Good afternoon. Our session today will focus on correctional psychiatry, improving access, safety and efficacy. My name is Bridget Mitchell. I will be your discussant for today, and I will be introducing our presenters. Our first presentation is titled Borderline Personality Disorder and Corrections by Dr. Irene Epstein. Dr. Epstein is a board-certified psychiatrist licensed in Illinois and New York. She is the associate medical director at Insight Plus Regroup. Dr. Epstein earned her medical degree at SUNY Downstate Medical School in Brooklyn, New York, and completed her residency training at Mount Sinai Hospital in New York City. She provides telepsychiatry services to inmates at correctional sites operated by the Illinois Department of Corrections. Our second presentation will be Enhancing Mental Health Services and Correctional Systems through Telepsychiatry by Dr. Hassan Mahmoud. Dr. Mahmoud is a board-certified psychiatrist licensed in Illinois and Massachusetts. He is the medical director and senior vice president at Insight Plus Regroup and is president of the Illinois Psychiatric Society and distinguished fellow of the American Psychiatric Association. He earned his medical degree and master of public health at the American University of Beirut. He worked as a medical officer at the World Health Organization before completing his residency training at McGaugh Medical Center of Northwestern University in Chicago. Dr. Mahmoud holds an academic appointment at Tufts University School of Medicine and has worked in inpatient, outpatient, and consultation liaison psychiatry and telepsychiatry. Without further ado, we'll begin with Dr. Epstein. Hi everyone. This talk will focus on borderline personality disorder in corrections, translating community-based treatments into the correctional setting. Here are our objectives for the talk. We will first review the prevalence of borderline personality disorder, or BPD, in correctional settings. We will discuss the factors associated with borderline PD in corrections. We will identify features of DBT, or dialectical behavioral therapy, that make it a particularly well-suited psychotherapy for the correctional setting. We will also review the literature on DBT for patients with borderline PD in correctional centers, including prisons and jails, and we will examine customizations made to DBT for the prison and jail setting. Some disclaimers, I'm the Associate Medical Director of a telepsychiatry company that provides services in correctional systems, and I'm a telepsychiatrist caring for patients in a state prison. I have no other financial disclosures or other conflicts of interest. So first, let's talk about some features of borderline personality disorder in corrections. Borderline personality disorder is characterized by a sort of stable instability. There is affective, behavioral, interpersonal, and identity instability. Some examples of symptoms that may, well, get someone in trouble with the law include anger, impulsivity, reckless driving, substance abuse, and rageful behaviors towards others. So it's no surprise that there are high rates of borderline PD in correctional settings, and I will say that this is definitely my experience as a telepsychiatrist providing services to patients in a state prison. The most recent estimates show that 25 to 50% of inmates in correctional settings have borderline personality disorder or significant borderline traits. This is relative to inpatient psychiatric units that have about 20% of borderline patients and 10% in outpatient settings. So what are the factors associated with borderline PD in corrections? As compared to other inmates, inmates with borderline are more likely to have experienced childhood sexual abuse, they are more likely to be incarcerated for violent offenses, and they are more likely to have comorbid antisocial traits or personality disorder. Interestingly, inmates with antisocial traits alone are more likely to have committed property crimes, perhaps crimes that are more cool and calculating, and those with borderline alone are more likely to have committed crimes associated with impulsive and physical aggression, so more crimes committed sort of in the heat of the moment. Inmates with borderline PD have higher rates of domestic violence, and this is across genders, and they are more likely to be female, although some recent studies show that there may be less pronounced gender differences in correctional settings relative to the community. So perhaps we should have borderline personality disorder in mind when we treat male inmates who have committed violent crimes. Next, let's quickly review the psychopharmacological treatment of borderline PD. There is no definitive medication that targets borderline personality disorder as a syndrome. Medications are often used off-label to target specific symptoms or comorbid disorders. Additionally, professional guidelines have been contradictory to one another in terms of giving us guidance with regards to medications. If you look to the right, in 2001, SSRIs were considered first-line for affective and behavioral dysregulation, with antipsychotics used for perceptual and cognitive disturbance less frequently. Then, in 2009, a professional guideline advised that psychotropics should be avoided for borderline PD, and more recently, in 2010, the evidence began to point towards the use of second-generation antipsychotics and mood stabilizers for affective and behavioral symptoms, not SSRIs. However, the consensus has always been that therapy is the mainstay of treatment. So let's talk a bit about dialectical behavioral therapy, or DBT, for borderline personality disorder. We all know that DBT is a widely researched therapeutic modality and is widely used for the treatment of borderline personality disorder. The theoretical underpinning of DBT is that borderline pathology develops