Forensic Psychiatry Steps into the Social Media Age

Regular followers of this blog know that every year about this time I put up a series of posts entitled "What I Learned." The purpose of the posts is to give people a peek inside the annual conference of the American Academy of Psychiatry and the Law as well as some exposure to the kind of topics forensic psychiatrists are interested in. General psychiatry residents may find it helpful, particularly if they are considering a career in forensic psychiatry and if they can't afford to travel to the conference. Our organization, AAPL, is an international group with members from Canada, the UK, Australia, and South America. Our international members deserve to see what's going on, as well.

This year, we will boost our international presence by livestreaming a select number of presentations through the Meerkat mobile app. Here is a schedule of the presentations we will stream. Directions on how to use Meerkat are below. In addition, select AAPL members have volunteered to moderate questions on each presention through Twitter. Hashtags will be announced through Meerkat, Twitter, and slides at the actual presentation. We've never tried this before, and we are all volunteers rather than professional videographers, so there may be a few snags or hitches but overall we're hopeful people will find it educational and fun. The conference begins on Thursday, Oct 22nd and continues through Sunday.

Here's the schedule:

Thursday 8:00-10:00	Graham Glancy  Witness Protection Program: A Matter of Training
Thursday 10:15-12:00	Ken Appelbaum The New APA Guidelines on Correctional Psychiatry
Thursday 2:15-4:00	Ryan Wagoner The Psychiatrist in Peril: Current Topics in Malpractice
Friday 8:00-10:00	Tobias Wasser  Novel Approach to Teaching Residents About Violence & Safety
Friday 8:00-10:00	Drew Kingston PhD  The Relationship Between Mental Illness and Violence
Friday 10:15-12:00	Caitlin Costello  Adolescents and Social Medica: Privacy, Brain Development and Law
Friday 10:15-12:00	Robert Forrest  Treatment of Transgender Inmates
Friday 4:15-6:15	Rosa Negron Munoz  Educational Factors Contributing to Juvenile Delinquency
Saturday 10:00-12:00	Madelon Baranoski  Role of Forensic Psychiatry in Veteran Evaluations
Saturday 2:15-4:00	Anna Glezer  Myths and Realities of Women in Prison
Saturday 2:15-4:00	Jennifer Piel  What Gets Judges in Trouble?
Saturday 4:15-6:15	Keith Stowell  Forensic Issues in Emergency Psychiatry
Sunday 8:00-10:00	Hal Wortzel  TBI Update: International Collaboration on mTBI and DSM-5
Sunday 8:00-10:00	Stephen Simring  Forensic Psychiatry and the Death Penalty
Sunday 10:15-12:15	Lynn Maskel  Rock and a Hard Place: Debating Sexual Sadism Diagnosis

Here’s how you use Meerkat:

1. First, go to the app store, search for “Meerkat app,” and download it.
2. Meerkat will ask you to type in your phone number for verification. Then, they’ll send you a four-digit confirmation code.
3. Next, connect the app with your Twitter account. (If you prefer, you can skip this step and check the app out in stealth mode.)
4. If you don’t want to add friends, don’t connect your accounts. Simply scroll down and you’ll see anyone who’s live streaming right away. Keep scrolling for more.
5. Search for and follow @AAPL2015. We will have a schedule of streams posted each day. For simultaneous sessions, AAPL members may use their own Twitter accounts which we will announce. You can search for them on Meerkat as well.

This is all a tremendous experiment so I want to thank my colleagues, AAPL, and our viewers in advance for participating. I'm looking forward to your questions, comments, and discussion.

--ClinkShrink AKA @ClinkShrink AKA Annette Hanson, MD Program Co-Chair

What I Learned Part 1

Hello from Chicago and the 45th Annual Meeting of the American Academy of Psychiatry and the Law!

One of the Shrink Rap traditions is that I blog tidbits that I picked up at various sessions of the forensic psychiatry conference. This year's conference was preceded (for me, anyway, not for all attendees) by a three day review course in preparation for my mandatory recertification exam next year. This is another way of saying that I'm starting the conference in "listener overload" mode, so my notes may be a little light this year.

As usual, the conference started out with a keynote address by current president Dr. Richard Weinstock. He gave a thoughtful presentation about forensic ethics as it pertained to consultation to the courts. He covered the essential ethical imperatives, the mandate to maintain impartiality and respect for persons, the presented several situations where these issues come into play along with a few other secondary considerations. This was good basic ground to cover for early career forensic psychiatrists. Of course, forensic psychiatrists do more than consult to the courts and I think in this post-9/11 age we need to think about broader potential role conflicts, particularly for those involved in consultation to law enforcement and national security agencies. But there's only so much you can cover in an hour.

Ethical issues---the theme of this year's conference came up again in a session about competency assessments of immigration deportees. I wrote about the dilemma of mentally ill detainees for Clinical Psychiatry News in my column "ICE and the Inpatient Psychiatrist." The challenge with these evaluations is that you have to determine whether the respondent is mentally capable of acting as his own attorney at a deportation proceeding. Never mind that even most lawyers have no knowledge of immigration law, and we expect a mentally ill non-English speaking person to be able to do this? What ethical issues? The good news is that steps are being taken and a policy is in place to provide qualified representation to these folks.

There was a panel debate on the indefinite civil commitment of psychopaths. This is more of an issue in the UK where they have a law which allows for this, but here in the US we have commitment laws for sexually dangerous or sexually violent individuals. There was no one in the packed conference room who was truly in favor of the "pro" side of this; even the lawyer on that side of the debate panel was careful to qualify his presentation so that people would know he was presenting a theoretical viewpoint which was not his own.

