The Unspoken Contract Between Doctors And Patients: Navigating Mental Illness In The Jail Setting

There exists an unspoken contract between doctors and patients. The patient tells the doctor what is wrong with as much detail as possible, and the doctor uses their knowledge and skills to make the patient feel better. However, this paradigm does not always work.

I am a jailhouse psychiatrist, working with some of the most mentally ill individuals today. Those with serious mental illness (SMI), such as schizophrenia or severe bipolar disorder, often suffer from a lack of insight into their own illness. This means that they cannot understand or be convinced that their thoughts are incorrect, even when faced with evidence to the contrary. This is known as a delusion – a fixed belief that cannot be changed.

The families of these individuals know the pain of trying to talk their loved one out of irrational beliefs. This problem is even more pronounced in the jail setting. Jails deal with individuals at their most acute stage, shortly after arrest. In addition to mental illness, these individuals may also be dealing with intoxication, substance abuse, and withdrawal. They are at their worst, facing the shock of incarceration as well as their usual issues.

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It is my job to assess their situation. As mentioned earlier, the doctor-patient contract is difficult to establish with these individuals, who may be experiencing a variety of mind-altering conditions and may not trust anyone, especially not someone associated with the authority of the jail. I must determine their medical, psychiatric, psychological, and social needs with limited information.

We also have a mental health court that deals specifically with cases where mental illness is a significant factor, requiring specialized services. While this does not excuse a defendant of a serious crime, there is a perception among those without SMI that this will be the case. As a result, some people claim to have mental illness in the hopes of being transferred to the mental health court. Interestingly, those with SMI rarely make this request.

In this context, I must use all the tools at my disposal. I review the electronic medical record, conduct multiple interviews, and observe the individual’s behavior. In a jail, I cannot force someone to take medication, so building a rapport is my only option. With time and compassion, I may be able to convince them to take medication for a few days. This can sometimes be enough to loosen the grip of their illness and allow for improvement. To earn their trust, I must remain compassionate, be honest about what I can and cannot do (such as releasing them from jail, which is only the judge’s decision), and follow through on my promises. Once these things have been established and there is some improvement in their SMI, we can reestablish the doctor-patient contract and work towards remission.

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