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

The Violent Mentally Ill

There's been lots in the news lately about forensic hospitals and the management of violence by psychiatric patients. Here's a short list:

1. Beyond the Gates of Gomorrah

A new book by Dr. Stephen Seager, a tell-all about his work in a California forensic hospital.

2. Broadmoor

A very rare documentary filmed within the walls of a British forensic hospital. In two parts, all on YouTube:

Ep 1 http://youtu.be/bNifHcZV_4Y  Ep 2 http://youtu.be/QNlGxWe-z6s 

3. Clinical Psychiatry News

My recent column, a review of new California guidelines for the treatment and management of inpatient violence. 
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Note from Dinah: the birds have nothing to do with the post, but I don't like it when Clink is too lazy to add a graphic.  Aren't they cute? 

What I Learned Part 3

Today I enjoyed the presentation about the role of the Academy and of the American Psychiatric Association in appellate litigation. Both organizations work together to file amicus curiae ("friend of the court") briefs for court cases that have relevance to psychiatry and the care of the mentally ill. The APA has participated in 127 cases since 1962, and AAPL has participated in 16 cases since 1985. Most briefs are written by the APA counsel (all of whom have been former Supreme Court law clerks). Most of the cases were criminal rather than civil cases, and several were cases that went before the U.S. Supreme Court. AAPL wrote briefs for cases involving intellectually disabled defendants facing the death penalty, and in the California prison case regarding overcrowding and access to mental health and other services. The AAPL brief was cited in the appellate opinion in 10 of the 15 cases, so the organization apparently does have some influence.

A panel presentation on the New York Safe Act was interesting, since the work on it was done long before the New York Times story came out on the subject. A group of forensic people tried to obtain data from the New York Office of Mental Health as well as the New York Division of Criminal Justice Services regarding the number of reports made, the professional training of those filing reports, the treatment settings the reports were made from, and the ultimate outcome of the reports. Both agencies refused to release data for a variety of reasons, either because "it was an election year" or because the statute was in litigation. In rare cases, the agency expressed concern over potential privacy issues where a report was filed in a county so small that the individual could easily be identified. Both agencies said that the only way to determine the number of guns actually seized would be to contact each law enforcement agency in every county---not a small feat for the state of New York. The only definitive statements given by OMH was that no reporter had ever been sued to date for making a report, and that there were some cases where reports were made by someone other than a mandated reporter (a psychiatrist, psychologist, social worker, or psychiatric nurse). None of these reports were acted upon or forwarded to local law enforcement. The implication appeared to be that if the information was coming from someone other than a mental health professional it might not meet the standard for requiring that dangerousness be due to a mental illness. This is speculation on my part; still, I'm not sure why a lay assessment of potential dangerousness---regardless of cause---wouldn't be taken seriously by someone. More evidence that common sense and public policy do not always go hand-in-hand.

The final session of the day was a panel presentation on consultation to law enforcement, easily the most testosterone-laden of any talk this week. The presenters were people who provided peer support, counseling and fitness for duty assessments on police officers. There was a lot of emphasis placed upon the need to slowly develop trust both with the department and the individual officer. In addition to post-incident counseling, mental health providers were involved in substance abuse and domestic violence counseling as well as crisis and hostage negotiation. I was impressed by some initial data they presented: that a police officer is two to three times more likely to die by suicide than to be killed in the line of duty, and that the life expectancy for an officer is 10 years less than the rest of the population (average age 66). This seemed like such a dramatic statistic that I figured I should do a little research about it myself, and I did. I found this article which contradicted the ten year number. In this 2013 study I found, the life expectancy of a police officer in Buffalo NY was actually 20 years shorter! Yowza.

Tomorrow's topics: Guns and the mentally ill, and research done on prisoners (ethics and barriers).

And a thank you as well as a shout-out to D.J. Jaffe for taking the time to tweet with me today. I'm trying to encourage the organization to have a more real-time social media presence during future conferences and your input was a great example of how the organization can broaden our discussions.

What I Learned Part 2

Day Two of the American Academy of Psychiatry and the Law Conference

I picked up a number of tidbits from the poster sessions:

-250,000 juveniles a year are sent to the adult criminal just system
-3/4 of all juveniles serving life without parole were sentenced in five states
-Louisiana uses an assertive community treatment program to supervise and restore  incompetent, nondangerous criminal defendants. This sounds like a good way to get people out of the hospital, or avoid having to send them there in the first place
-In Indiana, a survey was done of judges who have dealt with defendants claiming to be “sovereign citizens.” Most appeared in court for traffic violations or fraud rather than violent offenses. Tax evasion was least common charge.
-In a survey of PGY4 general psychiatry residents, most felt confident in their ability to perform sanity and competency assessments. Fewer felt confident in their ability to assess malingering or to participate in civil commitment hearings. This is concerning.
-Specialized processing centers (SPC) have been built for ICE detainees. They have 24/7 psychiatric coverage and freedom of movement, but no clinical review or medication over objection procedures.

