Undiagnosing St Joan: She Does Not Need a Medical or Psychiatric Diagnosis.

ABSTRACT: This article traces the history of Joan of Arc through her brief life that includes leading an army in defense of France at the age of 17 and ending with her death at the stake at the age of 19. In her activities, St Joan reported that she was guided by voices and visions in which she communicated with venerated spiritual figures such as St Michael and St Margaret. Questions have arisen about the nature of these experiences, and various medical and psychiatric diagnoses have been offered by contemporary experts. In our effort to evaluate the diagnostic proposals, we have examined the incidence of voices and visions in the Middle Ages, and we have followed that with a review of nonpathologic voice-hearing in our own era. We then move on to an analysis of some proposed medical and psychiatric diagnoses, all of which we find unconvincing. With this background, we argue that St Joan does not warrant a medical or psychiatric diagnosis. Such a conclusion, however, leaves us with another issue, that of Joan's achievements. How do we understand an adolescent being able to lead an army? Addressing this question proves more difficult than deciding whether St Joan warrants a diagnosis. In addition to her achievements in the war against Britain, Joan of Arc stands out as both the most documented person in Western civilization up until her era, and as the only person who has been both condemned and canonized by the Catholic Church.

Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study.

OBJECTIVES: Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia. METHODS: We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment. RESULTS: Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160). CONCLUSIONS: Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness. CLINICAL IMPLICATIONS: ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

Extreme risk protection orders in response to threats of multiple victim/mass shooting in six U.S. states: A descriptive study.

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy.

Varieties of Religious (Non)Affiliation: A Primer for Mental Health Practitioners on the "Spiritual but Not Religious" and the "Nones".

Given changing demographics of religiosity and spirituality, this article aims to help clinicians understand contemporary trends in patient religious and spiritual orientation. It first identifies and describes the evolving varieties of religio-spiritual orientation and affiliation, as identified in survey studies. Particular attention is given to the examination of those who identify as spiritual but not religious (SBNR) and None (i.e., no religious affiliation), which is important to mental health practice because many patients now identify as SBNR or None. Next, empirical data are considered, including what the literature reveals regarding mental health outcomes and SBNRs and Nones. We conclude with a summary of the main points and five recommendations that mental health practitioners and researchers need to consider regarding this increasingly large portion of the population.

Religion and Psychiatry in the Age of Neuroscience.

In recent decades, an evolving conversation among religion, psychiatry, and neuroscience has been taking place, transforming how we conceptualize religion and how that conceptualization affects its relation to psychiatry. In this article, we review several dimensions of the dialogue, beginning with its history and the phenomenology of religious experience. We then turn to neuroscientific studies to see how they explain religious experience, and we follow that with two related areas: the benefits of religious beliefs and practices, and the evolutionary foundation of those benefits. A final section addresses neuroscientific and evolutionary accounts of the transcendent, that is, what these fields make of the claim that religious experience connects to a transcendent reality. We conclude with a brief summary, along with the unresolved questions we have encountered.

Hospital treatment of persons found not guilty by reason of insanity.

After being found not guilty by reason of insanity (NGRI), individuals are typically admitted to a secure forensic hospital for evaluation and treatment. This patient population can pose a challenge to clinicians in the hospital setting due to significant violence risk, complex psychiatric presentations, and scrutiny from oversight boards and the public. This article reviews the scientific literature around several key aspects of hospital-based treatment of insanity acquittees, including the management of inpatient aggression, the provision of specific treatments to acquittees, the assessment of violence risk and readiness for release, and the process of community transition. The authors conclude that the existing literature is heavily weighted toward the study of risk assessment and recidivism, with relatively little attention paid to the study of therapeutic modalities and recovery-oriented care in this population.

Can Religion Protect Against Suicide?

The vast majority of the world's population is affiliated with a religious belief structure, and each of the major faith traditions (in its true form) is strongly opposed to suicide. Ample literature supports the protective effect of religious affiliation on suicide rates. Proposed mechanisms for this protective effect include enhanced social network and social integration, the degree of religious commitment, and the degree to which a particular religion disapproves of suicide. We review the sociological data for these effects and the general objections to suicide held by the faith traditions. We explore how clinicians may use such knowledge with individual patients, including routinely taking a religious/spiritual history. The clinician who is aware of the common themes among the faith traditions in opposition to suicide is better prepared to address religious/spiritual matters, as appropriate, in crisis situations. The clinician who understands the patient's belief system is also better prepared to request consultation with religious professionals when indicated.

Assessing Insanity Acquittee Recidivism in Connecticut.

