I am a forensic psychiatrist in private practice. A significant proportion of my practice involves evaluating mental health systems in jails and prisons throughout the United States, which are involved in class action litigation concerning the constitutional adequacy of the mental health services available to incarcerated persons with serious mental illnesses. These cases involve multiple on-site assessments, which generally require 2 to 4 days per visit.
When not on the road, my professional activities include a small outpatient practice, a general forensic psychiatry practice, and various teaching opportunities. As the associate director of the forensic psychiatry fellowship program at the University of Colorado Health Sciences Center, I have regular contact with our forensic fellows during their six-month rotation in an adolescent sex offender treatment program. Each forensic fellow accompanies me on one of my out-of-state prison monitoring trips. I also provide supervision to the fellows relevant to forensic evaluations. I teach several classes to our general psychiatry residents and fellows in addiction psychiatry relevant to forensic issues.
As a member of the School of Medicine's committee on senior clinical appointments, I review applications of clinical faculty members from all departments for promotion purposes.
My involvement with national psychiatric organizations has been primarily with the American Psychiatric Association, the American Academy of Psychiatry and the Law (AAPL), and the American Board of Psychiatry and Neurology, Inc. (ABPN). As chairman of the APA council on psychiatry and law, I have different levels of involvement in important areas impacting the practice of psychiatry. These areas have recently included the Health Insurance Portability and Accountability Act (HIPAA) guidelines relevant to research ethics, gun control legislation and the mentally ill, cybermedicine, and amicus briefs to the United States Supreme Court.
In addition to being a senior examiner for the ABPN oral examinations, I am also a member of the ABPN's forensic psychiatry recertification committee. Consequently, I am generally writing or reviewing forensic board examination questions periodically throughout the year.
I have provided the above summary of my academic activities in an attempt to explain why I am unable to provide in this essay an example of an actual typical day in my practice. However, I will summarize a composite week of my professional activities.
During the week I will be out-of-state for three days in order to monitor a correctional facility's mental health system's progress towards compliance with a federal court-ordered remedial plan, which is designed to result in a constitutionally adequate mental health system. These three days will usually involve 27 hours on site at the prison or jail, and another 16 hours of travel time.
The first day of the site visit, assuming that I had previously reviewed this jail or prison, will focus on obtaining an update concerning the status of the mental health system at the particular correctional facility. Information will initially be obtained concerning current staff allocations and vacancies, use of locum tenens clinicians, and mental health caseload statistics (e.g., total numbers, numbers by housing unit, diagnoses, level of care). If this very basic information is difficult to obtain, I know that I am in for a long day because such difficulty will generally reflect significant system problems.
By the end of the first day I will have identified areas that need to be further assessed. I will then work with the mental health and correctional administrators to establish a schedule during the next two days for interviewing caseload inmates, correctional officers, line mental health staff, and obtaining various documents and records.
The most interesting part of this work is talking with inmates, which occurs in settings ranging from "supermax" to "general population" medium security housing units. Depending on circumstances, these interviews may be conducted in a group setting, on an individual basis, or via a "rounds" (i.e., cell to cell) process in a locked down housing unit (e.g., disciplinary segregation housing). A straightforward, respectful interviewing approach with inmates (and staff) facilitates obtaining useful information in an efficient manner.
Not surprisingly, information obtained from inmates is often not reliable. Health care records, incident reports, correctional records, and other documents need to be reviewed in order to assess the accuracy of the information obtained from inmates. This necessary review is one of the more tedious elements of site visits.
An exit interview is scheduled for the last day of the site visit in order to provide feedback to the correctional and mental health staffs concerning the progress achieved towards compliance with the remedial plan. A large amount of information needs to be synthesized and presented in a fashion that will promote continued progress toward providing a constitutionally adequate mental health system.
+Table 1 provides a common schedule for a site visit assessment.
My laptop computer, which contains a very functional speech software program, has become an indispensable part of my practice and facilitates my ability to manage my workload in many different cities. The willingness of my colleagues to constantly provide coverage for me during my travels has been essential and appreciated.
When in my office in Denver, I treat a small number of outpatients and complete a larger number of different types of forensic evaluations. My teaching activities and intermittent school of medicine committee work are scheduled during these days as well.
My correctional psychiatry work has been very rewarding from an academic perspective. Correctional psychiatry helped to establish the subspecialty of forensic psychiatry to be recognized by the American Board of Medical Specialities. I have been able to help develop national guidelines for providing mental health services to incarcerated persons with serious mental illness, which has improved correctional mental health systems nationwide. Correctional mental health systems are one of the few public sector systems where the community mental health system has been successfully implemented because needed resources have often been court mandated.
The friendships and availability of key full-time faculty members and my private practice office colleagues for consultation purposes and general support have been very important to my professional development and career satisfaction. The longstanding relationships that have evolved from my involvement with the APA, ABPN, and AAPL have been equally important for me.