Design and implementation of community consultation for research conducted under exception from informed consent regulations for the PreVent and the PreVent 2 trials: Changes over time and during the COVID-19 pandemic.

INTRODUCTION: Emergency clinical research has played an important role in improving outcomes for acutely ill patients. This is due in part to regulatory measures that allow Exception From Informed Consent (EFIC) trials. The Food and Drug Administration (FDA) requires sponsor-investigators to engage in community consultation and public disclosure activities prior to initiating an Exception From Informed Consent trial. Various approaches to community consultation and public disclosure have been described and adapted to local contexts and Institutional Review Board (IRB) interpretations. The COVID-19 pandemic has precluded the ability to engage local communities through direct, in-person public venues, requiring research teams to find alternative ways to inform communities about emergency research. METHODS: The PreVent and PreVent 2 studies were two Exception From Informed Consent trials of emergency endotracheal intubation, conducted in one geographic location for the PreVent Study and in two geographic locations for the PreVent 2 Study. During the period of the two studies, there was a substantial shift in the methodological approach spanning across the periods before and after the pandemic from telephone, to in-person, to virtual settings. RESULTS: During the 10 years of implementation of Exception From Informed Consent activities for the two PreVent trials, there was overall favorable public support for the concept of Exception From Informed Consent trials and for the importance of emergency clinical research. Community concerns were few and also did not differ much by method of contact. Attendance was higher with the implementation of virtual technology to reach members of the community, and overall feedback was more positive compared with telephone contacts or in-person events. However, the proportion of survey responses received after completion of the remote, live event was substantially lower, with a greater proportion of respondents having higher education levels. This suggests less active engagement after completion of the synchronous activity and potentially higher selection bias among respondents. Importantly, we found that engagement with local community leaders was a key component to develop appropriate plans to connect with the public. CONCLUSION: The PreVent experience illustrated operational advantages and disadvantages to community consultation conducted primarily by telephone, in-person events, or online activities. Approaches to enhance community acceptance included partnering with community leaders to optimize the communication strategies and trust building with the involvement of Institutional Review Board representatives during community meetings. Researchers might need to pivot from in-person planning to virtual techniques while maintaining the ability to engage with the public with two-way communication approaches. Due to less active engagement, and potential for selection bias in the responders, further research is needed to address the costs and benefits of virtual community consultation and public disclosure activities compared to in-person events.

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.

Conceptualizing the forensic psychiatry report as performative narrative.

Forensic psychiatry has evolved into a recognized specialty. Two core competencies, often overlooked but commonplace in forensic psychiatry, are the constructing of forensic reports and the presenting of oral testimony. This article concerns the written forensic report and conceptualizes it as performative writing. We first review the development of the forensic report's structure over the past 30 years or so and then apply constructs from other disciplines as we propose a process for creating narrative forensic reports. Such writing is grounded in the discipline of psychiatry, relies on ethics-based principles of respect for persons and truth-telling, and uses language to tell a story that persuades the legal audience. We examine the impact of voice, pitfalls to avoid, and the concepts of witnessing and labeling, as we describe the process of formulating the narrative through the voice of the forensic expert.

A peer-support, group intervention to reduce substance use and criminality among persons with severe mental illness.

OBJECTIVE: This study compared the effectiveness of two interventions in reducing alcohol use, drug use, and criminal justice charges for persons with severe mental illnesses: first, a community-oriented group intervention with citizenship training and peer support that was combined with standard clinical treatment, including jail diversion services, and second, standard clinical treatment with jail diversion services alone. METHODS: A total of 114 adults with serious mental illness participated in a 2 x 3 prospective longitudinal, randomized clinical trial with two levels of intervention (group and peer support for the experimental condition and standard services for the control) and three interviews (baseline, six months, and 12 months). Self-report questionnaires assessed alcohol and drug use, and program databases assessed criminal justice contacts. The authors used a mixed-models analysis to assess alcohol and drug use, repeated-measures analysis of covariance to assess criminal justice charges, and correlational analyses to assess the relation between intervention participation and outcome variables. RESULTS: The experimental group showed significantly reduced alcohol use in comparison with the control group. Further, results showed a significant group-by-time interaction, where alcohol use decreased over time in the experimental group and increased in the control group. Drug use and criminal justice charges decreased significantly across assessment periods in both groups. CONCLUSIONS: Of the outcomes, only decreased alcohol use was attributable to the experimental intervention. Although this may be a chance finding, peer- and community-oriented group support and learning may facilitate decreased alcohol use over time.

Commentary: the place of performative writing in forensic psychiatry.

In this issue of the Journal, Robert Simon has explored the subject of the place that writing should occupy in the professional life of forensic psychiatrists. We have taken the platform so elegantly constructed by this erudite and prolific author and used it to discuss the quotidian and concrete task of writing the customary forensic psychiatry report. We look to other disciplines for mechanisms to analyze the written forensic report: concepts of voice, portraiture, and narrative. We ultimately conclude that preparing these reports is a complex undertaking and that writing with clarity, precision, and artistry in forensic psychiatry should be viewed as a core competency.

Accuracy of eyewitness identification is significantly associated with performance on a standardized test of face recognition.

