Correctional PsychiatryTCPR: Dr. Gariety, please tell us a bit about your background.

Dr. Gariety: I’ve been in practice for 23 years, starting out in community mental health, followed by 13 years in the federal bureau of prisons. Currently I work for a large regional medical group in the private sector.

TCPR: Tell me a bit more about the correctional setting.

Dr. Gariety: I worked at a high-security prison hospital, one of several medical/psychiatric centers within the federal bureau of prisons. There were about 1,200 prisoners at our facility. Several hundred were simply serving their time there, and the rest were either medical or psychiatric patients received from other prisons or jails. There were about 300 psychiatric patients at our facility, staffed with five psychiatrists and eight psychologists. Our staff included forensic clinicians who conducted court-ordered evaluations, and clinicians who did actual treatment. I was a treatment clinician. The psychiatric population was extremely mixed, with most of our patients suffering from some form of chronic mental illness, and/or severe personality disorders.

TCPR: What was your day-to-day job treating patients like?

Dr. Gariety: As you entered the institution each morning, you passed through a security gauntlet not unlike what you experience at the airport. Treatment was carried out by three multidisciplinary treatment teams. Our caseload consisted of 2 types of patients: those residing in locked housing (aka “solitary confinement”) and those in the general population (GP). The patients in GP could freely access their doctor, whereas patients in lockup couldn’t. Our work day typically began with morning report, attended by all disciplines, including correctional staff. Following report, our team’s psychologist and I would always do rounds on the locked housing units. We were somewhat atypical in committing ourselves to daily rounds on the locked units, but we felt it an essential priority which served both patients and staff in immeasurable ways. Rounding would often take up much of our mornings; afternoons were given to charting, writing orders, and individual talk therapy. At any time in the day, the routine was susceptible to emergencies requiring immediate attention, which usually occurred several times a week. This might be as innocuous as a patient in lockup becoming loud and disruptive, to something as serious as a suicide attempt or a medical emergency.

TCPR: So the GP patients would be the equivalent of civilian “outpatients,” and the lockup patients would be more like our “inpatients.”

Dr. Gariety: Essentially, yes. Patients in GP could freely move about the institution and access their doctor, whereas patients in locked housing couldn’t. The assumption was that GP patients didn’t pose a threat or a danger. They could come to my office at any time. With that being said, you always used your best judgment and listened to your gut as to whether or not to see an inmate in your office. My office was located where there was a lot of inmate and staff floor traffic. For privacy purposes, people couldn’t hear us, but they could easily see us via a window in my door. And we had instant access to security by phone or radio.

TCPR: How did it work seeing patients in locked housing?

Dr. Gariety: Rounding on a locked unit meant going from cell to adjacent cell, pressing your ear into the cell’s doorjamb while peering through a security-glass window, and talking through the doorjamb. The conversation you were having with the inmate was freely available to any interested staff or other nearby inmates who cared to listen in. As unconducive as this sounds, it’s where the majority of the most valuable talk therapy happened. Rounds also provided a means to role-model for the benefit of correctional staff.

TCPR: That’s interesting. How does that help correctional staff?

Dr. Gariety: Partly, it helps show how to de-escalate aggressive or psychotic behavior. But more importantly, it was a means of continually strengthening your alliance with the officers, who could be your best friends—or your worst enemies. Nothing earned more credibility with officers, or their respect, as much as their seeing you doing daily rounds and extending yourself to both patients and correctional staff alike. That alliance was essential to effectively working in a prison setting.

TCPR: I assume that daily rounds could be pretty time-consuming?

Dr. Gariety: Yes, but it was time well spent. The most disturbed individuals are in lockup, and it disincentivized a lot of their acting out and bad behavior knowing that they were going to see their doctor at least once every workday. It was a way of minimizing problems down the road.


 

This article originally appeared in:


The Carlat Psychiatry Report
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This article was published in print May 2016 in Volume:Issue 14:5.