Abstract
Correctional facilities in the United States house many individuals with mental illness requiring psychiatric care. This study investigates didactic and clinical experiences and attitudes related to correctional psychiatry among psychiatry residency program directors and medical student clerkship directors. An online survey was distributed to assess the current landscape of learner exposure to correctional psychiatry, topics related to criminal legal involvement among people with mental illness, and attitudes toward correctional psychiatry. A total of 96 individuals responded to the survey (overall response rate of 16%). About half of clerkship director (45.2%) and program director (51.1%) respondents report affiliations with correctional institutions. Few residency programs have a mandatory rotation (24.4%) whereas a higher proportion offer elective rotations (57.8%). Although medical student clerkship directors identify teaching correctional health as important, medical students have limited exposure and education on core topics of correctional psychiatry, perhaps related to reported heightened safety concerns. Correctional settings offer an opportunity to expose future psychiatrists to the care of people with criminal legal involvement as well as individuals with serious mental illness needing care. We found variable experiences in the exposure, education, and availability of rotations related to correctional psychiatry. Educators should advocate for learners to have further opportunities in these needed areas.
- psychiatry clerkship
- psychiatry residency
- correctional psychiatry
- medical education
- residency training
- forensic training
Jails and prisons in the United States continue to hold large numbers of people with mental illness, yet medical learners have limited exposure to these settings. Data from the Mental and Substance Use Disorders Prevalence Study found that the prevalence of any mental disorder (excluding substance use disorder) in prison was nearly 42 percent, consistent with self-report data within prisons.1,2 These estimates, with rates at two to six times those in the general population, are similar between jail and prison settings.3,4 The marked reduction in state hospital beds over the past several decades, limited access to community mental health services, the high comorbidity of illicit substance use among people with psychiatric illness, and the inadequacy of the community mental health system and society at large in addressing criminogenic risks and social determinants of health (SDOH) contribute to the high prevalence of psychiatric illness and substance use disorder in the carceral system.5,6
Incarceration is associated with a host of negative long-term health outcomes, including higher rates of trauma, suicide, physical health morbidity, postrelease mortality, and negative effects on population health and SDOH, such as housing and employment.7,–,12 Carceral settings have a clear need for psychiatric care but often lack sufficient clinicians to provide these services.13 This shortage is also likely related to a confluence of factors. Correctional systems may have limited resources to adequately support positions for mental health services. Further, psychiatric clinicians may have reservations about working in carceral settings, including safety concerns, lack of exposure to correctional care, the remote location of many carceral facilities, and stigma against incarcerated persons.14,15 Despite these challenges and reservations, correctional settings offer learners a host of benefits. Trainees learn about the experience of people who are incarcerated, the functioning of carceral systems, and how health care is delivered in these settings; encounter a range of psychopathology; and gain exposure to topics pertinent to forensic psychiatry.16
Outside of psychiatry, other medical specialties have correctional health-related curricula and programs targeting a range of learners and trainees.17 Some have advocated for rotations in correctional health to promote recruitment and retention of clinicians in these settings. A pilot jail-based rotation of family medicine physicians (N = 20) found that nearly 18 percent of graduates worked in a jail or prison.18
A 2001 national survey of residency programs across seven medical specialties, including psychiatry, evaluated resident education and experiences in the care of incarcerated persons. A mailed survey was completed by over 1,200 residency program directors (66% response rate) with follow-up telephone interviews that revealed only 14 percent of programs offered lectures on correctional health. Just 22 percent of programs offered clinical rotations for residents in correctional settings, yet 44 percent of programs had trainees providing care for incarcerated individuals with substance use disorders.19 A 2024 survey on medical education and criminal justice health found only 43 published undergraduate and graduate correctional psychiatric curricula among over 550 American medical schools and psychiatric residency programs.20 Although it is possible programs may have curricula that are unpublished and thus not captured by the study, the authors nonetheless conclude that “current curricula focused on the justice-involved population are insufficient in quantity to reach all medical learners” (Ref. 20, p 912). The results are consistent with a 2019 study on medical school curricula in correctional health that revealed approximately 20 percent of medical school graduates had exposure to criminal justice and health.21 A 2022 survey of 140 medical students (response rate of 14%) revealed that 75 percent of students were mostly unaware of correctional medicine and fewer (20%) considered practicing correctional health.22
