From posts to protection: Ethical considerations regarding forensic psychiatrists and a duty to warn based on social media

Increasing use of social media in forensic mental health evaluations will lead to new challenges that must be resolved by forensic practitioners and the legal system. One such dilemma is the discovery of information that would typically trigger a legal duty and professional ethics obligation for mental health professionals to breach doctor-patient confidentiality to promote public safety and prevent harm to vulnerable third parties. Although the law and professional organizations offer clear guidance for practitioners in the treatment role, there is currently no clarity from the law or instruction from professional organizations on what mental health professionals should do if they discover such information during a confidential forensic evaluation. For example, a forensic evaluator may find evidence on social media of an evaluee’s threats to seriously harm others, abuse of children and the elderly, or severely impaired driving. There are no clear guidelines for how a forensic psychiatrist should respond in these complicated situations. We review the legal concepts and historical evolution of confidentiality, privilege, and mandated reporter duties that forensic practitioners should consider in these legally ambiguous situations. Finally, we discuss ethics frameworks practitioners can implement to determine their most ethical course of action when faced with such dilemmas.     

Teleconferencing model for forensic consultation, court testimony, and continuing education

A medical center-based forensic clinic that provides the necessary comprehensive consultation, continuing education, court testimony, and clinical services through an applied model of teleconferencing applications is addressed. Telemedicine technology and services have gained the attention of both legal and clinical practitioners, examining trends and models of health care for underserved populations, and identifying where consultation with a team of professionals may benefit service providers in rural communities. The contribution offered herein provides an understanding of the history of the development of the clinic, a theoretical model that has been applied to a clinical forensic program that employs telepsychiatry services, and the ethical and malpractice liability issues confronted in using teleconferencing services. This model is examined through a child and adolescent forensic evaluation clinic. The goals of this model are offered, as are a number of applications within the broad spectrum of services utilizing telemedicine. Finally, changing patterns are addressed in clinically based health-care delivery for criminal justice, social services, and forensic mental health.     

An analysis of competency to stand trial: an integration of case law and clinical knowledge

In the past three decades competency to stand trial has emerged as a central issue in mental health law and forensic psychology. This article combines legal and clinical frameworks for a more integrated understanding of competency to stand trial. The legal framework focuses on Supreme Court decisions beginning with Dusky and reviews several legal theories of competence. The empirical framework is investigated within Grisso's (1986) conceptualization of legal competencies. In addition, the efficacy of specialized forensic assessments is evaluated, including the newly developed MacArthur Structured Assessment of the Competencies of Criminal Defendants (MacSAC-CD). The article concludes with observations of competency as a construct and their implications for forensic practice. © 1998 John Wiley & Sons, Ltd.     

Forensisch-psychiatrische Versorgungsstrukturen in Deutschland: Ein Vergleich zwischen Alten und Neuen Bundesländern

Differences and similarities of the forensic mental health hospitals in the New Federal States (NFS) (former East Germany) and the Old Federal States (OFS) (former West Germany) were assessed. The focus of the study was set on institutional features of these hospitals as well as on characteristics of the detained patients. Data were based on a survey conducted in 2006. Specifically designed questionnaires were sent to the mental health departments of the State Ministries, and to all forensic mental health hospitals (response rates 100% and 62%). The general finding is that structures of forensic mental health services in NFS and OFS, e.g. the number of beds per million inhabitants and institutional features, have become similar since the German reunification. The health staff-patient relation is equal for some professions, whereas for other professions this relation is even better in NFS. Differences exist regarding the forensic mental health law of the Federal States. Moreover, the proportions of some delicts and diagnoses in the detained clientele differ. In NFS, the need for forensic aftercare facilities is even more urgent than in OFS. In both parts of the country there is a need for the development of some aspects of quality assurance for both forensic mental health hospitals as well as governmental institutions. Generally, the evaluation of quality of structures, processes and results is yet impossible for many fields of forensic mental health care, because there is no sufficient data base.     

