Forensic Psychiatry Education in Child and Adolescent Psychiatry (CAP) Fellowship: Results from a Multi-site Survey.

OBJECTIVE: This study examined the current state of forensic education among child and adolescent psychiatry (CAP) fellowship programs, regarding specific forensic topics, teaching resources, methods, and experiences. The authors aimed to gather and analyze this data to assess the need for additional standardization of forensic psychiatry education in CAP fellowship, such as broader access to resources, and/or inform the development of a standardized curriculum, including milestones, in child and adolescent forensic psychiatry. METHODS: The authors collaboratively developed a survey instrument on child and adolescent forensic psychiatry education, which was then sent to 135 accredited CAP fellowship programs. The items included in the survey instrument were designed based on literature review, expert consensus, and a 1992 American Association of Directors of Psychiatric Residency Training survey on teaching ethics and forensic psychiatry. RESULTS: Completed response data was returned by 25 of the 135 programs surveyed. Complete responses came primarily from academic institutions (52% public, 36% private) with small- or medium-sized programs (1-12 total fellows, 88%; 11-29 faculty members, 56%). Programs reported on CAP forensic rotation sites, faculty members' level of expertise and involvement in forensic CAP, common forensic topics and experiences offered, and programs' attitudes towards specific topics and experiences. CONCLUSIONS: Child and adolescent psychiatrists must gain a clear understanding of the essential components of CAP forensic psychiatry during CAP fellowship, to mitigate discomfort when interacting with the legal system and meet the rising need for forensic CAP expertise across systems and structures impacting youth populations.

Variations in Application Instructions for Forensic Psychiatry Fellowships.

OBJECTIVE: In this study, the authors examined the consistency and the transparency of application instructions for forensic psychiatry fellowships in the USA. METHODS: The authors collected the names of US forensic psychiatry fellowships listed in the Directory of Forensic Psychiatry Fellowships maintained by the American Academy of Psychiatry and the Law. Using data from active fellowship websites, the authors extracted for each program: (1) timelines for applications and interviews, (2) whether an application form was supplied, and (3) the presence of specific application requirements (e.g., curriculum vitae, personal statement, letters of recommendation, residency training director evaluations, writing samples). RESULTS: Among 45 fellowship websites, 31 (68.9%) did not provide specific dates or months when their application cycle opened, nor did they indicate whether they accepted applications on a rolling basis. Fourteen (31.1%) did not have an application form, and 8 (17.8%) did not list application requirements. Among 37 programs that listed specific requirements on their websites, 36 (97.3%) required a curriculum vitae or letters of recommendation, 35 (94.6%) required a personal statement and/or letter of interest, and 27 (73.0%) required writing samples and/or evaluation materials from residency program directors. CONCLUSIONS: This study found considerable variations among online application instructions for US forensic psychiatry fellowships. Although many factors shape recruitment into forensic psychiatry fellowships, improving the consistency and the transparency of application instructions might decrease stress related to the application cycle and streamline recruitment into the field.

A Review of Forensic Fellowship Training: Similar Challenges, Diverse Approaches.

OBJECTIVE: As the specialty of forensic psychiatry and the numbers of justice involved individuals with mental illness continue to grow, forensic education is receiving more attention. To add to this discussion, the authors reviewed current training practices in forensic psychiatry fellowship programs. METHODS: As part of a project funded by the state legislature looking at psychiatry and psychology training, with special focus on state hospital partnerships, the authors interviewed and surveyed forensic psychiatry fellowship program directors and conducted site visits to select programs. Given the mandate, special attention was given to programs with state hospital and psychology training affiliations. RESULTS: The literature and fellowship directors identified several key features and challenges for forensic training programs. Forensic fellowships focused primarily on evaluations and consultations but differed in their offerings related to training in treatment, scholarship, and particular types of evaluations. Common concerns included maintaining adequate funding, variety of training experiences, adequate faculty time, and adequate institutional support. Directors described cultivating institutional support by demonstrating mutual benefit as particularly important for securing resources. CONCLUSION: Forensic fellowships operational during the 2016-2017 academic year offered a range of forensic training activities, but experienced common challenges such as inadequate funding and faculty supervision. Empirical studies are needed to evaluate the relationship between programmatic offerings, the noted challenges, and acquired competencies.

The Benefits of Required Forensic Clinical Experiences in Residency.