OBJECTIVES: This study assessed the relationship between Eyewitness Accuracy regarding a person met under conditions of high stress and performance on a standardized, neutral test of memory for human faces. METHOD: Fifty-three U.S. Army personnel were exposed to interrogation stress. Forty-eight hours later, participants were administered the Weschler Face Test and then asked to identify the one interrogator who they had encountered 48 h earlier. RESULTS: A significant positive relationship was observed between performance on the Weschler Face Test and performance on the Eyewitness task. Inaccurate eyewitnesses exhibited more False Negative errors when performing the Weschler Face Test. DISCUSSION: Trait ability to remember human faces may be related to how accurately people recall faces that are associated with highly emotional circumstances. Detection probability methods, such as ROC curve analyses, may be of assistance to forensic examiners, the police, and the courts, when assessing the probability that eyewitness evidence is accurate.

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.

The Connecticut Mental Health Center: Celebrating 50 Years of a Successful Partnership Between the State and Yale University.

September 28, 2016, marked the 50th anniversary of the Connecticut Mental Health Center, a state-owned and state-operated joint venture between the state and Yale University built and sustained with federal, state, and university funds. Collaboration across these entities has produced a wide array of clinical, educational, and research initiatives, a few of which are described in this column. The missions of clinical care, research, and education remain the foundation for an organization that serves 5,000 individuals each year who are poor and who experience serious mental illnesses and substance use disorders.

Pathological lying revisited.

Although pathological lying was first described in the medical literature over 100 years ago, it remains a poorly understood concept. Psychiatrists continue to grapple with the full ramifications of the condition, even though interest specifically in pathological lying seems to have waned in recent times. The impact of pathological lying deserves critical attention from forensic psychiatrists because of the implications that untruths have in a legal context. In this article, the authors review the considerable vagueness and confusion that has surrounded this concept and examine the extent to which a person can control lying behavior and the related question of whether pathological liars have responsibility for their actions. While providing a structured framework for considering pathological lying in the forensic context, the authors conclude that further systematic research is needed to resolve the questions raised in this article.

So you're sorry? The role of remorse in criminal law.

The role of remorse in judicial decisions in the criminal justice system has been addressed in scholarship and remains controversial. The purpose of this qualitative research was to examine the views of sitting criminal judges on remorse, its assessment, and its relevance in their decision-making. After approval of the study design by the institutional review board, 23 judges were interviewed in an open-ended format. Transcriptions of these audio-recorded sessions were analyzed phenomenologically by the research team, using the method of narrative summary. The results showed that the judges varied widely in their opinions on the way remorse should be assessed and its relevance in judicial decision-making. They agreed that the relevance of remorse varied by type of crime and the stage of the proceedings. The indicators of remorse for some judges were the same as those that indicated the lack of remorse for others. All the judges recognized that assessment of remorse, as well as judicial decision-making in general, must be altered for defendants with mental illness. The judges varied in their views of the relevance of psychiatric assessments in determining remorse, although most acknowledged a role for forensic psychiatrists.

Forensic mental health professionals in the immigration process.

This article adds to the existing literature on the role of mental health professionals in assisting attorneys in the asylum and refugee determination process primarily in the United States. The authors describe the legal context for asylum and refugee processing, challenges in conducting evaluations, diagnostic considerations, and specific competencies needed for mental health evaluators. Various cases are presented to illustrate key points. These cases purposely do not include any identifying information of any specific client, yet they are representative of the range and scope of issues that arise in this context.

Citizenship, mental illness, and the criminal justice system.

The concept of citizenship in regard to persons with mental illness has gained increasing attention in recent years, but little empirical research has been conducted on this topic. In addition, little research or conceptual writing has been done on the topic of criminal justice in regard to citizenship for people with mental illness, in spite of the high incidence of criminal charges and incarceration among this group. We review our work on an applied theoretical framework of citizenship, including its origins in mental health outreach work to people who are homeless and in a jail diversion program. We then suggest the contribution the framework can make to the intersecting issues of mental illness, its criminalization in the U.S., and the goal of community integration for people with mental illness.

Oral performance, identity, and representation in forensic psychiatry.

The specialty of forensic psychiatry is advancing in practice and in its scholarship. One task for an evolving discipline is to define and master the nature of its work. In this article we assert that the work of testifying in court is more than the sharing of specialized knowledge. It is performance. Anthropology, religious studies, political science, and psychology (among other disciplines) have investigated elements of face-to-face human interaction set within ritual and credentialed it as worthy of attention and belief. Such is the nature of expert testimony within forensic psychiatry. This is our position, but we also consider well-founded concerns about the ethics of highlighting oral performance. These topics emphasize the need for the discipline to recognize the unique nature of testimony, to master the work and control standards that assure excellence and ethics-based practice.

The state of contemporary risk assessment research.

The focus on assessing dangerousness in routine psychiatric practice developed when relatively little was known about factors related to violence, and the accuracy of predicting violence was distinctly below chance. Since the 1990s, however, significant research attention has been directed toward factors related to violence and mental illness, as well as toward factors related to the accuracy of risk assessment techniques. Sociodemographic and environmental variables have been identified as significant predictors of violence, as has the presence of substance abuse. However, the data on specific mental health variables are somewhat mixed. Many studies point to a modest increased risk of violence associated with major mental illness and psychosis, whereas other noteworthy studies have failed to confirm such findings. Studies of the accuracy of risk assessments indicate that both actuarial and clinical methodologies perform better than chance, although the former achieve greater statistical accuracy. Despite ongoing controversies, risk management strategies that encompass the strengths and limitations of our present knowledge are available to clinicians.