Working inside the walls

This chapter is a pragmatic discussion of the experience of working as a psychiatrist in correctional settings, whether jails or prisons. To work inside the walls, the psychiatrist must come to terms with the realities of the correctional setting in order to be secure, satisfied with the work, and clinically effective. There is no monolithic correctional culture. Each system and facility has its own unique culture and has evolved in some degree of isolation, emphasizing different philosophical approaches to the correctional mission and to criminal causation. This chapter examines the context in which clinical work is embedded: physical environment and security, correctional culture, personal safety, typical stressors, and individual liability. It is clearly not for everybody but the rewards can be tremendous. The quality of care in many facilities, especially prisons, is superior to care in the community. The clinical problems are unendingly fascinating. And, despite its downsides, having a setting with limited access to drugs that provides food, clothing, shelter, and medical care can allow a degree of patient improvement that may be difficult to realize in the community. Opportunities for creativity in treatment and program development are unparalleled. In many ways, correctional psychiatry is poised to lead the way in the treatment of some of the most ill and behaviorally disordered members of society.