when there is the combination of emotional vulnerability, so high levels of intense negative emotions that occur quickly and are slow to recede, an invalidating environment, so an environment that does not acknowledge or make room for these intense emotions, and a lack of skills, which is the poor ability to modulate these strong emotions and related behaviors. DBT targets that last component I mentioned, which is skills deficits. According to DBT, change occurs through building skills. So there is a sequential process of skills acquisition, skills strengthening, and skills generalization. This slide details the components of DBT. Perhaps the most important component is group therapy, which is the venue to learn and practice skills. As you see on the right, skills are divided into four modules, mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills. Group therapy lasts for one and a half to two and a half hour sessions and occurs weekly. The duration on average is about 24 weeks. Many programs last for six months to one year. In addition, there is individual therapy, the aim of which is to apply skills to individual situations and it runs concurrently with group and occurs weekly with 60 minute or so sessions. There are also consultation sessions. This is where cases are discussed among team members. Consultation sessions exist to ensure that the principles of DBT are upheld throughout treatment and is also a place for clinicians to speak about challenging cases and get support. These occur weekly and last for about one to two hours. Finally, there is phone coaching. This is when patients can call their therapist for in the moment coaching. The calls occur outside of therapy or individual sessions. I'm reviewing all of the components of DBT just to kind of emphasize that this is a time and resource intensive therapy. Now let's talk about DBT in correctional settings. So among the different psychotherapies for borderline PD, DBT is particularly well suited for the correctional setting. This is because there is a structured approach with clear behavioral target hierarchies and a systematic manner of managing suicidal or aggressive behaviors. This is really important in corrections where safety is paramount. So being able to offer a therapy that prioritizes and effectively manages these sort of very concerning behaviors is very appealing. And just to quickly go through the hierarchy, number one is life threatening behaviors. Then there are therapy interfering behaviors and then quality of life behaviors. So what does the literature say about DBT in correctional settings? To date, there are about 34 unique DBT programs worldwide that have been studied in the literature. 16 of these programs are in adult correctional settings such as prisons and jails, six programs in juvenile detention centers, and 12 in forensic institutions. There are many limitations to the existing studies on DBT in correctional settings. So only 23 of these programs actually evaluated the effectiveness of the programs. Many were not statistically significant due to small sample sizes and only three programs were actually randomized controlled studies. There's also a wide variety of modifications made to DBT and the lack of standardization among the programs. Finally, only three of these programs specifically looked at inmates with the borderline personality disorder diagnosis in the prison jail setting. Most of the programs treated inmates who had a wide variety of problematic behaviors and impulsivity. So next I'm going to talk a little bit about the three programs that specifically looked at DBT for inmates diagnosed with borderline personality disorder. These are all international studies. The first one here is called the Real Understanding of Self-Help Program. This was a study conducted in Australia with male prisoners. The end was 29. The training consisted of 10 weeks of therapy. So there were two hour groups that occurred twice weekly, which is a little bit different from the standard DBT where there was one session held weekly. So a total of 20 sessions. Individual sessions were only held on an as-needed basis. So when issues were inappropriate for group settings, they were discussed in individual settings. There was no consultation team or coaching. The outcome showed that there was a reduction in measures of depression, anxiety, and some qualitative surveys by caseworkers showed that there was improvement in motivation, social and communication skills. Importantly, there's no outcome measures of borderline personality symptoms specifically. The next study is called the Treatment of BPD in Prisons, Findings from the Two Dialectical Behavioral Therapy Pilots in the UK. So this is a study that took place in the UK among female prisoners. And there were actually two different programs. One was a year-long program and another was a 16-week program. So just to review some of the components of this DBT program, there was once weekly individual sessions, again, twice weekly group sessions, again, a little bit different from the once weekly group sessions of standard DBT. The consultation team meetings were not available in the first pilot, but because they proved to be actually really missing, they took place in the second pilot with good results. And interestingly, telephone consultation was available with this program. Some other features included orientation for participants, and there were no modifications to the content noted in this paper. In both the shorter and the longer programs, there were decreased global borderline personality disorder symptoms. So this included impulsivity, improved emotional regulation, decreased frequency, and lethality of parasuicidal and suicidal behavior. The final paper that I want to talk about briefly is called the HOST Program, a Pilot Evaluation of Modified DBT for Female Offenders Diagnosed with