The Myths, Realities, and Best Practices for Treating Justice-Involved Populations in Community Care

The Myths, Realities, and Best Practices for Treating Justice-Involved Populations in Community Care

Articles, Blog , , 0 Comments


– [Host] Welcome to Myths,
Realities, and Best Practices for Psychiatrists
Treating Justice-Involved Populations in Community Care,
which will be facilitated by Dr. Debra Pinals and Dr. Marvin Swartz. We’d like you to take a moment to read our brief disclaimer, as well as take a moment to acknowledge our webinar sponsors, who are Policy Research
Associates in Delmar, New York, and the Substance Abuse and Mental Health Services Administration. As previously stated, our
webinar presenters will be Dr. Debra Pinals, who is a
clinical professor of psychiatry and the director of the
Program in Psychiatry, Law, and Ethics at the
University of Michigan. She also serves as a medical
director of behavioral health and forensic programs for the Michigan Department of Health and Human Services. As well as our other webinar
presenter, Dr. Marvin Swartz, who is a professor and
head of the Division of Social and Community
Health at Duke University. We’d like you to take a
moment to briefly review the objectives of this webinar. And lastly, we’d like you to acknowledge the origin of this
project, which is simply that there is a huge
shortage of psychiatrists in the United States, with
about 77% of U.S counties reporting a severe psychiatrist shortage. Similarly, there are
fewer than 2/3 of adults who have a severe mental
illness that are currently receiving mental health services. And with that, I will send it over to Deb to continue the presentation. Thank you, Deb. – [Dr. Pinals] Great, okay, thank you. I just wanted to say, first and foremost, thanks to SAMHSA and to PRA
for inviting me to participate in this webinar. Working with justice-involved individuals has been a passion of mine
and helping to develop work force and training
a work force to do so is also something that’s
been critically important in my career as a former training director for forensic psychiatry fellowships and working in these settings as explained in my introduction. I hope you’ll all get a
lot out of this webinar. We’re going to start by talking
about the scope of the problem to help you understand the context of why now is a perfect time to be
thinking about these issues. First of all, we know that
the need is increasing, and as part of the Affordable Care Act, more people were able to receive
behavioral health services through their insurance. This has introduced an
influx of new patients that we are attending
to in a different way who have mental health and
substance use disorders. The influx has largely
been unable to receive all the treatment
options available to them due, in part, to a lack
of psychiatric resources, and we see this over and
over again in all the states. Similarly, as more
attention has been focused on jail diversion, which
has become more the norm than not, diversion
programs have developed, and with these programs, we
see an effort to help divert or release justice-involved persons back into the community with a tighter linkage to appropriate services. As a result, the number of
justice-involved persons in the community has
increased, but also attention on who has justice-involvement
has increased. And so the justice-involved population is identified as having many
behavioral health concerns that may need to be addressed. And similarly, individuals
with serious mental illness who have justice histories are
also increasingly identified, and their unique combination of needs is one of the things
that we are hoping that, through webinars like this
and other initiatives, a work force of psychiatrists will be able and willing to work with them and serve and help address these multitude of needs. Also, another issue that
we’re all dealing with is the opioid crisis, and many
counties and jurisdictions have begun to provide treatment resources to assist in combating the crisis. This has introduced many more people to behavioral health
services across the country, however, many communities
are unable to meet and treat everyone who needs
the behavioral health assistance as the demand outweighs the supply. We’re learning more and more
also about the co-occurring mental health conditions that go along with opioid use disorders,
and we are seeing more of these needs coming to the attention of behavioral health clinics. So there has been further
pressure and strain on behavioral health system to identify practices and strategies,
including the need for more psychiatrists
who are adept at working with individuals who are justice-involved to help address any issues related to behavioral disregulation
that could be helped by psychiatric intervention. There is also a supply that’s
decreasing exponentially, although we may be seeing
some slight increase in medical students
matching into psychiatry. We’re also seeing that psychiatrists are nearing retirement and
fewer early career psychiatrists are pursuing fellowships,
including fellowships in forensic psychiatry, or work within the public
mental health system, whether it’s in community mental health or in state hospitals or
correctional settings. So while the need is increasing, the supply is decreasing. So this slide is an
introduction to what will be a deeper dive of the scope of the problem in relation to the work force imbalance, and what the disincentives or
perceived disincentives are, and what some of the incentives might be for working with
justice-involved individuals. So, let’s talk a little about location of residencies as a start. The number of general
psychiatric residencies are seemingly low, considering the high
demand for psychiatry. There are about 209 general
psychiatry residency programs in 48 jurisdictions. This creates a relative psychiatric desert in the Upper Rockies. The situation is heightened
when one considers that the neighboring states
offer few residency options. There is new information
about the creation of a regional psychiatric residency track to serve the Billings, Montana,
area, and this was created in partnership with the
University of Washington, and funded by the
Helmsley Charitable Trust, which will essentially remove Montana from the psychiatric desert and welcome a change to this area. Nearly half of all
psychiatric residency programs are located in six states,
primarily in the coastal areas, which is another challenge
for getting psychiatrists out to those states that
have significant needs. Now, when you look at forensic
psychiatric fellowships, we see that there are 17 scholarships in psychiatric sub-specialties
such as rural psychiatry, public and community psychiatries, that also might promote engagement with justice-involved persons. In fact, the psychiatric
forensics fellowships focus on the area of forensic psychiatry with a growing interest in
correctional psychiatry as well. But not all individuals who work with justice-involved
populations need to have forensic psychiatry fellowships. In fact, as I stated earlier,
there are many opportunities for learning and working
in community psychiatry where one will eventually
work with justice-involved individuals, and you’ll be
hearing throughout this webinar from a variety of
psychiatric professionals who have various types of training that has led them to work
with this population. The 48 programs focused
on forensic psychiatry are depicted in this map, but again, there are expansive regional gaps, furthering the evidence for
psychiatric training deserts, particularly for people who
have justice involvement histories where it might be difficult to get some unique forensic
psychiatric expertise to help consult on cases. Another issue that we are
facing is where psychiatrists tend to practice most. Of the more than 37,000 known active psychiatrists nationwide, nearly half are located in six states. Another way to examine the data is to look at per capita rates. This is from Merritt Hawkins
by the NAMA master file. Jurisdictions along the Eastern Seaboard claim per capita
distributions of psychiatrists that are three times the national average, while states in the
Midwest and Upper Rockies have per capita rates well
below the national average. About 56% of general
psychiatrists practice in the state where they
received their highest degree, and a percentage that is well
above the corresponding figure across all physician specialties. The other thing that we know is that even when there is a
higher per capita ratio of psychiatrists, such
as depicted on this map, many of those psychiatrists
are not working in public mental health,
and are not working with, for example, Medicaid eligible patients and are not working with
justice-involved patients. And therefore, even the
per capital ratio doesn’t tell the full story for those regions where it may look there
is a greater wealth of psychiatric resources. There’s also a disproportionate
number of psychiatrists who choose to practice in
urban versus rural settings. One of the reasons that we
understand this is because of some of the misconceptions related to what it might be like to work between the urban and rural divide. A reasonable assumption
is that consumer needs for the psychiatric work
force will be greatest in states that lack GME
residencies or fellowships and in rural areas. However, as I said again,
even in urban areas, we may see a dearth of
