Wednesday, April 16, 2008

Telepsychiatry at TYC: Can you imagine [a psychiatrist] having a paranoid person and telling them, 'Talk to the TV screen!'

Arriving home a couple of hours in, I've been listening to the TYC oversight hearing at the Texas Lege for the last hour or so, and a telling discussion arose about the lack of specialized treatment frequently ordered by courts for serious offenders.

While capital offenders mostly get the treatment they need, the committee was told, other serious offenders do not. In response to questions from Rep. Sylvester Turner, it came out that only 40% of sex offenders sentenced to TYC receive the treatment that courts order for them.

However, because limitations on state resources caused the youth to not receive treatment, the youth are not penalized and kept in the system longer, explained the attorney leading the release committee (who, in a small-world moment, it turns out was a roommate of mine in a past life, though I've not spoken to her for many years - Hi Karen!). Instead, they're evaluated based on their progress in what's been dubbed the "transitional" treatment program. (The new "Connexions" treatment program is being piloted at the Al Price unit in Beaumont, and it could take as long as 15 months to roll out system-wide.)

Part of the problem is that TYC does not employ enough psychiatrists - they pay for the equivalent of 5.5 full-time psychiatrists per week, a substantial portion of which is done through "telespsychiatry." Corsicana, the "mental health" unit for TYC, only gets 34 psychiatrist's hours per week, and TYC pays for about 220 hours total system-wide. That seems really low for a system with around 2,500 troubled kids!

This is an issue where I'm 100% with Sen. Whitmire; I've never understood exactly how you provide psychiatric services over the TV. During an aside, Whitmire wondered to Chair Jerry Madden,while waiting for a witness to arrive, "Can you imagine [a psychiatrist] having a paranoid person and telling them, 'Talk to the TV screen!'"

No kidding! From what I've heard of telepsychiatry in Texas prisons and jails (I've called telemedicine the "physician's version of fast food") the whole system seems pretty minimalist.

I was also interested to hear estimates that TYC's population may decline to less than 2,000 by the end of the year, a trend I'd predicted in a public policy brief last fall on changing TYC policies. (To those who scoffed - I'm talking to you Plato - hah!)

I came in on the middle of a fairly intense discussion, and I'm going to go back to listen to the full hearing later, but the discussion of mental health shortages and the failure to provide court-ordered sex offender treatment really jumped out at me. I wonder what those local judges think when TYC releases those kids without having received the treatment they ordered? Since TYC controls both the release decision and the parole division, I guess the judges don't have much say. Maybe others who know more about all this can better explain how that works? Why hasn't some judge already just ordered TYC to provide more treatment ... by telegraph or pony express, if necessary?

MORE: See initial coverage of the hearing from the Dallas News, from KXAN-TV, and from AP.

36 comments:

Anonymous said...

Telemedicine is just a way around the lack of sufficient medical staffing in confinement facilties.

"Telepsychiatry" is a legal means of providing meds for the inmate Patient without physical interaction with the psychiatrist. Money talks and bovine excretion walks.

Managed health care is and smells like bovine excretion.

Retired 2004

Anonymous said...

Could someone summarize what transpired at the TYC oversight hearing today? Any fireworks?

Also, I would suggest that we stop to reflect on this tendency to blame our problems on Whitmire. He wasn't the one who got us (TYC) in this mess. We may never face up to how we got in this mess (facing the facts has never been the TYC way, has it?) but blaming Whitmire will only allow the Senators to see how stuck we still are in that same old sorry pattern. By now that pattern has worn pretty thin with many members of the state Senate and House.

If you know what happened today, please let the rest of us know.

Anonymous said...

There is a shortage of licenced sex offender treatment providers in Texas, and the youth commission cannot compete for their services. That's the reason why we are lucky to 40% in. Same with LCDC's. Hard to come by.

Anonymous said...

Well Grits, for once, you may be correct.

Plato

Anonymous said...

I have always wondered how Telepsychiatry was ethical. However, the example by Whitmire is really ignorant. In reality a clinically paranoid youth would not likely be at one of the facilities using telepsychiatry. Youth with mental health needs at these facilities are of the outpatient variety, typically stable on their medications and if they are not stable the facilities waste no time to send the youth to Corsicana for an extended evaluation.

In terms of treatment the state has really screwed itself with sex offenders and TYC. Sex offender treatment must be provided by licensed sex offender treatment providers. TYC is still claiming an exemption to this which expires in a year or two. Don't know the exact date. There are not enough treatment providers thus making those who are fully qualified able to demand a high salary, putting them out of reach of TYC.

