The rebirth of forensic psychiatry in light of recent historical trends in criminal responsibility.

The forensic specialist's expertise lies in mapping the interaction of cognitive, affective, and physiologic processes as they affect and are affected by the choices people make, and in connecting this analysis with laws, legal criteria, and other standards. More simply and broadly, it lies in describing both the unique and the universal characteristics of any human being and distinguishing clearly between the two. This is a psychiatrist who conducts in a different arena, and from a more critical perspective, but for the same larger humane purpose, the in-depth journey into the self and its response to stress that is the essence of clinical practice.

Captive patients, captive doctors: clinical dilemmas and interventions in caring for patients in managed health care.

This article explores common clinical dynamics resulting from the denial of choice that many patients experience in managed health care and proposes clinical adaptations for the treating or consulting psychiatrist. Patients who feel they have been denied the right to choose their health plan, treatment setting, or personal physician commonly go through a subjective experience analogous to that of being held captive. This sense of captivity can exacerbate the feelings of helplessness and hopelessness brought on by serious illness. It can also intensify the patient's feelings of alienation and betrayal when managed care constrains patient-physician decision making by limiting treatment options. These dynamics can lead to identifiable transference reactions and, in turn, to physician countertransference. Psychiatrists can do much to ameliorate these potentially destructive dynamics both as treating therapists and as consultants to general physicians. Indications for consultation or intervention are analyzed and specific clinical strategies to enhance the patient's decision-making capacity throughout the introductory, ongoing, and termination phases of the treatment alliance are reviewed.

The ethics of social risk reduction in the era of the biological brain.

In keeping with our transdisciplinary orientation, in this article we try to do several things at once. We address research on preventing mental illness and its relation to existing conceptions of public health, a topic to which insufficient attention has been paid in the era of the biological brain, while using this case study to illustrate the limits of conventional approaches in bioethics. After identifying the crucial need for methodological self-consciousness in prevention research and policy, we explore the implications as they relate to (i) the values embedded in the choice of research designs and strategies, and (ii) contrasting intellectual starting points regarding the biological plausibility of preventing mental illness. We then draw attention to the need for more thoughtful analysis of the appropriate role and limits of economics in making choices about prevention of mental illness.

Unanswered questions about the criminalization of therapist-patient sex.

Even though much has been written about the issue of criminalization of therapist-patient sex, many questions about the issue remain unanswered, raising doubts about the wisdom of nationwide adoption of criminalizing legislation. From a philosophical standpoint, we need to understand more fully what thoughts, emotions, and behaviors constitute consent. Furthermore we must determine how much value to give consent in relation to other social values and goals. From a clinical standpoint we still need a better understanding of what constitutes the therapist-patient relationship: what it is and when it is over. We must also examine more carefully the nature of power within a psychotherapeutic relationship. From a legal standpoint we must determine how criminalization affects constitutional privacy rights, as embodied both in state constitutions and the federal Constitution. From an empirical standpoint we need to assess the efficacy of current criminalization statutes and determine their effect on tort compensation for patient victims. We also need to assess the practical application of these statutes by juries. Without more thorough analysis of all the issues raised, the criminalization of patient-therapist sex by state legislatures may in fact cause more harm than good.

Beyond the black letter of the law: an empirical study of an individual judge's decision process for civil commitment hearings.

To study the role of parens patriae and "police powers" considerations in an individual judge's civil commitment decisions, the judge's reports of the impact of various characteristics of the patient were analyzed. The validity of this methodology was tested by comparing it to an alternative technique based on objective statistical analysis of the dependence of the judge's decisions upon patient characteristics. A probate court judge filled out a questionnaire after each civil commitment hearing over which he presided during a seven-month study. For each of 26 decisions, the judge rated the patient on 26 features and indicated the impact of each feature on the decision. The judge's responses were analyzed to measure the role of various statutory and nonstatutory considerations (expressed as patient characteristics) in the judge's decisions. Results using self-reported impacts are compared with an objective, statistical characterization of the judge's decision-making policy. As in previous studies, the parens patriae model more closely described the individual judge's decision process than the "police powers" model. Contextual variables (e.g., the patient's family favoring commitment) also were influential. Results with the two methods were similar. The methodology developed here can be used not only in further research on judicial commitment decisions but also to educate judges and other decision-makers individually faced with potentially tragic choices as to their personal implicit decision-making strategies.