psychiatrists choosing to work in public sector settings, which is again why this webinar, I think, is going to be very helpful for people interested in considering
working in this space. In this webinar, we’re going
to see a number of videos from people who are actually
providing psychiatric care and receiving psychiatric
care within the context of justice-involved individuals. In this first video, we
will see Dr. Grace Lee discuss how many
psychiatrists live and work in urban areas, but many justice settings are in rural areas, and
how this creates large gaps in treatment for those
that are justice-involved. – [Dr. Lee] Psychiatrists
tend to live and work in urban settings, in metropolitan areas, but many of the correctional settings, which is where you have a large, can wind up with a large
concentration of individuals with mental illness and the
criminal justice involvement are many times sited in rural communities. They can be hours away
from the next large city, so the geography becomes
a daunting problem. – [Dr. Pinals] The next issue
that we want to talk about in terms of the scope of the problem is the correctional status. The scope of the problem
includes a misperception that working with justice-involved persons can only be done in the institutions or correctional settings,
such as in jails or prisons. Although in my own personal experience, working in those settings
is just as rewarding as working in a community
mental health center, it is important for people to realize that most people outside
of law enforcement are unaware that justice-involved persons are in the community and may be under correction supervision
such that working with the justice-involved population also requires some very
interesting connections to working with probation or parole, depending on the status of the individual, and that can also be
another way of thinking about how working with
justice-involved individuals can be interesting in
terms of coordinating and collaborating with
correctional entities. In the next slide, we
introduce what’s known as the sequential intercept model, which many of the
listeners and participants to this webinar may be familiar with. The sequential intercept
model is simply a means of mapping out the justice system in order to find places
where possible identification of individuals with mental health and/or substance use disorders
could be appropriately diverted into treatment as opposed to further penetrating deeper
into the justice system. We use the diversion
broadly in this context, although it can have many meanings in different jurisdictions. But jail diversion is
a means of decreasing the high rates of incarceration for people who may need treatment for
a behavioral health issue where that’s the more appropriate and still safe course of
action for those individuals. We’re going to look at examples at each intercept in practice. In the first video, you’re going to see how, as we flow through the
sequential intercept map, Dr. Lee addresses how all
justice-involved people came from the community
and that they will end up back in the community. – [Dr. Lee] That the
criminal justice system, it can be mapped out from
arrest to adjudication to sentencing to incarceration, but the two bookends on either side that can’t be forgotten
are that they all come from the community and most of them are going back to the community. – [Dr. Pinals] In this
next video, you’ll see me, Dr. Carmen McIntyre, and
Dr. Elie Aoun discuss the type of work done at
intercepts zero and one. The work includes assessing all aspects of the person’s life,
including the need for work, social support, and
other factors in relation to their treatment needs
in diverting people away from the justice system
prior to going deeper into it. Likewise, insights on working with law enforcement are discussed. – [Dr. McIntyre] As I kind of
got out of my residency training and moved into my career in more community and public psychiatry, it
started off with really providing an integrated treatment team, where you were addressing not
just their medication needs, but what were their social skills needs, did they need housing,
did they need employment, did they need access to food, did they need access to
benefits and whatnot. And I think that was a great next start, but then when you start talking about diversion or preventing people
from getting justice-involved in the first place, then you have to start addressing some of these
social disparities. You had to start addressing
some of the injustice that’s out there, and you start talking about primary prevention,
which is really kind of before they get through our door. – [Dr. Pinals] And the message is
a complex message when you work with police, because
it’s about public safety. That’s the number one thing
that police need to ensure is that the public is safe, but it’s also about
teaching other strategies and approaches that might help, both improve public safety and lead to better outcomes overall
for everybody involved. So again, working with the
different police officers that I’ve had the opportunity to work with over the years, I’ve
never done police training without doing it with police
and hearing their perspectives. – [Dr. McIntyre] But also, it
will decrease incarcerations and involvement with the
criminal justice system, because as the primary
responders get used to this concept of psychiatric
crisis services, they’ll start bringing folks who have probable mental illness
or substance use disorders to the crisis services
as opposed to taking them to jail and booking them. – [Dr. Aoun] If you want to
change how law enforcement is practiced on the field,
everyone should get training. And something else they said was that the training they get is
very medically oriented. They would learn about schizophrenia and schizophrenia affective disorder and major depressive disorder
and major depressive episode. Like, we don’t care to know about this. What we care to know
is, we’re on the field, we’re seeing someone
yelling and screaming, we want to know is this
person mentally ill or is this person just
acting because they’re upset or they’re dangerous? Should we take them to a hospital? Should we take them to the precinct? We came up with the idea
of creating something that’s symptom-based, so
the topics that we decided to work on were like
agitation, anxiety, sadness. Instead of saying depression we used words that the officers could
relate to like sadness. And we decided to create online modules that would be easily accessible, that would be easily understandable, so we weren’t trying to
tell them about the most up-to-date research about the
treatment of schizophrenia or whether this anti-psychotic medication is better than that
anti-psychotic medication, but we wanted to tell them that this is what someone who’s psychotic
is likely to look like, and if you see someone
like this on the street, the behaviors you’re
seeing might be caused by a mental illness or might be caused by a drug overdose or it might be
caused by a drug withdrawal. This is an emergency
situation that requires something to be done on the field, while this is something
that requires treatment in a hospital, and this is
not necessarily something that needs treatment in the hospital, this is something that
needs to be dealt with using the normal police protocols. – [Dr. Pinals] In the next
video, we’re going to see Drs. Trestman, McIntyre, and Lang discuss the type of work they do as psychiatrists in intercepts two and three. Along this line, some of the differences between medical and judicial
terminology will be discussed, ways in which psychiatrists
work collaboratively with judges to help explain
and become interpreters for judges in working in
partnership with them, and the role that psychiatry
can play in court proceedings, as well as work within
correctional settings. – [Dr. Trestman] We have, as
psychiatrists, a wonderful opportunity to respectfully educate judges
and the staff of the court in ways that would allow them
to better provide options to incarceration for our patients. And so there is a give
and take in this process, because all too often in
most of our communities, there are not adequate
alternatives to incarceration. A judge might want to be
able to defer incarceration and refer someone to a treatment program, but it may not exist. And so for me, it’s been wonderful working with judges who are
interested in this area, and helping them understand
both the language, we each speak very different languages in law and in medicine,
and so helping us bridge those gaps to understand the opportunities for treatment, the needs for treatment, the challenges of relapse
as part of the illness, of drug abuse or of severe mental illness, has led to wonderful
transformative initiatives in different courts around the country. – [Dr. McIntyre] So one of the nice
things about just people in general starting to think more
about diverting people with mental illness from jail and prison is that we started talking more about the sequential intercept model. And there are a couple different ways that intercept two can play out. It might be a regular court system, but the judge recognizes that there are issues around behavioral health. It’s a severe and
persistent mental illness. This is trauma-related, somebody who’s in an abusive situation, for example. Or this is substance use disorder related, so they can choose to have
the person go into treatment before getting to the point of conviction. So it’s like, let’s give this a try. Let’s see, let’s get you
