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The Experience of Correctional Psychiatry
Patrick Gariety, MD
Psychiatrist at Group Health Behavioral Health Services, WA
Dr. Gariety has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Psychiatrist at Group Health Behavioral Health Services, WA
Dr. Gariety has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: 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.
TCPR: What was locked housing like?
Dr. Gariety: They were typically like what you see in the movies: two-tiered housing units where you walk onto an open area and the perimeter is lined by cells. You walk up some steps, and there is a catwalk accessing the second level. The cells are about 9’ x 6’ single cells with a cot, commode, and a sink. There is a security door with security glass, and there’s a slot that can be opened to pass things back and forth—food trays and other things.
TCPR: Were patients in lockup confined to their cells all day?
Dr. Gariety: Not necessarily. They were entitled to one hour of recreation outside their cell on most days, but for the rest of the day they were locked up except when permitted to shower. They were “rec’ed” (allowed recreation) outdoors, in chain-linked security pens. They submitted to wrist restraints anytime they were escorted from their cells to the rec cage area or to showers. Higher-functioning patients would routinely avail themselves of rec periods outside their cells, but some of the more paranoid and impaired patients took recreation infrequently, if at all. Or, if they’d misbehaved in some way, correctional staff might take it upon themselves to confine them to their cells and not offer them rec. For example, the officers might get fed up if a patient routinely defecated in his rec cage and decide to impose their own discipline, even though the patient wasn’t a danger to anybody—he was just being a nuisance.
TCPR: You mention recreational cages. Are they literally cages?
Dr. Gariety: Yes and no. They’re not as small as what you’re probably envisioning. They’re large chained-link enclosures, topped with razor wire, big enough to jog in a tight circle within it.
TCPR: It sounds pretty frightful.
Dr. Gariety: It is. Prisons are vast repositories of human suffering, which over the past several decades have become de facto asylums for the most seriously mentally ill, typically far removed from their families and communities of origin. Prisons aren’t designed to be therapeutic. In fact the dominance of law enforcement culture exacerbates mental illness (and sometimes, likely causes it) in numerous ways. The best example of this, in my opinion, is its over-utilization of prolonged solitary confinement. A significant percentage of the patients we cared for weren’t sentenced inmates, but rather were civilly committed to federal care. A good number of these civilly committed patients were sufficiently stabilized that they no longer were in need of prison hospital custody, but they couldn’t be released due to a lack of adequate resources in the community, ie, supervised housing—a horrible catch-22.
TCPR: What was the most interesting patient you encountered?
Dr. Gariety: The most interesting patients, by virtue of being so far removed from my prior practice experience, were transgender inmates to whom I provided feminizing hormone replacement therapy (one of my transgender patients castrated herself, in her prison cell, prior to successfully suing the Federal Bureau of Prisons for the right to initiate hormone therapy). The most sensational, vexing, and difficult patients were individuals who engaged in chronic self-injurious behaviors of all sorts: self-cutting, self-impaling, head-banging, foreign object swallowers, and people who stuck foreign bodies up every conceivable body orifice. Water intoxicators (psychogenic polydipsia) were also a big challenge in the prison population I worked with.
TCPR: What are some of the positive aspects of working in the prison system?
Dr. Gariety: The prison asylum I worked in was tough and challenging, but it was also often gratifying work. It offered an opportunity to safely work with very ill patients in-depth in a manner that I can’t imagine in any other practice setting. Treatment extended over months to decades. In terms of continuity and long-term inpatient care, it offered opportunities that are (tragic to say) fast disappearing outside the prison system. I enjoyed the tremendous heterogeneity of the population, and the wide variety of psychiatric problems I was presented with. I relished the fact that I was part of a multidisciplinary care team. I never felt like I was acting alone in the care of our patients. Many of our patients were profoundly personality disordered, and I shudder at the thought of having had to treat them without the benefit of other colleagues’ eyes on the patient and the treatment plan. I find professional isolation to be stressful in and of itself, regardless of how “sick” or “well” our patients are.
TCPR: It sounds like you could really get to know your patients.
