Assessing Adverse Outcomes and Learning Needs in Canadian Psychiatric Independent Medical Examinations.

Despite the importance of independent medical examinations (IMEs), there is virtually no literature on the risks to the IME assessor nor the learning needs of psychiatrists in this area. To address this deficit, a retrospective chart review of nearly 38,000 cases from the Canadian Medical Protective Association (CMPA) identified 108 files involving complaints or legal actions against psychiatrists performing IMEs. Most complaints identified by the CMPA were to regulatory bodies, including biased opinion, inadequate assessment, inappropriately relying on a requester's information without independent evaluation, nonadherence to regulatory body policies, cursory documentation lacking relevant details, and communication breakdowns. A survey by the Canadian Academy of Psychiatry and the Law (CAPL) and the Canadian Psychiatric Association (CPA) had 306 Canadian psychiatrist respondents. About 37 percent of psychiatrists completing IMEs reported medico-legal consequences, including complaints to regulatory authorities. Only 40 percent of those doing IMEs and 20 percent of all psychiatrists had formal training in doing IMEs. The studies confirm that despite a low but important risk of medico-legal consequences, many psychiatrists performing IMEs do not have formalized training. Using the new CAPL Canadian Guidelines for Forensic Psychiatry Assessment and Report Writing is a step to reduce the risk of such evaluations.

Toward a New Model of Training in Canadian Forensic Psychiatry.

The Royal College of Physicians and Surgeons of Canada has recently introduced a new model of training for residents and fellows in all specialties and subspecialties, including forensic psychiatry. This model, Competence by Design, is intended to improve the training of residents with the goal of increasing the competence of practicing specialists. In the Competence by Design model, training is broken down into four distinct phases. Residents prompt their supervisor proactively when they are ready to be assessed on a specific task, and the feedback is specific and corrective. A resident's performance of each designated task is reviewed by a competency committee, which decides when the trainee is ready to move on to the next phase. In this article, we review some of the problems with the current model of training and explore how this new model will improve upon this training. We anticipate that this model will prove effective at improving training in forensic psychiatry.

Validation of the Booth Evaluation of Absconding Tool for Assessment of Absconding Risk.

Although absconsion from secure forensic settings is uncommon, it can have serious consequences for the patient, the hospital, and the public. To assess risk of absconding in this population, using empirically based literature and clinical expertise, the authors designed a 28-item structured professional judgment measure, the Booth Evaluation of Absconding Tool (BEAT). To evaluate the psychometric properties of the BEAT, we completed a blinded, case-matched, retrospective study of absconders (n = 57) and non-absconders (n = 26) between 2009 and 2017. Together, the absconders accounted for 120 absconding incidents over the study period. The incidents had similar characteristics as previously published descriptive studies of absconding behavior. The BEAT demonstrated solid internal consistency (α = 0.78), promising inter-rater reliability across many items, and good accuracy in differentiating absconders from controls (area under the curve = 0.77). Considering the limitations associated with a retrospective chart review study, these results show promising reliability and validity for the BEAT and suggest that the BEAT could be a useful tool in assessing and managing absconding in forensic patients.

Third-party Assessments/Independent Medical Evaluations.

A position paper developed by the Canadian Psychiatric Association's (CPA) Professional Standards and Practice Committee and approved by the CPA Board of Directors on May 25, 2020.

Lessons from Canadian Courts for All Expert Witnesses.

Expert witnesses have a special place in court, bringing their knowledge and skills in the form of opinion evidence to educate the court. This allows the fact-finder to make legal decisions more effectively. Although experts are often allowed a role in civil and criminal matters, this brings certain risks to the court process. Admissibility of expert witness testimony in Canada has generally paralleled American law, including the standards enunciated in Daubert v Merrell Dow Pharmaceutical, Inc. (1993). Recently, there has been a series of decisions in Canadian law that has focused on the role of the expert witness in the court. Although only having precedence in Canada, these cases highlight important legal principles that all expert witnesses must navigate, regardless of their jurisdiction. We review these significant cases to assist forensic psychiatrists in recognizing and professionally navigating potential pitfalls in giving expert opinions.

Shaping Attitudes of Psychiatry Residents Toward Forensic Patients.

With increasing criminalization of the mentally ill, individuals with mental disorders more frequently come into contact with the legal system. Psychiatrists may find themselves evaluating these individuals in a forensic context or treating them. Unfortunately, resident trainees and psychiatrists may be uncomfortable with forensic matters and treating patients with medicolegal problems. To clarify the attitudes and experience of Canadian psychiatry trainees, attendees at a national psychiatry review course were polled. The results show significant discomfort and a lack of didactic and clinical education concerning these patients and their problems. However, didactic and clinical education were shown to be associated with both increased comfort with and willingness to treat these patients.

Stalking and Violence.

The three widely known stalker classifications assist in categorizing stalkers, which allows for better management of violence risk. Although 80% of stalking is done by men, women also engage in stalking, and their violence risk should not be underestimated. Juvenile stalkers do exist and juvenile stalking is also associated with violence. Clinicians can become a victim of stalking and may become victims of stalking by proxy, a special type of stalking behavior where the stalker involves other people or agencies to communicate with or track their victim. A careful stalking violence risk assessment is essential in the intervention and risk management process.

Sex Offender Risk Assessment and Management.

Sexual violence is common and can have profound effects on victims compared with other forms of violence. This violence includes unwelcome and forced sexual contact on adults or children. Assessment of individuals who perpetrate sexual violence starts with a comprehensive biopsychosocial evaluation after a finding of guilt. Clinicians should then evaluate risk. Based on this assessment, a risk management plan should be developed, directed at the specific risk of the offender. Management options include external control (eg, incarceration, probation), psychotherapeutic interventions, pharmacologic interventions, and treatment of comorbidity. This organized approach aids in reducing the risk of future sexual violence.

Elderly Sexual Offenders.

With the ever-aging population, the number of elderly sexual offenders are also on the rise. The courts and correctional system are increasingly faced with older individuals who have offended sexually. Previously, these older offenders were thought to be similar to younger sexual offenders. However, closer analysis suggests that many of these individuals pose a much lower risk to recidivate than the risk to recidivate of their younger counterparts. Still, an individualized approach to manage the risk of older offenders is required, as some may have particular risk factors relevant for their treatment and future stability, such as dementia or other mental health issues. Further, this population often has particular physical health issues and requires special consideration when being placed in the community. Assessment, treatment, and risk management in this special population of sexual offenders are discussed.

Mental illness and sexual offending.

Transinstitutionalization (ie, the criminalization of those with mental illness) is relevant to individuals committing sexual offenses. Mental illness can affect the treatment and risk management of individuals committing sexual offenses. In this article the current literature on mentally disordered sexual offenders is described, including how psychosis, mood disorders, anxiety disorders, attention-deficit/hyperactivity disorder, and dementing disorders may affect treatment and management.