assessed and then, yes, you have something that
needs to be treated, so let’s get you treated. And if you’re compliant with that, then we don’t proceed along
this path that leads to prison. – [Dr. Lang] I work primarily
at the Allegheny County jail, and we have something kind of unique there called the Behavior Assessment Unit. And what that entails is
performing evaluations for inmates that have been
arrested and come into jail, and we’re assessing their
competency to stand trial, making sure that they’re not
getting taken advantage of by the legal system due
to their mental health. In my role, we kind of
oversee those evaluations, go into the jail, talk to people, make sure they understand,
and then on the flip side, we’ll bring those results to the courtroom and kind of tell the
judges what’s going on, whether the people understand it or not, and whether or not they would
need any treatment further to help them regain that competence. – [Host] In this next video,
we’ll hear about some work that psychiatrists do in
intercepts four and five. – [Dr. Pinals] I’ve been working
also in re-entry activities in Massachusetts and Michigan,
and had the opportunity to see how re-entry works
in both those states. In Massachusetts, I was
responsible for something called the forensic transition team. They were assigned to identify people with serious and
persistent mental illness. They would do in-reach activities, where they would work with the individuals to help develop a release
plan with the supports that they would need upon
re-entry into the community, and then tracking them
for a period of time into the community to
make sure that there was a handoff to the
community provider system. In Michigan, I’ve been
working with re-entry through the state targeted response grant related to the opioid use disorder, and that’s again where
we have a case manager and a peer linked together to
do three months of in-reach and then six months of
post-release followup targeting people with opioid use disorders who have co-occurring
mental health conditions and providing them the supports that they need in the community. My experience in both those programs, obviously I had more years so far in the Massachusetts
program and the Michigan one is relatively new, but the re-entry space is really interesting to me. Having the behavioral health community come in and do re-entry
work creates the need to learn a whole new culture
and a whole new language, and similarly, for the correctional side, to work with the behavioral
health community, a whole new cultural
experience is brought to them. – [Dr. Pinals] As we think about
the perceived disincentives for working with
justice-involved individuals, we wanted to break down
some of the other thoughts that people have shared with
us as some of the reasons why it may not seem to be
the right type of work space or the right type of
population to work with. And so we want to discuss what
the perceived disincentives are and then hopefully do some myth-busting as we go through the webinar. So, in this video, in the next video, I and Dr. Lee will address some of these negative
misperceptions in relation to the justice-involved
population as a whole, as well as the stigma
that is sometimes attached to the psychiatrists who work with them. – [Dr. Pinals] Actually, the
disincentives seem overwhelming before you start working
with that population. – [Dr. Lee] Sometimes
early career psychiatrists or psychiatrists in training,
they have a certain degree of awareness that it’s a problem, that they should be interested in it, but they might have misconceptions
about what it’s like to work with those individuals. – [Dr. Pinals] I talked to
colleagues and said I was considering working in a women’s prison
and colleagues told me why would you want to
work with that population, they’re difficult to treat, they have personality
challenges and life challenges that are going to make it not a
rewarding part of your career. – [Dr. Lee] There’s a
lot of media attention, there’s a lot of press out
there about individuals with mental illness who are incarcerated, about how they’re arrested or managed in the criminal justice system, so there’s this awareness
that there is this group of individuals out there
with mental illness, that there is this field. – [Dr. Pinals] The fear
factor that many people have about working with this population, or the distaste for working
with the population, you meet people where they’re at, you start seeing them as people as we do with all of our patients. Everybody’s got their stories
that they come in with, and you start understanding them more as you understand them as people. So the distaste for the population is really not founded in my opinion. – [Dr. Lee] The stigma
that’s associated with being an individual with
criminal justice history is something that not just lay people are vulnerable to perceiving, but also psychiatrists as people, as well, not really knowing what
those individuals are like or what they need. And there’s also that
issue with the stigma that can attach to those people who work with individuals with
criminal justice histories or in criminal justice settings. – [Dr. Pinals] There’s also
the concerns about safety. On the whole, that’s one
of the largest barriers, we think, for having
individual psychiatrists work with this population is this belief that the population is violent
and that the settings in which psychiatrists would be practicing would be unsafe. The clips that we’re going
to show, the video clips, address this myth and then the
realities of the population really not being any more violent than people in the community,
in that if you do work in an institutional setting,
you may actually perceive greater safety than in other settings. In this video, we look at
some of these common myths with Drs. Metzner, Lang,
Aoun, McIntyre, and myself talking about some of these
perceived disincentives. – [Dr. Metzner] One of the
issues that I frequently hear from early career
psychiatrists is their concerns about it being a dangerous
environment to work in. – [Dr. Lang] You’re
working with a population that has charges of serious
nature against them. – [Dr. Aoun] A lot of
people who train in medicine have a lot of resistance to the idea of working the criminal
justice involved population, and they think of
potential for dangerousness that they’re worried
about going to prisons, even though, I mean, the research finds that people who work
in correctional systems have the safest jobs among physicians. – [Dr. Pinals] Oftentimes,
I felt safer working in some of the correctional settings that I was in than I did in other
settings that I’ve worked in where there hasn’t been
as much protection around. – [Dr. Metzner] It’s not a
significantly dangerous environment compared to other environments. That’s why you have correctional officers, or deputies as they’re
called in many jails. – [Dr. Lang] You’re in
a very secure setting. You have a lot of support around of you. You have correctional
officers, you have guards, you have counselors,
therapists, social workers. – [Dr. McIntyre] Corrections
officers, court officials, et cetera, they’re taught the same kind
of de-escalation techniques. And you know, quite frankly,
folks in corrections, whether it’s in court
systems, it’s in jails, it’s in prisons, you know,
they have a lot of experience dealing with folks once
they become agitated. When I’m working with
folks that are mentally ill and could potentially become violent, I’m safer if they’re around and if they’re part of the team than if I’m on my own in
an out-patient setting or on an in-patient unit. – [Dr. Pinals] The third
perceived disincentive is the belief that the
population has different and more complex clinical
needs, making it difficult, if not impossible, to treat them. And so it’s often a concern of colleagues who hear that you’re going to be working with justice-involved individuals to say, but are they really
people that you can help. And that is really
somewhere, one of the myths that needs some correction,
because the people that are justice involved
can be helped in many ways similar to those that
you see in the community, because they really are
the same sorts of people. You’re just seeing them
at different points in their illness and in
different environments. So they’re individuals with
similar mental health needs. The knowledge that they
are justice-involved or potentially going to be
incarcerated or are incarcerated can affect how people interact with them. But if we look back and peel
the layers of the onion back and see them as just individuals with their own unique set of health concerns and mental health
concerns and substance use treatment needs, we can perhaps do better at dispelling some of these
perceived disincentives. So in this video, you’re going to hear the idea about some of
these misunderstandings through Dr. Lee, Dr. Trestman, and myself. And we’ll discuss how the clinical needs of justice-involved people can be the same as those of clients in the community and they are already often being treated similar to how they are
within the community practices in terms of access to care. But our roles can also be to advocate for the care that they need. – [Dr. Lee] There’s a tendency
for those who don’t have forensic experience or forensic training to somehow start to think
