Pioneering Change in Juvenile Correctional Psychiatry

CLINICAL CONVERSATIONS

Elizabeth Lowenhaupt, MD, CCHP

Elizabeth Lowenhaupt, MD, CCHP, the new chair of the National Commission on Correctional Health Care Governance Board, is a board-certified pediatrician, psychiatrist, and child and adolescent psychiatrist. She serves as consulting medical and psychiatric director at the Rhode Island Training School, the state’s only juvenile correctional facility. There she provides direct psychiatric assessments and treatment to incarcerated adolescents and oversees all medical, dental, and psychiatric care for detained and adjudicated youth.

Lowenhaupt is also associate professor in the departments of psychiatry and human behavior and pediatrics at the Warren Alpert School of Medicine at Brown University. She is fully committed to the field, and developed the HOPE (Hasbro Outpatient Psychiatric Evaluations for Justice-involved and At-Risk Youth ) for Justice Clinic to expand psychiatric treatment for youth involved in the juvenile legal and child welfare systems across a continuum of community-based and residential treatment settings.

Psychiatric Times invited Lowenhaupt to share her insights, experiences, top issues facing the field today, and her hopes for the future.

Psychiatric Times: What are the biggest issues in the juvenile justice population today?

Elizabeth Lowenhaupt, MD, CCHP: Patients and families involved with the juvenile legal (and child welfare) systems often are the most vulnerable in our society. They face challenges associated with poverty, housing and food insecurity, trauma, racism, lack of access to health care and education, and more. Individual, family, and community-wide crises (ranging from acute episodes of medical or psychiatric illness, community violence, the pandemic, etc) impact them intensely, and the social service needs are immense.

Challenges to providing medical and psychiatric treatment to youth involved in the juvenile legal system have always included difficulty establishing rapport and trust when the system is often seen as not supportive; maintaining continuity of care when youth are moving from one place to another; and coordinating between agencies and systems to provide comprehensive services. Then there is the issue of stigma and supporting our colleagues in the community to feel comfortable caring for patients who may not fit into the typical treatment models that have been set up for adolescents (eg, not allowing a patient to miss more than a certain number of appointments, excluding patients from treatment programs if they have a history of aggression, lack of comfort providing care to adolescents with substance use disorders, and more).

Psychiatric Times:There has been much talk about the mental health epidemic in children since the pandemic, with increased rates of depression, anxiety, and suicides. How is this playing out in incarcerated adolescents?

Lowenhaupt: Incarcerated adolescents have always had disproportionately high rates of psychiatric illness. Depression, anxiety, and suicide remain major concerns for our patients, as does substance use. Shortages in direct line staff and clinicians have contributed to decreased capacity to manage these disorders for patients while they are in confinement facilities, and finding outpatient services upon their discharge can be extremely challenging.

In addition, there tends to be an ebb and flow in terms of which youth get referred for inpatient psychiatric admissions and which are detained by law enforcement, and availability of inpatient beds does seem to influence this. Whereas most regions and juvenile facilities saw a decline in census during the pandemic, for example, there now seems to be an increase again in part due to the limited availability of alternative levels of care, such as residential or group home treatment.

Psychiatric Times: What does the future look like for adolescents in the justice system?

Lowenhaupt: This is so hard to predict in our current political climate. I would say that in many of our more progressive states, there has been a movement toward less legal system involvement for juveniles, more focus on community-based programming, and preference for prevention/diversion opportunities instead of incarceration. Several of our professional organizations—including the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Society of Adolescent Health and Medicine along with several other non-medical groups—have advocated over the past several years for a federal minimum age for juvenile court involvement (currently states have a wide range of ages and many have no minimum age limit). There is also a growing awareness of the profound effects of trauma and the need for trauma-responsive care.

Psychiatric Times: Are there (should there be) any special considerations when a patient who was formerly in the justice system presents to a new clinician?

Lowenhaupt: Clinicians should ask questions and learn more about their patient’s experience with the legal system, as they do with any other part of the past medical, psychiatric, and social history. As with anything, our patients have had very different experiences—some may have experienced their involvement (including incarceration) as traumatic, while others may have seen it as an opportunity to access resources and support growth. Most will describe some aspect of the experience as a form of trauma that should be explored and addressed along with any other trauma.

