Supporting Our Patients, Supporting Ourselves

By William Elliott, PhD, Correctional Mental Health Consultant and Trainer

Physicians, nurses, mental health professionals, and other health care employees who work in jails and prisons must contend with sometimes manipulative and noncompliant patients, subordination to custody and security priorities, and a suboptimal physical environment. Inability to overcome these obstacles results in high levels of workplace stress, elevated risk for burnout, and early departure from the field. This article summarizes some of the findings and recommendations developed for a recently submitted research article.

Be Realistic and Firm

Correctional health professionals should establish realistic expectations regarding patient treatment compliance and symptom improvement. Expect patients to lie or distort information, malinger medical and mental health conditions, and demand goods and services that are contraindicated. For example. medications will be taken inconsistently, hoarded for later misuse, or sold to other patients. Exercise considerable patience with patient progress or lack thereof and measure it in short-term increments. Anticipate significant strong negative reactions to recalcitrant patients and be able to closely examine and work through those reactions so service delivery is not undermined.

Patients will inevitably test your willingness to offer special accommodations, prescribe unnecessary medications, and otherwise bend the rules. Under relentless pressure, some health care providers acquiesce to unreasonable demands and gain a reputation as a pushover. Alternatively, those who establish and enforce realistic limits grudgingly earn patients’ respect and solidify credibility with other staff members.

Avoid Power Struggles

Some patients remain in perpetual denial of their psychological or medical condition and forcefully resist any effort to persuade them to comply with a prescribed treatment regimen. Futile efforts often deteriorate into emotionally heated and unproductive arguments and debates. Try to avoid or mitigate self-defeating and unproductive power struggles with patients. Toward that end, employ indirect strategies, rather than direct confrontation.

I recommend using the 3 Rs: redirection, relabeling, and reversal of responsibility to effectively manage patient resistance to therapeutic interventions:

• Redirection temporarily moves the discussion to a noncontentious and emotionally neutral subject.
• Relabeling reframes the issue as something different from that under debate.
• Reversal of responsibility indirectly challenges the patient to examine the purpose of his or her opposition to treatment.

Maintain Boundaries

Attempts by patients to penetrate a correctional health professional’s interpersonal boundaries are inevitable and, if not effectively managed, can result in serious adverse consequences for the health care professional (but seldom the patient). It’s critical to remain vigilant for any indication of a boundary intrusion. Three ways to mitigate the risk for boundary violations:

(1) Make a clear distinction between friendliness and familiarity
(2) Limit self-disclosures to only those necessary for professional service delivery
(3) Refrain from even casual reference to sexual matters

Sadly, failure to adhere to these guidelines can result in criminal charges (e.g., sexual misconduct or contraband introduction), employment termination, loss of professional licenses, divorce, and other adverse outcomes.

Maintain Objectivity

Correctional health professionals sometimes blame themselves and/or react with intense anger when they are successfully duped or conned by patients seeking some secondary gain. Additionally, it’s easy to personalize unfavorable therapeutic outcomes even if the reason was the patient’s noncompliance with or resistance to the treatment protocol. Such reactions are neither reasonable nor helpful, so it is important to learn how to depersonalize a patient’s manipulation and failure to respond to treatment. Methods of doing so include openly discussing one’s thoughts and feelings with a trusted friend or colleague, challenging the irrational beliefs underlying the self-blame or retaliatory impulses, and adopting an attitude of healthy skepticism regarding patients’ self-reported treatment compliance or symptom improvement.

Work Within the System

Jails and prisons operate as paramilitary organizations dominated by rules and regulations, preoccupied with records and reports, and bound by tradition and precedent. Correctional health professionals who struggle to adapt to such a bureaucratic structure and elect to “fight city hall” become frustrated, discouraged, and burned out. A more prudent approach is to work within environmental constraints in the service of patient advocacy and quality improvement. Specifically, establish close and cooperative working relationships with security officers who create a safe and orderly environment within which health care professionals can deliver services, provide rich and reliable patient information, and facilitate patient access.

Take Care of Yourself

Health care professionals, especially those employed in forensic settings like corrections, suffer a higher level of workplace stress than that found in any other occupational sector. Consequently, they are more likely to manifest symptoms of burnout (e.g., exhaustion, cynicism, decreased personal efficacy), which can precipitate early exit from the field. Traditional coping strategies such as reducing workplace stress, eating healthy snacks, and engaging in exercise are usually helpful. I also recommend one or more of the following evidence-based based interventions for managing work-related stress and mitigating burnout risk: progressive muscle relaxation; meditation; stress inoculation training; mindfulness; yoga; tai chi; and positive psychology interventions.

The adoption of these strategies for successfully navigating the correctional environment and effectively coping with its attendant stress will enable correctional health professionals to deliver high quality services to complex and challenging patients and maintain a healthy work-life balance.

William Elliott, PhD, is a consultant who frequently works with NCCHC Resources. For information on staff training and improving the quality of health care systems, contact [email protected].