It is my understanding that County judges really have no authority over the youth's treatment once the youth is committed to TYC. TYC has limited resources and tries to provide it to those who need it most and who are most likely to benefit. There are alot of youth released to parole with sex offender treatment requirements.

dirty harry said...

Basically, you only need psychiatrists when there is medication involved. What TYC needs are some good counselors, therapists, and psychologists. But, they won't even pay for those, either.

Anonymous said...

Whitmire doesn't know what he's talking about (gee...what a surprise) when he criticizes telepsychiatry. Telemedicine can work very well IF you have competent psychiatrists. IN fact, since the legislature put these facilities in such remote places, telepsychiatry is just about the only way youth in those remote places can get psychiatric services.

Anonymous said...

Old Whit, is determined to shut down CRTC. He just keeps on and on about CRTC and how unsafe it is, because of the trees. He has it in for Corsicana for some reason. Wonder who ticked him off!

psyguy said...

I think there is a basic misconception of what the psychiatrists do at play here. As a psychologist in a facility, I can promise you that psychiatrists aren't providing 50 minute therapy sessions. If they were, then Whitmire's comments/concerns about telepsychiatry might be worth discussing further.

However, psychiatrists only provide 5 to 15 minute medication reviews. They review medical files and talk with the youth and their psychologists and caseworkers about the youths behavior and psychiatric symptoms. The focus is on whether or not the medication is helping and if there are any side effects. Medication adjustments may be made if indicated.

They are required to 'see' the youth physically to assess side effects. Telepsychiatry works well to provide 'face-to-face' consultations in a very cost effective manner in rural areas.

Anonymous said...

For the person wondering who ticked Whitmire off regarding CRTC, it wasn't a TYC staff it was his old friend Ms. Pope. She wanted the youth moved from CRTC because some kid got up in a tree one time. Her solution was to move them all to another facility where there were no trees. She must have put a lot of thought into that decision, mentally ill youth in a sterile correctional facility. I am sure that would have helped them.

Anonymous said...

To 4/17/2008 06:44:00 AM: Are you employed by UTMB Managed Care?

How many patients a day does the psychiatrist "see"? How many days a month is the psychiatrist scheduled AND completes the schedule (observes all the youth via the TV)?

Retired 2004

Anonymous said...

Another question for psyguy: If the psychiatrist prescribes new meds during the TV interview; when (how many days will pass) before he/she again observes the youth?

Retired 2004

psyguy said...

No, I'm not connected to UTMB.

Again, Psychiatrists aren't providing the treatment, they are managing the medications. Big difference.

The number of days they are at a facility (either in person or remotely) really depends on how many youth are on medication. Most often, they are available once per week for medication changes.

They should 'see' a youth once per month when the youth is stable on medication. More often when the youth is placed on new medication or medication adjustments are being made.

Again, I can't say what happens everywhere. I can only speak about my personal experience. I have worked at HHSC, and MHMR before that, as well as TYC.

Anonymous said...

Gosh psyguy, I thought Medication was a part of the treatment. So I guess the psychiatrist isn't part of the treatment team in TYC? Interesting, very interesting.

Retired 2004

Anonymous said...

I know when they "should" see the patient, I was asking when(or if) they did.

Retired 20404

Gritsforbreakfast said...

Somehow I don't find it comforting to hear a professional opinion that a psychiatrists' treatment of a psychotic or bipolar patient amounts to a five minute video conversation, concluding, "Yup, still crazy," then prescribing more meds. That sounds like warehousing of the worst sort, and if it's not medically unethical then I wonder what level of neglectful care would be?

Anonymous said...

Grits: Psychiatrists do not provide the treatment. Psychologists do. Psychiatrists deal with the medication issues. This is the case in any medical setting. Psychiatrists are not counselors etc., they essentially give a medical exam. Once a person has been placed on medication, a routine medicine check only takes a 15 to 30 minute appointment to ask the person how they are doing on the medication.

TYC has at least one pyschologist and 10 to 20 or more case workers at every facility. It is these folks job to observe the youth, interact with them, document their behavior, and counsel them.

The division of care between the psychiatrist, psychologists, and other counselors is industry standard.

Gritsforbreakfast said...

Well, by all means, if it's "standard" I guess it's not warehousing, then. (?)

The fact that most psychiatrists have become drug dealing quacks with little real function beyond pill peddling is it's own, separate issue outside the scope of this blog's purview. But TYC's mental healthcare is inadequate overall, and getting worse, and I think overreliance on telemedicine has a big role in that.

Anonymous said...

Gee Scott, that was awfully crude. What the hell happened to taking it easy on the name-calling, and what about the stereotyping? Funny, You never struck me as one of those liberal a-holes that don't practice what they preach.

Gritsforbreakfast said...