Last but not least, there was a panel presentation on the ethics of involvement in traditional media. There was a talk on the history, content, and implications of the Goldwater Rule and the extent to which television and talk show appearances could be used for public education without crossing certain boundaries. Again, a pretty basic talk covering issues I've written about before on this blog but it was good to cover again for the trainees and early career docs in the audience.

So that was the first day of the conference. For those of you interested in a more real-time data feed you can follow me on Twitter at https://twitter.com/clinkshrink using hashtag #2014AAPL.

What I Learned: Part 1

Hello from San Diego and the 44th annual American Academy of Psychiatry and the Law conference. One of the annual traditions associated with this conference is my series of "What I Learned" posts, which preserves little factoids, pieces of trivia and topics for me for future reference, and also tells members a bit about what they missed if they couldn't make the conference. For those interested in a more real-time experience, you can follow live coverage on my Twitter feed @ClinkShrink.

In spite of a three hour time difference and associated jet lag I did make it to the morning poster session. While I didn't get to every single poster, I did enjoy one that looked at the rates of military service for prisoners who committed suicide in New York over several years. One of the interesting things about this study was the fact that it was exempt from IRB review because all of the information was in the public domain as the result of a journalist's FOIA request. Having completed the story, the journalist turned over all the data to the poster's authors. Sweet. I don't recall all the numbers due to jet lag and mawazo mengi (keep reading), but the bottom line was that only three percent of the prisoners who completed suicide had a history of military service. Weird. Are veterans less likely to kill themselves in prison than while on active duty?? The poster wasn't designed to answer that question, but it certainly did raise the question in my mind.

Immigration issues are an emerging area of active forensic work now, and this was reflected again in this year's conference. I attended a panel presentation by psychiatrists from Yale and the Philadelphia program, who talked about the basis for deportation ("removal proceedings") and the common questions asked of forensic psychiatrists. An alien can file to be protected from removal based on a real history of persecution or being members of a group at risk for persecution, by being a victim of torture, or if their life or freedom could be threatened by return to the home country. The respondent's testimony about these issues must be credible. Psychiatrists are sometimes asked to testify as to why an alleged torture victim may have inaccurate recall of details related to their experiences, or why their demeanor or emotional reaction while discussing torture appears to be inconsistent with the experience. (All of this discussion brought to mind the prosecution of rape cases where the victim is "put on trial.") A psychiatrist might be asked to testify about a respondent's diagnosis and treatment needs and whether those treatment needs can be met in the home country. One panelist talked about transference and counter-transference issues in immigration evaluations, particularly about her own discomfort about testifying about deficits in her own country of origin's mental health system. I also learned it's good to know about culture-bound syndromes for these evaluations, like "mawazo mengi" ("brain fag"---yes, that's "fag" not "fog") or racing thoughts with headaches.

I was quite pleased to attend a panel presentation about the Goldwater Rule. As regular readers know, this is a persistent interest of mine that I've blogged, podcasted and written about before (here, here, here, here, and here). Now, the Shrink Rappers are finally not the only ones talking about this. The AAPL ethics and peer review committee put on a joint presentation in which they played several television interviews with psychiatrists commenting on criminal defendants in the news as well as on the President. There was vigorous and unanimous agreement about where the talking heads "crossed the line" of professional ethics, how the interviews could have been handled better and what recourse our profession had to address the offenders. Complaints have been filed within the APA against media consultants who violated our ethical rules, and in some states this may also be the basis for a licensing board complaint. Interestingly, social media was not even mentioned. I suspected this may be due to an inherent fear and suspiciousness about the use of social media by forensic psychiatrists. On a side note, but one I plan to track, is that the role of psychiatrists in national security issues and consultation to covert agencies was presented as a "grey area" of ethics. (Oh, I'd say it was a darker shade of grey myself.)

Finally, I attended a panel presentation on the management and reduction of inpatient violence put on by some of my Maryland colleagues. There was a review of the literature on risk factors related to inpatient violence (staffing levels, patients with a history of substance abuse and/or violence, an overstimulating---noisy---environment) and also a presentation of one inpatient unit's plan to reduce inpatient violence. The unit set up a designated "milieu manager" who did hourly rounds on the unit to touch bases with all the patients and keep an ear out for emerging tensions. They did patient-specific limited and targeted observation (a change from the usual practice of continuous, 24/7 observation). I forget the numbers on the assault rate, but what stood out in my mind was that the scores on the patient satisfaction survey I think tripled. The unit got the hospital award for the most improved patient satisfaction. Very cool project, and it was all set up, designed and run by the nursing staff.

Finally, the evening entertainment was a showing of the 1938 film "The Amazing Dr. Clitterhouse." Definitely worth watching even if you only watch the insanity trial at the end of the film. I may need to track down a clip of the "expert" testimony in that case. For peer review, of course.

The conference runs through Sunday and you can follow my coverage today and tomorrow @ClinkShrink. Thanks for attending with me.

The Hired Gun

I know I'm going to get nudged to talk about this article so I'll beat Dinah to the punch. Today's New York Times has a story entitled "Witness for the Prosecution" about a neuropsychologist who frequently is retained to testify on behalf of the state in criminal trials. The expert witness gets criticized for slanting his opinion in favor of the prosecution by ignoring previous history or making certain presumptions about the defendant's previous education or experience. You can read the article yourself, I won't repeat it here.

