They are not guards

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  • Hello and welcome to Correctional psychiatry 101. How many of you work in a correctional setting? Working in corrections can be a very tricky job. I used to think that “whats the big deal about a whole specialty of correctional psychaitry? Was it really that different? I mean isn’t it just regular psychiatry behind bars? I started working at the prison a year ago and have realized that the answer is NO. It is much different. Correctional psychiatry is very different from psychiatry in the community but this is a topic that you could take a week-long seminar about. Today I am going to try to talk to you about the basics of what I wished I knew when I started. Story about balvin de-escalating inmates rather than using a use of force on them. Other bad examples. Importance of these officers
  • A little vocabulary that is important. First the words Jail and Prison. A lot of people think that they are synonyms and mean the same things. They don’t. In corrections you don’t want to use them incorrectly. Jails are for pre-trial detainees or for people convicted of minor offenses. Jails are also often used to house people during short term movements or during trials. Prisons are typically for after people have been convicted of more serious crimes (felonies) and have longer sentences. Probation is different than parole in that it is when a judge gives a convicted person a trial of community supervision that if it goes well can take the place of an incarceration. Parole typically follows a prison sentence and is a conditional release of a person prior to the end of their maximum sentence. Idaho’s Riders is not this type of Rider, but more like this type (pop up baby). There are a few different types of Riders. This is an option that a judge has when sentencing inmates. Instead of sending them to prison for their whole sentence, the judge can send them to a more type of rehabilitative sentence. One type of Rider is a 3 month substance abuse rider at a new facility called “CAP.” Another type is a 3-6 months up close to Orofino at “Cottonwood.” or another type is a “365 day Rider” where the inmate can be incarcerated for “up to 365” or until the complete certain goals and classes. After a Rider if behavior was good and all the judges desired goals and classes were completed then the inmate can be released on probation. If the behavior was poor or the goals not met the judge can send the inmate for another rider or send then to prison for their full sentence. A Kite is basically like the communication system for inmates. It is how they can communicate with security staff or medical personnel. In mental health you get a lot of these. Often times they can be diagnostic in just the way that in a community psychiatric clinic voice mail messages from patients can tell you a lot about a patients current mental status, the kite can often give hints of worsening psychosis, mania, or other problems. A grievance is basically the inmates system to voice a complaint to administration. It could be about anything, but that includes psychiatric providers. Officers- now this seems fairly obvious what this word means, but it is important to know that the correctional officers that work in jails and prisons are highly trained professionals. Many of them have extensive training in how to work with mentally ill inmates. “Officer” is the term that they prefer rather than guard. This is a big no-no from us providers who really want to work together with the officers in many aspects.
  • This was the attitude in the past. Known as the “hands-off approach to corrections. This quote is from a virginia court in the case of Ruffin v. Commonwealth.
  • By this the courts rules that an inmate did not lose his rights as they crossed the threshold of the prison. In 1964 inmate were given the right to sue in federal court Because of their status as inmates and their inability to search and gather food, go to the doctor and pharmacy ect. They have the constitutional right to these things because they are unable to do so on their own. In a case DeShaney V. Winnebago County Department of Social Services
  • Another reason why getting acquainted with correctional psychiatry is important is because it is a growth industry. Tough-on-crime laws have dramatically increased the number of inmates over the recent years. The most recent statistics show that almost one in every 134 US residents is behind bars. This doesn’t even include all the people on probation or parole.
  • Does any one recognize this famous mental health institution? I’ll give you a clue, it is the largest mental health institution in the US.
  • LA County Jail (1400 mentally ill patients) Many of the studies look at if patients have ever been treated for mental illness, whether they have any current symptoms of mental illness, and ect. (how do symptoms that are associated with substance abuse play into that.) This would include a lot of people that I don’t think of as having a major mental illness. A lot of advocates call the shift of mentally ill patient from hospitals to jails and prisons the “criminalization of the mentally ill.” But when you cast a broad net that catches a lot of people who arent really “majorly mentally ill” but all it criminalizing their illness this does a diservice to both society and the truly mentally ill. We can at least pretty safety say that the number is somewhere about 10% and probably not over 70%. Here in Idaho the number of inmates on psychiatric medications is between 22 and 33 % in the male population depending on which facility you look at. In the female population it is between 60 and 80%. Both of these numbers are probably low and high in that there are likely some inmate with mental illness who are either not detected or refusing treatment, and there are likely some inmates in treatment that really don’t meet criteria for the mental illness that they are being treated for.