A 2023 scoping review on academic medical center educational programs in correctional health offers some reassurance. The literature related to correctional health curricula has grown over time, and medical trainees were well represented compared with other health professions. General impressions by trainees were positive, although most curricula focused on mass incarceration.23
The last known study that was dedicated to assessing psychiatric residents’ exposure to correctional psychiatry occurred over 10 years ago. With a response rate of 20 percent, the survey queried program directors regarding resident rotations at correctional facilities. Most respondents felt that a correctional psychiatry rotation would be valuable (84%) and relevant (85%) to resident training. This 2014 survey of residency program directors revealed that 30 percent of programs mandated a rotation at a correctional institution, whereas another 25 percent of programs offered an elective opportunity.24
Some have advocated for the Accreditation Council for Graduate Medical Education (ACGME) to include correctional psychiatry as a possible component satisfying the required forensic psychiatry training of general residents.25 Others have noted that, in line with the mission of academic medicine to care for all populations, including the vulnerable and underserved, we should provide trainees with opportunities to care for incarcerated individuals.26 Exposure to forensic experiences is associated with increased interest in working with forensic populations and in forensic fellowship, yet less than half of residents responding to a multisite survey completed a forensic rotation.27,28
The current survey updates findings on resident exposure to correctional psychiatry and broadens the scope to include medical students. The objective of this study was to evaluate the current availability of and attitudes toward clinical experiences and didactics for medical students and psychiatry residents in correctional psychiatry through a nationwide electronic survey.
Methods
We conducted an anonymous electronic survey of medical student clerkship and residency program directors to assess educational opportunities in correctional psychiatry. Qualtrics (Qualtrics; Provo, UT) was used for survey development, distribution, and collection. The survey was distributed via email through the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) email distribution list to query medical student clerkship directors. The survey was distributed via email through Qualtrics to residency program directors who were identified through FREIDA, the American Medical Association Residency and Fellowship Database.29 A total of five reminders were sent to each of the two groups. No financial incentives were provided for survey completion.
Survey questions (see online supplement) included respondent and program background information, such as role in the clerkship or residency program, state, and size of program. Additional information collected included program affiliation with a local correctional institution; if affiliated, what type of institution; whether faculty provide clinical services in correctional settings; and any mandatory or elective clinical experiences for trainees at a correctional facility. The survey further assessed didactic information related to the intersection of mental health and the criminal legal system, including education on mass incarceration, racial biases, and diversion programs. Finally, attitudes related to education and experiences in correctional health were assessed through a series of questions on a Likert scale, including the importance of correctional rotations and didactics, supervision, safety, and likelihood of utilizing virtual (telehealth) experiences.
Surveys that were started, but not fully completed, were excluded from the analysis. This study received Institutional Review Board exemption by the Office of Human Research Ethics at the University of North Carolina at Chapel Hill.
Results
Among clerkship directors invited through ADMSEP, 43 out of a possible 293 people (14.7%) responded. Among psychiatry residency program directors emailed directly, 53 of 311 program directors (17.0%) responded. In total, undergraduate and graduate programs from 30 states responded, with New York, Illinois, Texas, and Florida representing the greatest number of programs.
For survey results comparing medical student clerkship and residency program directors’ responses, refer to Table 1. It was more common for medical students to be offered a clinical elective (32.3%) in a jail or prison compared with a mandatory experience (6.5%). Most clerkship director respondents report didactics on the intersection between people with mental illness and the carceral system, although fewer specifically discuss the mental health needs of incarcerated people. Over half (51.9%) of clerkship director respondents find teaching about correctional health to be either “quite a bit” or “extremely” important, yet only a quarter rate offering a correctional psychiatry rotation as “quite a bit” or “extremely” important.
