Forensic Mental Health Evaluators' Unprocessed Emotions as an Often-Overlooked Form of Bias.

There has been robust interest in the influence of cognitive and implicit biases that can hamper a forensic mental health evaluator's ability to provide objective opinion evidence. By contrast, literature exploring the biasing effects of the examiner's unacknowledged and unprocessed emotions has been scanty. Borrowing from concepts originating from psychodynamic treatment literature, this article explores how a forensic mental health evaluator's emotional and transferential reactions can affect the assessment process and formulation of findings. We make the case that forensic mental health evaluators are not impervious to their own mental health concerns, including vicarious trauma. We ultimately argue for a cultural shift in forensic practice that acknowledges the unavoidable existence and influence of a forensic evaluator's human emotions, personal reactions, and conflicts, so that strategies can be developed for compassionate but careful management in training programs, supervision, and beyond. We suggest that self-reflection, sometimes with the aid of consultation and psychotherapeutic support, is not only important for clinical trainees but also could serve forensic practitioners throughout their careers, especially during challenging junctures in their personal and professional lives.

Public Disclosure on Social Media of Identifiable Patient Information by Health Professionals: Content Analysis of Twitter Data.

BACKGROUND: Respecting patient privacy and confidentiality is critical for doctor-patient relationships and public trust in medical professionals. The frequency of potentially identifiable disclosures online during periods of active engagement is unknown. OBJECTIVE: The objective of this study was to quantify potentially identifiable content shared on social media by physicians and other health care providers using the hashtag #ShareAStoryInOneTweet. METHODS: We accessed and searched Twitter's API using Symplur software for tweets that included the hashtag #ShareAStoryInOneTweet. We identified 1206 tweets by doctors, nurses, and other health professionals out of 43,374 tweets shared in May 2018. Tweet content was evaluated in January 2019 to determine the incidence of instances where names or potentially identifiable information about patients were shared; content analysis of tweets in which information about others had been disclosed was performed. The study also evaluated whether participants raised concerns about privacy breaches and estimated the frequency of deleted tweets. The study used dual, blinded coding for a 10% sample to estimate intercoder reliability using Cohen κ statistic for identifying the potential identifiability of tweet content. RESULTS: Health care professionals (n=656) disclosing information about others included 486 doctors (74.1%) and 98 nurses (14.9%). Health care professionals sharing stories about patient care disclosed the time frame in 95 tweets (95/754, 12.6%) and included patient names in 15 tweets (15/754, 2.0%). It is estimated that friends or families could likely identify the clinical scenario described in 242 of the 754 tweets (32.1%). Among 348 tweets about potentially living patients, it was estimated that 162 (46.6%) were likely identifiable by patients. Intercoder reliability in rating the potential identifiability demonstrated 86.8% agreement, with a Cohen κ of 0.8 suggesting substantial agreement. We also identified 78 out of 754 tweets (6.5%) that had been deleted on the website but were still viewable in the analytics software data set. CONCLUSIONS: During periods of active sharing online, nurses, physicians, and other health professionals may sometimes share more information than patients or families might expect. More study is needed to determine whether similar events arise frequently and to understand how to best ensure that patients' rights are adequately respected.

Treatment Delayed is Treatment Denied.

The past few decades have witnessed the steady development of a mental health jurisprudence dedicated to the preservation of human rights. Self-determination and personal autonomy are critical aspects of this perspective, pervading every facet of institutional psychiatric care. Of considerable concern, however, are those cases in which rote procedural approaches produce unintended consequences for the very persons such maneuvers were designed to protect. Delays-inherent in court-based procedures-may ironically lead to an acute illness becoming chronic, and to a single bout of inpatient services being transformed into a lifetime of revolving-door psychiatric admissions. This discussion is not about lawyers or lawyering; rather, it is about the proposition that a better system can and should be devised for advocates who must make do with the options they are dealt. A particularly problematic example is the "Rogers Guardianship" model currently prevalent in Massachusetts. Laws that effectively place on counsel and courts the challenge of second-guessing medical treatment decisions-with minimal latitude for counsel to exercise measured professional judgment-will inevitably generate, and empirically do generate, a degree of delay that ironically deprives patients of the liberation from illness that is the common goal of all stakeholders. Possible solutions to these difficulties are also suggested.

Confidentiality and Privacy for Smartphone Applications in Child and Adolescent Psychiatry: Unmet Needs and Practical Solutions.