For over 30 years now the movement and status of insanity acquittees in Connecticut has been supervised by the Psychiatric Security Review Board (PSRB). During this time, 365 acquittees have been committed to the jurisdiction of the PSRB, 177 individuals have achieved conditional release (CR) and 215 acquittees have been discharged from PSRB jurisdiction. This article examines revocation of CR by the PSRB, arrests of acquittees on CR, and provides the first report of arrests following discharge from the PSRB's jurisdiction. The literature on relevant aspects of recidivism is reviewed and compared with findings in Connecticut. There is little available literature about recidivism of insanity acquittees following release from supervision. In the present sample of individuals discharged from the PSRB, 16% were rearrested, a rate that compares favorably with other discharged populations of offenders. For discharged acquittees, community supervision on CR prior to discharge from the PSRB had a statistically significant effect on decreasing the risk of subsequent rearrest, as did both the length of stay in the hospital and the duration of commitment to the PSRB. This article presents descriptive information about revocations, arrests on CR, and arrests following discharge. These data are consistent with criminal justice studies demonstrating the value of community supervision in lowering recidivism. Copyright © 2016 John Wiley & Sons, Ltd.

Extreme Risk Protection Orders in Connecticut, 2013-2020.

Twenty-one states and the District of Columbia have enacted Extreme Risk Protection Order (ERPO) statutes, which allow temporary removal of firearms from individuals who pose an imminent risk of harm to themselves or others. Connecticut was the first state to enact such a law in 1999. The law's implementation and use between 1999 and 2013 were previously described, finding that ERPOs were pursued rarely for the first decade and that most orders were issued in response to concerns about suicide or self-harm rather than about interpersonal violence. The current study analyzes over 1,400 ERPOs in Connecticut between 2013 and 2020 in several domains: respondent demographics, circumstances leading to ERPO filing, type of threat (suicide, violence to others, or both), number and type of firearms removed, prevalence of mental illness and drug and alcohol use, and legal outcomes. Results are similar to the earlier study, indicating that ERPO respondents in Connecticut are primarily White, male, middle-aged residents of small towns and suburbs who pose a risk of harm to themselves (67.9%) more often than to others (42.8%). Significant gender differences between ERPO respondents are discussed, as are state-specific trends over time and differences between Connecticut and other states with published ERPO data.

The Connecticut Experience with Sell Legislation.

Since 2004, Connecticut has had two different mechanisms for involuntary medication of defendants hospitalized for restoration of competence to stand trial. In this article, we first describe the development of these two mechanisms and compare their procedural elements. The first procedure required a hearing in criminal court, in a process parallel to the subsequent U.S. Supreme Court holding in Sell v. United States; the later procedure uses a civil mechanism in probate court and was enacted in response to the dicta in Sell regarding the preferential use of alternate mechanisms for involuntary medication orders. To compare the effectiveness and efficiency of the two mechanisms, we examined 1,455 admissions to the state's secure forensic hospital for competency restoration for the calendar years 2005 through 2011. Petitions for involuntary medication of defendants were filed in five cases in criminal court (0.3%) and in 177 cases (12.2%) in probate court. The probate mechanism resulted in a significantly shorter duration of the resolution of the competence matter. Both mechanisms were effective at restoring defendants' competency (i.e., two thirds were restored by the criminal court process, and nearly 74% were restored in the civil process).

Criminal Justice and Suicide Outcomes with Indiana's Risk-Based Gun Seizure Law.

This article examines the application and effectiveness of a 2006 Indiana law designed to prevent gun violence by authorizing police officers to separate firearms from persons who present imminent or future risk of injury to self or others, or display a propensity for violent or emotionally unstable conduct. A court hearing is held to determine ongoing risk in these cases; a judge decides whether to return the seized firearms or retain them for up to five years. The study examines the frequency of criminal arrest as well as suicide outcomes for 395 gun-removal actions in Indiana. Fourteen individuals (3.5%) died from suicide, seven (1.8%) using a firearm. The study population's annualized suicide rate was about 31 times higher than that of the general adult population in Indiana, demonstrating that the law is being applied to a population genuinely at high risk. By extrapolating information on the case fatality rate for different methods of suicide, we calculated that one life was saved for every 10 gun-removal actions, similar to results of a previous study in Connecticut. Perspectives from key stakeholders are also presented along with implications for gun policy reform and implementation.

The death penalty in Catholic teaching and medicine: intersections and places for dialogue.

Current debate on the death penalty in public and professional spheres is seen as divisive in nature, disallowing the possibility of common agreement. The history of views of the death penalty within the Catholic Church illustrates centuries of tensions and ambiguities as well as a current posture that manages to hold these tensions while advocating a strong position. That history of church views itself contains allusions to and intersections with medicine. There is something tangible to be gained in understanding religious views on the death penalty, in the debates both within medicine and in the public sphere. An argument is made for sufficient overlap of contemporary purpose between the goals of church and medicine to warrant further dialogue in enhanced and deliberative democratic processes.

What is Truth? The Spiritual Quest of Forensic Psychiatry.