Borderline PD. This again occurred in the UK, and the participants were all female prisoners. Interestingly, the program itself was only eight weeks long, and there was this emphasis on shortened programs to ensure there was actual completion of the program, since this is the prison where there were relatively short average lengths of stay. However, if an inmate completed a program that was eight weeks long and was still there, she had the opportunity to complete additional modules. So there were actually five participants who completed three modules of the DBT. Interestingly, also, individual therapy occurred before group therapy. And it also consisted of weekly 15-minute sessions. After individual therapy was completed, there was group therapy, which occurred on a weekly basis, and there was a consultation team meeting that occurred weekly. This program was also associated with positive outcomes, including decreased suicidality, harm, reduction in violence and adjudications, as well as a decrease in global measures of psychological distress. Here I want to emphasize, again, some of the limitations of the DBT studies in general. So there was a lack of standardization among the DBT programs that were customized for the correctional setting. And this might be in part because each setting is really quite unique and has its own sort of requirements, different lengths of stay, different regulatory requirements, and resources. In addition, there were only a few studies and they were uncontrolled, examining DBT for patients specifically with borderline PD. And then finally, although the results of some of these shorter, less intensive programs were generally positive, it's still really unclear if they were delivering a quote potent enough dose of DBT to really actualize behavioral and affective change. So what are some of the challenges of implementing DBT in corrections? Some of these challenges are just the challenges of delivering psychiatric care to patients in correctional settings. So one, there are the clinician shortages, there are insufficient resources, there's also a limited clinician training in DBT, and a lack of regular external supervision to ensure that DBT principles were upheld throughout. There was a good amount of staff turnover and there was frequent removal of participants due to security concerns or because of prison transfers. There were also facility lockdowns, which made it impossible for therapy to occur on any given day. And there's also just a lengthy clearance process to implement studies in many of these sort of bureaucratic structures. Next, I want to talk a little bit about some of the customizations that were made for DBT. So there clearly, there was a lack of standardization among the programs, but there are a few commonalities. So one was the importance of collaborating with custody staff. This is something that most programs made sure to sort of implement in in the program. And the reason it's so important to collaborate with custody staff is because therapy will only occur if it's, if the staff will allow for it to occur, and if it is feasible given all of the rules that govern so much of inmate movement within facilities. It was really important to educate staff about the potential of this therapy to actually improve inmate behavior, and this is to facilitate buy-in. In addition, there were changes to the frequency of sessions as well as the duration of therapy itself. Many programs shortened the overall duration of the therapy, and this is because there was so much movement among certain facilities, and there are shorter sentences in some institutions. So in, say, the jail setting versus a maximum security prison. There are also shorter sessions and changes to the frequency of the group session. So actually two of the papers that I mentioned discussed how their group therapy sessions occurred twice a week instead of once a week, and the group session itself was shortened. So the reason for this is because of, one, limited resources. So to accommodate patients who might have difficulty maintaining attention for two and a half hours, they had to be shortened, and there's just perhaps not the staff available to conduct sessions that were so long. There are also increased frequencies of shorter sessions to hopefully improve retention and interaction outside of cells. In addition, there was a greater emphasis on certain components. So I would say there was a greater emphasis on group therapy, and this is in part because group therapy is shown more recently to be an effective standalone DDT treatment, as well as the fact that in comparison to, say, individual therapy, it's more efficient and more cost-effective. There were some studies that included sequential treatment with individual therapy and then group therapy or vice versa, and this was to reduce demand on the system and its limited resources at any particular time. Coaching, while it was available in some institutions, was generally not as feasible as these other components, nor was it as important, so coaching sometimes just did not occur. There were also frequent customizations made to the vocabulary and examples, so the content of the DDT itself, while at the same time upholding some of the principles. This was to increase relevance to inmates' daily experiences. Sometimes the vocabulary was simplified, made more concrete, and inmate-relevant examples were used. Visual aids and practical examples were also used to optimize comprehension and retention. So in this last slide, I want to emphasize the main lessons learned from pilot programs of DDT in correctional settings, specifically prisons and jails. Many of the programs emphasized afterwards that this pre-treatment orientation to educate staff and inmates was really critical to improve their buy-in and to ensure that everyone is on the same page and willing to sort of cooperate. It