The Forensic Mental Health Implications of Social Media Challenges.

Children and adults are increasingly spending time on social networking sites where they may be exposed to social media challenges. These challenges, which are essentially dares or competitions, often involve participants recording themselves performing various activities to create a short video which they then share online. Many social media challenges may be considered relatively benign, but others may involve behaviors or tasks that lead to adverse outcomes, including injury and death. In this article, the authors describe different types of social media challenges, susceptibility to risk-taking among social media users, and the potential criminal and civil legal aspects of these challenges. This article focuses on the forensic mental health implications of social media challenges, including considerations for forensic psychiatrists and other mental health professionals who may become involved in court cases related to these challenges.

The Use of Electroconvulsive Therapy on Death Row.

Despite high rates of mental illness among incarcerated people in the United States, use of electroconvulsive therapy (ECT) remains limited in jails and prisons. There are some published guidelines regarding the provision of mental health care, including ECT, in U.S. correctional facilities, but little attention has been paid to the use of ECT for individuals sentenced to death. This article examines ECT within the context of the death penalty, including court consideration of ECT in capital cases and historic uses of ECT to facilitate execution of people on death row. Given the unique clinical, legal, and ethics considerations in the use of ECT for people sentenced to death, the authors call for greater attention to these practices and propose general guidelines regarding the use of ECT in this population.

Considerations for the Writing of Certification Letters Endorsing Use of Emotional Support Animals.

Emotional support animals (ESAs) are different from service animals, therapy animals, and other disability-related assistance animals. Although pet ownership may confer psychological benefits, limited research has supported the use of ESAs to realize such benefits. If clinicians are asked to write a letter of support for use of an ESA, they need to be familiar with relevant federal, state, and local laws that regulate ESAs and with the essential components of an ESA evaluation. This article provides an overview of terminology; federal, state, and local laws related to ESAs; and clinical and ethical considerations for clinicians who decide to write these letters. The authors also review liability issues related to writing these letters, including those related to ESA aggression.

The Use of Battered Woman Syndrome in U.S. Criminal Courts.

Although not recognized by any edition of the Diagnostic and Statistical Manual of Mental Disorders, battered woman syndrome (BWS) has been offered as a defense in U.S. criminal courts for several decades. This article reviews examples of criminal cases in which BWS has been used in the United States as well as the implications of BWS for the practice of forensic psychiatry. Historically raised in cases of self-defense, BWS has also been used in criminal defenses involving duress, as well as by prosecutors to explain witness recantations. Case law suggests that expert witness testimony on BWS is often admissible in jurisdictions across the United States, yet its use in criminal defenses has received mixed responses from various courts. We examine limitations on the use of BWS in criminal courts and the potential use of posttraumatic stress disorder as an alternative and more reliable diagnosis in similar legal contexts.

Grave Disability in U.S. Jails and Prisons.

Many states authorize involuntary psychiatric care on the basis of grave disability, a legal standard often defined as a person's inability to provide for basic needs because of mental illness. Mental illness is prevalent in U.S. jails and prisons, and although correctional facilities must generally provide incarcerated people with basic necessities (e.g., food, clothing, and shelter), incarcerated people may still meet criteria for grave disability. This Open Forum examines the assessment and treatment implications of grave disability in correctional contexts and ways to support the well-being of incarcerated people who may meet criteria for grave disability.

Estimating Annual Numbers of Competency to Stand Trial Evaluations across the United States.

In the United States, criminal proceedings must be halted or suspended if a defendant is determined to be incompetent to stand trial. Competency to stand trial (CST) is one of the most notable intersections between psychiatry and criminal law, and evaluating defendants for CST is a key role for many forensic psychiatrists and other mental health professionals. Despite the significance of CST evaluations in U.S. criminal justice, the number of CST evaluations conducted across the country each year remains largely unknown. National estimates dating back to the 1970s have ranged from approximately 19,000 to 94,000 CST evaluations each year, but these numbers vary considerably and often stem from imprecise calculations. This article examines estimates of annual numbers of CST evaluations across the United States, the need to develop more accurate statistics, and ways to implement systems for tracking the numbers of CST evaluations across the country.