This article summarizes the current literature on clinical knowledge and practical gaps regarding the confidentiality and privacy for smartphone and connected devices in child and adolescent psychiatry and offers practical solutions and consideration for the next steps for the field. Important issues to consider include disclosure of information sharing, access privilege, privacy and trust, risk and benefit analysis, and the need for standardization. Through understanding the privacy and confidentiality concerns regarding digital devices, child and adolescent psychiatrists can guide patients and parents though informed decision-making and also help shape how the field creates the next generation of these tools.

A Proposed Model for Assessing Defendant Competence to Self-Represent.

The increasing number of criminal defendants who are choosing to self-represent poses special challenges for legal systems with regard to the types of limits that should be placed on a defendant's basic human right to defend himself without the assistance of counsel. While courts strive to respect the dignity and autonomy of the defendant that are encompassed in this right, they also want to ensure that justice is delivered and the dignity of the courtroom is maintained. The Supreme Court of the United States, in its opinion in Indiana v. Edwards (2008), held that while the right to self-represent recognized in Faretta v. California (1975) remains, states and trial judges can place limits on a defendant's right to self-representation when a defendant lacks the mental capacities needed to prepare and conduct an adequate defense. Following the court's lead, we first examine the types and range of tasks that a defendant who chooses to self-represent must perform. Based on this analysis, we propose a five-part model that forensic practitioners can use as a conceptual framework for assessing whether a defendant has deficits that would affect his competence to perform critical self-representation tasks. The five areas that the model recommends practitioners assess are whether a defendant can engage in goal-directed behaviors, has sufficient communication skills, can engage in constructive social intercourse, can control his emotions in an adversarial arena, and has the cognitive abilities needed to argue his case adequately. It is recommended that practitioners use the model in their testimony to provide the trier of fact with a comprehensive report of the areas in which a defendant has deficits that will prevent him from protecting his interests in receiving a fair and equitable trial.

Mobile Mental Health: Navigating New Rules and Regulations for Digital Tools.

Mobile health (mHealth) apps are becoming much more widely available. As more patients learn about and download apps, clinicians are sure to face more questions about the role these apps can play in treatment. Clinicians thus need to familiarize themselves with the clinical and legal risks that apps may introduce. Regulatory rules and organizations that oversee the safety and efficacy of mHealth apps are currently fragmentary in nature and clinicians should pay special attention to categories of apps which are currently exempt from significant regulation. Uniform HIPAA protection does not apply to personal health data that are shared with apps in many contexts which creates a number of clinically relevant privacy and security concerns. Clinicians should also consider several relatively novel potential adverse clinical outcomes and liability concerns that may be relevant to specific categories of apps, including apps that target (i) medication adherence, (ii) collection of self-reported data, (iii) collection of passive data, and (iv) generation of treatment recommendations for psychotherapeutic and behavioral interventions. Considering these potential pitfalls (and disclosing them to patients as a part of obtaining informed consent) is necessary as clinicians consider incorporating apps into treatment.

Do Consultation Psychiatrists, Forensic Psychiatrists, Psychiatry Trainees, and Health Care Lawyers Differ in Opinion on Gray Area Decision-Making Capacity Cases? A Vignette-Based Survey.

BACKGROUND: Previous research in the area of medical decision-making capacity has demonstrated relatively poor agreement between experienced evaluators in "gray area" cases. We performed a survey to determine the level of agreement about gray area decision-making capacity case scenarios within and between individuals of different professional backgrounds. METHOD: Participants received a survey consisting of 3 complicated decision-making capacity vignettes with an accompanying "yes/no" question regarding capacity and a certainty scale for each vignette. Participants were identified from mailing lists of professional organizations and local hospitals. We received responses from psychiatry trainees, consultation-liaison psychiatrists, forensic psychiatrists, and lawyers with experience in health care law. Results were analyzed using SPSS. RESULTS: Across the 3 vignettes, the percentage agreeing that the individual described had capacity to refuse medical treatment ranged between 35% and 40% for trainees, 33% and 67% for consult psychiatrists, 41% and 76% for forensic psychiatrists, and 40% and 83% for health care lawyers. Only question 2 reached significance between-group differences (Pearson χ(2) = 11.473, p < 0.01). Across vignettes, trainees were less likely to consider patients to have capacity for decision-making than were forensic psychiatrists and lawyers. CONCLUSIONS: As found in previous research, agreement among experienced evaluators appears generally low in gray area capacity cases. It is noteworthy that individuals of different professional backgrounds at times offer divergent between-group opinions on capacity.