that the criminal justice population, the justice-involved patients, are often in a different universe, almost. That they don’t understand them, and they also don’t
potentially need to worry about needing to understand them because they won’t need
to interact with them. But I think that what’s
important for everyone to understand is that
that’s not literally true. – [Dr. Pinals] The people
that are justice-involved are the same people that they might see in an emergency room. They’re the same people
that they might see on an in-patient psychiatric unit. They’re just seeing
them at a different part of their life and of their life journey. We know with the high rates
of justice involvement for people with serious mental illness that if you’re going to
take care of somebody with serious mental illness,
you’re going to encounter somebody that has been
through the justice system. – [Dr. Lee] Individuals with
criminal justice histories are people like any other people. Their mental health needs are very similar in many ways to the
patients they already know. – [Dr. Trestman] It was
one of those a-ha moments when I realized that these were exactly the same people I had been caring for over the last 20 years,
just at different points in the arc of their lives. These were people who
previously I had seen prior to becoming addicted to substances and becoming justice-involved. These were people who I had
seen who had been manic, had been incarcerated,
then were discharged, and I was treating them a year later, when they were back in the community. – [Dr. Pinals] Our fourth disincentive is that of financial compensation. It’s no secret that psychiatry is among the physicians’ specialty
that does not receive the highest compensation rate on average. Here you see some national
data presented to you. And although psychiatry compensation is certainly high enough to live well, when one thinks about
going into psychiatry in the first place,
comparing the compensation one could receive if one
chose a different specialty in medicine, it does make
for a choice that has created the need to
encourage medical students to see psychiatry as a worthy profession, despite the differential in
the compensation overall. In this data set, you see how compensation averages out for individual, certain types of psychiatrists working
in the public system. This probably reflects
forensic psychiatrists who, again, are salaried
within the public system as opposed to working
in a private practice, and again, that’s one of our challenges in getting, in thinking
about psychiatrists working with public patients is that the financial benefits for
working in a private practice is higher, often, than those for working within community mental health settings or within public forensic settings. And so therefore this issue
of financial compensation is a real one. Several states are trying
to work in the area of physician loan repayment, and there’s efforts to
look at those issues. There’s efforts to look
at how to improve salaries so that recruitment of
psychiatrists can continue in a positive direction. But right now, that is
one of the perceived disincentives for working
within this space. Again, it’s important to think about that there are many
settings that psychiatrists can work in and work with
justice-involved persons. You’re hearing from
different professionals who have chosen to practice
in jails and prisons, some in hospitals, whether it’s private acute psychiatric hospitals
or public state hospitals, who work at the interface with courts or work in community care practices or even those psychiatrists
who could work in this space where they’re partnering more closely with probation or parole, for example, through treatment court. There’s many different options for working with justice-involved individuals, and the settings can be varied. And so through these experiences, we learn more about how to
work with those populations and some of the benefits
of working with them. From this point forward,
I’m going to turn this over to my colleague Dr. Swartz
who was introduced earlier on, and I think he and I exemplify
these different roles that we’ve each played in the settings, with me more as a forensic psychiatrist, Dr. Swartz working largely in the field of community psychiatry and then working with justice-involved
populations and in settings as a community psychiatrist. I think Dr. Swartz has
terrific insights into this, and he will take this
webinar forward as we look at other areas where
perhaps the disincentives can be counter-balanced by incentives. – [Dr. Swartz] Yeah, thank you very much, and it’s my happy task to talk about some of the positive incentives to
working with this population. But I did want to emphasize
one of the points that Deb made earlier and that
is that forensic training is not, by and large, required
for this kind of work, and often folks who have an
interest in community psychiatry and working with
disenfranchised individuals are drawn to this work. And sometimes it’s not full time work, it’s part of a range of
activities that people engage in, and so, for many early
career psychiatrists, it can start out as a part time job that can expand or contract,
depending on their interests. So let’s get into some of the incentives for recruitment and retention of trainees and early-career psychiatrists. So, an aspect of working
with justice-involved persons that really is an incentive, is that it’s very
intellectually stimulating work. I can recall when I worked
in North Carolina prisons that some of the most
challenging diagnostic challenges I found in the prison. Very complex people with
fascinating psychopathology, and it was also stimulating
and is stimulating to have the opportunity to work with justice system personnel
in trying to navigate and negotiate how to provide
the best treatment possible within the resources available. It’s also an opportunity to work with and learn about social determinants and how they affect treating
justice-involved persons, and the social determinants
we’re talking about are poverty, cultural
norms, racism, sexism, geography, social
isolation, dealing with the legal consequences for their acts. And largely, extensive trauma
and multi-generational trauma that’s also a consideration
working with this population. One of the benefits to
working with this population, although, not maybe something of choice to the patient, is that they
tend to have longer stays and so there’s an
opportunity to try to dig in and to affect meaningful
change in a longer, what we’d call, length-of-stay
in the private side. So in this video, several
psychiatrists will discuss a number of exciting
opportunities involved in treating justice people. Some of these include
seeing meaningful change in recovering clients, as
well as cross-field knowledge and cooperative work
with the judicial system. Likewise, the ability to
impart change in a population of people that are frequently underserved can also be a great pleasure and reward. In these clips, we’ll see Matthew Lang, Jeffrey Metzner, Robert
Trestman, Carmen McIntyre, and Elie Aoun talk about
some of these incentives. Let’s see the clips. – [Dr. Lang] It’s very rewarding,
the work that I do there is mixed as far as, I get a
little bit of treatment, I have a little bit of
intellectual pursuits, some academic, and get
some challenging work, like testifying in court is
something unusual for me. I find that very, very challenging and very intellectually stimulating. – [Dr. Metzner] A jail setting
gives you an opportunity to do some long-term
treatment for the detainees who are there for many months that you don’t get to
do in many practices. And the advantage of being able to do some long-term treatment is you actually get to see people change, and in a community mental health center, you may see people after three months and think that they’re treatment-resistant and they don’t get better
and you stop seeing them. – [Dr. Trestman] All to often, we
see people only intermittently, in short episodes, or we may see them once every three or four months. That’s not some context that allows us to genuinely support meaningful change in our patients’ lives. – [Dr. Metzner] What you can
see in a longer term setting, people who ordinarily you would think were treatment resistant,
six months, 12 months, or even 18 months later
show significant improvement that you would’ve never been able to see. – [Dr. Trestman] One of the
opportunities in correctional settings, or in other justice-involved settings, is that we get to see
them on a regular basis. We get much more information about them. We have a genuine and much
more rich understanding of the challenges, their limitations, and their actual responses to treatment. – [Dr. McIntyre] It is a
population that’s typically going to be involved in healthcare for a long period of
time, so that you get to, you get to treat them to the
point where they improve, you get to treat them to
the point of recovery. – [Dr. Lang] I think one
of the big frustrations that some of the trainees
and medical students may have about psychiatry is it
doesn’t have the same kind of win factor that some of
the other specialties do, whether you get to fix the
bone and sew up the leg and see the person walking again. But I think working in
the justice related field has provided some of that
for me, which is great. You get some of that win sense in the fact of working in the justice
field gives you access to some tools and the legal system, whereas working in a clinical setting may not have those same tools. – [Dr. Aoun] The fact that you’re
