Jeffrey L. Metzner, MD, the 27th President of the American Academy of Psychiatry and the Law (AAPL) is very well known in forensic circles for his remarkable contributions to the practice of forensic psychiatry, his publications and achievements, and especially for his pioneering explorations and influences on correctional psychiatry. The impact of his involvement in correctional systems has been unparalleled for identifying and assessing the interface of correctional and custodial practices with the mental health needs of those incarcerated persons in the United States. This treatise is very limited because to write about or paint a portrait of this exceptional psychiatrist is a daunting task that would require far more space and elaboration than permitted here. The Journal began the tradition of publishing biographies of presidents of the organization in 2000. Although Dr. Metzner’s presidency tenure was from 2000 to 2001, the biography was not written. I am very honored to have been asked to remedy the omission and provide my thoughts about this remarkable psychiatrist and colleague.⇓
Jeffrey L. Metzner, MD
I learned of Dr. Metzner from reading several of his publications1,–,6 and his continuing involvements in the American Psychiatric Association (APA), AAPL, American Board of Psychiatry and Neurology (ABPN), and the National Commission on Correctional Health Care (NCCHC). We first met in 1996 when we became court appointed psychiatric experts in Coleman et al. v. Wilson et al.,7 a class action litigation case in California. We subsequently served on the examination and question-writing committees for forensic and general psychiatry board examinations. His expansive knowledge of both traditional forensic topics and correctional challenges was both impressive and illuminating. As I prepared this biography I became genuinely impressed by my colleague’s trajectory and truly remarkable professional activities and commitments.
The Constitutional requirements for adequate health care from Estelle v. Gamble (1976),8 and Bowring v. Godwin (1977)9 have been challenging for correctional institutions and systems to implement since the U.S. Supreme Court rulings. Dr. Metzner has pioneered (and continues to do so) in many of these systems directly and through his publications, teaching, and consultations to assist and instruct not only correctional systems but also the courts, legislators, advocates, clinicians, and others, as will be briefly referenced in this document. History and “his story” demonstrate that Jeffrey Metzner, MD has been involved with more correctional systems than any other psychiatrist in known history, including as a service provider, consultant, advisor, expert, and monitor. I asked how he has managed these experiences and maintained his own functioning, and what advice and recommendations he has for others. Appreciating many of these subjects requires some understanding of the course of his professional life and details regarding his early life experiences.
Background
Dr. Metzner is very private when it comes to his personal life, early years, and background, and yet for all of us who know him or of him, those early years are of interest for their influence on his approach and commitment to embracing the assessment and treatment needs of many of the most vulnerable and underserved among us: individuals involved in the criminal justice system. Those individuals who are incarcerated in jails as the criminal justice system processes proceed, and those incarcerated as sentenced prisoners constitute the only groups of individuals required and entitled to adequate health care, including mental health care.
Jeffrey L. Metzner was born in 1950 and grew up in Hagerstown, Maryland as the second of five siblings. He recounted some of his experiences in Hagerstown, in a very conservative rightwing county of approximately 30,000 residents that George Wallace carried in his run for the U.S. presidency. Experiences with discrimination were not uncommon as his family was one of approximately 100 Jewish families in the county.
Dr. Metzner described his upbringing with his family in Hagerstown in more detail. His father was in the scrap metal business and both he and his brothers worked in scrapyards. His mother was a nurse. His brother Stephen was exactly two years older and attended the University of Maryland. Jeff followed him and left college after three years, having been accepted to the University of Maryland School of Medicine. He was subsequently one of about 10 first-year medical students accepted in the Combined Accelerated Psychiatry Program (CAPP). As part of the program, Jeff did a summer rotation at the Spring Grove State Hospital. He was only one year behind Stephen in medical school and described the two brothers sharing an apartment together, as well as sibling rivalry that actually helped the two brothers to grow closer, with Stephen showing his younger brother the ropes. Jeff added that in 2022 he received the University of Maryland Honor Award and Gold Key from the Medical Alumni Association, nominated by his brother, Stephen. Their younger siblings were to become successful as an attorney (Lewis), a CEO of a metal recycling business (Jack), and an owner and executive recruiter in the engineering and architectural fields (Carol). Jeff exuded pride in his parents for their influence on their children and his father for having paid for all their educational pursuits.