The Bazelon Center has filed suit with the Department of Justice over the American Bar Association requirement to disclose disabling conditions like psychiatric disorders on the bar application, and over the requirement for some lawyers to work provisionally under supervision solely due to  a history of psychiatric treatment. Proposed language to restrict questions about psychiatric issues is being considered.

The APA is updating its resource document on assisted outpatient treatment. The final document is not available at this time and the organization's position has also not be finalized.

There was an interesting talk by one of the people working on the development of the Stalking Risk Profile, a new instrument designed to predict the relative risk of continued stalking of one victim, the risk of stalking a new victim, and the risk of violence posed by a stalker. It has shown good interrater reliability based on the stalker typology, and good predictive validity between high and low risk offenders. (The overall recidivism rate was 15%, but almost all of that was due to stalking the same victim.)

The final session of the day was a panel presentation, with pro and con arguments, regarding whether involuntary non-emergency medication should be administered in a correctional rather than a hospital setting. The "pro" side noted that in some jurisdiction the waiting time to hospital transfer can be months long, and that appellate courts have upheld the use of these "Harper procedures" (after the SCOTUS case Washington v Harper) for pretrial detainees. The most creative argument on the "con" side was by Michael Perlin, who suggested that involuntary medication of prisoners was a violation of the Convention on the Rights of Persons with Disabilities (CRPD), an international human rights agreement which the United States has signed on to. He suggested that any kind of involuntary treatment or detention based solely on the presence of a mental disability was discriminatory and a violation of that document. A creative but not persuasive argument.

So that was Day Two.

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.

PTSD and the Forensic Psychiatrist

 
This blog post is aimed at anyone considering a career in forensic psychiatry. Please read this interview in the Ottawa Citizen entitled 'Tough forensic guy' John Bradford opens up about his PTSD'.

I'm going to preface this post by saying that I know the man featured in this interview. He is an extremely accomplished and internationally recognized authority on the evaluation and treatment of sex offenders. To think that we could have lost him is a devastating idea to me. He has always been respected within the forensic community, but I respect him even more after this interview.

In this article Dr. Bradford talks about the recent stress a pretrial evaluation placed upon him when he had to work overtime, under a deadline, to evaluate a sexually sadistic murderer. He was required to watch actual videos of the crimes, to witness the killings and to hear the pleas of the women he knew were doomed. The experience brought back recollections of other serious crimes and cases he had been involved with in the past. In the interview he discusses the effects this had upon him over time and the challenges he faced when he finally needed to get help dealing with it. Getting treatment was particularly difficult for him, both because of his prominence but also because forensic psychiatrists are just supposed to be able to handle this stuff. In his own words:

“It’s complicated,” he says. “In my case it was macho. I’m a top forensic psychiatrist and I saw it as a weakness. I don’t talk about the treatment much because it’s difficult for me but getting to it early is important.”

I understand completely what Dr. Bradford is talking about here. Over the years, forensic psychiatrists end up hearing and seeing information about crimes that are pretty terrible. We see digital photographs of crime scenes, autopsy photographs, surveillance videos of murders, suspect interrogations, phone call tapes, written letters and other pieces of evidence that relate detailed information about violent crimes. A single case can require weeks and hundreds of hours of study with repeated exposure to horrible events.

Even without developing PTSD this can change your view of the world a bit. At times I joke that when I give directions now I don't use street names anymore, I give directions in terms of crime scenes: "Take a left and drive south a few blocks until you get to the church that was the scene of the ice pick murder, then take a right until you get to the samurai sword decapitation..."

Yeah, it makes life a little weird.

There are prohibitions about talking about active cases, for legal reasons, but there are also good clinical reasons why you don't talk about your cases with friends and family. Once you get these images in your head they don't go away, and it's not fair to place them into the heads of other people. I warn my program applicants about this too.

To a certain extent, medical training weeds out people who aren't able to handle this. I think there's a reason why my medical school put anatomy class as the first class on the training agenda. After four months hanging over a formaldehyde soaked body, it took me a while before I could eat chicken again. The muscle fibers and tendons just didn't look the same after anatomy class.

Some people complete forensic training and never touch a forensic case again and never do forensic work. I've often wondered about that, and wondered what we could do ahead of time to help people decide if they're really cut out for the work. Given Dr. Bradford's interview, we should probably also think about what we should be doing to look after the people who stay in the work.