able to kind of cause change and this change is not only
going to affect the people when they’re in prison,
but it’s going to have consequences that will help
them have healthier lives and be less likely to engage
in criminal recidivism and less likely to come back
to the criminal justice system, being able to affect change
like this is very rewarding. – [Dr. McIntyre] We have so
many societal injustices, inequities in access to healthcare, that in justice-involved
systems, we have a disparity. We have an over-representation
of minorities, of the poor, and people with mental health and substance use disorders. – [Dr. Trestman] The more I talked
with people who were actively justice-involved, I realized
that so many of them never had a chance to
lead the kind of life I had an opportunity to live. They grew up in horribly
distorted family settings, violent environments with
a great deal of abuse, neglect, and trauma was
a day to day experience. And so if we were ever going
to try and make a society that could genuinely see
itself as giving everyone a fair chance at a good life, then we really needed to make a difference in the lives of the
people who were cheated of those opportunities, and to try to give some chance to them by
treating them appropriately, treating their illnesses so
that they stood a decent chance of leading a satisfying life and beginning to develop
the intrinsic qualities that they had and never
had an opportunity to. – [Dr. McIntyre] So by being a
psychiatrist working in that field, you get to actively be involved
in righting some wrongs and assuring that there’s quality of care to a disenfranchised
population that really hasn’t had access to that. – [Dr. Metzner] The advantage of
being a mental health professional in a jail is you can help change that. And the way, the reason
you can help change that is when you do make that change, it makes life easier, not
only for the detainees, but it also makes life
easier for the deputies and the correctional officers. And once they see that, they’re going to more welcome your input in
changing the environment. – [Dr. Aoun] We can see 10,
20, 30 patients per day, but if we work with the legal system, if we work with the legal framework of the criminal justice
system, we can actually change the lives of thousands of people. – [Dr. Metzner] The third thing
that is rewarding is you get to see psychopathology that
you ordinarily don’t see. And so from a professional perspective, it’s very interesting. – [Dr. McIntyre] You get to
see such a broad spectrum of illnesses and
presentations to the illness. You get to work with
inter-disciplinary teams. You get to introduce pilots
of evidence-based practice. You’re going to see
everything, everything. In a corrections setting, you’ll see stuff that you’ve never seen before. – [Dr. Swartz] There really
are significant personal rewards for working with
justice-involved persons. And one of the largest
is having the opportunity to make a substantial
impact on individuals. And as we’ve mentioned,
despite the misperception that the justice-involved population is not able to recover, and
are therefore very frustrating to work with, often this
is really not the case, and the population is largely
accepting of treatment and grateful for the services we provide. In the next video clip,
we’re going to talk a little bit about the need
for personal satisfaction when choosing a career,
or at least a direction, and the video provides a lens
into several psychiatrists’ personal satisfaction with
having chosen this kind of work. We’ll also hear from Fay
Owens, a remarkable woman with lived experience
with the justice system and psychiatric treatment,
and hear a little bit about how she greatly
benefited from services provided in that setting. – [Dr. Metzner] The detainees
generally are very appreciative of receiving medical
and mental health help. They’re frequently not very used to being treated in a respectful fashion, so if you treat people
in a respectful fashion, and in fact, help them, they’re
very appreciative clients, and it’s rewarding to see, not only that they’re appreciative, but that you’re helping them
and that they get better. – [Dr. Trestman] The work I’ve
done in developing this kind of psychotherapy to help
people who are justice-involved to better manage their
lives, their emotions, to be able to focus on their
future goals and aspirations, has been incredibly
satisfying and one of the most rewarding things I’ve
had the pleasure to do. – [Dr. Pinals] Oh, it’s
absolutely personally rewarding. I mean, I can think of patients that I saw when I worked in the women’s prison or when I worked in a clinic for mentally-disordered offenders, and I can still remember
the patients that I saw and the relationships
that I was able to build. A lot of them didn’t
really have experience with relationships, positive
relationships in their lives. A lot of them had very
traumatic histories, and in working with them
and giving of myself, and feeling like I could do something, even though their needs
were sort of endless needs, I really felt like that
relationship made a difference. For me personally, it helped me grow as they were growing as well. – [Fay Owens] I think that
psychiatrists that work with justice-involved people need to just know them as people. If you just see people for people, take the justice-involvement out. Take the mental health out. Take all that out. We’re people. Somebody put a hand down
for me and pulled me up. Do that for the people. They’re going to be on
an amazing road trip. I suggest they buckle in,
because everybody’s not going to be as sweet as
me, but it’s definitely going to be worth it. – [Dr. Swartz] So you’ve
heard a little bit about some of the potential impact our services can have on the people we
work with in justice settings. And in this next section,
Dr. Lee and Pinals will delve a bit into some
of the treatment stories that have made a lasting
impression on them and moved them to continue work with justice-involved populations. – [Dr. Lee] He was a young
man with a somewhat varied criminal justice history, some drug sale, a little bit of assault, a few arrests under his belt already, but
also an undisputed history of schizophrenia and something
that won’t be unfamiliar to just about any clinician, a spotty history of taking his medication and keeping up with treatment. So this young man did not do well once he was arrested and at the jail. He withdrew, he didn’t take medication, he, quite frankly, didn’t
take care of himself. He didn’t communicate. He didn’t do much of anything. By the tame he came to the hospital, he was seriously underweight. And in the prison side,
they would have to be making decisions about what to do with him in a fairly short period of time. So knowing this patient,
my assumption would be that he would tell a new set of clinicians exactly what he told us,
which was everything was fine, he had no problems, he
was absolutely okay, and he was ready to go home. The problem is that that’s
also the exactly same thing he said when he first came in, when he was seriously
underweight, withdrawn, internally preoccupied, not doing well, and his recovery had
really only just begun. So what I did at that
point was I reached out to the clinicians in the next system. I gave them a clinical summary
and shared my concerns, and I heard later on that
they, when he reached them, they decided to not allow
him to go to the community, but instead to be hospitalized. So he was sent into the
state hospital system. Lo and behold, as I’m going to my new job, I run into him on the street, and this is maybe half a year later. He said, “You know, when
I went upstate to prison “they said I wasn’t ready to go home.” And I thought for a second
he was going to tell me how angry he was, that maybe he’d heard that I told them he
wasn’t ready or something. But that wasn’t what he said. Instead, he just kind of went on. He said, “You know, so
I went to the hospital, “and I stayed there for a while. “And I had to take my meds
and then I got better. “And now I’m home and I’m
going to a job interview.” So that was quite something. That’s all he said, he
said it all in a rush, and then he walked off. It’s a reminder that as clinicians we can all make a difference, even if it’s just for a little while. It almost doesn’t matter,
I have no idea where he is. It almost doesn’t matter how
it turned out in the end, because nowadays when I see a patient with that kind of history,
and I’ve seen that they made it out, they did well for a while, and they slipped back, that’s okay. We know that they can turn it around, and maybe it’s a couple steps
forward and a step back, but it’ll be another couple steps forward. And so the other thing
that I really appreciated about the fact that he took
the time to say anything is that it also let me
know that he appreciated what people had done for him. There was some awareness,
I think, on his part that a lot of people had
tried to take care of him and had gotten him to where
he’d been and were trying to help him reach some
other goal for himself. Really hoping that
psychiatrists who are trying to figure out what they want to do, that they stop and
consider this kind of work as something that’s
important and fulfilling and also very meaningful to somebody else. – [Dr. Pinals] The two stories of
patient care that inspired me most when I was a resident