The article quotes questions from the doctor's cross-examination about the assumptions he based his opinion on: how do you know the defendant took a psychology class? Why are you ignoring or not considering his mental health history? Why are you disregarding DSM diagnostic criteria?

All of this sounds pretty horrible, but the fact of the matter all the questions asked by the cross-examining attorney at the beginning of this article are routine questions that will get asked of any testifying expert. As I mentioned at our recent talk at the Johns Hopkins Odyssey lecture, these questions are designed to make the expert look incompetent or foolish. They are an attempt to undermine the credibility of the expert in the eyes of the judge or jury and to get him flustered and confused.

This is predictable, and to a certain extent it's a choreographed dance. When you express an opinion you will be asked the basis for that opinion---what information did you consider, did you have all the information, why do you rely more heavily on one source of information than another, did you consider the credibility of the information?

The next step is to alter all the details slightly in an attempt to get your opinion to waver or even change: what if this piece of information weren't true, or you found out a certain fact was different from what you assumed? How would this affect your opinion? This step of the process could go on for hours. It can be painfully boring for a jury, so when the NYT article talks about the importance of "presentation" and communication for a good expert witness, that's why. You have to hold a jury's attention for hours in spite of excruciatingly detailed questions, a court room that is either too hot or too cold, and chairs that you can't quite get comfortable in no matter how you twist.

Once all of this is exhausted the last stage is to attack you, personally. If you don't have the guts for this, if you have an issue in your professional past you'd rather not have public, this is the stage that will weed you out of the expert witness field. I note that the NYT article mentioned the expert's appearance on his Facebook profile, and also mentioned he had a Twitter feed. I plan to send this article to my students to remind them that anything they write, anywhere, could theoretically end up on the New York Times web site. I certainly keep this in mind when I blog and tweet. This is the chance you take when you do forensic work, whether or not you are forensically trained.

The last point I'm going to make using this article is the fact that this particular expert is retained as a prosecution expert. There are both advantages and disadvantages to being retained by one side or another, as opposed to working as a neutral court evaluator as I do. A defense expert has the advantage of being able to get in to see the defendant as soon as possible after the offense. This is good because you're more likely to get an accurate picture of the defendant's mental state at the time of the crime. A state or court's expert sees the defendant weeks or even months later, after bail review and arraignment and after the defense expert has had a chance to advise counsel on the likelihood of a viable insanity defense. Experts acting in a neutral court-appointed role have to work harder to gather the data to put together a retrospective picture of that mental state.


I could go on and keep rambling about this but that's enough for now. The NYT's point about the expert being a hired gun as an old one I've talked about before. Ironically, the NYT just made my point about this---if you are a hired gun everyone will know it, it will undermine your credibility and make you less useful as an expert. Being a hired gun is bad for business so most experts know you just can't get away with it over the long term. And that's one of the standard cross-examination techniques as well---trying to paint you as a hired gun.

Enough.

Speaking Ill of the Dead

I'm moving this discussion to its own post since it has little to do with mandatory employee health screening and I think it deserves its own section.

Jesse put up a link to a PBS news interview with Drs. E. Fuller Torrey and Elspeth Ritchie regarding Aaron Alexis, the alleged Navy yard shooter. This has spurred discussion about what, if anything, psychiatrists should be saying in the media about specific individuals with rumored mental illness.

I've gotten on a soapbox about this a number of times before and I don't want to be repetitive, so if you feel inclined you can search the blog for the labels "shooter psychology" and "spree killing." You can also read my Clinical Psychiatry News column about a similar situation, "Use of Psychological Profile to Infer Ivins' Guilt is Prolematic". (Titles are not my strong suit.) I wrote a followup column about this just last month when the president of the APA tweeted out a statement regarding the legal sanity of the Fort Hood shooter.

Honestly, at this point I feel like a broken record. (Oh dear, some of our readers have probably never played a record!)

In my opinion, no mental health professional should be making public statements about the legal sanity or mental state of a living criminal defendant prior to trial. Presently our APA ethical guidelines do not expressly forbid this, unfortunately. The guidelines make a generic caution against public statements regarding people we haven't personally examined in a principle known as the Goldwater rule. This has been interpreted to mean that public statements are OK as long as the professional makes an initial disclaimer that they have not personally examined the individual they're talking about.

This guideline was written and adopted before the Internet was invented, even before there were personal computers (back when people knew what 'records' were and what happened when they cracked).

I felt the time was ripe to bring this so-called Goldwater rule into the modern age, and I also felt strongly that we should include a specific caution or prohibition against public statements regarding criminal defendants. I drafted proposed language in an action paper which was later adopted by the APA. To my knowledge, the Goldwater rule is being revisited (and hopefully revised) right now.

But back to Aaron Alexis and the PBS interview. This is where it gets tricky. In contrast to the Fort Hood shooter, Jared Loughner and the Aurora theater shooter, this is a situation where people are making statements about a dead suspect rather than a living defendant. The impact on a dead person is, well, moot.

Nevertheless, there are ramifications to consider. Media statements may reinforce the notion of guilt in the public mind when the deceased was never actually tried or convicted, or any of the evidence put to the test. This was the case in the situation of the late Bruce Ivins, the anthrax mailing suspect. In that case the only physical evidence linking him to the crime was the genotype of the anthrax bacillus. This evidence was weak enough that FBI investigators were concerned it might not be admissible. He might have been innocent. The situation is slightly different for Aaron Alexis given that he was definitely at the scene of the crime and presumably the evidence of guilt might be stronger than in the Ivins case. But does that change our professional obligation to maintain respect for persons? At what point do we need to balance the real need for public education about mental illness, violence risk assessment and the pro's and con's of involuntary treatment against the distress of a surviving loved one? While public opinions about won't impact a dead suspect, they will impact the suspect's wife, children and siblings. Just ask the mother of the Columbine shooter.

