Neuroethics and neurolaw in forensic neuropsychiatry: A guide for clinicians.

As neuroscience technologies develop, ethical and legal questions arise regarding their use and societal impact. Neuroethics and neurolaw are growing interdisciplinary fields that address these questions. This review article presents the research agenda of both areas, examines the use and admissibility of neuroscience in expert testimony and legal settings, and discusses ethical issues related to forensic neuropsychiatrists claiming expertise in neuroscience, formulating medical opinions based on neuroscience, and considering its relevance to criminal responsibility. Forensic neuropsychiatrists should be aware of emerging neuroscientific evidence, its utility and limits in rendering diagnoses and explaining behavior, and, before seeking such evidence for legal purposes, its availability and admissibility. When testifying in matters involving neuroscientific evidence, ensuring truthfulness and balance, having sufficient and validated knowledge (including openness with confirming and disconfirming evidence), understanding standards of practice, and drawing relevant and appropriate conclusions remain important.

Improving the Integration of Social Determinants of Mental Health in the DSMs.

This Viewpoint discusses ways in which future editions of DSM could address social determinants in the diagnosis and treatment of mental health disorders.

Patient identity narratives through the cultural formulation interview in a New York City outpatient clinic.

Anthropologists have critiqued cultural competence programs in medical settings while introducing mental health clinicians to social theories on culture for practice. We explore how patients articulated narratives about themselves and how clinicians responded to such narratives through an intervention known as the Cultural Formulation Interview that anthropologists have helped develop. We conducted over 500 hours of fieldwork from 2014 to 2019 at an outpatient clinic in New York, analyzing multiple data (participant observation, medical records, patient-clinician sessions, and individual debriefing interviews) in a trial joining clinical and ethnographic methods. Our study enrolled 45 patients and six clinicians, yielding 117 patient-clinician appointments and 98 debriefing interviews. Most patients differed in how they presented their identities through demographic forms and discussed them in sessions with their clinicians. Two-thirds of the patients drew connections between their personal identities and experiences of mental illness. These results reveal why cultural identities should not be taken for granted in clinical settings.

Restarting Track II Diplomacy in Intractable Conflicts: How Psychoanalytic Concepts May Be Relevant.

Since the 1980s, psychiatrists, psychologists, and diplomats have proposed psychoanalytic theories to inform peacemaking in international relations through Track II negotiations, defined as unofficial meetings among influential stakeholders with access to government policymakers. These contributions have focused on initiating or maintaining Track II negotiations (Aggarwal et al., 2023). In this article, we apply psychoanalytic concepts to the problem of restarting negotiations that have previously failed. This study introduces theories based on a dialogue that a cultural psychiatrist trained in South Asian Studies moderated with the past directors of India's and Pakistan's foreign intelligence agencies to consider how both countries could recommence negotiations. The two former directors have participated together in five Track II initiatives between India and Pakistan. All three authors reviewed best practices for addressing impediments to Track II negotiations and how Track II negotiations may be reinstituted once stalled. We did this in a far-reaching discussion devoted to the psychology of peacemaking. We introduce the theories of trust as interpersonal authenticity, the normalization of conflicts, the back channel as a process to work through diplomatic resistance, and negotiator selection criteria. Our theories and method present new ways to apply psychoanalytic concepts to diplomacy.

Editorial: Combatting the Intergenerational Trauma of Structural Racism Through Practice, Policy, and Research.

Several recent studies have investigated the mental health consequences of structural racism. Structural racism has been defined as "macro-level societal conditions that limit opportunities, resources, and well-being of less privileged groups on the basis of race/ethnicity and/or other statuses, including but not limited to, gender identity, sexual orientation, disability status, social class or socioeconomic status (SES), religion, geographic residence, national origin, immigration status, limited English proficiency, physical characteristics, or health conditions."1 Researchers have hypothesized that the trauma of structural racism transmits across generations through pathways that are physiological (ie, compromised immune systems, activated hormonal stress responses), environmental (ie, limited access to housing, health care, employment, and income), social (ie, domestic violence, substance consumption, criminal justice involvement), and psychological (ie, family histories of depression, anxiety, and traumatic stress-disorders).2.

New Directions for Cultural Formulations in Forensic Psychiatry.

Forensic psychiatrists have called for greater attention to cultural and racial topics in assessing examinees. While suggestions for new methods are welcome, they can ignore the extent of scientific progress if existing assessments are not accurately appraised. This article analyzes the arguments of two recent publications in The Journal that mischaracterize the cultural formulation approach. Contrary to the idea that forensic psychiatrists have received little guidance on assessing an examinee's racial identity, the article shows that forensic psychiatrists have contributed to scholarship on assessing racial identifications through cultural formulations that elicit how minoritized ethnoracial examinees interpret their illness experiences and legal involvements. The article also seeks to dispel misunderstandings about the Cultural Formulation Interview (CFI), which clinicians have used to complete person-centered cultural assessments, including in forensic settings. Conducting research, practice, and educational activities on the cultural formulation can be ways for forensic psychiatrists to combat systemic racism.