proved to be really important to modify the duration of the treatment, the frequency of certain sessions based on average days in the given facility, to ensure that any one program was completed by the participants. It was also really important to have at least one team member that was highly experienced in delivering DDT, and this is sort of for a multiplier effect. This one person who has this expertise can then serve as a consultant for the other clinicians to ensure that DDT principles were being upheld. Consultation meetings proved to be really, really important, and this is, number one, again, to ensure that DDT principles were upheld, to foster quality care, and really importantly, to reduce staff stress. So it is challenging to work in a correctional setting. It is that much more challenging to work in a correctional setting with inmates with perhaps severe borderline personality disorder, and so having that venue to discuss cases and to debrief was really critical in ensuring that the staff was in a good place to deliver care. It was also finally important to kind of know your audience, so it was important to customize the language, the vocabulary, all of the examples that are sort of strewn throughout DDT manuals so that it actually applies to their specific experiences. So I hope many of you can take away some of these lessons learned and have it be sort of a jumping-off place to think about how you would like to best implement changes and care for these, care for our patients with borderline personality disorder in corrections. And here are some references for your review. Today we'll focus on mental health care and correctional systems and enhancing care delivery through telepsychiatry. The objectives of my presentation are to identify the barriers to care in correctional systems, appreciate the role of psychiatry in care, identify the advantages and challenges of telepsychiatry in corrections, discuss optimal implementation of telepsychiatry in correctional settings. With regard to the disclaimers, I'm the senior vice president for behavioral health and medical director of a telepsychiatry company that provides services within correctional systems. I have no other financial disclosures or conflicts of interest. So let's start by discussing the mental health care gap in prisons and jails. As many of you are aware, the prevalence of psychiatrists in corrections is very elevated. According to a Bureau of Justice statistics report about incarcerated individuals reported mental health problems defined as a recent clinical diagnosis and current mental health symptoms. And while different studies have provided different statistics, it is estimated that about 54% of inmates in state prisons have psychiatric conditions. The number is 45% in 64% in jails. Now with such high prevalence, we have several imperatives that really compel us and emphasize the importance of providing care to inmates. The first of these is the legal imperative. The Eighth Amendment of the Constitution states, quote, excessive bail shall not be required or excessive fines imposed, nor cruel and unusual punishments inflicted, end quote. What this means is that correctional facilities are required to provide adequate medical and psychiatric care through governmental or private medical staff. That means that a correctional facility or a correctional system would have to either provide the medical and psychiatric care itself or contract with other parties that are able to provide medical and psychiatric care. In addition to the legal imperative, there's also the ethical imperative. As many of you are aware, many seriously mentally ill persons are displaced from institutions into the community. And many of them unfortunately end up making their way to our legal institutions and eventually get incarcerated. And it is our duty to ensure that their psychiatric needs are met, and that treatment is not interrupted. In addition to these imperatives, it's always important to bear in mind the public health implications of enhancing access to mental health services because a healthier inmate population contributes to safer conditions for both inmates and for staff. Now, the psychiatric care gap in correctional systems is multifactorial. One of the main challenges that we face in enhancing access to care in correctional settings is the nationwide shortage of psychiatrists and other mental health clinicians across the country. In addition to the shortage, we also encounter the uneven distribution of psychiatrists who tend to be distributed on the east and west coasts or in urban centers. On the other hand, many correctional facilities are located in rural areas that are spread across large distances. And many of them also have multiple sites in these rural areas with long travel distances in between them. Another factor when clinicians are weighing whether to provide services in correctional systems are safety concerns among some clinicians. There's concern about physical safety, and more recently with the COVID epidemic, there are concerns about transmission of infectious diseases. Other access challenges for correctional systems include costs. And when we're talking about costs and providing care here, we're going to direct costs of providing care, also other aspects of costs or other aspects of care that to the costs. We have transportation costs for psychiatrists who at times have to travel long distances, either to a particular facility or in between facilities in order to provide care. We're talking about the cost of transporting inmates, inmates who have no access to care on site and the facility often required to go to an offsite facility for care, which can be extremely costly. In addition to it being costly, there's also the staffing requirements associated for the safety of the inmate and for transportation. And add to that the opportunity costs