This post is getting a bit long and I have other things to do, but I thought I'd spew out an initial reaction. There are also state laws about medical confidentiality which address the maintenance of confidentiality after death, but that's a topic for another post. Some confidential information might have become available to investigators when the suspect was still alive, in the heat of the incident when danger was imminent. Given that there will be no trial, we likely will never know. But these situations are bound to come up again so we should be prepared for these discussions.

What Would You Do? What Would You Want?

Courtesy of CNN, here are a couple real-life scenarios I thought I'd share with you. Both of these videos represent the kind of cases that a psychiatrist confronts in an emergency room. I'd like you to put yourself first in the position of the patient: suppose you've been sick before, but never this sick (let's take it for granted none of this is due to drugs for now). You have an advance directive in place that says you absolutely don't want treatment even if you're a danger to yourself (again, for the sake of the exercise it's an enforceable advance directive). You never addressed danger to others in your advance directive because you never anticipated it could get this bad.

What would you want done?

If you were the doctor, what would you do?


Now for the second scenario. Is there anything about this situation that might make your wishes or opinions different from the first one? What's the difference? And if none, why not?



Thank you in advance for thinking about these problems. All of you who commented on my Emancipated Patient post have taught me something and I'm grateful. I'm putting this up to learn more about your ideas, opinions and wishes. Please keep talking.

The Emancipated Patient

  

On our last blog post pseudo-Kristen laid the groundwork for what I'm about to say. In a comment there she said:

"I want the same scenario as the cancer patient. I want to say, as someone who is presently competent to make decisions, that this form of intervention was not life saving for me, it was harmful to me personally and drove me further from care. I want to be able to opt out of all forced treatment in case of psychiatric emergency…"

Presently this isn't possible. Although psychiatric advance directives exist, the reaction I've gotten from both doctors and patients is that they are essentially useless. Doctors don't like them because they can lose the ability to give involuntary medications---leading to a patient taking up a hospital bed who can't be treated. Patients don't like them because in many states they can't be used to prevent civil commitment.

This got me thinking. What would happen if advance directives had teeth? What would be the outcome if certain patients, after a certain process, were essentially exempt from ever being subject to involuntary care?

There is an analogous process we can look to in juvenile law. (Forgive the comparison, I'm not implying that psychiatric patients should be or are lesser than adults although I'm sure sometimes it feels that way.)

In juvenile law, if someone can prove that he is living independently of his parents and is not financially dependent on them, or is married and raising a child, he may have himself declared emancipated by a judge. This essentially grants the chronological juvenile the same legal rights as an adult---he can sign contracts, consent or refuse medical treatments, and do other things not otherwise available to children.

Imagine a process by which a psychiatric patient could claim absolute treatment decision rights. He has perfect insight, has a reasonable understanding of what his illness is and what the symptoms are, the effects these symptoms have on his loved ones and employment, and all the possible ramifications of getting sick (yes, even the risk of suicide or criminal acts). Let's temporarily suspend all the obvious objections to this from family, psychiatry, and society in general and assume for the sake of discussion that such a process were magically adopted by the legislature.

Voila. You're free.

What happens next?

Ideally, nothing different. The patient gets better on his own or with the voluntary help of a mental health professional on either an outpatient basis or with a consenting inpatient admission.

Maybe he doesn't get better, but also doesn't want the "help." He struggles along on a daily basis, maybe functional or not-as-functional as he might be. Maybe he doesn't struggle along. He stops eating, stops bathing, stops drinking, loses weight and his family gets worried. He still doesn't want the "help."

Here's the point where everybody really starts getting nervous. The ugly question, the question not to be said out loud by any psychiatrist:

Should a psychiatric patient have the right to let himself die? (I feel a bit sick just writing that.)

At this point let me be clear that my own personal opinion is NO. This is only a theoretical discussion.

Now let's make things even more complicated. I'm going to draw on a real life, actual legal opinion for this hypothetical.

Before our hypothetical patient drew up his motion for emancipation he had to be assessed as competent to file for emancipation. Psychiatric advance directives have a similar requirement. But the Federal Court of Appeals for the state of Vermont has said that this is a violation of the Americans with Disabilities Act since medical patients don't have to prove competence before signing a medical advance directive. In Vermont, a theoretically incompetent person could sign an advance directive refusing all psychiatric care.

Personally I think a formal emancipation process would be better than taking that risk.

I could take this one step further and make the hypothetical even more extreme by pointing out that Vermont also just passed a law allowing physician assisted suicide (what if you want the right to die due to an terminal-if-untreated psychiatric condition?). I think I'll stop here for now. This slope is slippery enough.

Discuss.

What I Learned Part 2

Oh my, it's hard to keep my mind on professional things when I see a hurricane headed toward my home. The airline says they're not expecting it to affect my flight back, but I'll believe that when I see it.

But on to the conference...

The poster session was notable for a nice outcome study done in Georgia about the efficacy and cost impact of a jail-based competency restoration program. Another poster about assisted outpatient treatment in New York showed that there was considerable variation in willingness to seek outpatient commitment, possibly related to available outpatient services. There was a presentation about the use of restraints in pregnant psychiatric patients which was interesting. There was a national survey of mental health program directors which showed that up to 80% of responding systems had no established policy about this.