Eliciting social stressors, supports, and determinants of health through the DSM-5 cultural formulation interview.

Objective: As recognition of the importance of social determinants of mental health has increased, the limitations of clinical competence-enhancing interventions that do not emphasize this approach have emerged. The Cultural Formulation Interview (CFI) is a cultural competence intervention that emerges from a confluence of social medicine and medical anthropology traditions. Limited research has examined how patients respond to CFI questions on social-structural aspects of illness and care to assess whether the CFI adequately elicits information on social determinants of mental health. Methods: Patients' responses during a first intake appointment to three CFI questions on social stressors, supports, or barriers to care from 27 patient-clinician dyads are analyzed through qualitative content analysis. The data come from a hyper-diverse clinical setting in Queens, New York, where no ethnoracial group has a majority and all patient-clinician dyads reflect cross-cultural interactions. Results: At least one social determinant was coded in 89 of all cases, and nearly 44% included themes related to multiple determinants of health. The most-commonly coded theme was social relationships (n = 21), followed by financial instability (n = 7), stigma (n = 5), housing instability (n = 2), and poor access to healthcare, involvement in the criminal justice system, employment instability, area-level poverty, and immigration policies (n = 1 each). Conclusion: Our work shows that social determinants of mental health can be elicited through the CFI. Future work should examine how this information is included in clinicians' formulations and whether the cultural formulation approach would benefit from additional revision to facilitate assessment of socio-structural factors.

The Evolving Culture Concept in Psychiatric Cultural Formulation: Implications for Anthropological Theory and Psychiatric Practice.

For thirty years, psychiatrists and anthropologists have collaborated to improve the validity of psychiatric diagnosis. This collaboration has produced the DSM-IV Outline for Cultural Formulation (OCF) and the DSM-5 Cultural Formulation Interview (CFI). Nonetheless, some anthropologists have critiqued the concept of culture in DSM-5 as too focused on patient meanings and not on clinician practices. This article traces the evolution of the culture concept from DSM-IV through DSM-5-TR by analyzing publications from the American Psychiatric Association on the OCF and CFI alongside scholarship in psychiatry and anthropology. DSM-IV relied on a culture concept of coherent ethnic communities sharing coherent cultures, primarily for minoritized ethnoracial individuals in the United States. Changing demographics and newer immigration patterns around the world deminoritized the culture concept for DSM-5. After George Floyd's death and demands for social justice, the culture concept in DSM-5-TR emphasized social structures. The article proposes an intersubjective model of culture through which patients and clinicians work through similarities and differences. It recommends a revised formulation that attends to clinician practices such as communicating, diagnosing, recommending treatments, and documenting, beyond collecting patient meanings. It also raises the question of whether an intersubjective model of culture prompts reconsiderations of culture-related text in other sections of the DSM. The social sciences can redirect attention to the clinician's culture of biomedicine to close patient health disparities.

How Psychoanalytic Theory and Track II Diplomacy Can Inform Each Other: A Dialogue with the Former Heads of India and Pakistan's Foreign Intelligence Agencies.

Starting with Sigmund Freud, psychoanalysts have considered the psychological dimensions of peacemaking in international relations. In the 1980s, psychiatrists, psychologists, and diplomats began developing theories on Track II negotiations, defined as unofficial meetings among influential stakeholders with access to government policymakers. In recent years, psychoanalytic theory building has waned with the decline of interdisciplinary collaborations among mental health professionals and practitioners of international relations. This study seeks to revive such collaborations by analyzing the reflections of an ongoing dialogue between a cultural psychiatrist trained in South Asian studies, the former head of India's foreign intelligence agency, and the former head of Pakistan's foreign intelligence agency on applications of psychoanalytic theory to Track II initiatives. Both former heads have participated in Track II initiatives to build peace between India and Pakistan and agreed to react on the record to a systematic review of psychoanalytic theories on Track II. This article describes how our dialogue can offer new directions for theory building and the practical conduct of negotiations.

Integrating neuroscience in psychiatry: a cultural-ecosocial systemic approach.

Psychiatry has increasingly adopted explanations for psychopathology that are based on neurobiological reductionism. With the recognition of health disparities and the realisation that someone's postcode can be a better predictor of health outcomes than their genetic code, there are increasing efforts to ensure cultural and social-structural competence in psychiatric practice. Although neuroscientific and social-cultural approaches in psychiatry remain largely separate, they can be brought together in a multilevel explanatory framework to advance psychiatric theory, research, and practice. In this Personal View, we outline how a cultural-ecosocial systems approach to integrating neuroscience in psychiatry can promote social-contextual and systemic thinking for more clinically useful formulations and person-centred care.

Psychiatric Disorders, Military Misconduct, and Discharge Status for U.S. Veterans.