  • In women #2is PTSD
  • So can we be lazy about the care we provide to inmates? NOOOO! May even be a higher standard.. Because of the should. But that doesn’t mean that the patient or inmate always gets what they want. In fact in my opinion it raises the bar on our need to be responsible providers and do what we believe is truly best in the patient’s interest.
  • Only people with a constitutional right to treatment. Every person who, under color of any statute, ordinance, regulation, custom, or usage, of any State or Territory or the District of Columbia, subjects, or causes to be subjected, any citizen of the United States or other person within the jurisdiction thereof to the deprivation of any rights, privileges, or immunities secured by the Constitution and laws, shall be liable to the party injured in an action at law, Tx is 1. he/she engaged in protected conduct of which the defendant knew, he/sh experienced some adverse action, and some causal connection between the protected conduct and the adverse action.
  • Only people with a constitutional right to treatment. Every person who, under color of any statute, ordinance, regulation, custom, or usage, of any State or Territory or the District of Columbia, subjects, or causes to be subjected, any citizen of the United States or other person within the jurisdiction thereof to the deprivation of any rights, privileges, or immunities secured by the Constitution and laws, shall be liable to the party injured in an action at law, Tx is 1. he/she engaged in protected conduct of which the defendant knew, he/sh experienced some adverse action, and some causal connection between the protected conduct and the adverse action.
  • This is important to remember. Although this may be true there is a difference between us and other drug dealers. We are treating illness with our medications. But it is important to remember that our medications are frequently abused and misused. The most frequent is probably anything sedating (seroquel, zyprexa, tricyclics, TCAs, trazodone, heaven forbid benzos or sleepers) but it isn’t limited to that. Stimulating (snorting Wellbutrin) and even some confusing ones (snorting Prozac). It is important to weigh the risks and benefits of providing psychotropic medications and decide whether or not it is warranted in each situations.
  • This is not meant to be a comprehensive correctional psychopharmocology but just some tips for anyone who may be new to corrections. It is interesting that I used to think that only controlled substances were “abuseable.” I have since learned otherwise. Wellbutrin is a concern because it is chemically somewhat similar to a stimulant and inmates sometimes when using it inappropriately will crush it and snort it. It can be another form of currency. Any sort of sedating medicine has a street value inside corrections. Medication that I would have never guessed like trazodone, doxepin, clonidine. Also have value and are abuse, traded and misused to sedate. It kind of makes sense because instead of just sitting there whittling away your time, or rehabilitating you could just sleep it off. Also antipsychotic medications like seroquel and zyprexa are abused for the same reasons. Tricyclic medications are great medications but need to be used with a lot of caution in correctional settings. They have a double trouble problem. They are sedating and they are fatal in overdose. Sedating medications in corrections are often hoarded and they taken in larger quantities and in the case of TCAs, this could be a potentially lethal combination. Stimulants don’t even need mention to why they are abused, but it can be tricky trying to deal with inmates who demand treatment for their ADHD. Anxiolytics like benzodiazepines are abused also for obvious reasons, but in corrections you even have to watch for the misuse of medications like clonidine, nuerontin, and buspar. Often times sedation from medications that are not absolutely necessary can interfere with an inmate’s ability to rehabilitate. Medications can also be a security and safety concern. Weaker more vulnerable inmate can be threatened and coerced into cheeking their medications and giving them up to others to abuse. Now after these warnings I also want to add that no everyone is malingering. Not everyone is abusing the medications. Each inmate should be carefully evaluated and the appropriate treatment should be prescribed. There will be times when the above medications are appropriate. One trick we try to use is crushing medications. Sometimes mixing them with water or applesauce. The problem is that even though that seems fool-proof, it is just another step that has to be done correctly and consistently or there can be problems. I know one colleague from some crazy state that I won’t mention (California) who asked the correctional officers to watch and see how often things were crushed and he reported that it depended on the staff member. Some did it and others never did.
  • This is also an eye-opener. You will be asked for a lot of special favors that may appear clearly helpful to the inmate that if given will cause big problems for the institution. These decisions should be taken with caution and care as if they are done lightly you will have not a run on a bank, but a run on your clinic. Once again not a guaranteed “no” but very careful to any exceptions and should be well supported by clinical evidence.
  • Malingering. This word should always be used with caution. Its definition is “ “.