What I Learned: Part 3

(Picture explanation to follow.)
Usually I write about the conference in the order that I hear things, but in this case I'm changing things around a bit to start with the topic I know most of our readers would be interested in. Involuntary treatment.

A Canadian nurse presented the results of a small but interesting study about the experience of being placed in a seclusion room. She developed a list of open-ended questions that she asked of both the nursing staff and secluded patients, 13 of each. Most of the patients who had been placed in seclusion had a psychotic illness, either schizophrenia or schizoaffective disorder. Five also had antisocial personality disorder.

Both groups were asked about the reasons for seclusion, their attitude toward the quality of care received while in seclusion, whether it was necessary and finally given the opportunity to describe the "ideal" seclusion room.

As expected, the nurses rated "safety" as the number one reason for use of seclusion, and none saw it as punishment. They emphasized that alternative interventions were always preferred and that extended negotiation was often used as a means of avoiding it. They emphasized the importance of having a good rapport in order to avoid escalation. Although the nurses were evenly divided on whether seclusion improved or impaired the quality of care given, most agreed that seclusion rooms could be beneficial in the short term for a patient's mental state. They reported feeling shaken and traumatized themselves when required to put someone in seclusion and said that debriefing with a colleague was helpful. They consistently emphasized the importance of a "QTIP" attitude ("quit taking it personally") when threatened or assaulted: "They could be cussing at you...spitting at you...hitting you. But you got to put all that aside because you know that's not the real person you were talking to the day before."

The surveyed patients had been placed in seclusion for an average of four or five days in the past six months. All but two patients had negative reactions to the experience and did not find the room beneficial for their mental states, although most understood the reason for the intervention. The experience was described in a wide variety of negative terms, but the most prominent theme was boredom. Two patients had positive reactions to the experience: relieved to avoid the stress of a potential confrontation with other patients, or even the opportunity to be "more creative" when left alone. The nursing protocol generally required the nurses to minimize patient stimulation and this meant that staff tried to minimize communication, and patients generally didn't like this. They were more likely to describe the experience as punitive, or used as an alternative to spending time with the patient. Lack of privacy, cold temperatures, difficulty with access to showers, soap and dental hygiene were also cited as a problem. Some patients were even served "finger food" rather than be trusted with utensils.

Both groups agreed that seclusion was a preferred alternative to physical restraints.

As a result of this study the group came up with recommendations to modify the physical conditions of the seclusion rooms, to provide more opportunities for interaction with staff while in seclusion, and to offer the option of listening to music.

This was the second presentation this week in which a project was organized and lead by a ward nurse, with resulting concrete recommendations to improve direct patient care. Nice.

Now to back up and discuss the poster presentations:

There was a survey of more than 600 Pittsburgh police drawn from all levels of service, including command staff and investigators. The purpose was to assess their attitudes toward the usefulness of mental health involvement in police matters. Most respondents rated crisis debriefing or personal counseling relatively low, but rated utility high for help with crisis or hostage negotiation. Interestingly, although most respondents weren't investigators (thus, had no direct experience with it) many rate "profiling" or investigative assistance as highly useful. About 25% of the respondents had been through CIT (crisis intervention training) and it was going to be made mandatory.

I'm a bit biased about the next poster since I know the investigator, but it's still a good one. It involved a battery of neuropsychology tests to look at which cognitive functions were most correlated with good or poor vocational outcomes. In other words, disability determination. Out of the entire battery, the strongest predictor was cognitive processing speed as measured by a simple paper and pencil test that took six minutes to administer. I thought this finding had intriguing potential for further study to look at correlations with general competence to stand trial.

There was a national survey of correctional mental health systems which tried to identify barriers to psychiatrist recruitment and retention. The most interesting part of this for me was the fact that anxiety or fear of the correctional environment was the biggest barrier to recruitment but the lowest factor for retention. That's consistent with my experience bringing new staff in to prison: after a few weeks you realize it's just not as horrible as everybody warned you it would be. (Or that journalists report.)

A poster about "Big Data" presented the results of a national survey of AAPL members regarding their use of Internet search data in clinical and forensic practice. About half regularly did Internet searches or reviewed social media related to their cases, and most have found useful information. Most thought there was a need for better guidelines for this practice given the ethical issues involved.

Today's session reflected ongoing concern about gun laws and firearm related violence. One poster presented the outcome of seven years of experience with a firearms seizure law in one Indiana county.  Court data from 2006 to 2012 was presented. During this time only 254 guns were seized. In the early years (2006 to 2007) most patients didn't bother to show up for their firearm retention hearing, or they voluntarily surrendered the weapon. In later years, courts dismissed the case and  returned the weapon in 80% of cases. The time to resolution of the case averaged 300 days. In two-thirds of cases, reason for seizure was threat of suicide and 3.5 weapons were recovered when the police transported the patient to the ER, voluntarily or involuntarily. In other words, the seizure law didn't take many weapons off the streets but it did make people more adamant about getting their weapons back. There was no data presented about suicide rates during this time.