Divorce and the Multidimensionality of Men and Women’s Mental Health: The Role of Social-Relational and Socio-Economic Conditions

Research consistently reveals that the divorced generally face more mental health problems than the married. Less attention however has been paid to positive mental health indicators. Insight in these however may help policy makers and care providers to see both the broader picture and stimulate active coping. Using data from the European Social Survey (2006–2007), differences in both feelings of depression, and in feelings of self-esteem, autonomy, and competence between the married (N?=?14,072) and divorced (N?=?4,304) are estimated for women and men separately. Drawing on stress and coping theories, we map how specific social-relational and socio-economic conditions relate. Analyses reveal that divorce is related not only to more feelings of depression, but also to lower levels of self-esteem and competence. Difference scores in mental health based on marital status are also found to differ significantly between men and women for competence, with the difference being more pronounced in men. Additionally, social-relational and socio-economic conditions explain much of the gap in depression scores—and to a lesser extent, in self-esteem and competence scores—between the married and divorced. Finally, some interesting gender differences were found in how social-relational and socio-economic conditions relate to mental health when divorced, with women especially seeming to benefit from advantageous socio-economic conditions.     

Twenty Years Post‐genocide: The Creation of Mental Health Competence among Rwandan Survivors Through Community‐based Healing Workshops

Twenty years after the genocide, many Rwandans still suffer from the psychological wounds of the past. The country's mental health agenda is based on individualised and psychiatric approaches that help some but cannot be provided on a large scale. Further, many reconciliation initiatives have been based on public testimonies, which have been shown to be potentially re‐traumatising, leading to calls for small‐scale community‐based approaches to healing, which constitute a middle way between individualised and public approaches. Drawing on the concept of ‘mental health competence’ (Campbell and Burgess, 2012), this study evaluates one such approach: the Life Wounds Healing workshops offered by the African Institute for Integral Psychology. Twenty‐one semi‐structured interviews were conducted with former workshop participants, staff members and the institute's founder to investigate their views on how these workshops can help genocide survivors. The results suggest that the workshops succeed in creating mental health competence by establishing a safe social space for people to open up, increasing people's critical understandings of the processes of pain — and potential for healing — that informs behaviour change, generating bonding social capital and offering participants' income‐generating possibilities. Copyright © 2015 John Wiley & Sons, Ltd.     

The admissibility of expert testimony regarding malingering and deception

This article discusses the legal admissibility of expert testimony and the ability of mental health professionals to detect malingering and deception among defendants. A legal analysis of the admissibility of expert testimony regarding malingering and deception in formal legal proceedings is presented. Some guidelines are provided to help mental health professionals and attorneys determine the admissibility of evidence they intend to introduce. Although psychologists and psychiatrists currently have a limited ability to identify accurately malingering and deception, expert testimony about the genuineness of a defendant's mental illness is likely to be held admissible for both practical and evidentiary reasons. In contrast, evidence about a witness' credibility is rarely admissible. In addition, psychologists are ethically obliged to recognize their limitations in making representations about their skills.     

Itemmetric and scale analysis of a new computer-assisted competency assessment instrument (CADCOMP)

Male defendants (n = 99) who had been court ordered to a forensic treatment facility as incompetent to stand trial were tested using the Computer-Assisted Determination of Competency to Proceed (CADCOMP) instrument soon after admission (median days = 15). Shortly thereafter, competency was assessed by a forensic psychiatrist and by a majority decision of three mental health professionals who viewed a videotape of the forensic psychiatrist's interview. From the CADCOMP item pool, 18 scales were constructed on conceptual grounds. Internal consistency analyses revealed that most scales had reasonable item homogeneity and scale reliability. In addition, item and scale analyses, with few exceptions, followed predicted patterns of intercorrelation and association with competency as determined by both criteria. Scales and items measuring serious psychopathology, psycholegal ability, and criminal history demonstrated the strongest associations with competency. These findings suggest that additional research on CADCOMP is warranted. The instrument shows promise for use in forensic research and assessment.     

An introduction to organic brain syndromes

Organic brain syndromes are of forensic interest for several reasons. First, patients with organic brain syndromes may require judicial determination of competence in any of a number of areas, e.g., testamentary capacity, need for financial guardianship, or competence to make medical decisions. Second, any patient whose mental state is of legal interest will need evaluation for contributing organic factors; uncovering these factors may have considerable medical and legal consequence. Third, the discovery of organic factors may be decisive in the outcome of a judicial proceeding, where “hard” biological data are often accorded more weight, and are thus more persuasive, than “soft” psychological data. This article provides an introductory overview of the organic brain syndromes. For each syndrome, the clinical features are described and are illustrated with a case vignette, the more common etiologies are presented, and selected aspects to the evaluation are highlighted. In addition, since the detectian of malingered mental illness is a key component in many forensic contexts, characteristics are described which help to distinguish actual from malingered mental illness.     