OBJECTIVE: The growth of forensic psychiatry has spurred efforts to improve forensic psychiatry training in general psychiatry residency. The Accreditation Council for Graduate Medical Education requires that residencies provide an experience that "exposes" residents to forensic issues, but leaves the specifics to individual programs. However, there is growing need for psychiatrists to understand the unique circumstances of individuals with mental illness involved in the criminal justice system. METHODS: The authors developed a new mandatory forensic rotation for general psychiatry residents and conducted a pilot study to assess its impact on residents' interest and comfort working with criminal justice-involved patients, interest in forensic fellowship, and knowledge of available resources for consultation and supervision. RESULTS: Rotation completion was associated with a significantly increased interest in working with forensic populations and pursuing forensic fellowship, but no changes in residents' level of comfort or knowledge of supervisory and consultative resources. CONCLUSIONS: This study adds to the growing body of literature describing the benefits of expanding forensic education for residents.

[Development of a forensic psychiatric curriculum in Belgium and the Netherlands]. / De ontwikkeling van een forensisch psychiatrisch curriculum in Vlaanderen en Nederland.

BACKGROUND: Forensic psychiatry attracts considerable attention from media and politicians. All psychiatrists, not only those working in the forensic field, should be able to evaluate safety for society on the one hand and qualitative health care for psychiatric patients on the other. However, little attention is paid to specific forensic issues, in both psychiatric training and in medical school.
AIM: To map relevant topics for a forensic psychiatric curriculum in medical schools and psychiatric residency training.
METHOD: The main findings regarding educational topics in forensic psychiatry are discussed based on policy papers and scientific articles.
RESULTS: Four important topics should be covered in general psychiatric training, i.e. mental health legislation, risk assessment and management, professionalism and ethics, and expert witness training. The Netherlands has a specific training programme for psychiatrists interested in expert report writing and testimony for criminal courts. In Belgium, psychiatrists can acquire specific professional competence in forensic psychiatry.
CONCLUSION: Acknowledgement of the above-mentioned topics in the general medical and psychiatric curriculum will lead to better knowledge and competencies for all psychiatrists, both in Belgium and the Netherlands. Continuing attention and evaluation will be necessary given the high societal relevance.

Supervising trainees in research: what does it take to be a scholarly project supervisor?

OBJECTIVES: Scholarly projects (SPs) are a compulsory component of psychiatry training in Australasia. This article outlines the role of a research supervisor in supporting a trainee to complete an SP. METHODS: A total of 10 old age and forensic psychiatry SPs were reviewed with regard to aims, methodology, supervisor input, trainee tasks and additional resources. RESULTS: The main supervisor tasks are described and discussed. They include practical advice on study design, ethics applications, critical appraisal, data analysis, academic writing and publication. CONCLUSIONS: Supervising SPs can bring significant rewards in awakening a trainee's interest in research. Key competencies for research supervision are discussed and further recommendations for supervisor support and training are provided.

Civil forensic psychiatry - Part 2: specific issues.

OBJECTIVES: This paper describes the main areas of civil forensic psychiatry (FP) and the skills required by psychiatric experts. Some specific areas of civil FP are discussed, including tort law reform, reliability of psychiatric evidence, contentious psychiatric disorders, and the many domains of civil FP. CONCLUSIONS: Civil FP is an important sub-specialty component of forensic psychiatry that requires greater emphasis in the training and continuing education of psychiatrists. A process of accrediting psychiatrists as having competency in advanced civil FP may be of value.

Enrichment activities in the medical school psychiatry programme - could this be a key to engaging medical students in psychiatry? A study from a high secure forensic psychiatric UK hospital.

BACKGROUND: The majority of research studies on medical student attitudes toward psychiatry focus on influencing factors and the medical school experience. This study evaluates the effectiveness of a one-day visit to a high secure forensic psychiatric unit on medical students' attitudes towards psychiatry and also assesses career intentions and the factors influencing these. METHOD: Change in attitudes and career intention were measured by administering a questionnaire, which included the 30-item Attitudes Toward Psychiatry (ATP-30) survey, at the start (time 1) and end (time 2) of the one-day visit. Qualitative data on factors influencing career choice was also gathered. RESULTS: Evaluation of 284 responses revealed a significant increase in positive attitude towards psychiatry from time 1 to time 2 in the sample as a whole. The most influential factor on consideration of psychiatry as a career across all groups was the medical school clinical placement. For those that tended away from choosing psychiatry as a career, patient prognosis was important. CONCLUSIONS: Poor recruitment in psychiatry in the UK is already established which will doubtless be compounded by controversies surrounding the proposed new junior doctors' contract. Now more than ever, the need to inspire and motivate those at medical school encountering psychiatry is crucial. Our findings add to the body of evidence that the medical school clinical attachment is fundamental in shaping attitudes. However, these results also show that a well-planned visit to a specialised psychiatric unit outside of traditional placements can have a significant impact on students' attitudes toward psychiatry and mental illness in general. There is limited literature in the UK on enrichment activities within the psychiatry medical school curriculum. We propose that developing opportunities for enrichment activities within psychiatry could increase the scope of how we engage students in this fascinating field of medicine.