At a panel discussion about gun laws since the Virginia Tech shooting I learned that in 1999, the first year that NICS (the background check system) went live, 81,000 firearms applications were denied (only 1.8%) and fewer than 0.1% were denied due to mental illness. By 2012, still only about 1% were denied but mental illness was the basis for 22% of the denials. I also learned that in order to take possession of a revoked weapon, police can only knock on the door and ask for the weapon. Apparently revocation does not serve as a basis for a search warrant. I hadn't thought about that issue.

Last but not least, there was a presentation on national laws related to zoophilia. (Thus, the turkey.) If you feel a need for dinner party trivia, I can tell you that 31 states have laws against zoophilia and that it could be either a felony or a misdemeanor. A LexisNexis search of cases using the term "zoophilia" turned up 26, usually in relation to an appeal of a sex offender commitment. The disorder was cited as a sign of generally more serious psychopathology in connection with other paraphilic disorders. I also learned about the practice of people known as "furries." If you want to know what that is, I will only tell you if you retweet a link to this post ten times:

Day 3 of the American Academy of Psychiatry and the Law, summaries here: http://t.co/ahtZbOfFeh #forensic #psychiatry #AAPL2013

— Clink Shrink (@clinkshrink) October 27, 2013

What I Learned: Part 2

Welcome to the second day of the AAPL conference. Dinah knows I have to throw in a bird picture somewhere. The fighting gull picture is in honor of the birds duking it out overhead during my boat ride across the bay last night. More to follow.

I started out the day with a review of new legal cases pertinent to forensic psychiatry. In training forensic psychiatry students are required to learn a set of legal opinions known as the "landmark cases," in other words, decisions that have profoundly influenced the practice of psychiatry. The trick with this is that you don't always know when the opinion is issued whether it will have a large impact over the long term. AAPL does a pretty good job of picking out the cases that will have significant influence.

The panel presentation I attended talked about the history of the Plata case, the Supreme Court opinion which ordered the state of California to decrease its prison population by 42,000 inmates. This is a significant decision since there are several other states in this country (Maryland included, the home of the Shrink Rappers) in which the prison system is running at 140% over capacity. This is the same level of overcrowding as California. The Supreme Court was divided about whether to order this. Justice Scalia called this the "most radical injunction in this nation's history." There was data presented about the number of crimes committed by the released inmates, but there was no context given to know if this rate was higher or lower than expected for California's parolees. Most inmates weren't released, they were just moved to local detention centers---thus shifting the burden but not necessarily solving the problem.

The other cases were US v Comstock, the Supreme Court case about the civil commitment of Federally detained sex offenders; Ryan v Gonzales, about competency in habeas corpus proceedings; Delling v Idaho, about the constitutionality of abolishing the insanity defense (states are allowed to do it), and Snyder v Phelps, the Westboro Baptist protest case from Maryland which said that free speech in a public place was not grounds for intentional infliction of emotional distress. On the child psychiatry side of things, all the cases related to the sentencing of juveniles. Graham v Florida outlawed life without parole for nonhomicide offenses. Miller v Alabama outlawed mandatory life without parole for juvenile homicide offenders.

After the landmark case presentation I continued my current theme du jour: immigration. I listened to a great talk by attorneys and a psychiatrist involved in the class action suit, Franco-Gonzales v Holder. For those of you who aren't familiar with what's going on in the world of immigration, now's the time to pay attention because it will affect all of you eventually. (You can read the preliminary injunction here.) Franco-Gonzales is an intellectually disabled immigrant who was arrested for throwing a rock during a public brawl. He was arrested and served a one year sentence. Immediately after this, he was taken into custody by ICE and held for five years. He had no pending criminal charges, had already served his time, and had no lawyer. Because of his mental disability he was unable to represent himself or take any legal action on his own. His case was combined with six others, all involving seriously mentally ill unrepresented detainees who had been held for at least six months. The court in this case has ordered the Federal government and Immigration and Customs Enforcement (ICE---the branch of the government holding the detainees) to provide "qualified representation" (legal services) to these detainees. They have also been ordered to assess their competence for self-representation. All of this means that mentally ill people are starting to be granted fundamental due process rights that never existed before, even though they are not American citizens. We are now also going to have to figure out how to provide community mental health services for undocumented immigrants with serious mental illnesses, even though they are not eligible for public benefits. (Ironically some of these detainees, if deported, might be deported to countries with better mental health systems than ours!)

