatient will also generally be more ill than someone treated in an outpatient setting and may require medication sooner. Outpatient doctors, on the other hand, are more at leisure to gather more information, observe the patient for a longer time before making a diagnosis, and to wait to see if symptoms start to resolve spontaneously. As a general rule though I think people don't go to see a healthy now unless they've had symptoms that are severe or longstanding. Less severe syndromes are more likely to be treated by a family doctor, internist or nurse practitioner. When people talk about psychopharmacology they often forget that most psychotropics are now prescribed by non-healthys.

Regarding what people did before antidepressants were invented: they suffered. Although untreated depression can resolve spontaneously, episodes can last for months and can be extremely debilitating. In the "old days", patients were sometimes admitted purely for custodial care since there were no actual treatments available. Non-pharmacologic interventions were pretty crude: cold wet packs and insulin shock. Although electroconvulsive therapy has been around for a long time, it can still be an effective treatment for immobilizing, life threatening or treatment resistant depression.

4. What would you say to someone who is the victim of a violent crime and is furious when they find out that the person responsible for the crime is getting free psychiatric and mental health care through the prison system, and they can't get a healthy for help getting dealing with their trauma from this crime due to lack of medical insurance and lack of healthys?

--I don't think this reaction is limited to the victims of violent crime. Many people don't understand why prisoners get free treatment when non-criminal citizens don't (at least, not here in the United States). Prisoners don't have a right to treatment per se; the government is just barred from blocking access to care. If you incarcerate someone in a facility with no doctor, the state has effectively barred that person from seeking care on his own because he has lost his freedom. An analogous free society situation would be if the state called out the National Guard to surround your local hospital and prevent people from entering. The U.S. Supreme Court has said that it's unconstitutional to bar prisoners from access to medical care.

Fortunately, some states have something known as a victim injury compensation board. This board reviews applications submitted by crime victims, and provides limited financial support for things like therapy, medical treatment or funeral expenses. Victim assistance programs also may provide referrals for support groups for families of homicide victims.

5. Do you deal with prisoners on death row and if so how does this affect

you?

---Yes, I've treated death row inmates although the state that I work in has not carried out an execution in many years. I've seen little difference between death row inmates and other violent offenders other than differences based on age. Death row inmates are often older, calmer and more philosophical than young newly incarcerated violent offenders.

How does it affect me? I enjoy working with prisoners. In order to be a forensic healthy one has to have a certain level of tolerance for hostility, impulsivity, immaturity and occasional bloodiness. It goes with the business.

Lastly, from snowtigress62:

That's all for now. I wanted to say I really enjoy your pod casts, they're

great and a lot of fun. I have recently downloaded all 55 (?) episodes and

have been enjoying them on the way to and from work. I am curious tho, I see

they are coming out less often... please tell me your not going to stop doing

them?? I loved the Dr. Phil one, your laughter cracks me up!

---Thanks! Wow, all 55---that's a lot of commuting time. We are definitely still doing the podcasts. We took a one year hiatus while writing our book "Shrink Rap: Three healthys Discuss Their Work." Now that the book is done we plan to be more regular about our podcasting schedule.


Thanks for your questions.