Clerkship and Residency Program Directors’ Responses
Psychiatry residency programs are more likely to report an affiliation or working relationship with a local correctional institution (51.1%), offer an elective clinical experience (57.8%), and offer a mandatory clinical experience (24.4%). Similarly, nearly all (90.9%) cover the intersection between people with mental illness and the carceral system and the mental health needs of incarcerated people (82.9%). Systemic biases are commonly covered in residency curricula (73.0%), and about half review diversion programs. Half of residency program respondents find teaching about correctional health to be either “quite a bit” or “extremely” important, yet only 30 percent feel the same about offering a correctional psychiatry rotation.
About half of clerkship (45.2%) and residency (51.1%) program respondents reported affiliations or a working relationship with a local correctional institution, whereas half of all respondents reported no faculty working in carceral settings. Significantly more clerkship directors (37.0%) reported “extreme concern” about correctional institutions being safe learning environments compared with residency directors (13.6%) (p < .05). Nearly half (48.2%) of clerkship director respondents, compared with 30 percent of residency program directors, were either extremely unlikely or unlikely to incorporate a virtual (telehealth) correctional clinic instead of a standard in-person rotation.
Discussion
This nationwide survey updates previous work assessing psychiatry residents’ exposure to correctional institutions and expands to include medical students’ experiences. Fuehrlein et al.24 reported in 2014 that 45 percent of programs responding to a national survey lacked a correctional psychiatry rotation for residents, with 30 percent and 25 percent having mandatory and elective rotations, respectively. This current study, which achieved a comparable response rate, found a slightly lower number of program directors reporting a mandatory rotation in a correctional institution (24.4%), although a higher proportion offering elective correctional psychiatry rotations (57.8%). Few clerkship directors reported a mandatory clinical experience in a correctional institution for medical students (6.5%), whereas more offered elective correctional psychiatry rotations (32.3%).
It is unclear why slightly fewer residency programs have mandatory correctional psychiatry rotations today compared with the prior study. It may be an artifact of the low response rate in both surveys. Alternatively, fewer mandatory experiences may be a result of programs moving toward a model of selective rotations to fulfill ACGME requirements, leading programs to offer more elective rotations now than a decade ago. It is interesting that our data reveal an increase in elective rotations despite the 2014 survey indicating that program directors felt they had little scheduling flexibility to incorporate more elective offerings.24 Residency program directors today may not find mandatory correctional psychiatry rotations as important as they did previously. For example, Fuehrlein et al.24 reported that 84 percent of respondents would find such a rotation to be “somewhat” to “very” valuable. In the present study, only 30 percent of program directors reported it to be “quite a bit” to “extremely” important.
A larger factor, however, may be that half of survey respondents did not view the incarceration of people with mental illness as a topic of importance in their curricula. It may be, as Rubinow noted in 2014, that the criminalization of mental illness remains “largely out of the view and consciousness” of training directors (Ref. 30, p 1043). Although the problem of mental illness and criminal legal involvement is more widely known now, we suspect the persistent inattention to carceral populations in training may reflect underlying stigma regarding incarcerated persons, the structural separation between academic centers and carceral facilities, general logistical obstacles, time constraints to address incarcerated populations, limited faculty and mentorship, and the lack of a specific competency or milestone in carceral health.16,31,–,33 An additional contributing factor is that misconceptions persist regarding correctional psychiatry.14 Respondents, particularly clerkship directors, continue to view correctional facilities as unsafe training sites for learners. Although data are limited regarding staff injuries in carceral settings, it is not clear that safety risks are higher than in emergency departments, community inpatient units, and state psychiatric hospitals.14,34 Correctional and forensic psychiatrists, along with the larger house of medicine, may need to advocate more as to the mental health care needs of incarcerated persons and the long-term effects of incarceration on health to help justify and expand academic training opportunities in carceral psychiatric care.