Forty-Five Years of Civil Litigation Against Canadian Psychiatrists: An Empirical Pilot Study.

OBJECTIVES: To extract the themes pertaining to prudent psychiatric practice from written court judgments in Canada. METHODS: We searched the medical and legal literature for cases involving civil litigation against Canadian psychiatrist and reviewed all available written judgments. We completed a thematic analysis of the civil actions against psychiatrists as conveyed by those written court judgments. We classified the cases according to the disposal status and the essential lessons from the decisions on standard of care and practice by Canadian psychiatrists. RESULTS: Forty such cases were identified as involving psychiatrists over a 45-year period. A subgroup included those dealing with limitation periods and disclosure applications. Thirty of the 40 cases (75%) were decided in favour of the defendant psychiatrists, including 2 dismissed for running over the limitation period. The cases that actually went to trial suggest that documentation and obtaining second opinions are protective against claims of negligence. Inpatient cases resulting in successful litigation against psychiatrists involved fatal outcomes, but not all fatal outcomes led to successful litigation. CONCLUSIONS: The key lessons from these cases are the importance and relevance of regular best clinical practices, such as documentation, obtaining second opinions, following guidelines, and balancing competencies in the expert and manager or advocate roles. Incorporating these practices should allay concerns about litigation against psychiatrists.

Comparative study of forensic psychiatric system between China and America.

Laws and regulations about the forensic psychiatric systems in China and America were compared, and suggestions for improving the forensic psychiatric system of China were provided. There are many differences regarding the role of the forensic psychiatrist, the initiation of the assessment and the admission of expert opinion because of elements in the legal systems in China and America. The Chinese system has the advantages of objectivity, cost saving and high efficiency; but it has deficiencies in procedural justice and the admission of expert opinion. China can persist with the current system while taking measures to give more rights to the litigants to participate in their assessment, and while improving the quality and utility of the expert opinion; however, this review article will compare broadly the two systems without addressing human rights issues or procedural justice issues, nor will it presume to address the entirety of Chinese systems. In addition, China is developing its legal system for dealing with the mentally ill defendant in situations involving the criminal justice system and civil commitment. Although China enacted new laws regarding the mandatory treatment for the mentally ill, both in criminal and civil systems, there remain many aspects to be improved, including but not limited to a system of review of the decision to detain a patient on psychiatric grounds, and the need for provisions in the laws preventing indefinite detention. From this viewpoint, America's laws and regulations are instructive for us, in matters such as the method of dealing with the mentally ill defendant who is "incompetent to stand trial", "not guilty only by reason of insanity" or "guilty but mentally ill". The conditional release of the committed mentally ill person and the special programs in the forensic security hospital are all worthy of study by China in order to manage the mentally ill offender and to reduce the recidivism rate.

Sudden discovery of a previous nonclinical relationship with a potential patient: implications for subsequent psychiatric treatment.

Suddenly encountering a patient who happens to be a person with whom a therapist has had a previous nonclinical relationship poses special problems for both the therapist and patient. The problems--including countertransference issues, dual relationships, and other concerns surrounding subsequent therapy--are discussed in this column through the use of examples. The authors conclude that the potential disadvantages of treating such patients outweigh any advantages that might come from previous relationships. The consequent recommendation is that such patients be referred to other clinicians.

Forensic experts' perceptions of expert bias.

How do expert witnesses perceive the possible biases of their fellow expert witnesses? Participants, who were attendees at a workshop at the American Academy of Psychiatry and Law were asked to rate for their biasing potential a number of situations that might affect the behavior of an opposing expert. A Rasch analysis produced a linear scale as to the perceived biasing potential of these different kinds of situations from the most biasing to the least biasing. Working for only one side in both civil and criminal cases had large scaled values and also were the first factor. In interesting contrast, a) an opposing expert also serving as the litigant's treater and b) an opposing expert being viewed as a "hired gun" (supplying an opinion only for money) were two situations viewed as not very biasing. Order of Hierarchical Complexity also accounted for items from the 1st, 2nd and 3rd factors. The result suggests that the difficulty in understanding the conceptual basis of bias underlies the perception of how biased a behavior or a situation is. The more difficult to understand the questionnaire item, the less biasing its behavior or situation is perceived by participants.