I really enjoyed listening to the forensic psychiatrist who treated an undocumented immigrant and hearing how she advocated for this patient, as well as from Franco-Gonzales' own lawyer who was in the position of having to figure out what to do for this client when there were no existing laws AT ALL to cover his situation or to provide a basis for release. It's quite creepy to think that in this country someone can be held for five years, without a lawyer or even a right to one, without having committed any new crime.

Lastly, I always make a point of attending the presentation by the AAPL computer committee. This is my rare opportunity to geek-out with fellow tech nerds. The most important topic this year was the new HIPAA requirements for using secure email to transmit protected health information, and the need to have a business associate agreement (BAA) with any cloud storage service you use to save clinical information. This applies to anybody using things like DropBox or Google to store documents or other clinically relevant data. The trick is that Google won't sign a BAA for clinicians unless you're using their fee-for-service business apps (which are reportedly secure, although probably not from the NSA) and I think DropBox may not sign a BAA at all. So: do some homework, this may apply to you.

Today is my last conference day and I'll be heading home early tomorrow. I give heavy props to my nameless but fearless former fellow who arranged our alumni dinner last night here on his home turf and gave us a terrific tour of the bay. He raised the bar substantially for all future alumni events. (And yes, nameless fellow, you WILL return to Maryland some day. I will not give up. And now I know where to find the boat.)

Follow trending AAPL news today at @ClinkShrink.

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.

Your Patient Died. Who Cares?

 

 

I thought I'd share what I saw on my Twitter feed as soon as I got up this morning. I immediately felt a blog post coming on, particularly after reading the Twitter comments as they rolled in. I felt a bit sick, knowing what some of my colleagues in Ohio must be going through right now. This post is for you.

When it comes to patient suicide, correctional psychiatry is probably one of the higher risk subspecialties within psychiatry. The average prisoner has three risk factors for suicide before he even steps into the facility: he's male, young, and has an active substance abuse problem. There's even a recent study to suggest that being charged with a crime increases one's risk of suicide, even if that person is never incarcerated.

Considering this, if you practice correctional health care for a few years it's pretty likely that at some point you will experience a patient suicide, either as a health care first responder, as an administrator or as a mental health clinician. I feel like I need to write this blog post to warn you about something:

Don't expect your friends, family and colleagues to understand why you're upset that somebody died.

I know that sounds counterintuitive, but that's just the reality of correctional health care. The general public---and even some physicians---are going to instinctively give you a "who cares? He's just a criminal" response even if they don't know the person or what he was locked up for.

Let's consider the responses I've seen just today regarding the suicide of Ariel Castro, the man who kidnapped three women and held them prisoner for several years (comments drawn from a network news site):

• Great news! Seriously, it's great that Ohio taxpayers won't have to pay to house and feed this scum bucket.
• He did society and himself a favor....good thing he's gone!
• Too bad that he didn't live to be locked up and suffer for a few decades.
• Too bad he couldn't have been chained to a wall while the inmates he was being protected from got rewarded for taking turns demonstrating the receiving end of his version of the universe. Can't exactly hang yourself when your chained to a wall. Cruel and unusual? If it's not cruel and unusual, it's not punishment.

Yeah, that could be your patient they're talking about. And all your patients watching the news or reading a newspaper will see this public reaction and know that the rest of the world truly could care less about them. Your job, temporarily, is about to become much harder. Fingers will be pointed, armchair psychologists who have never set foot in your facility will "know" how the system or you as a clinician must have failed, and new redundant policies will be created that will make your health care delivery system less efficient.

This will pass. Eventually, people will grasp the fact that this man who successfully hid multiple felonies for several decades probably also had the skill to hide a planned suicide attempt. Your colleagues in other parts of the country will step up to the plate to remind the media, and the general public, that correctional and forensic psychiatrists are taking an active role to implement suicide prevention policies and training that have dropped the correctional suicide rate substantially in the last twenty years.

And maybe, just maybe, it will lead people to recognize the importance of what you do.

Just a few thoughts from inside the walls, given that next week is National Suicide Prevention Week.

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.

My Patient Is Not A Peanut Butter Cup

On CBS news yesterday I saw this report about mentally ill people who end up in jail. The sheriff of the Cook County jail complained that psychiatric patients who don't take their medication become criminals and added, "We're not a mental health facility. These people should not be here.''

Simultaneously this week in the Baltimore Sun we have this story, where hospital workers complained because malingering criminals were being held at their facilities.

This week's news is a terrific example of what I call the Reese's Peanut Butter Cup problem of forensic patients. (I put up the old commercial for reference.) Each side is basically complaining that they have to provide care for someone. Nevermind that people can't be cleanly divided between the "mad" and the "bad," or that people who "only" have personality disorders can still die from those disorders. We waste a lot of time and energy arguing about who should be where and who should be doing what.