There was a panel presentation about the AAPL guidelines for sanity evaluations, which are being updated. Members were given the opportunity to comment upon the current guidelines and any issues that needed to be revised.

I was pleased to see ethics featured prominently at this conference, including a very informative panel presentation about the process by which AAPL and APA manage ethical complaints and the difficulties writing and enforcing professional guidelines. I learned that about 10 to 15% of ethical complaints to APA district branches are related to forensic issues.

The luncheon speaker was David Kaczynski, brother to the infamous Unabomber Theodore Kaczynski. He gave a very moving talk about his early life with his older brother, Kaczynski's gradual withdrawal from his family and society in general, and the slowly growing realization that his older brother was indeed a killer. He talked about his struggle to come to terms with his suspicions, the impact on his elderly mother and what it felt like to be caught between preventing future murders and potentially sending his brother to a death sentence. He talked about his work after the trial, reconciling with some of the victim's families. My most memorable quote: "Teddy's bombs destroyed lives, but healing is possible."

The early afternoon session was a smorgasboard of random topics. There was a survey of judges regarding their willingness to allow defendants to represent themselves at court (pro se defenses). Judge weight heavily the defendant's ability to understand the risk of a pro se defense and the defendant's willingness to accept standby counselor. Psychiatric input is considered, but mainly as it related to a description of symptoms and impairment rather than the ultimate opinion of competence. There was a description of a telepsychiatry program used in the New York prison system, where fourteen facilities used teleconferencing to provide over 12,000 patient contacts in one year.

Finally, the secondary them of this conference appears to be the use of psychological tests by psychiatrists. The last session of the day was entitled "Psychology vs Psychiatry in Risk Assessment". The panel presented individual cases and general principles related to the use of violence prediction instruments and how they are currently used in forensic work. The limitations of these instruments were also discussed, which was interesting because this is not something that often gets discussed by those who use them (at least in my experience). One example of this was the use of a violence risk instrument for conditional release. Since the risk of dangerousness must be due to a mental illness, and since the instrument did not rely upon illness-based dangerousness, the instrument was not relevant to the legal question at issue.

So that was the day. You can follow my live tweets from the conference at: www.twitter.com/clinkshrink

Podcast #66: The Professional Shrink Rap

Roy talks the top 25 search phrases that lead people to our Shrink Rap blog. 
They include, "Statistics of talking too much on a date,"  "World's largest zucchini,"  "Does Angry Birds make you depressed?"


We talk about when should a psychiatrist call in sick?  How sick is too sick?  How distracted is too distracted?  Are psychiatrists good at self-monitoring?


Roy discusses an article called Professionalism in Psychiatry. 

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

You're A Whore

On my post "The Violent Patient", Anonymous Clinician wrote this comment:

"Frankly, I have little respect for Forensic Psychiatry these days. It is a whore subspecialty until proven otherwise, as it is doing what is financially convenient for the MD and just making general psychiatrists pick up the messes."

The accusation that forensic psychiatrist are 'hired guns' is not a new one. When I was a medical student I did a neurosurgery rotation. Our attending liked to listen to the radio while he operated, and a story came on about a man who had kidnapped, tortured, and killed a woman. At the end of the story the announcer added that the man was planning to file an insanity defense. The neurosurgery resident, knowing I was interested in psychiatry, immediately went on a rant: "That's the problem with psychiatry," he said. "Somebody does something criminal and there's always a psychiatrist somewhere saying he was crazy and shouldn't go to prison. This guy should be locked up for the rest of his life. They should do the same thing to him that he did to that woman."

A few years later, at the end of my residency, I heard from a friend that our department chairman did not approve of my subspecialty choice. "It's too bad she's going into forensics," he had told my friend. Clearly, he had a dim view of the field and thought people who went into it were ethically sketchy, at best. (Ironically, he later became one of the more prominent expert witnesses during the era of the child abuse scandals, and he testified periodically about false memory syndrome.)

Shortly after I began my fellowship, Dr. Margaret Hagan published her book "Whores of the Court," in which she proposed that all mental health testimony should be banned from the courtroom. (Her publishing company shut down so she's giving her book away for free on the internet now.)

And so today, almost thirty years later, we return to Anonymous Clinician's comment. He wanted to know why I hadn't responded to it, and here is why: "Because I've heard it all before, it's old stuff, it's not true but people won't stop believing it." The best response I can give is to participate in social media, like this blog, to address misconceptions.

Here are the common misconceptions about forensic psychiatry:

1. Forensic psychiatrists 'get people off' from their crimes.

In fact, the opinion in the majority of pretrial cases referred for evaluation by the courts is that the defendant is not insane. Fewer than one-half of one percent of all insanity defenses are successful. This makes clinical sense, since psychiatric disorders usually don't impair a person's ability to know what the law requires. And it's not the psychiatrist making the decision about guilt or innocence: that decision is made by a group of average citizens---the jury---or by a judge. Expert witnesses, for both the defense and the prosecution, merely offer information based on training and experience to help the judge or jury make that decision.

2. Forensic psychiatrist will say what they're paid to say.

A good attorney will not hire a 'hired gun.' They are paying a lot of money for a witness who is credible, and a forensic psychiatrist with a reputation for being a 'whore' is not going to go very far with a judge or jury. Being a 'hired gun' is bad for business for the forensic psychiatrist too since a bad reputation cuts pretty far into your referral base.

Also, remember that in many cases the forensic psychiatrist is not retained by a private attorney. Many forensic psychiatrists are employed by state health departments. They are salaried employees, not private practitioners. As such, their income is independent of the opinions they form.