Hospitalization of criminal defendants for evaluation of competence to stand trial or for restoration of competence: clinical and legal issues

The clinical and legal literature abounds with articles dealing with competence to stand trial; while most agree that criminal defendants must be capable of defending themselves before the state can bring them to trial, a number of articles are quite critical of the procedures by which these concepts are operationalized, some even going so far as to suggest abolishing the requirement for competence altogether. One of the major problems leading to the criticisms is the unnecessary loss of liberty involved. Although the length of incarceration has decreased significantly since the 1970s, the majority of states still permit, or require, hospitalization for evaluation of competence, and even more so for treatment to restore competence.The author reviews case law and presents data from his survey of current state statutes and responses from state forensic mental health program directors, to demonstrate the rarity of outpatient treatment to restore competence. He argues that outpatient treatment for defendants who do not require hospitalization on clinical or public safety grounds should be available, on both clinical and legal grounds, and provides recommendations for establishing such programs in the community.     

Mental health professionals and child custody disputes: Are there alternatives to the adversarial process?

An increasing problem that can have serious consequences for children, adults and social institutions is child custody after divorce. The risks associated with the various courses of action in child custody cases are discussed. Alternatives to the adversarial process are presented. The position of the legal system is explained and the importance of the involvement of mental health professionals is emphasized. Also discussed are the possible roles mental health professionals can assume on behalf of the child in working with the family and the legal system.     

Residential mental health assessment within Dutch criminal cases: a discussion

In Dutch criminal cases in which doubts arise about the defendant's mental health, a forensic assessment will be requested. This is provided either by the multidisciplinary staff of residential clinics who conduct forensic evaluations for the court, or by mental health professionals contracted on a part-time basis by district courts. This article discusses the procedures applied in such cases as well as the relevant legal provisions. It focuses particularly on the clinical observation, evaluation, and reporting that is carried out over a number of weeks in the residential setting of the Pieter Baan Centrum. Specific attention is paid to procedures applied in this clinic. It is suggested that Dutch procedures for the use of mental health expertise can best be characterized by three aspects: multidisciplinary observation and reporting, the use of a sliding scale for indicating degree of responsibility, and, finally, the involvement and payment of experts by the state as such, rather than by the prosecution and/or the defense. Copyright © 2001 John Wiley & Sons, Ltd.     

Validity of the Brief Psychiatric Rating Scale Within a Forensic Inpatient Hospital

Although the Brief Psychiatric Rating Scale(BPRS) has been utilized across several clinical settings, its potential utility within forensic psychiatric hospitals has not yet been investigated. Given the diversity of training and background among correctional mental health workers (i.e., psychiatrists, psychiatric nurses, occupational therapists, recreation therapists, psychologists, social workers,etc.) it is possible that the uniform use of the BPRS among the correctional staff would require extensive training and that substantial “refresher” training may be required to maintain the integrity of rater practices. The present study examined the ability of previously trained forensic mental health professionals to accurately assess psychopathology using the BPRS. Overall,experienced raters demonstrated relatively high concordance rates with “gold standard” ratings across three BPRS training videos (Case 1, Case2 and Case 3). No overall “rater drift” was apparent. However, raters were found to make significantly more errors when rating behavioral observation ratings than for ratings based on self-report patient statements. Findings suggest that ratings done by forensic mental health workers are relatively accurate when compared to “gold standard” ratings established for assessment of community and forensic psychiatric patients. This revised version was published online in July 2006 with corrections to the Cover Date.     

Characteristics and outcomes of insanity acquittees in Oklahoma

The insanity defense is perhaps the most vigorously debated topic at the interface of the legal and mental health systems. This article addresses the need for empirical evidence by providing data on insanity acquittees and their later outcomes in Oklahoma, a jurisdiction not previously studied. Information was obtained on the demographic, legal, psychiatric, hospitalization, and post-hospitalization characteristics of all 61 defendants acquitted not guilty by reason of insanity (NGRI) and treated on the state forensic unit during a 5-year period. Insanity acquittees had few resources, significant psychopathology, and extensive involvement with the legal and mental health systems prior to the NGRI offense. Follow-up of three groups of discharged patients--those released at an initial court review, those who completed the NGRI treatment program, and those who absconded from the forensic unit--revealed that those who escaped from the unit had significantly more arrests and subsequent legal charges than regularly discharged patients.     