The bottom line is that we have to figure out how to deliver the right care to the patient regardless of the setting. Forensic patients require treatment as well as security. That sheriff needs to realize that his facility will always require a psychiatric infirmary and mental health services and that he's not going to be able to "clean house" off all the psych patients. Similarly, hospital workers can't write off every assaultive patient as being "just a sociopath."

We need to beef up hospital security so everyone, patients and staff alike, can feel safe. And jails need to be given enough mental health staff so the administrators won't feel like they're being overrun with chaos.

Getting rid of the patient is never the right answer to a health care system problem.

Texas: Never Too Sick for Death Row

Oy, if you're very sick and very dangerous, Texas is not the place to be. Oh, it never was and maybe it never will be.  

In Maryland, if someone is in the hospital and wants to leave, the vast majority of the time, they get leave.  If the staff thinks they should stay, they get to sign a leaving AMA form --against medical advice.  In rare instances, if a voluntary patient wants to leave, but they are felt to be imminently dangerous, then they can be certified, and held on the floor until there is hearing.  At the hospital where I did my residency, hearings were held on Wednesday when an administrative law judge came in for that purpose, so how long a patient was stuck there without 'due process' depended on what day of the week this went down.  In Texas, you can be committed against your will, but apparently as I've learned from yesterday's New York Times, if you've signed in, you can't be held and committed, no matter how sick, psychotic, and dangerous you are.  Really?  I'm back to my original thought: oy!

From Advocates Seek Mental Health Changes, Including the Power to Detain:

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it. 

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him. 

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them. 

He was on a mission from God, he said, to free their hearts of demons. 

What a travesty.   And here in Maryland,  yesterday a court sent a 15 year old boy, tried as an adult, to prison for life, commuted down to 35 years, for a school shooting / attempted murder.  The boy took his step-father's gun, which fortunately,  was not a rapid fire weapon, but a shotgun (I think), and before he could get too many rounds fired, a heroic teacher tackled him and the single wounded victim survived.  The boy left a suicide note, but his plan to die that day was foiled.  He's reportedly been improving with treatment in a county detention center, and he pleaded guilty to the charges, no insanity defense sought, no trial necessary, just a hearing for sentencing.  I won't comment on whether I think it serves society to send a child to prison with adults for 35 years.  

To those who oppose involuntary hospitalization under any conditions at all, I have to ask, what do you think should be done if you become so psychotic that you believe it's necessary to kill your own children and eat your own eyeballs?  In Texas, it's clear: you're free to do so and the state will just kill you. 

Pick Your Insanity Test

Here's my followup to the post I started yesterday.


If the insanity defense were reformed (again), you'd have to decide which new legal test you'd use. A legal "test" is a written definition or standard. In general, there are two insanity tests in common use: the ALI test and various derivations of the McNaughton test. The McNaughton test states that a defendant is insane if he is unable to understand the nature or quality of the act, or---if he did understand the nature of his actions---that he didn't understand that they were wrong. In 1955 the American Law Institute (A.L.I.) wrote the Model Penal Code in an effort to make criminal laws uniform across the country. The Model Penal Code's insanity test, also called the ALI test, states that a defendant is insane if he "lacks substantial capacity to appreciate the criminality of one's conduct or to conform one's conduct to the requirements of the law". It has two parts, a cognitive standard and a volitional or behavioral standard.

Here is a link I posted last year to a state-by-state break down of insanity standards. It's a little out of date; Kansas is listed as using the McNaughton test but they have since abolished the insanity defense.


Frontline did a nice series a while ago about the insanity defense and they have a summary of the historical tests here.

Reforming the Insanity Defense

Over on Peter Earley's blog there is a post entitled "How Fair Is The Insanity Defense" that you should all go over and read. I thought about writing a comment there but quickly released this would require a post of its own, so here it is.


He starts out with a case description of a man with an undoubtedly severe mental illness who either shot or assaulted many people while delusional. In 1992, after a failed attempt at civil commitment, he shot and killed two people. At trial state psychiatrists testified that he knew killing was wrong, even though motivated by delusion---in other words, a legally sane crime by the McNaughten test of insanity (which Mr. Earley describes well, I won't be repetitive here). He was sentenced to death and eventually executed in spite of a recommendation for commutation by the Texas Board of Pardon and Paroles.

Mr. Earley is critical of the McNaughten test and feels that we should rethink the legal definition of insanity. He also advocates to end the use of private forensic experts, a point I'll return to later.

First, I think the public should understand there is a certain logic to when and how a defense attorney decides to file an insanity plea. Mr. Earley is appropriately critical of attorneys who file the plea "when their client is obviously guilty and they don't have any other rational explanation to fall back on." It's true that there is sometimes a hidden agenda for requesting a sanity evaluation: there may be a chance that an evaluation could turn up mitigating information that could be used at sentencing, or as leverage in a plea bargain.