Narrative and reflection: training in a correctional facility.

This commentary describes the author's experience working at two separate detention centres during her fellowship. She initially describes her experience performing forensic evaluations. The terms 'competency to stand trial' and 'criminal responsibility' are defined. It then describes the author's experience working in an inner city and suburban detention centre. The two environments and patient demographics are compared to a traditional inpatient or outpatient community setting. Fictional patient encounters, based on an amalgamation of actual patients, are discussed.

Effectiveness of a single day induction programme in changing medical students' attitudes towards the speciality of forensic psychiatry.

OBJECTIVES: We aimed to investigate the effectiveness of a day visit in changing attitudes towards a high-security forensic psychiatric hospital, with regard to the current recruitment difficulties in psychiatry. METHODS: Broadmoor Hospital, a UK high-security psychiatric hospital, runs day visits for medical students, led by doctors. At the beginning and the end of the day students wrote their responses to the question, 'What do you think of Broadmoor?' Attitudes and themes were identified, and their prevalence was analysed. RESULTS: The responses of 296 students were initially analysed; however, 19 responses had to be excluded because they were illegible or incomplete. Before the visit, 15 responses were rated as positive, 169 neutral and 93 negative. After the visit, 205 responses were positive, 69 neutral and three negative. The themes that changed markedly following the visit were those indicating a change to favourable attitude. CONCLUSIONS: A single day visit was shown to be effective in altering the attitudes of medical students towards forensic psychiatry within a high-security psychiatric hospital.

Forensic Psychiatry Milestones: Experience After 1 Year.

OBJECTIVE: In 1999, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties identified six core competencies for medical practice. In 2013, the milestones were introduced to demonstrate these educational outcomes across each specialty. This study represents the first examination of the sub-specialty Forensic Psychiatry Milestones. METHODS: Members of the Association of Directors of Forensic Psychiatry Fellowships were surveyed. Areas of inquiry included whether milestones assisted in identifying areas of deficiency in fellows or programs, whether the graduation milestones matched the goals of training, and what changes were planned, or had been made, based on their implementation. RESULTS: Twenty-six of 35 programs responded, for a response rate of 74%. The majority found the milestones somewhat or very useful, half found the graduation-level milestones matched the program's graduation goals, and a significant majority reported that the milestones assisted in identifying improvements, change, or intended change. In choosing terms to describe the milestones, however respondents chose a variety of negative or neutral terms, rather than positive ones. CONCLUSIONS: The milestones provided a standard mechanism for identifying areas for improvement and a common language to standardize practice. However, due to the variability across fellowship programs and the limitations of educational resources and time, implementation of the new ACGME requirement was characterized in largely negative terms. Recommendations for improvement included modification of the milestones themselves, flexibility in their implementation, and evidentiary support for their use.

Impact of Repeated Questioning on Interviewers: Learning From a Forensic Interview Training Project.

Forensic interviewers have a difficult job with high risk for career burnout and secondary trauma. Few studies have addressed how new forensic interviewers or trainees experience repeated questioning and multiple interviews. This study simulated the process of training new forensic interviewers through the creation of two interview videos in which social work graduate students participated as actors portraying the roles of interviewer and child. These films served as instructional aids preparing graduate social work students for professional child welfare roles while promoting research-based approaches to interviewing children about sexual abuse allegations. Qualitative data from two cohorts of student actors were collected to analyze interviewers' perspectives on repeated questioning and interviews in child sexual abuse cases. Two themes were extracted from the subjects' experiences: "It is emotionally taxing" and "Navigating the interviewer role is unexpectedly complex." Exposure to repeated questions and multiple interviews affected the performance and confidence of the interviewers.

Testifying in a mock court: the experiences of forensic advanced trainees.