or loss associated with travel time. At times where patients would be receiving care or psychiatrists would be delivering care, a lot of time can be, quote, wasted, end quote, because of travel requirements. And adding to all of this, since it's April 2020, there's the added challenges associated with COVID and the fact that transportation itself carries its own dangers. There have been historically many proposed solutions to bridging the care gap. However, the two most talked about are incorporating correctional psychiatry into medical school and residency programs, and improving funding to recruit and retain rural psychiatrists. And while there has been some improvement in these two areas, these measures have taken a significant amount of time and they do require a significant amount of political will in addition to ongoing funding, which is scarce. Meanwhile, our prisons and jails need more immediate solutions and our inmates need care as soon as possible. Because of that, over the past few years, correctional systems are increasingly turning to telepsychiatry to bridge the care gap. Let's talk about telepsychiatry more generally. First, telepsychiatry is the use of video conferencing and other information and communications technologies to deliver healthcare services remotely. Telepsychiatry has been around since the 1950s. So we have decades of research showing that it is an effective, cost efficient and acceptable method of healthcare delivery. It has been shown to be effective for a variety of patient populations, different age groups, and different clinical settings, including corrections. And it has been shown to have clinical outcomes that are comparable to face to face encounters. Telepsychiatry has been used to treat a wide range of diagnoses, including mood disorders, anxiety disorders, psychotic disorders, trauma related disorders, and substance use disorders to name a few. Telepsychiatry has been used to deliver direct patient care, consultation services, as well as medical education. And studies have shown that video conferencing does not compromise a therapeutic alliance and that it is associated with high degrees of satisfaction among both patients and clinicians. Now, while the adoption of telepsychiatry has been steadily increasing for the past few years, particularly the past two years, the public health crisis resulting from COVID-19 has resulted in exponential and rapid increase in adoption of telepsychiatry. And this is for a variety of factors. One, we have the safety that telepsychiatry provides to both clinicians and patients alike, the convenience of providing remote care, the restrictions on movement and transportation that have discouraged many clinicians and many patients from leaving their home, and significant regulatory and reimbursement changes that have occurred in March and April of 2020 at both the federal and state levels that have really lifted at least many of the restrictions that had been hindering the adoption and expansion of telepsychiatry. Now, telepsychiatry is associated with many advantages within correctional systems. Telepsychiatry improves access to care by drawing from a pool of psychiatrists beyond the county or state where the correctional facility is located. It bypasses the shortage and uneven distribution of psychiatrists and other mental health clinicians in this regard. And by providing more ready access to care, it reduces the backlog and the wait times to be able to receive psychiatric services for inmates. And one of the more crucial aspects of telepsychiatry is its ability to provide on time, in place crisis management within correctional systems, avoiding the need of transporting patients to healthcare facilities. More relevant to the COVID-19 situation is that telepsychiatry ensures continuity of care in the context of lockdown or restrictions on movement during COVID-19. Some of the other advantages of telepsychiatry is its ability to optimize efficiency. It optimizes efficiency by eliminating the need of clinicians to travel, and they can spend that time seeing patients. The other aspect of that is the unfortunate situation of having to transfer inmates outside of correctional facilities into other facilities that provide healthcare services in the absence of a psychiatrist or another mental health professional. The challenge there is that for every inmate who's transported outside the correctional facility, multiple officers often must be present. In addition to the cost associated with that, this may lead to staff shortage in the facility because the correctional officers are pulled away from the correctional facility. And that creates security risks and is overall an inefficient use of scarce resources, both when we talk about human resources and financial resources. The other advantage associated with telepsychiatry is decreasing the healthcare costs. And we're talking here about reducing staffing costs, reducing travel costs, certainly reducing the cost of having to transfer patients to other facilities and reducing the opportunity costs of not being able to see patients due to inefficiencies. One other advantage that telepsychiatry provides is because it increases access to mental health services healthcare facilities, or rather correctional facilities, are able to avoid heavy legal fines that are imposed when the correctional facilities are unable to deliver adequate care to their inmates. So just to recap the advantages of telepsychiatry, for psychiatrists, we're talking about eliminating the need to travel long distances or from one facility to another. The other advantage is insulating the psychiatrist from prison politics and hierarchical structures. It's also an opportunity for the psychiatrist to be able to focus on patient care because they are removed from that hierarchical culture and because they don't have to worry about their