This is also a good time to mention the impact of systemic racism on so many of our patients and families. Asking questions, exploring the impact, and offering support and trauma-responsive interventions for patients who are looking for help with this may allow them to share without fear of judgment or stigma.

Psychiatric Tines: What are you most excited about as you take on this leadership role?

Lowenhaupt: Our patients are so resilient, the opportunity to improve the system so exciting, and the people who choose to work in the juvenile legal system are so compassionate and dedicated to the field.

I’m excited to continue to learn from my patients and my colleagues. I’m excited to continue to expand the scope of our expertise to others who have so clearly expressed an interest in working on not only the individual patient care, but also the bigger-picture challenges such as addressing systemic, structural, and institutional racism in the juvenile legal system. So many of our trainees are eager to get involved and make an impact. There is momentum for the work and our patients deserve it!

I’m also really excited to represent the fields of psychiatry, and child and adolescent psychiatry in particular, in the larger field of correctional health care. Right now, in particular, and especially with patients involved in the legal system, behavioral health and wellness represents such a crucial aspect of promoting growth and overall health for our patients. And the best part about working with adolescents is that there is still so much hope for their future—how exciting to be a part of that!

Psychiatric Times: What do you want your colleagues in psychiatry to know about the field?

Lowenhaupt: Our patients who are involved in the legal system—especially juveniles—are mostly the same as our patients anywhere else, with the same social challenges and often systemic racism contributing heavily to where they end up. When they’re coming to us for psychiatric treatment, we should recognize the trust they are putting in us (especially if they have reasons not to trust “the system”) and embrace the opportunity to connect with them in whatever way we can. Although correctional facilities generally have health care services in place—especially those that have achieved accreditation through the National Commission for Correctional Health Care or other similar organizations—they absolutely need psychiatric and behavioral health consultation to provide a healthy and safe environment to patients while they are there.

I hope that my colleagues will reach out to me or the correctional psychiatrists who have treated their patients before and after them so that we can continue to improve the overall quality of psychiatric care, care coordination, and access to care for all of our patients.

Psychiatric Times: What first drew you to the field – both psychiatry in general and the psychiatry in the justice system in particular?

Lowenhaupt: I love stories and systems. Psychiatry allows me to hear my patients’ stories and, for whatever reason, I can tolerate the tough ones. Child and adolescent psychiatry in particular allows me to learn my patients’ stories, help them figure out what they want to have happen next, and then support them in trying to get there.

I feel privileged that my patients share their stories even when they are in the midst of the most difficult chapters, and nothing is better than hearing from an adolescent or young adult that they’ve met their goals despite all of the hurdles along the way. Working with patients within the juvenile legal system allows me not only to support my patients as they write and rewrite their stories, but also to apply my knowledge and experience of the systems they’re navigating to improve the process and the environment so that maybe those hurdles will be a little lower for the next kids.

I respect and value different perspectives not only from my patients and their families, but from the many different types of individuals who support them along the way—from medical, dental, and psychiatric providers to behavioral health clinicians and nurses, from correctional officers and social case workers to superintendents and administrators, from judges to attorneys. As we think about and strive toward a more just and peaceful world for our children, all of us must work together to do what’s best for our patients and our society.

Psychiatric Times: Is there anything else you would like to share? Any work you would like to mention?

Lowenhaupt: I am, of course, grateful to all of my mentors, supervisors, friends, and family who have supported me in this journey. I encourage all of my colleagues and trainees in the field of psychiatry and beyond to follow their passion; work with the patients who bring them the most joy; and seek help and learning as much as possible along the way.

In that vein, I do want to mention that I’ve been taught recently to try to shift the language away from the term juvenile justice system, where so little is just, when we think about who in our society ends up in this world. I appreciate this suggestion, and you’ll notice that I refer to the juvenile legal system because language matters. I welcome further suggestions and ideas for how best to influence this work and our field over the coming year. Thanks so much for the opportunity to share some of my experiences and ideas here.

Psychiatric Times' strategic alliance partner, the National Commission on Correctional Health Care, works to improve the quality of health care in jails, prisons, and juvenile confinement facilities. NCCHC publishes standards for health services in correctional facilities, operates a voluntary accreditation program for institutions that meet those standards, offers certification for correctional health professionals, conducts educational conferences and webinars, and produces other resources.