Medical students appear to have limited education on the intersection of people with mental illness and the criminal legal system and sparse exposure to mass incarceration and racial biases. There are various barriers to implementing carceral didactics or rotations in the medical student clerkship. More than half of schools report no affiliation with a correctional institution and half do not have faculty working in carceral settings. Broadening academic-carceral partnerships would increase the availability of faculty preceptors and aid faculty development, among other benefits.35 A model example may be the University of Texas Medical Branch (UTMB) Correctional Managed Care, which provides 80 percent of all medical care to the Texas Department of Criminal Justice and involves nearly all medical students and residents in the care of incarcerated persons.36 This partnership clearly enhances trainee exposure to correctional health, and similar collaboration between academic centers and departments of correction would further serve to break down barriers in learners caring for incarcerated persons.
The safety of the carceral environment may be a larger concern, particularly among clerkship directors. Most likely, however, is that clerkship directors have learners for a limited amount of time within the overall medical school curriculum, typically ranging from four to eight weeks.37 Clerkship directors may not rank correctional health as pressing as psychiatric topics with greater relevance to core student examinations. Notably, however, more clerkship directors than residency program directors identified that teaching correctional health is either quite a bit or extremely important. Thus, although attitudes to subject importance are similar, clerkship directors have fewer opportunities to incorporate these teachings into their curricula.
One strategy to mitigate safety concerns to enhance exposure to correctional populations would be to utilize virtual patient encounters. A growing number of correctional institutions have turned to telebehavioral health to provide care and have identified strengths, including improved security and safety.38 Barriers may exist to offering a telebehavioral correctional health elective for learners that this survey was unable to fully address. Only two clerkship directors answered they were either “likely” or “extremely likely” to incorporate a virtual correctional clinic. Despite having greater safety concerns, clerkship directors do not appear interested in incorporating virtual clinical options. It is unclear why, but perhaps directors are concerned about adequate supervision if all parties are separate. This theory may be further supported by a lack in partnerships with correctional institutions.35
An alternative to implementing a telebehavioral correctional health elective would be to incorporate didactic programming into the clerkship. Residency programs incorporate such didactics more frequently than medical student clerkships, likely related to the four-year timeframe in which a broader range of educational topics can be covered. Given the likelihood that time in the clerkship is a barrier to implementation of didactic series, directors may advocate for medical schools to incorporate carceral health didactics into other portions of the curriculum. Incorporating guest lecturers who work in correctional psychiatry would offer increased interactions with learners who may be curious to hear more about working in these kinds of institutions. Similarly, our institution hosts panel discussions with formerly incarcerated people, allowing students to hear directly about health and other struggles in carceral systems. Alternatives to clerkship-specific didactics could include a social medicine course in the preclerkship years or electives in the fourth year.39 Experiences with community-based programs focused on the care of formerly incarcerated persons or diversionary programs can complement or be alternatives to direct carceral experiences if the latter cannot be offered.40 A recent study showed that even brief exposures to correctional health can enhance medical students’ attitudes toward incarcerated populations.41
Other strategies to reduce barriers related to trainee access to correctional health experiences and education may include increased integration of correctional systems into the larger community and academic health systems. For instance, enhanced integration of the electronic medical record for state agencies with academic medical centers can improve continuity and quality of care. Additionally, funding for prerelease and reentry services could include health services offered by academic clinics.42 These sorts of initiatives may help show clinicians and learners that correctional health is accepted as part of the broader community health care system and training programs.
Rotations or didactics in carceral medicine, by better informing future clinicians, have the potential to affect race and health-related inequities of individuals with mental illness involved with the criminal legal system. These survey data indicate that most psychiatry clerkship curricula do not address these topics, although the increasing number of people with mental illness in correctional institutions and the lasting impact of incarceration on health argue that they should. Advocacy for structural changes at large governing organizations, such as ACGME, may be needed to bolster such rotations or didactics for clerkship students and psychiatry residents.
This study had several limitations. The sample sizes for each group were relatively small. Although our response rate is roughly consistent with other survey studies, it does introduce a potential responder bias. Those who responded to a request to complete a survey on correctional psychiatry may be more interested in this topic. The ADMSEP email distribution list may have resulted in duplicate responses from the same institution, and sampling bias is possible if clerkship directors were not subscribed to the ADMSEP email distribution list. For residency programs, sampling bias was possible if the FREIDA database was not updated.29 Direct emails reduced duplicate responses through the Qualtrics distribution software, which only sends reminders to those who have not yet completed the survey. This survey only collected categorical responses rather than narrative descriptions, thus limiting the ability of respondents to provide additional context. Finally, we did not assess whether medical students received carceral didactics or other experiences outside of their dedicated psychiatry clerkship.