Litigation Over Sleep Deprivation in U.S. Jails and Prisons.

Incarceration can disrupt healthy sleep, and insomnia is associated with psychiatric symptoms and poor general medical health among incarcerated people. In recent years, considerable litigation has arisen over sleep deprivation in U.S. jails and prisons. This column examines litigation over conditions of incarceration, such as noise, inadequate bedding, constant illumination, medication restrictions, and early wake-up times, that may affect sleep duration and quality. The potential adverse effects of inadequate sleep on incarcerated individuals, as well as associated litigation, suggest the need for policies that reduce unnecessary sleep deprivation and promote healthy sleep in correctional facilities.

Laws and Ethics Related to Emotional Support Animals.

The use of animals for therapeutic benefit is well-established. For example, for individuals with a disability such as blindness, trained service dogs can enhance the ability to live independently and participate fully in society. An emotional support animal (ESA) is an untrained animal that is used to support a person disabled by an emotional or mental disorder. For an animal to qualify as an ESA, a mental health or medical professional needs to write a letter saying that the animal is needed for the mental health of the person with the disability. This article describes the legal framework for service animals and ESAs, as well as the differences between them. We summarize information about the Americans with Disabilities Act, the Fair Housing Act, the Air Carrier Access Act, and other laws governing an individual's right to be accompanied by a support animal. We also summarize the clinical research on ESAs and argue that, although there are few studies on the clinical effectiveness of ESAs, a broader body of research indicates that animals may have positive clinical effects on medical and mental illness. Finally, we suggest there is a need for further research and provider education on ESAs.

Effectiveness of Police Crisis Intervention Training Programs.

Approximately 1,000 people in the United States were fatally shot by police officers during 2018, and people with mental illness were involved in approximately 25 percent of those fatalities. Crisis Intervention Team (CIT) training is a specialized police curriculum that aims to reduce the risk of serious injury or death during an emergency interaction between persons with mental illness and police officers. CIT has been implemented widely both nationally and internationally. Given the increasing resources devoted to CIT, efforts to analyze its effectiveness and outcomes relative to other approaches are important. Studies of CIT and similar interventions are found within both the mental health and the criminal justice arenas, which use very different terminologies, approaches, and outcome studies, rendering unified analyses challenging. This article describes the CIT model and reviews several recent systematic analyses of studies concerning the effects of CIT. Studies generally support that CIT has beneficial officer-level outcomes, such as officer satisfaction and self-perception of a reduction in use of force. CIT also likely leads to prebooking diversion from jails to psychiatric facilities. There is little evidence in the peer-reviewed literature, however, that shows CIT's benefits on objective measures of arrests, officer injury, citizen injury, or use of force.

A Systematic Approach to the Detection of False PTSD.

Posttraumatic stress disorder (PTSD) can occur after a traumatic experience and can cause severe symptoms that interfere with a person's psychological, physical, interpersonal, occupational, and social functioning. It is important to accurately identify genuine cases of PTSD and, as part of the differential diagnosis, to rule out instances of false PTSD. False PTSD diagnoses can adversely affect treatment planning, resource management, and research. The subjective nature of stressors, stereotypic presentation of symptoms, wealth of resources detailing how to malinger PTSD, and the high stakes for individuals involved in criminal, civil, and disability evaluations create challenges for making an accurate diagnosis. This article presents a systematic approach to help clinicians and forensic evaluators distinguish genuine PTSD from false variants of the disorder. It describes the types of false PTSD to be considered as alternative diagnoses, including malingered PTSD (for external gain, such as receiving a disability pension or evading criminal consequences), factitious PTSD (for internal gain, such as assuming the victim or hero/veteran role), and misattributed PTSD (legitimate psychopathology misdiagnosed as PTSD). The authors describe clinical features and psychological testing that may be leveraged to aid in reaching a more valid diagnosis.

Risk Assessment of Online Child Sexual Exploitation Offenders.