were cases of individuals, one of whom I treated
throughout my residency. He was a man with very
serious mental illness and had his psychotic break
while he was getting his PhD. This man’s journey took him
to Bridgewater State Hospital. During the time of his psychotic break, he became quite paranoid
and had exhibited symptoms and had engaged in behavior that got to the attention of police. And he ultimately went
and went for an evaluation of his competence to stand trial and criminal responsibility. This was way before I
started working with him, this was in his history. By the time I saw him, he
was homeless, very psychotic, hadn’t really stuck in treatment easily, and I got assigned to take on his case. And I worked with him for three years throughout my residency. And he came to his appointments,
we developed a connection, I put him on medications,
I put him on clozapine, which seemed to help quell
his thought disorganization to a certain extent. He was able to get
attached to a housing unit and really became somebody who lived with his mental illness
in the best way possible. But the relationship
that he was able to build and the treatment alliance
that I was able to, I felt, accomplish, to the
point that as I was leaving my residency, he came, we had ended, we had had our last
session, and he came back and he was very disorganized
and it was hard sometimes to understand what he was saying. But he knocked on my door and he said, “Can I borrow some dollars so that “I can buy you flowers to thank you?” He was a justice-involved
person in his life, and his life just took a
path that he hadn’t expected, and that story just really
was a patient’s care story that lives with me to this day. – [Dr. Swartz] So some
of the biggest advocates for our work are actually
people with lived experience that have benefited from our practice. Some of the stories you’ll hear now are from people with lived experience who were positively
impacted by psychiatrists and are enormously grateful
for having the opportunity to receive the services. Similarly, psychiatrists can play a role in helping a client set up other aspects of their life, as you’ll see in the video. They can encourage a client
to go back to school. They can help them find and sustain both housing and employment. In the next video, you’ll
hear from Mr. Ralph Correa, Ms. Jeanette Toledo, Fay
Owens, and Mr. Davon Harris, who are all peer advocates. They’ll provide us with a brief understand of how receiving treatment
from psychiatrists helped changes their lives for the better. – [Mr. Correa] What I would say
is to work with your patient, your client, and let them know that they could achieve something in the world, that like me, just
because they are diagnosed with whatever diagnosis they are with, that that’s just a diagnose,
that they are somebody in this world and they could achieve the goals that they are
looking forward to do. – [Ms. Toledo] When you have a
psychiatrist that believes in you, that changes your whole
perspective on your outcome, on how you’re going to help yourself, and that’s what happened to me. When the psychiatrist
treated me like a human being and he didn’t treat me like a diagnosis, he didn’t treat me like
a number or a chart, like a illness, he treated
me like a human being, like a mother, like a
woman, and like a person and a human being, that’s when I opened up and I was willing to accept the help, because acceptance is very important when it comes to mental
illness and recovery. So if the psychiatrist can understand that recovery’s possible, because for some reason,
they feel that recovery’s not possible, recovery is possible. If they have the patience and they listen and they could understand
that with patience, active listening, there
could be a connection there. If you believe in us, like
that doctor believed in me, and took the time out
to really understand. – [Ms. Owens] So, I got to see who
Fay is, like, I’m really amazing. I’m intelligent. I’m diagnosed, I am not my diagnose. I’m productive. I’m old as dirt, but I’m passionate. I’m amazing, I’m humbled by my experience of having an opportunity
to help people like me. Like, you don’t, I had no clue that I was capable of
taking my life experience and instilling hope in people. That is not what I was signing up for. I was not aspiring to be this, and I’m forever grateful
to my psychiatrist, to God, to people that are in my life. I’m trying to find the right
words so that you get me. People see stuff in me that I don’t see, that I’ve been told that there’s an aura that comes off of me that invites people to actually just stop and talk to me. People in the street, I have
my headphones in my ear, I’m vibing, I’ve got
this little mean face, because I don’t want you to say nothing, and people will stop
me in the midst of that and drop some stuff for me to seek advice. And I didn’t know that was in me. So yeah, my psychiatrist has unleashed this amazing woman that, in spite of her mental
health, is productive. – [Mr. Correa] When I was released,
I went to a three-quarter house. It’s like a shelter. And then I was from there
here, where I’m at now, where is Heart Street at St.
Vincent’s supportive housing. And I got a new psychiatrist,
which my diagnosis changed. At CCM, Community Counseling
Meditation Services, the psychiatrist there was more different. I had a few of them, but they were like, more positive about me. They would give me compliments like Ralph, you can do this. You are diagnosed with an illness, that doesn’t mean who you are, and that brought me to the state of mind that I could do something. My new psychiatrist now, she’s awesome, she also tells me that I could become what I’m training now, as a peer advocate, which I have an award of WRAP, I’m very happy about that. I graduated with my GED and everything because of these psychiatrists
that I dealt with at CCM at a different level. Like positive talking to me, like you could do this, just
because you are diagnosed with PTSD doesn’t mean that’s who you are. And that put me to think, it really did. And as I see my life changing and evolving in a flower, like a rose, it’s like, wow, and I’m like more, I want to go see my psychiatrist. I want to tell her the good news. It’s just an awesome thing
just to see someone flourish and other people, my
family members is like, wow, Ralph, and I’m
like, yeah, I’m doing it. I’m 13 years now, it’s a struggle going, but the positive input I
have at my therapy place with my psychiatrist is
just, it’s just awesome. – [Mr. Harris] It was a
great experience, I can say. She continued the medication
that Kirby Forensic had me on, but she gave me the
same level of treatment, unlike Rikers Island, she
actually came to the problem, tried to find the root of my psychosis. She believed it was a poly substance abuse that began initially. It became reoccurring trauma
from other events in my life, and she basically properly
assessed the issue. I met a really awesome psychiatrist when I came home from prison. She connected me to education. First she inspired me about the school. She inspired me to do a lot of things. While there, I went back
to community college. She inspired me to search for employment. I found a job, am in
the process of obtaining a more secure job at this moment. She got me housing through her program. While, I’m living in permanent housing. She got me into community college. Now I’m at NYU. A lot of people who are mentally ill and victims of the justice system, I don’t want to say victims, caught up in the justice system, period. A lot of these people, unfortunately, they’ve been placed in an environment with bad conditions and so
they think it’s a bad stigma. People think, oh these
people are dangerous, or they’re unable to be worked with, or they’re just going to keep doing the same thing over and over. When just one person can come in, like a psychiatrist or a
therapist or a social worker, but particularly for me,
it was a good psychiatrist and one or two therapists, who come into a person’s
life and you can inspire them and you can change them and
you can help them understand their diagnosis better. You can help them decipher reality better and just get back on track, man. Because it’s very much needed. You need people that care,
because a lot of people, they just need that emotional support, and they definitely need someone that can properly assess their
issues and point them in the right track, get them
on the right medication, help them become productive
members of society once again. – [Dr. Swartz] So for many
of us considering a career work/life balance,
particularly for a physician, is often an important consideration. And when you think about working with justice-involved
persons, for good or for bad, there’s a greater ability
to make one’s own schedule because the person in a justice setting generally is available
to meet with on schedule. Typically, folks working,
psychiatrists working in these settings aren’t on call, or have a minimal amount of call, and are afforded more flexibility in terms of work/life balance. In the next video,
we’ll hear from Dr. Lang and Dr. Olivero about the
achievable work/life balance that’s possible when choosing to work with the
justice-involved population. – [Dr. Lang] I think personally
for me, it’s being able to maintain a healthy work/life balance, and that was something
that was really important to me going through medical
school and residency and putting in all those