While a resident in psychiatry, Dr. Metzner met a young nurse, whom he described as beautiful, very competent, very confident, and having “no interest” in dating a physician. After serious efforts to convince Linda Wurpel, the two became a couple and married. Subsequently, their son Dylan was born, and the young family remained based in Colorado after his residency. Linda, while having the lion’s share of home parenting, as Jeff was on the road frequently, went on to receive her JD, a master’s degree in psychiatric nursing, and established her career as a knowledgeable and powerful nursing administrator.
The Emerging Psychiatrist
Dr. Metzner was both forthcoming and humble in describing the experiences that led to his long- standing status as an “expert” in the field of forensic psychiatry and his expansive career in correctional psychiatry. He noted his preference for the term “correctional” versus “carceral,” although he understands the reasons for such a change. During our discussions, he made numerous references to the mentors and colleagues who provided opportunities for him to learn from others and how they have shaped the trajectory of his career.
Jeff received his MD from the University of Maryland Medical School and completed his psychiatric residency at the University of Colorado’s Department of Psychiatry. He has written extensively on the psychiatric care of incarcerated persons in jail and prison populations.10,11 He has provided consultation to judges, special masters, monitors, state departments of corrections, city and county jails, the U.S. Department of Justice, the National Prison Project, Homeland Security, and others involved in the field of correctional psychiatry in over 40 states and territories. Throughout his career, Dr. Metzner has been and continues to be an active member at the national level in the APA, AAPL, and the ABPN. He currently serves as Clinical Professor of Psychiatry at the University of Colorado School of Medicine in Denver, Colorado. He continues to be sought after as an expert witness, monitor, and consultant, but is selective in the number of jurisdictions to which he will devote his time and talents.
His approach to monitoring systems in court-ordered consent judgements, settlement agreements, or other court orders is very precise and methodical. We became members of a team of clinicians, attorneys, and administrators to attempt to assess, evaluate, consult, and report our findings to the Special Master and ultimately the court. Jeff quickly established a standard for the rest of the team for efficiency, thoroughness, and timeliness for this process, affectionately earning the nickname “Terminator” because of his no nonsense approach and technical skills. As I became more exposed to different systems and the incredible variability in both understanding and responsiveness to incarcerated individuals living with mental illness and behavioral challenges and the earlier reality that psychiatrists and mental health professionals were “guests in the houses of corrections,” the need for a balanced yet firm approach was clear. The histories and practices regarding heath care, and more specifically mental health care, were a far cry from what we see today and what is required regarding standards of practice, credentials and licensure of staff, and quality management and information systems, as well as liaison services to corrections staff. Dr. Metzner and others were at the forefront of making these essential and necessary changes realities. Alan Stone, MD, very well known in forensic psychiatry, nominated Dr. Metzner for the Isaac Ray Award in forensic psychiatry and in addition to detailing several of Jeff’s achievements and accomplishments, wrote this: “Dr. Jeff Metzner is, in my opinion, the central figure in correctional psychiatry in the entire United States and one of the preeminent experts in the World.” Dr. Stone continued “Jeff Metzner does the kind of work that few of us are willing or qualified to do and does it with impressive professional integrity. He is making a difference.”
The Accomplished Expert
Dr. Metzner received the Isaac Ray Award in 2008 and continued to be immersed in forensic and correctional psychiatry as a prolific writer, reviewer for numerous journals and publications, clinical professor at the University of Colorado Departments of Psychiatry and Pediatrics, examiner for the ABPN (and its predecessor, the American Board of Forensic Psychiatry, Inc.), and multiple honors from the APA, ABPN, the National Alliance on Mental Illness (NAMI), universities and others, including the Megargee Distinguished Contribution Award by the International Association for Correctional and Forensic Psychology. Dr. Metzner was also the corecipient, with Robert Trestman, MD and Kenneth Appelbaum, MD of the Manfred Guttmacher Award by the APA and AAPL in 2016 for their book, the Oxford Textbook of Correctional Psychiatry.12 Dr. Metzner has authored or coauthored 34 book chapters, 35 peer-reviewed articles, and numerous newsletter articles and book reviews.