Setting aside the hidden agenda, the fact of the matter is that insanity pleas are filed rarely compared to the overall number of offenses that happen every year. This is particularly true of misdemeanors. That's because an insanity plea, if successful, could lead to the defendant ending up under court or health and mental hygiene supervision for years. A simple guilty plea could get a client out of jail, with or without supervision, in months. The attorney is obligated to act in the stated wishes of his client, and that wish is obviously going to be to get out as soon as possible. Thus, we usually only see insanity pleas filed in very serious, felony cases.

So how rare is it? In Maryland, an insanity plea is filed in fewer than one-half of one percent of all crimes commited in a year, both in Circuit and District Court. Out of all crimes committed in Maryland, only 0.032% end in a successful insanity verdict. This certainly doesn't suggest that the defense is being abused.

Regarding the proposal to use court appointed experts (please see also my previous post on private evaluations):

We're already doing that. Most jurisdictions have individual psychiatrists or psychologists working on behalf of the court, either in a court-affiliated medical clinic or under contract with the state's department of health. As the system usually works, this independent court-appointed evaluator completes an assessment and sends a report with an opinion about sanity back to the judge who ordered the evaluation, with a copy sent to the defense attorney who filed the plea and to the prosecution. (Exact details of who gets the report, when they get it and how it can be used may vary between states. I'm speaking in very general terms here.)

Then and only then will a private expert get involved, mainly because one side or the other won't be happy with the independent expert's opinion. In my experience, this usually takes place when the independent expert thinks a defendant is sane and the defense wants to challenge the report. In Maryland, if the court's expert finds someone insane that opinion is almost never challenged by the prosecution because both sides recognize, and agree, that this person is very very sick. (I think the number is somewhere near 90% agreement on insanity but I don't have the study in front of me.)

In short, the insanity defense is hardly ever used and private forensic expert involvement is even less common than that. Out of a few hundred evaluations done every year in our forensic hospital, only a handful will involve a private opposing expert.

Whether or not the legal test of insanity should be changed is an issue that arises regularly throughout history, most recently in 1984 following the assassination attempt on Ronald Reagan. Then, Congress passed the Insanity Defense Reform Act which changed the test on a Federal level. It excluded any category of mental illness from serving as the basis of an insanity plea unless the diagnosis was a "serious" mental illness. Many states, including Maryland, revised their insanity statutes following the Hinckley verdict. Four states have completely abolished the insanity defense.

And I guess that's the trick when it comes to opening the bag of worms of insanity reform: there's always the chance, particularly given the outrage following the Connecticut shooting, that the defense could be thrown out altogether. And then where would my seriously mentally ill forensic patients be? The Supreme Court recently had the opportunity to hear a case that would have challenged the constitutionality of a state statute barring the defense, but they turned the case down.

OK, that's wraps up my response. I just wanted to provide a little more background and factual information to the topic since it is going to be discussed a lot in the news as certain high profile cases come to trial.

Check My Math

The APA put out a statement in response to the NRA's recommendation to put armed guards in every school. Quoting from the statement:

“Only four to five percent of violent crimes are committed by people with mental illness,” said the APA’s president, Dilip Jeste, M.D. “About one quarter of all Americans have a mental disorder in any given year, and only a very small percentage of them will ever commit violent crimes,” he added.

 So Dinah sent me an email asking this question:

"So if 1/4 of all people have a mental illness in any given year, and 56% of people have a lifetime incidence, then why are only 4-5% of violent crimes committed by people with mental illnesses?  It might seem that we'd all want to be mentally ill so we wouldn't be violent."

 My answer to that is:

Only 4-5% of crimes are committed by mentally ill people because most violence is due to personality disorders combined with substance abuse, and once you combine that trifecta the number of people at risk of committing violence drops quite a bit.

Here are the prevalence rates:

ASPD 15% prevalence (per ECA study)
MI 25% prevalence
SA 10% prevalence (per NIDA)

The population of the US at this minute is 314,996,054 (US Census Bureau). So, at any point in time now we've got:

	(per million)
MI alone	79	314,996,054 x .25
MI + ASPD + SA	5.9	314,996,054 x .25 x .15 x .1
ASPD + SA alone	4.7	314,996,054 x .15 x .1

In other words, very few mentally ill people commit violence crimes because most of them don't have the main necessary risk factors. And there are relatively few people with ASPD running around so that when you throw in the MI folks it doesn't increase the pool that much. And when it comes to violent crime, a disproportionately small number of people commit the majority of offenses. The relative risk of a small number of violent offenders outweighs the small number of mentally ill people who have the trifecta. Does that make sense?