Do forensic practitioners distinguish between testifying and consulting experts? A pilot study.

Forensic mental health professionals (n=44) reviewed a series of statements that an attorney might make to a consulting or testifying expert. Each statement was rated for its degree of appropriateness to either the consulting or the testifying role. In light of increasing attention paid to this topic in the forensic practice literature, as well as long-standing distinctions recognized by the legal profession, it was originally hypothesized that participants would differentiate clearly between these roles; however, results of this pilot study indicate that forensic practitioners do not possess a consistent sense of which activities rest most comfortably within testimonial as opposed to consulting duties.

Expert witness and Jungian archetypes.

Jung's theories of archetype, shadow, and the personal and collective unconscious provide a postmodern framework in which to consider the role of the expert witness in judicial proceedings. Archetypal themes, motifs, and influences help to illuminate the shadow of the judicial system and projections and behaviors among the cast of the court in pursuing justice. This article speaks to archetypal influences and dialectical tensions encountered by the expert witness in this judicial drama. The archetype of Justice is born from the human need for order and relational fairness in a world of chaos. The persona of justice is the promise of truth in the drama. The shadow of justice is untruth, the need to win by any means. The dynamics of the trickster archetype serve and promote injustice. These influences are examined by means of a case example. This approach will deepen understanding of court proceedings and the role of the expert witness in the heroic quest for justice.

Reflections on ethical issues in psychopharmacology: an American perspective.

Psychopharmacology has revolutionized psychiatric practice but raises a number of ethical issues. This review from an American perspective first describes ethics analyses and attempts to portray the ethical practitioner. Pressures that interfere with appropriate prescribing come from outside the prescriber and from within, including from insurers, other treatment staff and the prescriber's own will to act for the patient. Clinicians also face binds in which alternate choices seem to have merit and leave the prescriber feeling pulled in contradictory directions, frequently related to risk-benefit dilemmas. The ethics of psychopharmacology poses many questions that cannot yet be answered at the current state of the field. Pharmacology also seems to promote extremes of attitudes, such as "All such drugs are poisons" and the like. This review then provides some risk management principles, and concludes that such a review, though not comprehensive, may serve to open questions that are not always considered by clinicians.

Deposition dos and don'ts: strategies for the expert witness.

The deposition is an important stage in the legal process, which poses special challenges for the deponent. This article reviews those challenges from the standpoint of the expert witness, addressing the stages of the deposition, the deposing attorney's strategies, the role and goals of the expert witness serving as the deponent, the approach to answering the attorney's questions, strategies for clarifying or reframing those questions, and the approaches to reviewing the deposition after the transcript has been printed. The article emphasizes tricks and traps used by the deposing attorney and how to avoid them.

"Certainty" and expert mental health opinions in legal proceedings.

This pilot study addresses the legal and scientific ramifications of the "certainty" expressed by mental health professionals when functioning as expert witnesses in criminal and civil proceedings. The sporadic attention paid to "certainty" in the professional literature has typically taken the form of general policy oriented analyses as opposed to empirical, data-driven investigations. In the current study, 25 doctoral and master's level mental health professionals were provided with 53 different statements. Some statements addressed "certainty" itself in the typical fashion (e.g., "Reasonable Degree of Scientific Certainty," "Reasonable Degree of Medical Certainty," and "Reasonable Degree of Psychological Certainty"). Other statements were confined to specifically legal standards of proof (e.g., "Beyond a Reasonable Doubt," "Preponderance of the Evidence," and "Clear and Convincing"). Additional statements included those that bore at least some direct forensic relevance (e.g., "Based upon All the Data at My Disposal," "In My Medical Opinion," and "In My Clinical Judgment"), as well as those of a non-forensic nature (e.g., "I Would Bet My Life Savings," "On My Word of Honor," and "I Am Personally Convinced"). Ratings were provided on one form as if the participant had uttered the statement, and on another form as if another expert witness had uttered the statement. Overall, participants did not tend to identify traditional legal terms as expressing the highest level of "certainty," and respondents tended to ascribe more "certainty" to the same terms when uttered by themselves as opposed to when uttered by other expert witnesses. Those providing forensic testimony will do well to accommodate the court's traditional requirements while developing and preparing to justify their own notions of just what "certainty" denotes in this context.