Over the past two decades in the United States, a dramatic increase in access to the Internet has facilitated an increase in the production, viewing, and distribution of child pornography. In this context, forensic mental health professionals may be called on to estimate the risk of future violence, especially of contact sexual offenses, among individuals charged with online sexual offenses. We summarize demographic and clinical characteristics that differentiate online from contact and "mixed" offenders (those who commit both online and contact offenses), offending histories of these three groups, and the current state of knowledge regarding risk of progression from online-only to contact offending. Multiple studies suggest that online, contact, and mixed offenders demonstrate distinct profiles, and wide variations exist in the offense histories of online-offending groups. Longitudinal studies of individuals charged with online offenses are few in number and are mostly limited to detection of formal charges. Nevertheless, available studies suggest that most individuals who are charged with online offenses and who do not have histories of contact offenses are unlikely to engage in future contact offenses. Within the limitations of the current literature, we suggest guidance for the evaluation and treatment of online offenders.

Controversies Concerning the Canadian Not Criminally Responsible Reform Act.

In Canada, individuals found not criminally responsible on account of mental disorder are subject to the disposition recommendations of the Provincial or Territorial Review Board of the jurisdiction where the offense was committed. Bill C-14, known as "The Not Criminally Responsible Reform Act" made changes to the postverdict disposition process of these individuals. This legislation was consistent with a broader "tough-on-crime" agenda of the previous federal government. The legislative changes codify that Review Boards take public safety as the "paramount consideration" in making their recommendations. The legislation also creates a new "high-risk" category for certain offenders and imposes limitations on their liberty. Further, Bill C-14 seeks to enhance victim involvement in the disposition process. The passage of this legislation has generated significant controversy in the medical and legal fields. Critics have stated that there is an absence of empirical evidence on which to base the amendments, that the legislation was an overreaction to high-profile cases, and that Bill C-14 is in questionable compliance with the Canadian Charter of Rights and Freedoms. In this review, we explore the potential catalysts involved in the creation of Bill C-14, the controversy surrounding the legislation, and the potential future impact on practicing forensic psychiatrists and on the forensic mental health system in Canada.

Adolescents and Social Media: Privacy, Brain Development, and the Law.

Adolescents under the age of 18 are not recognized in the law as adults, nor do they have the fully developed capacity of adults. Yet teens regularly enter into contractual arrangements with operators of websites to send and post information about themselves. Their level of development limits their capacity to understand the implications of online communications, yet the risks are real to adolescents' privacy and reputations. This article explores an apparent contradiction in the law: that in areas other than online communications, U.S. legal systems seek to protect minors from the limitations of youth. The Children's Online Privacy Protection Act provides some protection to the privacy of young people, but applies only to children under age 13, leaving minors of ages 13 to 17 with little legal protection in their online activities. In this article, we discuss several strategies to mitigate the risks of adolescent online activity.

Sex Offenders in the Digital Age.

With most youths now using the Internet and social networking sites (SNSs), the public has become increasingly concerned about risks posed by online predators. In response, lawmakers have begun to pass laws that ban or limit sex offenders' use of the Internet and SNSs. At the time of this article, 12 states and the federal government have passed legislation attempting to restrict or ban the use of SNSs by registered sex offenders. These laws have been successfully challenged in 4 states. In this article, we discuss examples of case law that illustrate evolving trends regarding Internet and social networking site restrictions on sex offenders on supervised release, as well as those who have already completed their sentences. We also review constitutional questions and empirical evidence concerning Internet and social networking use by sex offenders. To our knowledge, this is the first paper in the psychiatric literature that addresses the evolving legal landscape in reference to sex offenders and their use of the Internet and SNSs. This article is intended to help inform forensic mental health professionals who work with sex offenders on current concerns in this rapidly evolving legal landscape.

Minors and Sexting: Legal Implications.

