Conflict Resolution in Corrections

When I meet one of my prison patients for the first time and introduce myself, the response I sometimes get is, “So, what can you do for me?” This question is a natural segue to explore the goals, parameters, and limitations of the therapeutic relationship. A good therapeutic relationship is important in any clinical practice, but in the correctional setting it’s particularly important, because a poor or adverse relationship can lead to noncompliance, bad medical outcomes and even violence. Therapeutic relationships in jail and prison are difficult to create and maintain for several reasons.

The physician-patient relationship is inherently imbalanced; in a jail or prison there is the added complication that the patient has no choice of provider and constrained treatment options. An inmate may believe that treatment recommendations are driven solely by the financial interests of the physician, or that an intervention is being recommended simply to protect the physician from litigation. Correctional patients are more likely to be cognitively limited, mentally ill, or poorly educated, which can compromise the physician’s ability to explain treatment options and risks. Prisoners may hold values or priorities that differ from that of the clinician. For example, an inmate may decline needed medications or treatments if this would prohibit him from participation in rehabilitation programs or institutional work assignments. A prison culture that values strength and independence might stigmatize an inmate who feels a need to talk to a therapist. Finally, the therapeutic relationship in jail or prison is time-limited and occasionally disrupted by institutional transfers.

Clinician factors also can affect the physician-patient relationship in prison. An inexperienced physician may be intimidated by a patient who directly threatens him, or who implies a threat of violence or litigation. Experienced clinicians face the risk of therapeutic nihilism with prison patients who are repeatedly noncompliant or demanding. Extra patience is required for working with prisoners who value immediate relief over longterm improvement, or whose risk-taking tolerance is higher than that of the clinician. Cultural differences between the physician and the prison patient also affect the relationship, when the prisoner values family or “outside” advice over the advice given by a trained medical professional.

The physician’s imperative is to act in the best interests of the patient, even when this conflicts with the patient’s stated interests or desires. The goal of the correctional clinician is to retain patient trust while building patient self-reliance and personal responsibility.

Much has been written about the physician-patient relationship, but in general there are three predominant models: the paternalistic model, the autonomous or informed consent model, and the shared decision-making model. The paternalist model requires the physician to be the sole decision-maker, with the patient as the passive recipient of medical advice. The autonomous model places the patient (or “consumer”) at the focal point of treatment while the physician plays a peripheral service-provider role. Most medical encounters today employ the shared decision-making model, in which an informed and educated patient makes a decision about treatment with the trusted guidance of a physician.

A collaborative physician-patient relationship can be created through the use of decision aids, such as patient education materials and practice guidelines. Some facilities already use education-appropriate, culturally informed pamphlets for patient education regarding sexually transmitted diseases and other medical illnesses. Similar materials could be adapted for use by correctional psychiatrists. The physician-educator can explain the use of disease-specific practice guidelines when making treatment recommendations, so that the prisoner can understand that recommendations are consistent with best professional practices. Finally, allowing the inmate time to consider the decision and seek advice from family members can create a feeling of autonomy and responsibility in the treatment process.

With some adaptation in current practices, correctional health care need not be an adversarial process.

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

When I meet one of my prison patients for the first time and introduce myself, the response I sometimes get is, “So, what can you do for me?” This question is a natural segue to explore the goals, parameters, and limitations of the therapeutic relationship. A good therapeutic relationship is important in any clinical practice, but in the correctional setting it’s particularly important, because a poor or adverse relationship can lead to noncompliance, bad medical outcomes and even violence. Therapeutic relationships in jail and prison are difficult to create and maintain for several reasons.

The physician-patient relationship is inherently imbalanced; in a jail or prison there is the added complication that the patient has no choice of provider and constrained treatment options. An inmate may believe that treatment recommendations are driven solely by the financial interests of the physician, or that an intervention is being recommended simply to protect the physician from litigation. Correctional patients are more likely to be cognitively limited, mentally ill, or poorly educated, which can compromise the physician’s ability to explain treatment options and risks. Prisoners may hold values or priorities that differ from that of the clinician. For example, an inmate may decline needed medications or treatments if this would prohibit him from participation in rehabilitation programs or institutional work assignments. A prison culture that values strength and independence might stigmatize an inmate who feels a need to talk to a therapist. Finally, the therapeutic relationship in jail or prison is time-limited and occasionally disrupted by institutional transfers.

Clinician factors also can affect the physician-patient relationship in prison. An inexperienced physician may be intimidated by a patient who directly threatens him, or who implies a threat of violence or litigation. Experienced clinicians face the risk of therapeutic nihilism with prison patients who are repeatedly noncompliant or demanding. Extra patience is required for working with prisoners who value immediate relief over longterm improvement, or whose risk-taking tolerance is higher than that of the clinician. Cultural differences between the physician and the prison patient also affect the relationship, when the prisoner values family or “outside” advice over the advice given by a trained medical professional.