Delivering Diagnoses: Parents as Translators and Withholders of Children’s Mental Health Diagnoses

There is a lack of research on how mental health diagnoses are delivered and explained to children and the effectiveness of these strategies. This qualitative study examines how emerging adults recall the delivery of mental health diagnoses in childhood and how they suggest these diagnoses should be delivered to children. Semi-structured interviews were conducted with 42 emerging adults (aged 18–22) who were diagnosed with attention deficit hyperactivity disorder (ADHD), depressive disorders, generalized anxiety disorder (GAD), and/or bipolar disorder in childhood. Findings reveal that parents, rather than mental health professionals, often inform children of their diagnoses. The data suggest that parents often act as translators of diagnostic information, acting as liaisons between mental health professionals and their children. The paper explores ways in which parents and mental health professionals withhold diagnoses from children, and how this affects children’s experiences. Drawing on their own experiences, participants offer suggestions regarding the best ways to deliver diagnoses to children. Findings suggest that adults should share mental health diagnoses openly with children. Implications for social workers and other allied health professionals who support families when children are diagnosed are discussed.     

Ethical Care for Vulnerable Populations Receiving Psychotropic Treatment

The increasing use of pharmacotherapy raises specific ethical concerns for psychologists working with vulnerable populations. Due to a shortage of trained specialists, professionals without training in mental health, such as primary care providers, are increasingly prescribing and monitoring psychotropic medications. Vulnerable populations (e.g., older adults, people currently low in social status, immigrants, and racial/ethnic minorities) face additional barriers to mental health treatment and are at heightened risk when these factors intersect. Hence, these patients experience unique barriers to receiving optimal psychopharmacological care and are differentially vulnerable to deleterious outcomes associated with misdiagnosis and overmedication. Taken together, these factors fuel inequities in the access, quality, and utilization of mental health care. Psychologists working with these patients are ethically mandated to protect patients from harm and ensure equitable care across patient populations. Specifically, psychologists must respond to the dilemma of how to effectively treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated while remaining within the bounds of their competence. This article recommends pathways to address these dilemmas through education, training, research, and advocacy.     

The psycholegal factors for juvenile transfer and reverse transfer evaluations

It remains unclear whether forensic mental health assessments for juvenile reverse transfer (to juvenile court) are distinct from those for juvenile transfer (to adult court). This survey consisted of an updated review of transfer and reverse transfer laws (in jurisdictions that have both mechanisms) in light of the generally accepted three‐factor model of functional legal capacities involved in transfer evaluations (i.e., risk, sophistication–maturity, and treatment amenability). Results indicated that a majority of states' reverse transfer statutes refer explicitly or implicitly to the same three psycholegal constructs identified as central for transfer. Given the legal similarity between transfer and reverse transfer, potential practice implications and directions for future research are discussed.     

The Client Cultural Competence Inventory: An Instrument for Assessing Cultural Competence in Behavioral Managed Care Organizations

The rapid growth in Behavioral Managed Care Organizations has led to increasing concern about the future availability of culturally competent mental health services for ethnic minorities. Prior efforts to assess cultural competence of mental health services have focused exclusively on agency providers and individual mental health professionals rather than on clients' perceptions of care. We introduce the Client Cultural Competence Inventory, which has several advantages over other cultural competence measures including its (a) lower susceptibility to social desirability bias, (b) ability to assess attitudes concerning a broader range of therapists, providers and plans, and (c) focus on clients rather than the psychiatric community as the central force in determining cultural competence. Preliminary psychometric analyses of the inventory are presented from data gathered in a group of parents with children who are severely emotionally disturbed.     

Use and abuse of mental health experts in child custody determinations

Changes in standards for child custody determinations have resulted in an increased demand for mental health professionals to serve as expert witnesses. However, the entry of mental health professionals into custody disputes has been met with harsh criticism of the value of their contributions. Critics have generally pointed to the absence of substantive requirements for who may serve as an expert mental health witness, the ambiguities inherent in the best interests standard, the weak scientific basis for psychology and psychiatry, and the questionable measurement techniques employed by mental health professionals as reasons for increased regulation of forensic mental health services. This article critically reviews these concerns and proposes a regulatory model that addresses the salient issues.