The search for truth is a foundational aim and value of forensic psychiatry. It is also a deeply spiritual exercise. It must, therefore, be possible to describe a spirituality of forensic psychiatry, which I attempt to begin in this article. This exploration opens with a discussion of spirituality and its contexts. I then examine the nature of vocation in its application to medicine, psychiatry and the law. This proceeds to a close evaluation of the attitudes and activities that I will argue occupy the groundwork of forensic practice and form pathways to truth: presence, empathy, compassion, and centering. I then examine some of the forces that harm the expression of truth in the courtroom, and the means for healing those injuries. Concern for the common good, an integral part of my own spirituality, arises repeatedly in this discussion. I conclude with thoughts on the search for truth, in our work and in ourselves, and an invitation to colleagues to imagine forensic psychiatry as a spiritual practice. My hope is that this endeavor will stimulate reflection among forensic clinicians and encourage further inquiry and explication.

A Consultation and Supervision Model for Developing the Forensic Psychiatric Opinion.

Receiving feedback on one's work from colleagues is an essential part of clinical and forensic psychiatric practice. Often the material on which feedback is sought concerns past cases. When the material relates to current cases, particular safeguards are needed to protect important interests. This paper lists the interests that must be protected when feedback is provided through clinical consultation and supervision meetings in a forensic psychiatric training program. These are the interests of the person being evaluated, the attorneys, the people providing feedback to the evaluator, and the employers of the people providing feedback. The principles that the training program applies in determining attendance at, and participation in, these meetings are described. Finally, scenarios are presented that illustrate the application of these principles. Such application has allowed trainees and others to receive the benefits of consultation and supervision in the course of developing their opinions while protecting the interests of those involved.

Commentary: compassion at the core of forensic ethics.

In 1982, Dr. Alan Stone raised a central dilemma in ethics for forensic psychiatry that has prompted significant and important discussion of the concerns about twisting justice, prostituting the profession, and operating without adequate ethics guidelines in the course of our work. In presidential addresses to the membership of the American Academy of Psychiatry and the Law (AAPL), Dr. Paul Appelbaum and Dr. Ezra Griffith have attempted to deal with Stone's challenges, the former by providing a theory of forensic ethics, the latter by advocating cultural formulation and narrative as the methodology of our work. In his present contribution, Dr. Griffith advances the idea of narrative to involve compassion for the subject of the evaluation. In so doing, he brings us to a far more satisfactory resolution of the dilemma described by Dr. Stone. The obligation to show compassion deserves to be at the core of any valuable statement of forensic ethics. The role of compassion in justice, as discussed, for example, by Simone Weil, warrants further interdisciplinary study.

The forensic psychiatric report.

The construction of a written forensic report is a core component of forensic practice, demonstrating the evaluator's skill in conducting the evaluation and in communicating relevant information to the legal audience in an effective manner. Although communication skills and quality of written documentation are important in clinical psychiatry generally, they form the sine qua non of successful forensic work, which consists in telling complex stories in a coherent and compelling fashion. High quality forensic reports require careful preparation from the earliest stages of work on a case. They generally follow an expected structure, which permits the evaluator to provide all the data necessary to form a carefully reasoned opinion that addresses the legal questions posed. Formats and content of reports vary according to the type of case and the circumstances of the evaluation and so require flexibility within customary frameworks. The style and quality of writing are critical to the crafting of forensic reports. The effects on legal decision-makers of various approaches to the presentation of information in reports has not been studied empirically, but guidance from experienced forensic psychiatrists is available. There is a small body of research on quality improvement in forensic writing, and further empiric study is warranted.

DSM-5 and substance use disorders: clinicolegal implications.

Presumed distinctions between substance dependence and substance abuse have been at the heart of the development and utilization of substance-based diversion from criminal prosecution to treatment for the past several decades, including its use in drug courts. These distinctions have been promulgated by organized psychiatry since the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) in 1980. With the release of DSM-5 and the replacement of abuse and dependence categories with a single use disorder construct, the legal grounds for diversion in many states now stand at odds with organized psychiatry and its adoption of recent science. This article reviews the scientific basis for the DSM's new classification scheme, the dilemmas posed for states with statutes that rely on the abuse/dependence distinction, and potential remedies for legislatures wishing to keep pace with evolving research and clinical practice.

Pursuing the journal mission.

The mission of The Journal of the American Academy of Psychiatry and the Law, as articulated in its Instructions for Authors, is to be a forum for the exchange of multidisciplinary ideas and thoughtful and respectful scholarly analyses related to the theory and practice of forensic psychiatry. Recent refinements of The Journal's structure and policy can be understood as an effort to articulate a vision for emphasizing vibrant exchange of diverse scholarly activities and ideas expressing the highest levels of professionalism and concern for the ethics of forensic psychiatry and publishing. In this article, we explore the challenges encountered in realizing that vision, including managing the tone and level of discourse, creating structure without inhibiting creativity, demonstrating respect for persons in the use of case report material, expanding and guiding the utilization of peer review, promoting the new voices of authors with less writing experience, defining conflicts of interest for publishing purposes, and maintaining editorial independence in the context of serving organizational needs. We illustrate these challenges with recent experiences, explicating the decisions of the senior editors in an effort to be transparent about The Journal's processes and to encourage feedback from our readers about the adequacy of these practices.