OBJECTIVES: We aimed to examine the experiences of advanced trainees in forensic psychiatry as they practise testifying as expert witnesses in a mock court setting. METHODS: Five advanced trainees (including the first author) submitted court-ordered forensic reports in advance of attending the mock court. Senior colleagues had roles of Judge, prosecution and defence lawyers. House officers and medical students were summoned as jury. Over a year, each trainee had the experience of direct and cross-examination by opposing legal teams. Following the mock trial, each participant was given immediate feedback and subsequently asked to complete a semi-structured questionnaire. RESULTS: The experience of participating in a mock court has learning value for advanced trainees specialising in forensic psychiatry in anticipation of giving evidence in a court of law. Constructive feedback enabled attendees to gain valuable education in a supportive setting. Of particular value was guidance in the use of technical language in presenting evidence in a court setting, knowledge of the breadth of questions that could be put forth to an expert witness, desensitisation training in an adversarial albeit simulated setting, and acquiring skills in staying calm under pressure. CONCLUSIONS: The importance of a well-written report, good preparation and anxiety management were significant learning points.

Forensic psychiatry in Europe: The perspective of the Ghent Group.

OBJECTIVE: The Ghent Group was established in 2004 as a forum for forensic psychiatrists from different countries in Europe in order to bridge the gaps in knowledge, experience, practice and care which exist between them due to their different legal traditions and constitutions in dealing with people having mental disorders who come into conflict with the law. METHODS: The Ghent Group considers itself as a loosely organised think tank to which all interested and invited professionals can contribute without statutory restraints. Its aim is to facilitate communication with mentally disordered offenders appearing in court, to understand the procedures of our neighbouring countries and to find common ground between clinicians. RESULTS: The major focus of the Ghent Group is on teaching and training both at a national level, where one can learn about the methods of training from each other, and at a European level. The group of trainees from different countries experiment in seminars in solving medico-legal cases considering European Human Rights issues and their respective national procedures and institutions. CONCLUSIONS: This helps not only to understand the differences between the national medico-legal procedures but also to deepen the understanding of the principles and practice in one's own country.

[The Institute Philippe-Pinel and the department of Psychiatry of the University of Montreal: intricate paths]. / L'Institut Philippe Pinel et le Département de psychiatrie de l'Université de Montréal : des parcours intriqués.

The Institute Philippe-Pinel (IPPM) and the Département de psychiatrie de l'Université de Montréal, who are both celebrating their 50 years, have intricated paths and a long history of collaboration. Since its conception (1964), the Institute Philippe-Pinel was planned to become a site for training and teaching in the bosom of the Université de Montréal.Unique in its mission to offer state of the art psychiatric care and forensic assessments to patients presenting a high risk of violence, the Institute Philippe-Pinel, throughout the years, was also able to leave its mark by the way of academic teaching to psychiatric residents and trainees of all disciplines, of organizing national and international conferences, of research and by the publication of numerous articles and books in the field of forensic psychiatry.With, from its beginning, psychiatrists at its helm, the Institute Philippe-Pinel has at all times greatly contributed to the academic activity of the department. Highly committed psychiatric clinicians and professors were always involved at all levels of the psychiatric department. With the coming of the forensic subspecialty, the commitment and influence can only continue.

General psychiatric residents and corrections: moving forensic education beyond the classroom.

Mental illness in the criminal justice system is one of the most important and underserved public health challenges in psychiatry today, but few general psychiatry residency programs offer clinical education in correctional psychiatry. Developing such rotations might seem intimidating to educational leaders unfamiliar with the criminal justice system, but a variety of potential solutions exist for residency programs to offer this increasingly important clinical training.

Training directors' self-assessment of forensic education within residency training.

OBJECTIVE: The authors provide information pertaining to forensic education within psychiatry residency based upon training directors' self-assessment of their programs, utilizing the 2007 ACGME program requirements for forensic psychiatry as an assessment guideline. METHODS: A sample of 100 general psychiatry residency training directors from 182 training programs in the USA were selected by a random number generator to complete a survey to evaluate forensic training provided within their residency programs. RESULTS: Seventy-one percent of the 100 surveyed training directors completed and returned the questionnaire. Ninety-three percent of training director respondents reported their program meets the ACGME program requirements for graduate medical education in forensic psychiatry. The forensic topics covered most thoroughly in general psychiatry training are involuntary civil commitment and violence risk assessment. The topics covered least thoroughly include exposure to courtroom testimony, writing a forensic report, and evaluating a defendant's criminal responsibility. The respondents further indicated most forensic psychiatry topics are covered more extensively through educational exposure than through clinical exposure. CONCLUSIONS: Greater effort may be required to emphasize clinical and educational exposure to certain forensic psychiatry topics during the course of general psychiatry residency training, to ensure that the forensic topics of greatest importance are appropriately addressed.