Sorry 'bout that, though if crude it's an essentially accurate description of a modern psychiatric work. They're prescription machines, just as you describe. But what's the point of a psych M.D. if the job can be done in five minutes, and everybody already knows what the meds are for schizophrenia, bipolar, etc.? That's a racket, IMO.

The final straw for me on viewing this profession as wholesale legal drug pushers actually came recently, when they released the studies saying SSRIs didn't work, coincidentally, just as the patents expired and generics become available. But low and behold they've got a new round of (patented) drugs you can try. How many tens of millions of Americans did psychiatric drug pushers con into taking an expensive placebo? How much faith am I really supposed to have in such pseudoscience?

Anonymous said...

Question for 7:18 PM: The "10 to 20 or more case workers at each facility" have what qualifications? Are they MSW's, Masters Level Psych Majors? What is their job title? Are they Case managers with a high school education or some general college subjects? are they clinicians or "paper pushers" (fill out the forms, answer the offenders questions concerning visitation, phone calls, how much more time wil he have to do before he can go home)?

Based on your statement concerning psychiatrists don't treat; only medicate; does this mean that Child Psychiatrists only medicate children??? Please! Psychiatry is the study and TREATMENT of mental diseases.

During the early 1990's I was the supervisor of a maximum security Intermediate Mental Health Treatment Facility for convicted adult felons. I saw first hand what type of treatment these people received. I thought it was lacking but the majority of the treatment personnel did the best they could with what they had to work with (I'm not talking about the inmate patients, I'm talking about the part time phychiatrists).

Industry Standard? We are not talking about objects, we are talking about human beings. I believe the term "National Standard" is used by true care-givers.

Retired 2004

Anonymous said...

Whitmire is talking to the wrong group. The psychiatrist by telemed is provided by UTMB and are in charge of it on the facilities. The psychologist have to cowtow to the infirmary for any help.
Supposedly they were going to take over the psychology department and casework under medical treatment being part of pyschology...but with no signed contract, the kids get what they get.

Anonymous said...

I just have to jump into the psychiatry debate here. I'm a psychologist and I have worked with a lot of caring and competant psychiatrists throughout my career. It is true that their role in mental health treatment has become focused mostly on diagnose and medicate - because there is a need for that in many cases, they are the only ones who can do it, and that is all most insurance/agencies want to pay them for. I know some (mostly older)psychiatrists who are wonderfully trained in psychotherapy - but when you are expected to see 20+ patients a day, only see a given patient every few months, yet you still want to do something to help, then a good diagnosis and appropriate medication may be the best you can do. I do believe that medication is/was over-relied upon in TYC, often by well-intentioned psychiatrists who don't have the time or opportunity to do anything else and who realize that there are not enough other trained mental health staff, such as psychologists or social workers to help the youth either. Yes - the system is broken, but don't lay it all on the psychiatrists. I think telepsychiatry is a poor substitute and should be an option of last choice. But if you need a way to manage psychotropic medication in a rural setting that has no local psychiatrist, it may be better than nothing. Especially if there are some competant psycholoigsts and social workers on-site who can collaborate with the psychiatrist and provide those treatment elements you cannot provide by video. Psychiatrists aren't the problem nor is telepsychiatry. They are tools. Like any tool, they have their place. It's relying on them in situations where they don't fit or where there are better tools available that causes the problem. That's a management issue.
>Don Brantley

Anonymous said...

Easy Don; I know there are professional mental health care-givers working their butts off, attempting to provide treatment, regardless of how inadequate it is. As you stated the system (?) is broken.

You alluded to the cold, hard facts of mental health treatment in a Texas State Agency: medicate, medicate, medicate!

If the patient is incarcerated another cold hard fact that over-rides treatment is bed space. Isn't it amazing how someone that required acute care suddenly can be transferred back to an intermediate care bed (or sometimes even back to general population!)?

Psychiatrists are getting paid to provide the meds and the psychologists/treatment team members are going along to get along. And that my friend is leadership and ethical issues, NOT just poor management.

Let's just have a nurse turn on the tv and camera, give a local, and stitch the old neck up after a self inflicted injury. I mean it isn't the best but what the hell;it's better than nothing!

Retired 2004

Anonymous said...

Will having UTMB over ALL treatment be a better option? A cheaper one? Both?

Anonymous said...