physical safety. And so they're able to focus on caring for the patient in a manner that is also efficient and more cost-effective. For inmates, by providing services via telepsychiatry and enhancing access to care, we're eliminating the need to travel from the correctional facility to an outside site to receive care. This way, inmates are able to remain in the facility that they're familiar with. Telepsychiatry via videoconferencing improves safety for all, including for inmates. Because the psychiatrist is perceived to be detached from prison politics and the hierarchical culture, there is a somewhat of a greater trust in clinicians who are not beholden to the pressure of that culture when they're delivering care remotely. And so inmates are more likely to confide in them and establish a better rapport. And finally, with the enhanced access to care, what we're seeing is improved and more timely treatment for inmates, which ensures continuity of care and avoids the deterioration and symptoms that would occur when patients do not receive the care that they need. So next, let's talk about correctional telepsychiatry with regards to the challenges that we face. Historically, we've encountered many challenges when trying to implement telepsychiatry programs in correctional systems. One of the challenges that we face that's not necessarily correctional related, but more has to do with telepsychiatry, but of course applies here, is licensure. With telepsychiatry, the psychiatrist must still be licensed in the state in which the patient is located. In addition to that, many correctional systems also require that the psychiatrist be licensed in the state where that psychiatrist is located if that state is different from the state where the patient is located. This unfortunately may deter many psychiatrists from applying or going through the process of obtaining multiple licenses because these processes can be time consuming, burdensome, and costly. In addition, it might cause significant delays in start dates. Over the past couple of years, we've witnessed some positive changes. The most prominent for psychiatrists and medical doctors in general has been the Interstate Medical Licensure Compact, which is an expedited path for licensure for physicians who meet certain qualifications. Some of these qualifications include being board certified in their specialty, not having a criminal record, not having medical legal, ongoing medical legal issues, and several other qualifications. The nice thing about this pathway is that say I'm licensed in the state of Illinois and I would like to be licensed in the state of Idaho. These states are compact states. I am able to request a letter of qualification from Illinois and have that sent directly to the state of Idaho. Once Idaho receives the letter of qualification, they're able to process a license application fairly quickly and sometimes within only a couple of weeks. Right now, 29 states as well as the District of Columbia and the Territory of Guam are taking the compact and this number has been increasing gradually over the past couple of years. In addition, what we're witnessing right now with the COVID-19 epidemic is that many states have either waived requirements for licensure if someone is licensed in another state or have developed their own pathways of expediting licensure applications in order to facilitate delivery of care. Some of the challenges that we've encountered when implementing telepsychiatry programs in corrections have been technological in nature. See, many correctional sites have aging infrastructure. Were built many years ago. Many of them tend to be these older correctional, sorry, concrete structures in rural locations with limited connections when it comes to high-speed internet. But also even when they are connected to high-speed internet, the thick concrete wall make the signal, the Wi-Fi signal hard to get. In addition to this challenge, we also face a lack of electronic health record systems in many cases, which unfortunately make the process of documentation and exchanging patient information difficult and challenging, in addition to it being inefficient. We make it work when we need to, particularly using encrypted email and other HIPAA-compliant ways to exchange PHI. But overall, it makes the process less efficient. And with these challenges, we notice a perception, or rather a misperception, that these challenges are insurmountable for adults. As they can delay it and require some work when it comes to implementing telepsychiatry programs, but overall, we still successfully. The other challenge we encounter is cost. And it's true that telepsychiatry programs require initial costs that can be thousands because of the need to develop or purchase software, hardware equipment, significant infrastructure. However, many studies have demonstrated that long-term costs are reduced with telepsychiatry programs. And we're talking about costs associated with transportation to outside facilities, talking about costs with providing care early on and preventing symptom deterioration, improved health outcomes, and the overall decreased utilization of other healthcare services. And the last challenge I'll talk about when it comes to implementing telepsychiatry programs in correctional systems is the bureaucracy. Many correctional systems are these large systems, and larger systems tend to have a significant amount of bureaucracy. However, with correctional systems, there's also the added layer of the political aspects of making decisions. And there's also the added layer of the bureaucratic aspects of making decisions and changes, as well as legal mitigation factors that are unique to the setting and that tend to dictate many of the decisions, even when it comes to healthcare services. These factors contribute to delays in implementation. So even when there is political