hours and training. I really wanted to make sure that after I got out of training, I
still had some time to myself. I was able to pursue my
own personal interests: fitness, literature, movies, music, and have the time to do those things. Working with the justice
related population, it allows me the flexibility
to pursue those interests, but at the same time satisfies the professional needs that I have. – [Dr. Olivero] In the field,
the time frame in terms of work can be much more flexible. There are no, most of the
jobs, there are no calls, so you can have a better personal life, plan family vacation,
whatever you want to do in terms of your life. – [Dr. Swartz] One of the
things we wanted to address here is getting exposure and some experience in working with justice-involved persons, in part because having a
preview of a job experience often is a helpful way to choose a career. Unfortunately, residency
programs in psychiatry have a variable amount of exposure to justice-involved
populations, in part because the ACGME requirements
for forensic experiences are not very clear and don’t provide as much guidance as they might about what the requirements might be. Ultimately, site visits, working in courts by completing assessments and evaluations and becoming exposed to
working with professionals from the justice system are some ways that can increase exposure to
working with this population. Advocacy from residents and
early-career psychiatrists for their own education is also important, and one important thing that residents and early-career psychiatrists can do is seek out elective experiences
to get greater exposure with this population. In the next video, we look
at training recommendations for forensic psychiatry residency
and fellowship programs, as well as suggestions and
advice for current residents and early-career psychiatrists from practicing psychiatrists who work with justice-involved populations. – [Dr. Lang] It can be
difficult for medical students and residents to find a
rotation or an experience with somebody within their training area. – [Dr. Olivero] Most of the
time, the clinical rotations that involve forensic settings
are very short in time, and the psychiatrist
or the medical student or the psychiatry
resident is only involved in doing treatment. They are not involved in doing
the forensic evaluations. They don’t even get a chance to observe the forensic evaluator. – [Dr. Pinals] Residency directors
don’t themselves necessarily have that as their focus or their interest unless that’s kind of who they are and what they’ve spent their
professional life developing. – [Dr. McIntyre] But I really think
that early-career psychiatrists at least start off with getting some sort of experience in it, however you can. Electives when you’re in training. Kind of moonlighting or whatever. – [Dr. Pinals] I think it’s really
important for people to see places. I’m a big believer in site visits and seeing where patients have been and where, how it would be to think about sort of what their experience has been. – [Dr. Metzner] The advantage
of the medical schools having those kinds of
electives or rotations, it provides not only an opportunity to train psychiatrists
and medical students to work in such environments, but it also exposes them
to the environments. – [Dr. Olivero] And I think
they should be exposed to that as soon as possible in their training so that they can understand
what are the legal concepts, what kind of things, in terms
of the mental health symptoms can affect their patient in
the criminal justice system. So having more exposure,
more elective time, and not only teaching them
about the medical concepts, because we get that in medical school, we get that during residency. But also formally teaching
them about the law, about police records, what they mean, how can they get access
to it, is essential for a full understanding
of their patients. – [Dr. Lee] All these
systems came into play and the different ways that they operated, the different needs of
those different systems, the different mentalities that they bring to managing the same set of people that we were thinking about clinically. It was a very important
experience in terms of understanding how
they worked individually, how they came together as a
bigger criminal justice system, how to communicate with
those different parties, and ultimately, how to
navigate that environment with all those different
agencies and individuals and parties at play to still create a setting that made clinical sense. So that was all very important coming out of real time experience that
I think can’t be gotten simply by reading about it or
spending a little bit of time going through as a trainee. It was, the experience of having to be an attending psychiatrist
and making decisions and navigating those relationships was really, I think, invaluable in terms of understanding the system
and helping me develop the approach that I have
to non-clinical work now. – [Dr. McIntyre] And I honestly
think, looking back on my own career, if I had started there, if you can learn how to get people in the
corrections setting better across that full array, then I think there’s nothing that you
would see on the outside that you wouldn’t be equipped to handle. – [Dr. Lang] I think
that’s absolutely critical for both the program
directors and the trainees to kind of seek out an kind
of build those relationships with anybody that works in forensics or does any type of justice-related work. – [Dr. Pinals] Here’s where
I think young residents who are interested in the
field can ask for experiences that they think of. Another thing that I’ve
seen is that residents come up with their own ideas of wanting to gain exposure to something. And there’s always elective
opportunity that can be built into the program. – [Dr. Olivero] As soon as they
have a hunch that they would like to work with any patient population, involved in the criminal justice system, start getting involved
with that population. Volunteer, ask the program
directors who have electives in jail, in a court,
in a community setting where the patients are involved in the criminal justice system. Ask about it, read about
it, talk to your supervisor. Not only take the information
that they give you, question what you’re doing, and what are the legal
reasons of what you’re doing in treating your patients. And you get to understand patients more because you will see the experience that they’re having with
the criminal justice system, how it affects their life, how it affects their
mental health symptoms, and you will be able to better
assist them in the future. – [Dr. Lang] Nothing replaces
the actual hands-on being in the environment, seeing what it’s like, and getting a true experience. I know that it’s not possible for all the medical students and residents to get into every aspect
of the forensic work, but just to get a little taste of it, just enough to see, maybe the didactics didn’t give you a true
sense of how it really is, or maybe you had some of
those preconceived notions about what forensic work looks like or what a jail setting
or correctional setting may be like to work in. – [Dr. Lee] Without the experience,
what people are imagining is not necessarily reality. – [Dr. Pinals] Exposure to
settings, patients, and mentors, I think, are some very key components to helping inspire young professionals and helping educate young professionals who might choose that as a career path or who might treat
people in other settings, but need to know about
that in their backgrounds. – [Dr. Swartz] So another important aspect of working with this population, aside from the pure forensic experience, is also gaining greater
exposure to cultural competency and social determinants of health. The next video discusses some
of the social determinants and cultural competency
issues that are inherent in working with this population. – [Dr. Aoun] This has to do with
the criminal justice system, when you are part of a minority group, even though you’re not more likely than if you were in a majority to use drugs or to engage in drug-related crimes, you’re a lot more likely to be arrested or incarcerated or be put
on parole or probation for a drug-related crime. And when you’re in that position, you’re a lot less likely to
receive treatment for addiction. And if you do receive treatment, you’re less likely to
receive evidence-based treatment for addictions. It’s going to go on your criminal record, which is going to make
it a lot more difficult for you to get housing, to get all sorts of welfare programs, get employment, which is going to make
your living situation more difficult, and if you
have a history of addiction that’s not well treated,
you’re very likely to either relapse or
engage in selling drugs. So in residency training,
I think people need to understand why the social
determinants of health are a major contributor to the maintenance of involvement with the
criminal justice system and the maintenance of the disease burden. – [Dr. Pinals] You have a greater
sense of where people have been in their own life and in their own kind of road to self-improvement and recovery and the things that you’re
working with them on as a psychiatrist, even
if you’re ultimately not going to work in
a setting that focuses on that justice-involved population. You know, when I work
in the emergency room and I do a shift, it’s not
uncommon to see somebody who just got out of a