3. Forensic psychiatrists aren't doing 'real' psychiatry.

In other words, they're not clinicians. Ah, so untrue. Most forensic psychiatrists will tell you that it's important to retain at least a part time private practice because it's too demanding to have a 100% evaluation-oriented practice. Some forensic psychiatrists don't do evaluations at all, but devote all their time to providing clinical care to patients in correctional facilities or secure hospitals. Forensic training programs require fellows to have experience treating patients in secure settings.

The post is getting a bit long so I'll stop now. Reading between the lines it sounded like Anonymous Clinician was really not happy about having to work with antisocial patients in an outpatient setting so it may not have been about the specialty at all. But there's my response.

(Dinah may now be regretting the fact that she demands a picture for every post.)

NYT: When Lobotomy Was Seen as Advanced

This is an eye-opening essay about how lobotomies were used back in the day.
[posted via email]
From The New York Times:
ESSAY: When Lobotomy Was Seen as Advanced
New research indicating that Eva Perón was lobotomized not long before her death is a reminder of how enthusiastically this operation was once embraced.
http://nyti.ms/tRibGb

The Very Badly Behaved Health Care Practitioner

I've been asked several 'ethical dilemmas' in the past few weeks.  I'm putting them up on Shrink Rap, but please don't get hung up on the details.  These aren't my patients, but the details of the stories are being distorted to disguise those involved.  The question, in both cases, boils down to: Should the mental health professional report the patient to his professional board?


In the first case, a psychiatrist is treating a nurse who is behaving badly.  The nurse is stealing controlled substances from the hospital and giving them to friends who 'need' them.  She doesn't intend to stop, and her contact with the psychiatrist was only for an appointment or two before she ended treatment.  Should the psychiatrist contact the state's nursing board?   Is he even allowed to?


In the second case, a psychotherapist  sees a patient who is also a psychotherapist (I will call the patient here the patient/therapist).  The patient tells the therapist he having a sexual relationship with one of his own patients (the patient/victim).  This is clearly unethical, but the patient/victim is an adult and the relationship is "consensual" in that it is not forced or violent.  There is no question that if a licensing board knew of this, the patient/therapist would lose his license.  Should the treating therapist report his patient for unethical behavior?  Ah, he asked a colleague on the Board and was told that he must report this, and if he doesn't, his own license could now be at risk.  If he now reports it, as instructed, can the patient/therapist turn around and sue him for breaching his confidentiality?  After all, he was seeking help with his problem, he believed it was protected information, and now he will be sanctioned out of a livelihood.    Does it matter if the therapist is a physician (for example, a psychiatrist) as opposed to a psychologist or social worker or nurse practitioner?  I realize that all mental health professionals have confidentiality standards, but are the confidentiality laws that apply to physicians/clergy/attorneys the same as they are for other mental health professionals? 

Tell Me.... an Ethical Dilemma

Sam is young man is applying for a summer program, a real resume builder.  Among other things, the application asks if he has been treated for a psychiatric disorder.  In fact, he's seen a therapist and he's felt anxious at times.  His internist gave him some Lexapro samples and he feels better.  The symptoms of his problems have been limited to his own subjective distress.  His anxiety is not something that has disabled him, in fact he has not missed a day of school in 3 years -- and then for the flu-- he sees his therapist on the weekends, and no one would know he's been uncomfortable unless he told them.  He's never been in a hospital, he's ultra-reliable, and he has great grades and extracurriculars.  Any way you look at it, Sam is an energetic guy on the road to success.


What should he write on the form?  It's a yes/no check box, no questions or place to clarify, so if he says yes, well, that could mean he has some subjective anxiety, or it could mean he has attention deficit problems, or it could mean he has been hospitalized 6 times after becoming violent, or has a severe mental illness.  He's worried that his anxiety will throw him into a subset of applicants that the committee would rather not deal with: why choose someone for a project who has a mental illness if another equally qualified applicant is available without this issue to address?


Sam's mother say he should check "yes."  He has been in treatment and he has a diagnosis and he takes a medicine.  He has a psychiatric disorder and he needs to be honest. 


Sam's father says that the question defies the spirit of what the committee wants to know.  They want to know, Dad presumes,  if there will be issues or problems or things they might need to accommodate, and there is no reason to believe that Sam's problem will interfere with his ability to negotiate life in a competitive or stressful environment.  Sam, he contends, does not belong in the same category as someone who has attempted suicide, been hospitalized, missed work, or behaved in a disruptive or dysfunctional manner. If anything, Sam's anxiety drives him to focus and achieve and to be very conscientious.  He's not ill, his father says, he's just more anxious on a spectrum of normal anxiety.


I want to know why forms get to ask such questions and put people in the awkward situation of having to answer something that is none of anyone's business versus being dishonest.  It seems that if someone wants to know this, it might be asked in terms of "Do you have any health issues that might require any special accommodation?"  Is there a limit to what random forms can ask and whether you're behaving unethically if you choose not to answer their questions or answer it less then completely?  Sam tried leaving the question blank, but the computer wouldn't let him submit the form without checking all the boxes first.  Can they ask if you have deviant sexual fantasies?  If you've ever committed a crime (regardless of whether you've been charged or convicted)?  If you say provocative things on your blog?

Physician Online Behavior: Professionalism and Social Media

Mark Ryan, a Virginia family physician, wrote a blog post for Mayo Clinic Center for Social Media three weeks ago, reviewing the many definitions of "professional behavior" for physicians and how that might apply to our social media interactions.