In summary, correctional institutions house large numbers of people with mental illness who need quality psychiatric care. The high volume of individuals exiting the carceral system also ensures that most, if not all, psychiatrists will encounter formerly incarcerated persons in community settings. Even if they do not practice in carceral settings, psychiatrists should have exposure to jails and prisons so that they understand what happens in them and to allow them to better care for their patients in the community who have experienced incarceration. Trainees have variable access to rotations in carceral settings or didactics about core topics pertinent to the intersection of mental illness and the criminal legal system. Training programs, for both psychiatry residents and medical students, should consider broadening access to carceral rotations and didactics to improve the care of this underserved and vulnerable population.
Online Supplement
Correctional education survey
Please provide your role within your psychiatry clerkship/residency program.
○ Residency program director (1)
○ Residency associate/assistant director (2)
○ Medical student clerkship director (3)
○ Medical student associate/assistant clerkship director (4)
○ Other - please specify (5) _______________________________________
In which state is your program located?
▾ Alabama (1) … I do not reside in the United States (53)
What is the approximate size of your program’s graduating class of 2022?
_______________________________________________________________
Does your training program have the following?
| Yes (1) | No (2) | |
|---|---|---|
| Affiliation or working relationship with a local correctional institution (1) | ○ | ○ |
| Mandatory clinical experience in a correctional institution (2) | ○ | ○ |
| Elective clinical experience in a correctional institution (5) | ○ | ○ |
If yes:
What type of institution(s) are affiliated with your training program.
□ Jail (1)
□ State prison (2)
□ Federal prison (3)
Within your program, do your learners receive didactic instruction on the following?
| Yes - all learners (1) | Yes - some learners (2) | No (3) | Not sure (4) | |
|---|---|---|---|---|
| Interaction between people with mental illness and the criminal legal system (6) | ○ | ○ | ○ | ○ |
| Mental health needs of incarcerated people and/or those with criminal legal involvement (7) | ○ | ○ | ○ | ○ |
| Phenomenon of mass incarceration in the United States (3) | ○ | ○ | ○ | ○ |
| Racial biases within the criminal legal system (4) | ○ | ○ | ○ | ○ |
| Diversion programs such as Crisis Intervention Team (CIT) training, mental health courts, or specialty probation (5) | ○ | ○ | ○ | ○ |
If yes to “instruction on diversion programs”:
Is the exposure to diversion programs via didactics or direct experience?
○ Didactics (1)
○ Direct experience (2)
○ Both didactics and direct experience (3)
Do any faculty in your department provide clinical services in a correctional setting?
○ Yes (1)
○ No (2)
○ I don't know (3)
How important is teaching correctional health is in a psychiatric didactic curriculum?
○ Not at all important (1)
○ A little bit important (2)
○ Moderately important (3)
○ Quite a bit important (4)
○ Extremely important (5)
How important is it to offer a clinical correctional health rotation as part of your training program?
○ Not at all important (1)
○ A little bit important (2)
○ Moderately important (3)
○ Quite a bit important (4)
○ Extremely important (5)
How concerned are you that adequate clinical supervision for learners is available at your local correctional institution?
○ Not at all concerned (1)
○ A little bit concerned (2)
○ Moderately concerned (3)
○ Quite a bit concerned (4)
○ Extremely concerned (5)
How concerned are you that your local correctional institution is a safe learning environment?
○ Not at all concerned (1)
○ A little bit concerned (2)
○ Moderately concerned (3)
○ Quite a bit concerned (4)
○ Extremely concerned (5)
How likely is your program to incorporate a virtual (telehealth) correctional clinic into your curriculum instead of a standard in-person rotation?
○ Extremely unlikely (1)
○ Unlikely (2)
○ Neither unlikely or likely (3)
○ Likely (4)
○ Extremely likely (5)
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2026 American Academy of Psychiatry and the Law
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