Ugh, I just spent far too much time trying to get the table formatting right and then Blogger messed up my HTML code. I give up. And I can't believe I'm writing about this the day before Christmas.

Happy Holidays!

Oh yeah, one more thing:

The APA response dings the NRA for conflating mental illness with "evil," and criticizes the NRA for using the term "lunatic." I'm going to ding the APA for referring to my prison patients as "evil." I'm going to object to that, big time. The people I treat may have poor judgement, may have substance abuse problems, may have done awful things during desparate times, but I have met very few truly evil people even in prison. Demonizing and dehumanizing criminals is a very very bad idea. These people are part of our society, they will be coming back to our cities and neighborhoods some day, and it does nobody any good to say that my correctional patients are evil people. Please.

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

What I Learned Part 1

Those of you who have been reading the blog for a while know that every year I blog and live-tweet from the American Academy of Psychiatry and Law conference. This year we are hosted in Montreal, the land of fine dining and the most beautiful language in the world. Thus, the foodie picture. When I fly back I will be carrying extra baggage and I don't mean my luggage.

The poster session this morning was quite crowded and I wasn't able to get near most of them, but I did see a lot about legal and clinical implications of synthetic marijuana. Forty-one states have laws criminalizing sale and use of these new chemicals which go by a variety of street names. Effects on mental state can be extreme, including disorganized and violent behavior and hallucinations. So far there are no known longterm clinical effects associated with its use, however. Intoxication has been used in criminal defenses to mitigate culpability (although not generally successful as the basis for an insanity defense) and in states where the substances are still legal courts are struggling to figure out how it should play into a mental state defense.

Dr. Charles Scott gave an outstanding presidential address entitled "Believing Doesn't Make It So: Forensic Education and the Search for Truth." He discussed the evolving---and higher---expectations for forensic evidence, including psychiatric testimony, and how this should inform forensic training and practice.

The next session was a very nice (if I do say so myself) panel presentation about civil commitment of mentally ill offenders following release from prison. California has a mandatory civil commitment law which requires transfer of certain violent offenders with serious mental disorders to a psychiatric hospital at the end of incarceration. Legal challenges to this law were discussed and compared to the New Jersey system, which uses a non-mandatory administrative procedure instead. Finally, these procedures were compared to the state of Maryland where there is no established transfer policy but a wide degree of consultation and collaboration between the correctional and mental health systems, which in many cases obviates a need for hospital transfer.

[At this point in the day I stepped out for lunch and came back four courses later. Oh my, the food was amazing.]

The afternoon session was a very practical panel presentation about who should get access to forensic reports and the implications of HIPAA on evaluee access to protected health information in the report. Historically forensic reports were considered legal work products rather than medical documents, and as such an evaluee did not necessarily have a right to get a copy of or read the report. Under HIPAA some types of reports---such as a disability evaluation or fitness for duty evaluation---might be considered to be protected health information which an evaluee has a right to access. This is an evolving area, however. And under HIPAA, evaluees do not have a right to reports generated for civil, criminal or administrative hearings. This isn't a settled issue and there was good audience discussion.

The evening session was a mock trial which presented the new DSM 5 proposed criteria for hebephilia. The limitations and implications of the new criteria were discussed, which appeared to rely heavily upon an assessment of the victim's Tanner stage. The issue was presented in the context of a fictional sex offender civil commitment hearing, with three mock experts: one for the state, one for the defense, and one independent court-appointed expert. A strong case was made against inclusion when the defense expert testified that the new criteria could result in an 80 percent increase in false positive diagnoses.

So that was the first day. More to come so stay tuned. Live-tweets can be followed at: www.twitter.com/clinkshrink. [For those concerned about speakers' informed consent for social media coverage, all presenters are advised at abstract submission that sessions are recorded and they know that sessions may be covered by the media.]

Podcast #69 : Partnering WITH Patients

Here are the topics we discuss on this fine evening at Roy's house:

• What does "Shrink Rap" mean (reader request)?

• Roy talks about an "amazing" conference he went to called Partnership with Patients.  This conference was started by Regina Holliday, patient-advocate-extraordinaire. Here are some links for things that caught his attention:
• HealthCamp: http://HealthCa.mp/kansascity
• http://partnershipwithpatients.com/
• Donate to Patient Pod at Medstartr at http://bit.ly/patientpod where Pat Mastors is trying to raise $4200 by Oct Nov 20 (oops, we missed that deadline) (the date was extended... please help fund the project. ~Roy).

•  Clink talks about a Massachusetts legal case regarding gender reassignment of prisoners

• And finally, we talk about a reader's question about how and why patients test their therapists/psychiatrists.

      

• 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. 
  
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