Obviously, no one person is responsible for these changes over time, and in my view, if Dr. Metzner did not change the landscape from “guests” to “essential and necessary participants” at the decision-making table in correctional systems, he was certainly one of the initiates to move the seat of psychiatry to the table as valued members. This culture change from “suffered inclusion” to essential and valued membership in correctional mental health and policy decision-making by psychiatrists and other mental health professionals now helps to form the necessary bedrock for adequate and humane care.
Dr. Metzner described his interactions and learning experiences from several mentors with fondness and reverence. He met his first mentor, Dr. Jonas Rappeport, and became introduced to forensic psychiatry while still in medical school at the University of Maryland. Dr. Rappeport was a very well-known forensic psychiatrist and Dr. Metzner reflected on this meeting and introduction as one of the key moments in his career. During that time, George Wallace was shot by Arthur Bremer and Mr. Bremer pled not guilty by reason of insanity. Dr. Rappeport was one of the two main psychiatric experts to examine Mr. Bremer and medical student Metzner was exposed to forensic psychiatry in that high-profile case. Although he had not initially considered psychiatry for residency training, he attributes this and other experiences as affecting his decision to attend the psychiatric residency training program at the University of Colorado.
Jeff pursued his career in general and forensic psychiatry and his travel schedule became quite remarkable. Traveling to over 40 states and territories, Jeff could clearly be referred to as the Johnny Cash of correctional psychiatry, as his mantra could be the song lyrics “I’ve been everywhere, man, I’ve been everywhere!”13 In addition, as he became more involved with correctional facilities and systems, the deficiencies became more apparent and Jeff collaborated with several individuals and organizations to identify and assess these systems and develop standards and position statements that have become the benchmarks upon which psychiatric and mental health care in corrections have been consistently based.6,14,15
Dr. John Macdonald was a faculty member during Jeff’s residency and became a mentor to him. Dr. Macdonald is most renowned for his articulation of the triad of “unfavorable prognostic factors” (childhood fire setting, cruelty to animals, and enuresis) (Ref. 16, p 130) and his profiling of serial killers.17 This influence would have very relevant connectivity to Jeff’s understanding and interactions with incarcerated individuals.
In addition, during his residency in Colorado, Jeff was able to complete an optional year as one of the doctors on the forensic division at the state hospital, which inspired him to explore and become a member of AAPL. Jeff reports he was inspired by the welcome he received and the exposure to established experts and cutting-edge education around forensic psychiatry over the years.
After his residency, Dr. Metzner worked with another mentor, Dr. Brandt Steele at the Kempe Center at the University of Colorado. This opportunity included working with individuals at the forefront of understanding the battered child syndrome and Jeff was invited to serve on a child protection nationwide consultation team.
During our years working with Jeff, I and other members of the team had the good fortune to work for the court under the direction of the appointed Special Masters, J. Michael Keating, Esq., and subsequently Matthew A. Lopes, Jr., Esq. Both men developed exceptional and comprehensive teams and encouraged our socializing and developing an effective and sustainable team culture. During this time, I met his wife Linda and son Dylan. Our friendships and comradery developed over the years, and it became quite clear that Linda provided the “balance, support, and love” for Jeff. Most of us in this business have come to understand the crucial importance of our support systems in helping us to remain healthy and committed to the remarkable challenges that are abundant and unique in working with the populations behind the walls, both incarcerated individuals and those responsible to provide constitutionally adequate mental health care.
Dr. Metzner reflected on many of the challenges encountered in assessing correctional facilities early in his career that included only minimum written standards, guidelines, policies, and procedures relevant to mental health care and systems in jails and prisons. He identified the most significant problems at the time as establishing these written criteria, recruitment and retention of qualified staff, and changing the correctional culture. He described his experiences in correctional facilities with sheriffs, wardens, and line officers who emphasized their missions: this is “not a hospital,” “this is jail,” or “this is prison.”