It is apparent to me that what is considered appropriate or not for physicians using social media (eg, should you friend a patient on Facebook?) is still being tested and figured out. However, Mark's post reminds us that there are certain principles that remain immutable, despite the technology.

My Doctor, My Expert

In Dinah's post "The Chapter I Wish We Had Written" an anonymous commenter wrote about his problems finding an expert witness for his or her employment discrimination case (since I don't know if Anonymous is male or female I'm going to use a standard male pronoun in this post---apologies if I got this wrong). Anonymous asked his doctor to help with the case, but he refused. He explained to Anonymous that he would be a biased witness and Anonymous also understood that the doctor's involvement might affect the therapeutic relationship. Anonymous's doctor gave her a number of referrals to forensic psychiatrists, but since he was not working with an attorney no expert would take the case. Anonymous was understandably frustrated by this situation.

I wanted to write about this because this situation comes up fairly often and I get calls from friends, colleagues and former students asking how to handle it. I've already written about what to do when you get served with a subpoena in my post "When Lawyers Call."

First of all, I think Anonymous's doctor was particularly astute to recognize the dilemma that arises when trying to help patients in situations like this. I try to prepare psychiatry residents during their training to help them handle this problem, but in the days before forensic rotations were required in residency doctors didn't get that preparation. Anonymous's doctor is either young enough that he had forensic education during residency, or old enough that he got some real-life experience with it. Either way, he was right to recognize that he could be biased and that he was not in a position to offer a forensic opinion, and to make a referral to others who could.

In civil litigation expert testimony is usually needed to address the following questions:
-what is the plaintiff's diagnosis?
-what are the symptoms of that illness and how do they impair the plaintiff's life?
-what is this treatment for this condition?
-has the plaintiff improved as much as he will improve?
-what caused the plaintiff's condition?
-what are the plaintiff's permanent damages?

A treating clinician is usually called as a "fact" witness. A fact witness is someone who testifies about information they've directly seen or heard. Fact witnesses can't draw conclusions or offer opinions about their observations, and they can't be paid for their time testifying. Expert witnesses are allowed to draw conclusions or offer opinions about their observations.

Sometimes it gets tricky sorting out whether or not a treating clinician is being offered as a fact witness or as an expert witness. For example, a medical diagnosis could be considered a "fact" because it's a piece of information documented in a medical record. Testimony about a medical diagnosis could also be considered expert testimony, because the doctor is drawing a conclusion from his observations: ("I observed a sad expression and the patient reported persistent feelings of anhedonia and worthlessness, so I concluded the patient had clinical depression.").  It's important to clarify up front whether the clinician is serving as a fact witness or as an expert witness.

Role clarification is also important because you also have to clarify who is paying you and for how much. Some unscrupulous lawyers may try to call a doctor as a fact witness, knowing fact witnesses can't get paid for their time, but then will try to squeeze an expert opinion out on the stand regarding causation and damages. Shame, shame, on these folks! If you are qualified as an expert on the stand, you are entitled to expert witness fees.

Regardless, generally accepted ethical guidelines state that it is a conflict of interest to serve as both a forensic expert and treating clinician. If you end up stuck in that position---say you can't get out of a subpoena and you are required to offer expert testimony about a patient's diagnosis and factual information about treatment---how do you avoid looking like a fool or hurting your patient?

First, admit what you haven't done as a "real" forensic expert: you haven't interviewed collateral informants, you don't have all the investigation reports or records, you don't know your patient's entire litigation or criminal history, or the extent of pre-existing injuries, etc etc. For all these reasons, you are unable to offer an ultimate opinion about causation or damages. No one can force you to form an opinion if you have none. In this situation, "I don't know" is the correct answer.

If you know you're going to have to testify, prepare your patient in advance for what you might have to say. Because you're given access to many personal areas of a patient's life, some irrelevant but damaging information could be brought out in court. No one should be surprised, particularly not in a negative way, about what is being said. A treating psychiatrist should also be prepared for what could be said about him in court: How many times did you take your board exams? And did you pass? How much money do you make from expert testimony? Did you consider other possible causes of your patient's problem? Why didn't you do (X, Y or Z)? A clinician could be left feeling like the shoddiest doctor on earth, and that isn't going to help the next time the patient comes into the office.

CPN: The Anthrax Report

--I'm posting this for Clink because she is in prison where she can't access blogger.


In ClinkShrink's post on Clinical Psychiatry News she points to some ethically troubling actions in the official investigation into Dr. Bruce Ivins's alleged involvement in the 2001 Anthrax attacks, including the sale of a report containing his medical records.  

 Use of Psychological Profile to Infer Ivin's Guilt is Problematic

Weiner Diagnosis?

 

In Shrink Rapper world, we get a lot of email from publicists about books, TV spots, upcoming events.  This was in my spam box today:

Rep Anthony Weiner is expected to resign today after weeks of scandal surrounding his lewd text messages, tweets and photos.  Even in his tearful media conference, Weiner could not explain why he participated in such behavior.  According to NYU Medical Professor and Internist, Dr. Marc Siegel, the congressman’s behavior is systemic of a larger psychological problem, which must be addressed before fixing the addiction to online sexual activities.  

 

Dr. Siegel says, “This seems to be an example of extreme narcissism, inflated self image, depersonalization, loss of contact with reality, addiction, and the power of the Internet as a medium (like the Wizard of Oz you feel you are hiding behind the curtain)”.

 

To discuss the dangers of addiction and steps to overcome the serious illness, Dr. Siegel is available to offer is medical knowledge.  As a medical practitioner and FOX’s House Doctor, Dr. Siegel has spent years diagnosing and treating people in the national media spotlight.