change or expenses to care or legal rulings from lawsuits that do require expanding access to care, change takes a significant amount of time. Another challenge that we've encountered when implementing telepsychiatry in correctional systems has been personnel changes. Unfortunately, we've seen that some in-house staff have the perception that telepsychiatrists are outsiders or telepsychiatrists do not care for inmates or do not have the interest in providing services at the time where the telepsychiatrists that we work with are very dedicated to serving the inmate population and very interested in providing care. It's just that there are so many other barriers that we talked about earlier that may prevent them from traveling to the correctional facility to do so. However, even with very dedicated telepsychiatrists, at times we still encounter that there are fewer opportunities for interaction with the rest of the mental health team and other staff like correctional officers. And there is still some misconceptions about the ability of the telepsychiatrists to provide care, about the efficacy of the services. And there is a general belief that still persists today, less so than compared to before, but it just, it still is a lingering belief that face-to-face communication and video conferencing may differ in quality and depth compared to in-person. And what we found is that integrating telepsychiatric clinicians directly into correctional systems and in a manner that ensures high collaboration with the local care team is key to success. When we're talking about an integrated approach to care, we're talking about an approach that ensures that the telepsychiatrist is really an integral member of the treatment team. And that ensures collaboration with correctional officers, other members of the mental health team, nursing staff, primary care physicians, and other specialists. And in order to ensure that, we employ a resource called a telehealth provider, really a systematized and open communication with staff that is often on a daily basis, in the sense that we have our telepsychiatrists have huddles before they start seeing patients and after seeing patients in order to align different team members on the same priorities and on treatment plans. And we found that one very useful way in order to enhance this integration is to have the telepsychiatrists train onsite, tour the facilities and meet the staff that they will be collaborating with. So when we talk about optimizing telepsychiatry, there really are different approaches to doing so. It's important for us to have an organizational ethos of providing the best care possible and having that ethos really dictate the way we implement telepsychiatry programs. It's very important that we have a collaborative approach to care. And it's very important with that collaborative approach to have clear reporting structures, a process by which clinicians report different concerns, escalate issues, and ensures that immediate challenges are addressed. And as I mentioned, it's very important to have regular check-ins and communication protocols between different team members to ensure timely relay of corroborative information. When we're talking about inmates receiving care via telepsychiatry, I think it's very important that we educate inmates on telepsychiatry in part of the informed consent approach in the sense that inmates should be educated about the kind of services that will be provided, especially when it comes to mental health services they will be receiving, but also the mode of delivery of these services in order for them to be able to make an informed decision about their care. In addition, particularly in correctional settings, it's important to assure inmates about the confidentiality and security associated with these telepsychiatry sessions that are conducted via video to ensure that they know these videos are not recorded, that the content of the conversation will not be shared except for treatment purposes. Interestingly enough, we find that in many sites where we provide services, many inmates are more likely to be granted a private room than when they are receiving in-person care. And it's important to ensure continuity of care and to avoid fragmentation of care when delivering telepsychiatry. One of the added advantages of delivering care remotely is that we often are able to continue to provide care to the same inmate, even if transferred within that same correctional system from one part of a prison to another or from one site to another, which I think is amazing. Finally, I would just like to leave you with some thoughts about optimal implementation of telepsychiatry programs in correctional settings and the factors that contribute to the optimal implementation. First and foremost, it's very important to have political will. Political will is the main factor that will drive change within correctional systems. And it is to a large degree what determines whether there is funding for any telepsychiatry programs. Funding is essential in order to enhance the infrastructure, to purchase the technology and be able to implement the program. And it's important along with that to have organizational and staff buy-in. One way to do that is to conduct significant training and education for all team members, including clinicians, staff members, and inmates. Correctional officers, I should emphasize, are key staff members in this context. And finally, it is essential that the telepsychiatry services are provided in a manner that is integrated, that ensures open communication and accountability of different team members and that ensures continuity of care. These are some references for further. ♪♪

correctional psychiatry

Borderline Personality Disorder

BPD

dialectical behavioral therapy

DBT

telepsychiatry

mental health services

correctional systems

treatment outcomes