Dr. Metzner explained that while there are many concerns that have been similar for both forensic and correctional psychiatry, including problematic physical plants, irrelevant or insufficient programming, and inadequate staffing allocations and vacancy rates, forensic hospitals typically have fewer of these problems, except in states where there are not enough forensic beds to meet the needs of individuals awaiting judicial determinations of competence to proceed to trial. Unfortunately, these delays result in extended stays in jails for individuals who need evaluations and may need hospital level of care.
Dr. Metzner described his experiences and particular concerns regarding some of the unique problems in corrections and mental health. Even before the COVID-19 pandemic that affected the world, achieving adequate staffing of correctional officers, sheriff’s deputies, and administrative and support staff was problematic. There were similar challenges with recruitment and retention of multidisciplinary clinical staff, including psychiatrists, psychologists, nurses, licensed professional counselors, social workers, occupational therapists, rehabilitation therapists, and others depending on the size, mission, and population of the institution. These challenges increased during the COVID-19 pandemic. Dr. Metzner emphasizes the crucial requirements for staff members working toward licensure in their relevant fields, such as ongoing training and supervision, and an adequate quality management system to measure and improve performance.
Dr. Metzner detailed his extensive career in correctional psychiatry, yet he has also been involved in various forensic cases. We discussed his role as an expert witness in Colorado v. Connelly,18 which focused on Miranda questions involved in the forensic psychiatric examination performed by Dr. Metzner. He advises forensic examiners to only engage in cases within their area of expertise, document carefully and thoroughly their findings, opinions, and basis for those opinions, and anticipate that their reports and testimony will be critically reviewed. He advises the inclusion of as much information in reports as possible while keeping it readable. He encourages clinical professionals to consider that answers are not always clear, and they need to be prepared to articulate the potential opinions, and why they decided as they did.
Current and Future Challenges
Dr. Metzner has been a long-standing advocate to address what he says are the top two interrelated challenges to providing mental health care to incarcerated individuals: suicide and restrictive housing (segregation or isolation).
He described restricted housing, depending on the system, as comprising anywhere from four to seven percent of all housing in correctional facilities. Although this is a relatively small percentage of total bedspace and individuals, over 50 percent of all the suicides in corrections occur in restricted housing. Dr. Metzner focuses on the utilization and conditions of confinement in restricted housing and the impact on individuals living with serious mental illness or experiencing a mental health crisis. He recalls his early days of working in corrections when 50 to 60 percent of the people in segregation (“the hole”), and more recently restrictive housing units (RHU), were on the mental health caseload. Largely because of the combination of litigation and, equally important, the standards established by professional health and mental health organizations (e.g., the APA and recently NCCHC, as well as other professional associations), there are now standards to limit or prohibit placement of individuals with serious mental illness in restricted housing for prolonged periods of time. Dr. Metzner recounted his experiences with Jamie Fellner, Esq.19 and others in working to create and develop standards through position papers and subsequent Task Force Reports by the APA20,21 and other national organizations involved with correctional mental health care.
Implementation to limit the use of RHUs has been controversial in many systems because of concerns for staff and institutional safety in using more ethical methods to manage incarcerated individuals who are disruptive or threatening to staff and other incarcerated individuals. Dr. Metzner emphasizes the need for clear policies and procedures, behavioral management interventions, and adequate treatment of possible underlying mental health conditions. He continues to advocate for “changing the conditions of confinement to more humane conditions.”
