Less than a decade ago, Minnesota’s psychiatric hospitals were facing a serious shortage of forensic psychiatrists, mental health professionals specially trained to conduct psychiatric evaluations and treatment of people accused of crimes.
Dr. Chinmoy Gulrajani, forensic program fellowship director, Minnesota Department of Human Services (DHS) and adjunct associate professor at the University of Minnesota Medical School, remembers that time well. He had been working as a forensic psychiatrist and medical director for inpatient services at Kings County Hospital Center, a large psychiatric Hospital in New York City, when he received a flyer saying that the state of Minnesota was looking for forensic psychiatrists at all levels.
Interested in relocating to a more livable community, Gulrajani reached out to find out more about the job openings. What he eventually learned was surprising. “The state forensics system was facing serious shortages,” Gulrajani recalled. He was told that in the not-so-distant past, St. Peter Regional Treatment Center, one of the state’s largest psychiatric hospitals, was, “replete with well- qualified forensic psychiatrists,” until an internal scandal shook the ranks.
News reports at the time said that friction between administrators and medical staff at the facility led to an exodus of physicians. “This hospital, one that required eight very specialized psychiatrists to manage,” Gulrajani said, “suddenly was left with one.”
Gulrajani was excited by the challenge that this situation presented. He learned that the University of Minnesota Medical School and DHS had plans to launch a new fellowship program designed to attract more forensic psychiatrists to the state.
The fellowship program, he was told, needed a director who could develop the program, and promote and supervise participants. Gulrajani threw his hat in the ring, and after a series of interviews was selected for the job. “I came in knowing what I was stepping into,” he said. “I was drawn to the challenge.”
Setting up a fellowship program to attract more forensic psychiatrists to the state is a long-game approach, but Gulrajani and his colleagues at the medical school and DHS agreed that this was the best way to attract the kind of candidates they were looking for — younger physicians who are committed to staying in the state and caring for the mental health of its citizens.
“I came here in 2014,” Gulrajani said. “This is a very specialized program. You need to have a lot of ties in the community to be able to get something like this off the ground. It took me a little over a year to get it started, but now is really taking off.”
These days, the fellowship program is successful, drawing a strong, steady field of applicants, he added: “Now we have so much interest from medical students it is humbling. I could not have done this without the generous support from the Minnesota Department of Human Services.”
Not only is the fellowship attracting younger psychiatrists to the state, other recruiting efforts are also having the same impact, Gulrajani, 48, said. Like many members of the state’s psychiatry workforce, several of the psychiatrists who left in 2010 were, “definitely older and had been getting close to retirement,” he explained. “The interesting thing that happened in Minnesota is that when the state started actively recruiting for the hospital, many of the doctors who came in were younger.”
In 2014, the year Gulrajani was recruited, two other psychiatrists were also hired by the state. “One is my contemporary,” he said. “One is five years younger than I am. Since then, all of the recruiting done has been with younger physicians. Before I came in, there was one or two psychiatrists at the state who were older than I am. Now I am soon to be the oldest psychiatrist in our state forensic system.”
Bringing down the average age of Minnesota’s forensic psychiatry workforce isn’t the only goal of the state’s hiring campaign. Gulrajani said that he and his colleagues have designed the fellowship program with the goal of introducing forensic psychiatrists to the benefits of a career in public-sector work.
With a nationwide shortage of psychiatrists, med school graduates often have their choice of career placements, Gulrajani said, but he’s made it his goal to spread his love of government-agency work with the fellows selected for his program.
“I don’t know that many physicians would think of the state system as a career choice before this program came along,” Gulrajani said. For him, the decision to work for the state was an easy one. He wants his program’s fellows to understand why: “I had always been drawn to public-sector psychiatry. What the program has done in that regard is it has given multiple exposures to trainees at all levels about what the public sector looks like, what efforts are being made to improve it and also the benefits of work in the public sector. It is one of the best places to make a career. We try to make that clear to all of our fellows, through real-life experience and rewarding interactions.”
Though she went into medical school with a plan to become a psychiatrist, Christine Prato admits that she knew little about forensics and the intellectual challenges connected to the specialty.
Prato completed psychiatric residency training school in Washington State, where psychiatry residents are required to do a rotation in forensics. During her forensics rotation, Prato was paired with a mentor. “I had an opportunity to follow him around for six weeks,” she recalled. “We got to travel around the state, performing forensic assessments.”
The aspect of psychiatry that connects with the legal system, assessments are a central part of a forensic psychiatrist’s job. In criminal cases, forensic psychiatrists may be asked by judges or attorneys to provide testimony on a plaintiff’s mental state or capacity to make decisions related to in their legal case.
As she accompanied her mentor on visits with individuals involved in the legal system, Prato realized that she was fascinated by this complicated work. It spoke to her active, inquisitive mind. She decided she wanted to make it her career.