Dr. Gariety: I would see nearly everyone on my caseload daily—if only by crossing paths with them while rounding on other patients. This is in contrast with my current outpatient practice, where I see a patient every several months for a 20- to 30-minute med check. Every morning in report, we had all disciplines providing patient updates, so I was always hearing things through other people that allowed me to keep tabs on how my patients were doing. In terms of safety issues, I worry more about the safety of my current outpatients than I did about my prison patients.
TCPR: In what way?
Dr. Gariety: I didn’t worry as much about suicide with my correctional patients. I knew each of them well, and it was a relatively easy and routine thing to put someone on suicide watch. In the community, that’s not at all the case. Perhaps a majority of my outpatients have some degree of suicidality, and I worry about them a lot. So, in terms of stress, it was easier to manage that aspect of the job in the correctional setting.
TCPR: You work in a civilian care organization now—what are some of the key differences from the prison system?
Dr. Gariety: In the prison system, I worked closely with a multidisciplinary treatment team in delivering care. We were given a fair amount of autonomy in making decisions. Insurance companies and billing codes didn’t exist. In my current job, the emphasis is on maximizing productivity and finessing E&M codes to maximize reimbursement. My clinical focus is narrow, and near exclusively relegated to psychotropic medication prescription. It’s more isolating than my prison work, and I find it less interesting. I have little sense of being part of a wider multidisciplinary milieu.
TCPR: Any final thoughts?
Dr. Gariety: The main challenge I faced in working with prisoners was making a human connection with individuals who were used to being treated as less than human, and who typically had no reason to trust anyone employed by the prison. You had to be willing and able to meet them, wherever they were, even and especially in places of rage and hostility. For lots of inmates, this meant our willingness to stop at their cell door each time we passed by, and engaging with respect and genuine concern. This typically didn’t make any dent in their mental illness, and often didn’t do anything to change their chances of getting out of lockup, but it did mean a great deal to them to be treated with humanity. Recognizing the value of this required a shift away from only thinking about patients in terms of cure and change, to the more humbling stance of caring, even with the most clinically hopeless cases.
TCPR: Thank you for your time, Dr. Gariety.
General PsychiatryDr. 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.
TCPR: What was locked housing like?
Dr. Gariety: They were typically like what you see in the movies: two-tiered housing units where you walk onto an open area and the perimeter is lined by cells. You walk up some steps, and there is a catwalk accessing the second level. The cells are about 9’ x 6’ single cells with a cot, commode, and a sink. There is a security door with security glass, and there’s a slot that can be opened to pass things back and forth—food trays and other things.
TCPR: Were patients in lockup confined to their cells all day?
Dr. Gariety: Not necessarily. They were entitled to one hour of recreation outside their cell on most days, but for the rest of the day they were locked up except when permitted to shower. They were “rec’ed” (allowed recreation) outdoors, in chain-linked security pens. They submitted to wrist restraints anytime they were escorted from their cells to the rec cage area or to showers. Higher-functioning patients would routinely avail themselves of rec periods outside their cells, but some of the more paranoid and impaired patients took recreation infrequently, if at all. Or, if they’d misbehaved in some way, correctional staff might take it upon themselves to confine them to their cells and not offer them rec. For example, the officers might get fed up if a patient routinely defecated in his rec cage and decide to impose their own discipline, even though the patient wasn’t a danger to anybody—he was just being a nuisance.
TCPR: You mention recreational cages. Are they literally cages?
Dr. Gariety: Yes and no. They’re not as small as what you’re probably envisioning. They’re large chained-link enclosures, topped with razor wire, big enough to jog in a tight circle within it.
TCPR: It sounds pretty frightful.
Dr. Gariety: It is. Prisons are vast repositories of human suffering, which over the past several decades have become de facto asylums for the most seriously mentally ill, typically far removed from their families and communities of origin. Prisons aren’t designed to be therapeutic. In fact the dominance of law enforcement culture exacerbates mental illness (and sometimes, likely causes it) in numerous ways. The best example of this, in my opinion, is its over-utilization of prolonged solitary confinement. A significant percentage of the patients we cared for weren’t sentenced inmates, but rather were civilly committed to federal care. A good number of these civilly committed patients were sufficiently stabilized that they no longer were in need of prison hospital custody, but they couldn’t be released due to a lack of adequate resources in the community, ie, supervised housing—a horrible catch-22.