Dr. Metzner recognizes the challenge for practitioners and encourages them to reference and use the standards to advocate for change in correctional systems and inform administrators when the use of restricted housing for prolonged periods is below the standard of care set by the APA, the NCCHC, the World Health Organization, and other correctional and international organizations. Dr. Metzner maintains that eliminating restrictive housing would significantly decrease the rate of suicides. He referenced Lindsay Hayes, who has devoted his career to suicide prevention and has shown that an adequate institutional suicide prevention program that is successfully implemented can significantly reduce the rates of suicide in corrections.22
Dr. Metzner has identified and written about the need for standards, policies and procedures, and provision of adequate mental health treatment within correctional facilities, as well as the need for diversion of arrestees and detainees and the use of probation at the early stages of the criminal justice process. He further stresses the need for adequate discharge planning and increased numbers and adequacy of community programs to facilitate ongoing treatment for people living with serious mental illness after release.
During our discussions, Dr. Metzner responded to my questions about how and what an ideal system would be. He said the originally conceived elements of the community mental health system model, which has varied in implementation in the community, often related to inadequate funding, can actually be implemented in a jail or prison setting. Such elements include a psychosocial rehabilitation approach via a full range of levels of mental health care: outpatient, residential (i.e., special needs), crisis stabilization units, inpatient psychiatric care, and a consultation liaison approach with custody staff to develop a more humane environment.
The failures to implement the full range of mental health services that should be available in the community, but are frequently under-resourced, are challenges for clinicians who want to advocate for community diversions and postrelease aftercare. Dr. Metzner is clear: “You shouldn’t have to go to jail to get adequate mental health services.” He added, “but if you have to be in jail, there have to be adequate mental health services for your needs.”
Dr. Metzner expressed his thoughts regarding some of the conflicts between advocating for diversion of people with mental illness from jail involvement contrasted with how poor community mental health resources are in many communities. In some cases, the jail can more consistently provide a structured setting and adequate mental health services.
Dr. Metzner emphasizes that to develop and implement an adequate community mental health system model in corrections there are some basic assumptions. The first expectation is that about 75 percent of people on the mental health caseload in the correctional setting are going to be receiving outpatient treatment. The outpatient treatment model must have proper mental health staff resources and an adequate physical plant to assure both sound confidentiality and safety for all involved.
Regarding the delivery of inpatient care, larger systems should have their own inpatient units. For smaller systems, there should be an arrangement with the forensic division of the state hospital for a limited number of beds. In Dr. Metzner’s experience, 10 to 15 percent of the caseload need a special needs level of care or a special residential level of care within the jail. These special needs levels of care, if provided, will reduce the demand for inpatient beds. Finally, Dr. Metzner identified the need for crisis or infirmary care for short stays and for the treatment and management of actively suicidal individuals.
Dr. Metzner highlighted Fred Cohen’s “Access Concept” in describing the requirements for the constitutional efficacy of a correctional system to include adequate physical and human resources, and access to both for incarcerated individuals.23
Dr. Metzner acknowledges the challenges for those who work in correctional systems to practice wellness for themselves and pay attention to their own resilience. He has said many times: “I don’t know if it’s the long hours, the environments they work in, but taking care of themselves, it seems often is a challenge. It is a tough institution to work in, particularly when you’re overworked and understaffed.” His words ring true: “You should be a strong advocate for your patients, and you should be actively involved in your professional organizations.”
When asked how he has cared for his own health and wellness, Dr. Metzner responded that his family has been very supportive of him. His wife, son, grandsons, family, colleagues, and friends have been and are the essential spokes in his own wheel of self-care. Very sadly, Linda, Jeff’s wife and his primary support passed away in 2023. The celebration of her life was very well attended by her extended family, her family of friends, colleagues, and associates, as well as Jeff’s family, friends and colleagues. Jeff attributes much of his success and resiliency to the consistent love and support of his wife and the ongoing support of his family.
Dr. Metzner concluded with this: “I think my greatest contribution has been advocating for adequate mental health resources and appropriate systems within jails and prisons. I think that I’ve shown people that when you do that, it makes life easier for custody staff and it makes life easier for incarcerated individuals. I have been involved in significant cases which helped evolve the standard that people with serious mental illnesses should not be in restricted housing. I think that is probably my greatest contribution.”
Footnotes
Disclosures of financial or other potential conflicts of interest: None
- © 2024 American Academy of Psychiatry and the Law