The physician’s imperative is to act in the best interests of the patient, even when this conflicts with the patient’s stated interests or desires. The goal of the correctional clinician is to retain patient trust while building patient self-reliance and personal responsibility.

Much has been written about the physician-patient relationship, but in general there are three predominant models: the paternalistic model, the autonomous or informed consent model, and the shared decision-making model. The paternalist model requires the physician to be the sole decision-maker, with the patient as the passive recipient of medical advice. The autonomous model places the patient (or “consumer”) at the focal point of treatment while the physician plays a peripheral service-provider role. Most medical encounters today employ the shared decision-making model, in which an informed and educated patient makes a decision about treatment with the trusted guidance of a physician.

A collaborative physician-patient relationship can be created through the use of decision aids, such as patient education materials and practice guidelines. Some facilities already use education-appropriate, culturally informed pamphlets for patient education regarding sexually transmitted diseases and other medical illnesses. Similar materials could be adapted for use by correctional psychiatrists. The physician-educator can explain the use of disease-specific practice guidelines when making treatment recommendations, so that the prisoner can understand that recommendations are consistent with best professional practices. Finally, allowing the inmate time to consider the decision and seek advice from family members can create a feeling of autonomy and responsibility in the treatment process.

With some adaptation in current practices, correctional health care need not be an adversarial process.

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

When I meet one of my prison patients for the first time and introduce myself, the response I sometimes get is, “So, what can you do for me?” This question is a natural segue to explore the goals, parameters, and limitations of the therapeutic relationship. A good therapeutic relationship is important in any clinical practice, but in the correctional setting it’s particularly important, because a poor or adverse relationship can lead to noncompliance, bad medical outcomes and even violence. Therapeutic relationships in jail and prison are difficult to create and maintain for several reasons.

The physician-patient relationship is inherently imbalanced; in a jail or prison there is the added complication that the patient has no choice of provider and constrained treatment options. An inmate may believe that treatment recommendations are driven solely by the financial interests of the physician, or that an intervention is being recommended simply to protect the physician from litigation. Correctional patients are more likely to be cognitively limited, mentally ill, or poorly educated, which can compromise the physician’s ability to explain treatment options and risks. Prisoners may hold values or priorities that differ from that of the clinician. For example, an inmate may decline needed medications or treatments if this would prohibit him from participation in rehabilitation programs or institutional work assignments. A prison culture that values strength and independence might stigmatize an inmate who feels a need to talk to a therapist. Finally, the therapeutic relationship in jail or prison is time-limited and occasionally disrupted by institutional transfers.

Clinician factors also can affect the physician-patient relationship in prison. An inexperienced physician may be intimidated by a patient who directly threatens him, or who implies a threat of violence or litigation. Experienced clinicians face the risk of therapeutic nihilism with prison patients who are repeatedly noncompliant or demanding. Extra patience is required for working with prisoners who value immediate relief over longterm improvement, or whose risk-taking tolerance is higher than that of the clinician. Cultural differences between the physician and the prison patient also affect the relationship, when the prisoner values family or “outside” advice over the advice given by a trained medical professional.

The physician’s imperative is to act in the best interests of the patient, even when this conflicts with the patient’s stated interests or desires. The goal of the correctional clinician is to retain patient trust while building patient self-reliance and personal responsibility.

Much has been written about the physician-patient relationship, but in general there are three predominant models: the paternalistic model, the autonomous or informed consent model, and the shared decision-making model. The paternalist model requires the physician to be the sole decision-maker, with the patient as the passive recipient of medical advice. The autonomous model places the patient (or “consumer”) at the focal point of treatment while the physician plays a peripheral service-provider role. Most medical encounters today employ the shared decision-making model, in which an informed and educated patient makes a decision about treatment with the trusted guidance of a physician.

A collaborative physician-patient relationship can be created through the use of decision aids, such as patient education materials and practice guidelines. Some facilities already use education-appropriate, culturally informed pamphlets for patient education regarding sexually transmitted diseases and other medical illnesses. Similar materials could be adapted for use by correctional psychiatrists. The physician-educator can explain the use of disease-specific practice guidelines when making treatment recommendations, so that the prisoner can understand that recommendations are consistent with best professional practices. Finally, allowing the inmate time to consider the decision and seek advice from family members can create a feeling of autonomy and responsibility in the treatment process.

With some adaptation in current practices, correctional health care need not be an adversarial process.

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.