11:44, I think the answer is NO to both questions. Moving mental health care under UTMB will only further the divide between those providing "treatment" and those providing "custody." For proper rehabilitation, these processes need to be integrated. Furthermore, UTMB is a medical-model agency. Their focus will be on specific treatment interventions for specific youth with identified medical diagnoses. Those without a medically treatable diagnosis may not be considered their responsibility (watch how the contracts gets written). Rehabilitation services for behavioral and social problems, the largest issue for TYC youth, is usually not a priority in the medical model. I also don't see how they can save money without reducing services/providers significantly. UTMB could not get away with paying psychiatrists or psychologists what TYC currently pays them - it would not be internally consistent. I'm not saying paying them more is a bad idea, it just isn't the way to save money unless you spread them even thinner (say by only serving those with clear mental health diagnosis and getting to decide yourself who has that diagnosis vs. who is just "conduct disordered"...)

>Don Brantley

Anonymous said...

I find it interesting to note the tangential nature of this discussion. The original questions were why is TYC not providing sex offender treatment and is there enough psychiatric services available to adequately provide for the youth of TYC. I think the second question is too colored by my opinion as a psychologist. I think they play too much of a role. The first question is much more interesting to me

The sex offender treatment issues is not just a TYC issue but also a TDCJ issue. The State of Texas passed legislation that requires anyone providing treatment for sexual offending behavior to be specifically licensed for that therapy. It does not matter that I am a psychologist or a psychiatrist or any other treatment provider to treat a sexual offender I must be licensed to do so and perform a specific type of treatment. Many professionals object to this and have examined evidence that reveals that completion of these prescribed programs are not useful in predicting sucess. So why do we have to be licensed to perform a treatment that the evidence suggests does not work?

Anonymous said...

Let's look at this truthfully.......

Thought you might like to know. A psychologist with TYC only make $36,000 per year (starting). It requires a master's degree and a license within 2 years. We all know what getting a raise is like, so that's about as much as they make. PA's make more (starting), and truthfully, most JCO VI's make more. You want treatment??? Pay them more. Right now, Mart is down about 7 psych's. I understand, why would they want to work at TYC when there are a lot of places that will compensate for their education and license. You get what you pay for. Oh yeah, then they have to be ADO, on call, and all the regular work too.

Anonymous said...

Sorry, I would take an Associate Psych Job over PA any day of the week.

I agree that given the current profession that a pay raise would be appropriate but PA's tend to shoulder far more responsibility.

Anonymous said...

In reference to the sex offender treatment issue, the real problem is that the licensing scheme of the Sex Offender Treatment Council has so restricted license professionals that enough licensed sex offender treatment providers do not exist in Texas and will not for the forseeable future.

As to UTMB taking over anything, they can not adequately handle TYC medical care on a cost plus basis.

Howard A. Hickman

Anonymous said...

Well, I work at the Mart Unit and I can tell you that the staff of the sex offender treatment center are jokes. They are not licensed and they are abusive and never show up for there kids. The black lady that was sent from San Saba is a complete and ignorant joke and is very abusive to those kids and broadcasts they business around so they end up beat up. TYC is a joke in the way of treatment but the judges are too. Somebody go and look at the kids in the treatment and 15 months to roll but extended they stay because TYC can't get it together - they need to be sued.

Anonymous said...

Watch the magic number of 1000 youth with "mental health issues" be magically reduced should UTMB gain control of psychology (the referral source).

Anonymous said...

The UTMB contract will be out soon and then you will see what this has all been about.
Money! = Managed Mental Health Care

Anonymous said...

Grits, sorry, got a laugh out of your "quote." While many kids in TYC have a myriad of disorders Schizophrenia is generally not one of them.

If a TYC kid suffers paranoia it is generally well earned from living on the streets and fending for themselves. If any of the youth in TYC were to develop the paranoia to which you imply it wouldn't likely be until after there release from TYC.

Most of the youth who need serious psychiatric care are often a result of years of emotional, physical, and/or sexual abuse. Often these youth may be suffering from symptoms of PTSD but too often because the symptoms are similar the youth may be diagnosed with Bipolar so he/she can be treated with mood stabilizers and anti-depressants. This only treats the symptoms but not the source of the problem, the years of abuse.

TYC is not equipped to provide the treatment these youth need, unless you have some truly talented csws.

I really don't see a problem w/ tele-psychiatry since it TYC historically had trouble finding adequate psychiatric care at all of the facilities. It was a creative solution to meet a need TYC was having a difficult time meeting.

The question for each youth really is... are the the youth of TYC accurately diagnosed (diagnosing is more of an art than an exact science) and then are they receiving the appropriate Mental Health treatment.

Anonymous said...

9:48, What makes you say that the UTMB contract is almost out? Are they working on a new one?

Anonymous said...

Some of the best psychiatrist TYC ever had have left in the last 3 years due to the rumors of a UTMB takeover. If that doesn't speak loudly I don't know what does. Managed mental health care is not in any way an improvement. They will dictate what meds can be used and how much time is allowed for treatment. The bill will go up for this care and the treatment will go down. Who will pocket the money?