Sexting is the sending or forwarding of sexually explicit photographs or videos of the sender or someone known to the sender via cell phone. It has become common practice among young people, as cell phones are being given to adolescents at ever younger ages. Youths often send messages without giving appropriate thought to the content of the images. In studies on the subject, rates of minors who have sent sexual images range from 4 to 25 percent, depending on the age of the youths surveyed, the content of the messages and other factors. Because transferring and viewing sexually explicit material when the subject is a minor can be considered child pornography, there can be serious legal consequences. Several states have enacted legislation to help differentiate between child pornography and sexting by minors. The trend reflected in statutes has been that minors involved in sexting without other exacerbating circumstances should be charged with a less serious offense. There is no clear national consensus on how sexting by minors is adjudicated, and therefore we compared several statutes. Case examples are used to illustrate the range of legal outcomes, from felony charges to no charges. Two sexting episodes that were followed by suicide are described. We also address the role of the forensic mental health professional.

Prospective study of violence risk reduction by a mental health court.

OBJECTIVE: Although many mental health courts (MHCs) have been established to reduce criminal justice involvement of persons with mental disorders, research has not kept pace with the widespread implementation of these courts. Whereas early MHCs were restricted to persons charged with nonviolent misdemeanors, many MHCs now accept persons with more serious charges for whom ameliorating risk of violence is a greater concern. This study evaluated the relationship between MHC participation and risk of violence by using a prospective design. It was hypothesized that MHC participation would decrease the risk of violence during a one year follow-up compared with a matched comparison group. METHODS: The sample included 169 jail detainees with a mental disorder who either entered an MHC (N=88) or received treatment as usual (N=81). Seventy-two percent had been charged with felonies. Participants were interviewed at baseline and during a one-year follow up, and their arrest records were reviewed. Propensity-adjusted logistic regression evaluated the relationship between MHC participation and risk of violence, controlling for potential confounders such as history of violence, demographic characteristics, baseline treatment motivation, and time at risk in the community. RESULTS: MHC participation was associated with reduction in risk of violence (odds ratio=.39). During follow-up, 25% of the MHC group perpetrated violence, compared with 42% of the treatment-as-usual group. CONCLUSIONS: MHC participation can reduce the risk of violence among justice-involved persons with mental disorders. The findings support the conclusion that the MHC model can be extended beyond persons charged with nonviolent misdemeanors in a way that enhances public safety.

Recent victimization increases risk for violence in justice-involved persons with mental illness.

A large body of research has examined relationships between distal experiences of victimization and the likelihood of engaging in violence later in life. Less is known about the influence of recent violent victimization on risk for violence perpetration. To our knowledge, this is the first study to examine prospectively whether recent victimization in adulthood increases the risk of future violence. Specifically, the present study assessed the incremental validity of recent violent victimization in the prediction of future violence in a sample of justice-involved adults with serious mental illness. The study examined (a) whether recent experiences of violent victimization (i.e., within 6 months of the baseline assessment) predicted a greater likelihood of perpetrating violence in the next year, and (b) whether inclusion of recent victimization enhanced the predictive validity of a model of violence risk in a sample of justice-involved adults with severe mental illness (N = 167). Hierarchical logistic regression analyses indicated that exposure to recent violent victimization at the baseline assessment predicted a greater likelihood of engaging in violent behavior during the year follow-up period. Additionally, recent exposure to violence at the baseline assessment continued to explain a significant amount of variance in a model of future violence perpetration above the variance accounted for by well-established violence risk factors. Taken together, the findings suggest that recent victimization is important to consider in understanding and evaluating risk of violence by persons with mental disorders who are involved in the criminal justice system.

Transgendered and incarcerated: a review of the literature, current policies and laws, and ethics.

Being transgendered, described as feeling that one is of the opposite gender, can be a difficult experience in today's culture. Those who are transgendered and incarcerated experience much more stress. There is a significant population of transgendered individuals in today's prison system, with estimates suggesting that the number is higher proportionally than in the general population. The question of how to treat these individuals while maintaining the safety and security of the institutions remains unanswered. In this article, we review the epidemiology of transgendered individuals in the general population and correctional facilities, describe current guidelines for the standard of care, and discuss how various correctional systems in this country apply them. We will also review case law with respect to the management and treatment of transgendered incarcerated individuals. Finally, we discuss the challenges involved in serving this population, such as provision of safe housing and medically necessary treatment. This review is provided to help in educating the forensic expert on current questions and potential future directions in the management of this population.