  • Don’t forget. Strange presentation check for it.
  • Sleep, ADHD, or any other thing. We do treat it. You just may not like the treatment option that we offer to treat it. Then you aren’t being indifferent to it. You are offering a legitamate treatment No constitutional right to treatment for substance abuse problems.
  • Also mention importance of confidentiality.
  • This could be a good thing. Less likely to be using. More supervision Hard to be gravely disabled. If some gets really depressed, psychotic, or manic then likely someone will let you know. "Unfortunately, I do believe that some of the mental health treatment that we provide in prisons is better than what one might get in the community," says Dr. Reginald Wilkinson , the head of the Ohio prison system. "I've actually had a judge mention to me before that, 'We hate to do this, but we know the person will get treated if we send this person to prison.' When you know the courts are more apt to send a person to prison because they are going to get treated, there's something disconcerting about that."
  • They are not guards

    1. 1. Scott Eliason MD
    2. 2. Vocabulary Jail vs Prison Probation vs. Parole Inmate types Kite Grievance Officers
    3. 3. Constitutional Concerns 1871 court said: A convicted felon… punished by confinement in the penitentiary instead of with death… is in a state of penal servitude to the State. He has, as a consequence of his crime, not only forfeited his liberty, but all his personal rights except those which the law in its humanity accords to him. He is for [the] time being a slave of the state.
    4. 4. Constitutional Concerns 1960s brought about “hands-on” approach Inmate’s special status Recent years back to “hands-off”
    5. 5. Epidemiology 2.3 million incarcerated Shift to jails and prisons?
    6. 6. Epidemiology Largest Mental Health Facility- LA County Jail The Criminalization of mental illness Wide range of studies 10-76% major mental illnesses
    7. 7. Epidemiology Substance Abuse (70-90%) Antisocial Personality Disorder (50%) Women PTSD
    8. 8. APA “The fundamental policy goal for correctional mental health care is to provide the same level of mental health services to each patient in the criminal justice process that should be available in the community.”
    9. 9. Pitfalls Legal Drugs Special Favors Malingering Too much Malingering Drug Use “We don’t treat that…” Dual Agency
    10. 10. Legal Right to treatment USC title 42 section 1983 Malpractice- 4 Ds Board of medicine Grievances
    11. 11. 4 D’s Duty Dereliction Damages Direct Cause
    12. 12. Legal Right to treatment USC title 42 section 1983 Malpractice- 4 Ds Board of medicine Grievances
    13. 13. Drugs in Prison Who is the biggest drug dealer is your facility?
    14. 14. Drugs Wellbutrin Sedating medications Tricyclic antidepressants Stimulants Anxiolytics
    15. 15. Indications for Benzos Acute Mania Severe reactions Agitated Psychosis Alcohol/Benzo Taper
    16. 16. What’s Wrong with a littleBuspar? It’s just Buspar.
    17. 17. Special Favors Lower Bunk Memo Shoes In house meals Cell changes Excuse slips
    18. 18. Malingering Secondary gains: Housing change Medications Trip to the hospital Evidence of disability for future SS Protection Easier time Escape Responsibility
    19. 19. Too Much Malingering “He’s just manipulating” “Its just the drugs”
    20. 20. Drugs in Prison (Really) Random UA 10% positive
    21. 21. “We don’t treat that” Constitutional Right to Treatment “Deliberate indifference to serious medical needs”
    22. 22. Dual Agency 1. What is your role A. Disciplinary B. Treatment C. Court ordered evaluations
    23. 23. Clinical Pearl Sleep Mood disorders Psychosis Get out of the office Documentation tips
    24. 24. Suicide Violent offense risk factor Kidnapping and child sexual abuse charges Bad News Most common first 24 hours to week of incarceration Hanging
    25. 25. Violence Mentally ill offenders More likely to have violent offenses More likely to get into fights while incarcerated
    26. 26. Great Opportunity Different than outpatient world Less drugs More structure Healthy regular diet Education Exercise Jobs available Training Treatment
    27. 27. What can I do? I’m just one… D T D D S B
    28. 28. What Can I do? I’m just one… Diagnosis Trial tapers for those with one time episodes or mild episodes Decrease Polypharmacy Document Sympathize Behavioral Activation/Alternative Treatments
    29. 29. Cases JC 24 year old male with substance abuse and very atypical psychosis.
    30. 30. Cases CM 24 year old male with substance abuse and very atypical psychosis.

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