TCPR: What was the most interesting patient you encountered?
Dr. Gariety: The most interesting patients, by virtue of being so far removed from my prior practice experience, were transgender inmates to whom I provided feminizing hormone replacement therapy (one of my transgender patients castrated herself, in her prison cell, prior to successfully suing the Federal Bureau of Prisons for the right to initiate hormone therapy). The most sensational, vexing, and difficult patients were individuals who engaged in chronic self-injurious behaviors of all sorts: self-cutting, self-impaling, head-banging, foreign object swallowers, and people who stuck foreign bodies up every conceivable body orifice. Water intoxicators (psychogenic polydipsia) were also a big challenge in the prison population I worked with.
TCPR: What are some of the positive aspects of working in the prison system?
Dr. Gariety: The prison asylum I worked in was tough and challenging, but it was also often gratifying work. It offered an opportunity to safely work with very ill patients in-depth in a manner that I can’t imagine in any other practice setting. Treatment extended over months to decades. In terms of continuity and long-term inpatient care, it offered opportunities that are (tragic to say) fast disappearing outside the prison system. I enjoyed the tremendous heterogeneity of the population, and the wide variety of psychiatric problems I was presented with. I relished the fact that I was part of a multidisciplinary care team. I never felt like I was acting alone in the care of our patients. Many of our patients were profoundly personality disordered, and I shudder at the thought of having had to treat them without the benefit of other colleagues’ eyes on the patient and the treatment plan. I find professional isolation to be stressful in and of itself, regardless of how “sick” or “well” our patients are.
TCPR: It sounds like you could really get to know your patients.
Dr. Gariety: I would see nearly everyone on my caseload daily—if only by crossing paths with them while rounding on other patients. This is in contrast with my current outpatient practice, where I see a patient every several months for a 20- to 30-minute med check. Every morning in report, we had all disciplines providing patient updates, so I was always hearing things through other people that allowed me to keep tabs on how my patients were doing. In terms of safety issues, I worry more about the safety of my current outpatients than I did about my prison patients.
TCPR: In what way?
Dr. Gariety: I didn’t worry as much about suicide with my correctional patients. I knew each of them well, and it was a relatively easy and routine thing to put someone on suicide watch. In the community, that’s not at all the case. Perhaps a majority of my outpatients have some degree of suicidality, and I worry about them a lot. So, in terms of stress, it was easier to manage that aspect of the job in the correctional setting.
TCPR: You work in a civilian care organization now—what are some of the key differences from the prison system?
Dr. Gariety: In the prison system, I worked closely with a multidisciplinary treatment team in delivering care. We were given a fair amount of autonomy in making decisions. Insurance companies and billing codes didn’t exist. In my current job, the emphasis is on maximizing productivity and finessing E&M codes to maximize reimbursement. My clinical focus is narrow, and near exclusively relegated to psychotropic medication prescription. It’s more isolating than my prison work, and I find it less interesting. I have little sense of being part of a wider multidisciplinary milieu.
TCPR: Any final thoughts?
Dr. Gariety: The main challenge I faced in working with prisoners was making a human connection with individuals who were used to being treated as less than human, and who typically had no reason to trust anyone employed by the prison. You had to be willing and able to meet them, wherever they were, even and especially in places of rage and hostility. For lots of inmates, this meant our willingness to stop at their cell door each time we passed by, and engaging with respect and genuine concern. This typically didn’t make any dent in their mental illness, and often didn’t do anything to change their chances of getting out of lockup, but it did mean a great deal to them to be treated with humanity. Recognizing the value of this required a shift away from only thinking about patients in terms of cure and change, to the more humbling stance of caring, even with the most clinically hopeless cases.
TCPR: Thank you for your time, Dr. Gariety.
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