“It is a unique field of psychiatry,” Prato said of forensics. “To do it well it requires specialized training. Even when your training finishes, your learning never ends. You’ll always be learning more. You learn from every assessment you do.”
The idea of always learning appealed to Prato. “That’s what attracted me to forensics,” she continued. “You’ll always be pushing yourself. There will always be more to learn. You’ll never get to a place where you say, ‘I’m good now.’”
As the end of her residency neared, Prato began thinking about her next step. Searching for places to do more training in forensics, she stumbled on the University of Minnesota Medical School’s fellowship program.
“I came here and interviewed, and after talking with the program directors, I realized I really enjoyed Minnesota,” she said. “I felt like the state has put time and effort into supporting our population of patients. That was something that drew me to the area.”
Prato was accepted into the fellowship program in July 2019. She liked the way the program introduced fellows to the many areas of the work, through shadowing and mentorship with professionals in different areas of the state’s mental health and legal systems.
“You get to live in both worlds through this fellowship program,” Prato said. “You get your opportunity to learn various aspects of forensic psychiatry. As part of our training we do spend time in St. Peter, but the majority of the training time is spent going to jails, talking to individuals who are incarcerated, going into the hospitals, doing various civil commitments. You are introduced to so many things.”
After Prato completed her fellowship, she was hired as a forensic psychiatrist at St. Peter Regional Treatment Center. She continues to use the skills gained in her fellowship, including petitioning the court on behalf of her patients for treatment options while advocating for their best interest.
While her current position at St. Peter is more clinical, with less emphasis on performing evaluations, Prato said she still has the opportunity to use her experience submitting legal petitions to allow for involuntary medical treatment such as with medication or electroconvulsive therapy for individuals with serious mental illness.
It’s important work, Prato said, and she’s happy that her experience allows her to do her job in a professional and respectful manner.
“The fellowship training made me a better clinician,” Prato said. “I have more awareness of the court procedures and of the law that supports them and of the legal elements that go into filing these petitions. It also helped me to better understand the people these decisions directly impact.”
Understanding both sides
Because he’s always wanted to understand the way things work, Matthew Kruse felt attracted to the idea of being a forensic psychiatrist. “I’m really interested in systems of care and how what happens outside of the immediate doctor/patient relationship can impact the quality of care for individual patients,” he explained. “Forensics deals with a lot of these systems that can have a big impact on the outcomes of patients’ quality of life.”
Kruse, who was in the first class of forensic psychiatry fellows at the University of Minnesota Medical School, said that much of the work of a forensic psychiatrist involves digging deep to answer questions and solve puzzles about how to better serve people with mental illness involved in the state legal system.
“Forensics is an area where you are essentially using your clinical expertise to answer a question for the legal system,” Kruse said. “The answers to those questions hinge somewhat on an individual’s clinical state.” If a law only applies to certain people with certain types of illnesses, he said, “lawyers aren’t going to be able to understand if this person has the illness because they are not clinicians. Most doctors aren’t going to be able to know what the intention of the law is. They can’t communicate that in ways that lawyers can use.”
This void is where a forensic psychiatrist can step in, Kruse said: “Forensic psychiatrists work from both sides. They understand both perspectives.”
While many traditional psychiatrists work directly with patients, assessing their mental state and managing their medications, a forensic psychiatrist’s work can be more varied, Kruse said. He appreciates the variety in his line of work.
As clinical director at Anoka Metro Regional Treatment Center, Kruse explained: “My time is split, half between direct patient care and half with administrative work. I make sure that the units are appropriately staffed, make sure that our clinicians have the tools they need to do their job safely. My other job is patient care. I have my patient panel, the patents I’m looking after, I do assessments. I provide treatments. I work with the treatment team. I get them better and get them discharged.”
Kruse also spends time with trainees, including fellows from the forensic psychiatry program, as well as with medical school residents. As president-elect of the Minnesota Psychiatric Society, he is focused on getting medical students interested in his subspecialty, hoping to continue to expand the ranks of forensic psychiatrists in the state.
At the medical school, he said, “We’ve been able to create a formal forensic psychiatry rotation for residents so they have time to get exposed to what the field holds, to get direct experience here at Anoka. If they decide they like it, they can apply to go into the field.”
While some people might think that working in a state psychiatric hospital could feel negative or discouraging, Kruse said that he actually feels the opposite way. There has been great improvement in treatments for mental illness, and that, combined with a growing societal acceptance of mental health disorders, has made his work feel optimistic. He and his colleagues are now able to help people with serious mental illness recover, a reality rarely discussed decades ago.
“Psychiatric illnesses are very treatable,” Kruse said. “We don’t have a lot of cures per se, but we have very effective treatments that can help people find recovery and lead normal lives.”