For three years, the U.S. District Court for the District of Connecticut has issued rulings in Manker v. Spencer and Kennedy v. Esper to certify veterans as a legal class to sue the United States Navy and Army, respectively. Each dispute centers on whether the military denied discharge upgrades to personnel who developed mental health disorders during their service. This article analyzes the facts, reasoning, and dispositions of each case, which address medicolegal standards for evaluating the relationships among psychiatric disorders, alleged misconduct during military service, and military discharge status. Implications for psychiatrists are considered in the military and civilian health sectors.

Person-Centered Cultural Assessment Can Improve Child Mental Health Service Engagement and Outcomes.

OBJECTIVE: Disparities in child mental health service engagement suggest traditional evidence-based practices do not properly consider cultural and contextual factors relevant for marginalized families. We propose a person-centered approach to improve the cultural responsiveness of services. Preliminary research supports broadening standard assessments to include a person-centered evaluation of patient cultural factors, however, controlled studies have not been conducted in the context of children's mental health care. METHODS: Participants included families (N = 89; 89% racial/ethnic minority) receiving services for child externalizing problems. Prior to intake, caregivers were randomized to receive either Assessment as Usual (AAU) or AAU augmented with the Cultural Formulation Interview (CFI+AAU), a brief caregiver assessment of cultural factors affecting their child's problems and family help-seeking. RESULTS: Implementation data showed strong provider fidelity and clinical utility. Following assessments, CFI+AAU caregivers (relative to AAU caregivers) reported feeling better understood by their provider, and providers reported better understanding CFI+AAU families' values. Caregiver satisfaction was rated highly overall, yet providers reported being more satisfied with the assessment when the CFI was incorporated. Engagement outcomes found CFI+AAU families were significantly more likely than AAU families to subsequently complete the first phase of treatment. Further, among families receiving services in Spanish, CFI+AAU, relative to AAU, was associated with significantly higher treatment attendance, homework completion, and treatment response. CONCLUSIONS: The results underscore the utility of incorporating a brief cultural assessment in pretreatment assessments. To improve the cultural responsiveness of services, efforts may do well to promote the uptake of person-centered approaches such as cultural assessment into usual care. Registered at clinicaltrials.gov (NCT03499600).

Diversity and Inclusion Training in Health Care: What the Evidence Suggests.

On September 22, 2020, then-President Donald Trump signed Executive Order 13950, titled "Combating Race and Sex Stereotyping." This order restricted the types of diversity and inclusion (DI) training that federal agencies and contractors could offer with federal funding. In this column, the author denounces that order, uses this critique to examine DI training sessions in their current forms, and suggests evidence-based solutions for organizations that are committed to dismantling racism. Mental health organizations must move beyond single, standalone DI training sessions that target individual providers and initiate institution-wide activities that embrace antiracism and structural competence.

Implementing the Cultural Formulation Interview in a Community Clinic to Improve Appointment Retention: A Pilot Study.

Despite consensus that clinicians should receive cultural competence training to reduce mental health disparities among racial-ethnic minority groups, few studies have evaluated training in community settings. This column delineates implementation of the DSM-5 Cultural Formulation Interview (CFI) at a community hospital. Participating clinicians were able to implement the CFI after a single training session and offer administrative support and instructions on customizing care with lower- and middle-income, racially and ethnically diverse patients.

International law and mental health evaluations at Guantanamo: Is medical repatriation a solution for most detainees?

This article analyzes the ruling in al-Qahtani v. Trump which establishes a new legal mechanism for Guantanamo detainees being held in indefinite detention to receive independent psychiatric evaluations from mixed medical commissions in order to determine eligibility for repatriation on humanitarian grounds. The article first reviews how the U.S. government created a legal framework for Global War on Terror detainees that differs from established conventions under international humanitarian law to protect prisoners of war. It discusses the circumstances of a Guantanamo detainee named Mohammed al-Qahtani who was tortured in U.S. custody, according to Guantanamo's top official. The U.S. government has declined to refer legal charges against him but also refused to release him since he has been considered a threat to U.S. national security. The article analyzes how al-Qahtani's attorneys challenged the legality of his detention and referred to an independent psychiatric evaluation played to establish the legal basis for "irreparable harm." al-Qahtani's independent psychiatric evaluation asserted that he displayed symptoms consistent with those exhibited by survivors of torture. Legally, the ruling establishes a precedent for Guantanamo detainees who are being held in indefinite detention to compel the U.S. government to clarify their legal status or arrange an examination by a mixed medical commission. Twenty-two other detainees out of the forty still at Guantanamo fall in this legal category, so the precedent has far-reaching consequences. Finally, the prospect of mixed medical commissions composed of international experts who are collaborating to render a medical opinion raises questions about how independent psychiatric evaluations would be conducted in practice.

United States of America v. Majid Shoukat Khan: Guantánamo's first ruling to consider torture in mitigating sentencing for detainees.

In June 2020, a Guantánamo military judge ruled in United States of America v. Majid Shoukat Khan that he has the legal authority to mitigate Khan's criminal sentence as a remedy for illegal pretrial punishment if his attorneys prove that he suffered torture and other cruel, inhuman, and degrading treatment in government custody. This commentary analyzes the ruling and its implications for Guantánamo's legal system, detainees, and forensic medicine.