 

If you are interested in speaking with Dr. Siegel, please contact me at .

 

Best,

Rena  

 

Rena Resnick

5W Public Relations

Oh my, I thought.  I read it twice. An internist is going to comment on Anthony Weiner's narcissism, motivations, sense of self, and contact with reality?   Sounds like a shrinky thing to me, but the Goldwater Rule prohibits psychiatrists from commenting on the mental state and diagnosis of someone they haven't personally examined.  Does that mean it's okay for other specialists to talk about the mental state of someone they don't know?  Hmmm...   I guess we'll see what he has to say, but I'm not so sure about this.

We Still Don't Say

It's been nearly 5 years of Shrink Rap posts--this is post number 1,402. I've rambled and ranted so much, I don't know what I've said and what I haven't said, much less what the other Shrink Rappers have talked about.

So Meg asked ClinkShrink to comment on this article about Bernie Madoff's psychotherapy in prison. Mary Jo says we could have a field day with Charlie Sheen (it was a joke, as evidenced by the : ) in the comment...at least I think it was a joke).

Instead, I thought I'd write about the Goldwater Rule and how shrinks can't talk to the media about people they haven't examined. This feels familiar. Maybe ClinkShrink already posted about it? A quick search, and I 'remembered' that I wrote a post called We Don't Say just about two years ago.

Regarding Bernie Madoff and Charlie Sheen, I think we'll stick to "No Comment."

The Ethicist On Whether Shrinks Should Lie to Keep Their Clients

I hope everyone had a wonderful holiday! We've been busy brining, basting, baking, eating, and visiting with family. Sad to go back to the daily routine.
-----------------------

In today's NY Times Magazine the ethicist entertains the question of whether it's okay for a psychiatrist to lie to keep his clientele. (!)

I am a psychiatrist who happens to be an atheist. Occasionally a patient asks me what religion I follow and, displeased by my answer, seeks another psychiatrist. I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s. Nevertheless, candor sometimes costs me a patient. May I claim a belief in God to avoid damage to my credibility and business?

VAIDYANATH IYER, THE WOODLANDS, TEX.

If you want the ethicist's answer, check out the column here.

I think that most of us would agree that it's not okay to lie with the intention of keeping business. What if a patient asks how long you've been practicing, and your sense is that the patient wants an experienced psychiatrist-- would it be okay to say 10 years, rather than 1 year? Clearly not.

Personal questions can be awkward, however. In traditional psychodynamic therapy, the therapist doesn't answer personal questions---the "blank screen" is necessary for the treatment, and the meaning behind the question is explored. This can be very off-putting to some patients, and for myself, I find that it feels disingenuous, and I prefer to simply answer questions. It helps that I don't get many questions: Do you have children is the most common, I've been asked my religion a couple of times, if I have a dog (Yes, two, would you like one?). Here and there, I've been asked rather unusual questions (Do I have a cook? Who has a cook? No, but I'd like one!)

It seems to me that if something like this is essential to the patient's comfort level, then they should ask this on the phone before the first session. Does it all matter? Who knows---they make good therapists in all shapes and sizes and the interpersonal fit often is found in the least expected place. And my guess is that the ability to accurately diagnose and treat a mental illness has relatively little to do with any of these matters. Probably people are more picky about the personal lives of their shrinks than their brain surgeons, but maybe they shouldn't be.

Related Posts:

Self Disclosure and Being Genuine

A Shrink Like Me

What to do when your Patient Friends you on Facebook or Follows you on Twitter

I participated long-distance in a social media workshop for the 2010 MedInfo conference (#medinfo2010) in Cape Town earlier this week. Kate Anthony and DeeAnna Nagel from the Online Therapy Institute were also participants, and the provided and excellent discussion of professional ethics, dual relationships, and good therapeutic behaviors as they relate to online interactions with patients and prior patients.

Excerpt:

Jane is your client. Both of you live and work in the same community. Jane is the director of a local charity. She sends you an invitation to be one of her contacts on LinkedIn.

Marcie is a former client. She was a teenager when you treated her. Several years later she has friended you on Facebook with a private message thanking you for being such a positive influence in her life. 

John is a current client who has begun following you on twitter.  He has send you a direct message and has also sent you an @reply to one of your tweets. He recently posted a tweet stating what a great therapist you are with a link to your website.

Mary has been your client for over a year. She has a history of childhood abuse and you have encouraged her to write in a journal. You receive an email from her asking to change times for her next appointment. She closed her email with “By the way, the journal writing has been so helpful, I have decided to start a blog. Here’s the link! www.maryrevealsinherblog.com. You open the link to discover that her first blog entry contains emotionally charged and highly graphic information about past childhood sexual abuse she has not previously revealed in therapy.

Kim was your client for over a year. You have not heard from her in at least that long. She was often hostile during sessions and would call between sessions feigning crisis and then apologise for her behavior during the previous session. The reason for termination was due to her move out of the area. Today you do an internet search for your name and you see that Kim has created a website, www.bewareofbadtherapy.com. Your name is on the website’s blacklist with links to excerpts of verbatim chat transcripts from sessions you held with Kim online.

To listen to their responses to these scenarios, watch the video at http://www.onlinetherapyinstitute.com/ethical-implications-for-therapists/ (the weird sound effects at the beginning last about 20 seconds or so... just wait for them to stop, it's worth it... and you get to hear input from their Second Life cat, Reva).


It would be great to hear your experiences with this issue in the comments, whether as a patient or as a therapist.