prison or who was brought in by police, so to have that understanding of what they’ve been
through really is important. – [Dr. Olivero] In a community
setting, where a lot of patients that I had were involved in
the criminal justice system, they didn’t have the
resources to get treatment, pay for medication, their
lives were quite complicated. So I saw how the criminal justice system can affect their life completely, and having a knowledge
about that helped me understand them better, be more creative about treatment options, and also helped me
analyze and look further, not just the symptoms, so
what’s going on with their lives and having a forensic knowledge, and doing a good forensic evaluation could help them solve their problems with the criminal justice system. – [Dr. Lang] I think that
working with a justice population gives you immediate access to vast amounts of their life and you have
to have an immediate rapport with somebody because
there’s so much on the line. They might be facing
some legal challenges, they may be dealing with
some social challenges that brought them into jail, homelessness, family abandonment, all
kinds of different issues that you have to hurry
up and have a grasp of, because those are the
things that they’re going to ask you to address. – [Dr. McIntyre] As I kind of
got out of my residency training and moved into my career in more community and public psychiatry, it started off with really providing an
integrated treatment team, where you were addressing not
just their medication needs, but what were their social skills needs, did they need housing,
did they need employment, did they need access to food, did they need access to
benefits and whatnot. – [Dr. Olivero] So they may
not have money to have someone help them around, but
if you have a little bit of knowledge about resources
out there in the community, the hospital or other
agencies that may be able to help this person. It’s not just about the
medication or the therapy, they may not even have the
time to sit down with you for a therapy for 30 minutes
in a week or even two weeks, but knowing about what’s
out there available for them may be helpful for yourself
and for the patient. So maybe offering this patient, there may be some services where they can get their laundry done for free, or some information about a food pantry, some free legal counsel, things like that that you may incorporate
into your treatment may help this person, their stressors, and ultimately, their mental health. – [Dr. Swartz] So the final
video talks a little bit about mentoring. Mentoring is a really important aspect of choosing a career, in that it provides some career advice and a reality check about work and what work
conditions will be like. So let’s look at this next
video that illustrates the importance of mentors
and the importance of seeking them out. – [Dr. Pinals] I also
think it’s really important to be exposed to mentors. I would not have taken
the path that I took in terms of my career if I had
not been exposed to mentors who helped me see the value, the interest, the intellectual rigor that goes with thinking about policies and practice with justice-involved individuals. – [Dr. Aoun] I was fortunate
to have several great mentors who’ve really shaped how I think, how I talk about, how I think about issues around the criminal justice system. – [Dr. Lang] I was lucky enough
to have two different mentors, but both of them provided
me with just such a wide range of experience
and wanted to make sure that I saw everything in the field. And that was really
something I owe them a lot, having access to those
different types of experiences, those different settings,
I know we’re talking about justice related populations, but there’s so many
different aspects of those, different settings that
you can practice in, different evaluations you can do, different types of treatment, just getting an idea of what those entail was really valuable and I’m
very thankful to them for that. – [Dr. Aoun] Working with
mentors who’ve been in the field, who are connected to
people in different fields, who’ve worked with the
criminal justice system helps you, one, go over your ideas and figure out what works
and what doesn’t work, and it kind of teaches you a lot of, you’re learning humility from someone who’s been in the field for a long time. You see someone who
you’ve always thought of this person as the smartest person I know. This is someone who’s book
I’ve read all my life, and then to see them interact with the criminal justice
system with a lot of humility, to see them interact with prisoners, to see them interact with people who’ve committed terrible
crimes with a lot of humility, is a great advantage. It teaches you to kind
of be a better person in general and a better doctor. – [Dr. Trestman] You don’t
have to know in exacting detail a project that you want to work on. Rather, if you understand
what you are interested in in a broad domain, that can
help you in an interview, and that’s what you’re really doing, you’re interviewing people
who might become a mentor. You’re interviewing
organizations that you may join as a resident. You’re interviewing
people who you might join as a fellow in forensic psychiatry. And so the more clear you are about what you want, that
immediately elevates you in terms of any competitive advantage, and it will make so much
easier an individual to say I would be
delighted to work with you. – [Dr. Pinals] So, finding
a mentor is a challenge, and I would say I’ve had many
mentors in different ways. So one is, early on as a resident, you sort of look around
and see, oh, I want to be like that person when I grow up. Or I might want to dabble
in what they’re doing. They seem to have an interesting career. And then asserting yourself is part of it, and I find young residents, and myself, it’s hard to knock on someone’s door and say, can I have a conversation? You don’t know if you’re
allowed to do that. I know I have not spoken
to a single psychiatrist of my age or even older
who wouldn’t welcome somebody knocking on their door. So I think younger professionals, early-career psychiatrists,
need to be encouraged to knock on a door for somebody that they’ve seen in the
workplace that’s interesting to them or that might have a career that makes them curious to learn about it. I also think that there’s networks that are available to people. For example, in the American
Psychiatric Association, there’s mentoring networks
that you can tap into. The American Academy
of Addiction Psychiatry has mentoring networks. The American Academy of Psychiatry and Law has some networking opportunities. We started the Women of the
Academy of Psychiatry and Law for young women who are
interested in forensic psychiatry, many of whom are interested
in correctional psychiatry, and in fact, many of whom are working in correctional environments. So there are organizations
that are natural networking environments. I look forward to these meetings. I have a friend group
from all over the country, and so my mentors have
not just been people more senior to me, but
they’ve been this group of colleagues that I sort of established over my lifetime, really, of seeing people on a regular basis, hearing
what each other are doing, and then tapping them, and so your mentor doesn’t have to be
somebody older and wiser, it can be somebody that
you’ve sort of grown up with and has now gained their
experience themselves and you can bounce off each other. – [Dr. Swartz] So, one
of the important aspects of trying to address psychiatrist shortage and maldistribution is
finding other programs such as loan forgiveness
that would address some of these shortages. And one of the things we want to recommend is that in addition to
the existing student loan forgiveness programs
and the identification of physician shortage
areas, we also maybe think about service to this
population as a place for enhancing financial incentives and beefing up loan forgiveness programs or other incentive programs
to this population. But I do want to conclude that, you know, when people think about careers, often they make the mistake about of thinking of a career as a single thing, as a sort of you pick a career, I’m going to do this or
I’m going to do that, and I think for many, many people, what happens is they try something, and what we hope we’ve
accomplished in this webinar is to introduce this idea
of giving working with this population a try and for those of you who have some trepidation, maybe
you don’t jump in initially with both feet, but take a job part-time or for some portion of your time at least, and give it a try. And I think those of us
involved in this webinar think that it will lead
to immeasurable rewards. – [Dr. Lee] I think the
value in psychiatrists having exposure to the population, to developing a deeper understanding, is not just in necessarily
coming to work, specifically, in a criminal justice setting, but also if they’re going to
be community psychiatrists or clinic psychiatrists or even acute care in-patient psychiatrists. – [Dr. McIntyre] So I encourage
early-career folks, think of it. If it’s not going to be your life mission, think of it early on,
because I really think it’s going to make you much better at what you do afterward. – [Dr. Lee] But that those
things that we learn about just to be good doctors
and good psychiatrists are still fundamentally
the most important thing.

Leave a Reply

Your email address will not be published. Required fields are marked *