Decision making in times of crisis can bring out both the best, and worst, in cognitive processes - with those characterizations generally determined by the outcome rather than the quality of the decision making process. Crises bring with... more
Decision making in times of crisis can bring out both the best, and worst, in cognitive processes - with those characterizations generally determined by the outcome rather than the quality of the decision making process. Crises bring with them a need for action, felt by individuals as well as institutions. This need is driven by a number of factors, e.g. affect, justice, economics, and political considerations, and shaped by a variety of biases and heuristics commonly encountered in risk appreciation and decision making. Using the example of efforts to combat terrorism, this presentation will address the inherent tension between innovation and “science” when new approaches are sought to address a crisis, how affect influences the decision making process in such situations, the role a multidisciplinary analysis and decision making process can play in sparking innovation and arriving at solutions, and the importance of leadership in the problem solving process.
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The legal considerations for threat assessment and management practitioners are many and varied. Constitutional, statutory, regulatory, and common law considerations all play a role in the legal landscape for professionals engaged in the... more
The legal considerations for threat assessment and management practitioners are many and varied. Constitutional, statutory, regulatory, and common law considerations all play a role in the legal landscape for professionals engaged in the discipline. This chapter focuses on key legal issues that affect the practice of threat assessment and management, with an emphasis on the U.S. legal system and primary relevance to those countries that follow the Anglo-American legal tradition. While the chapter provides a broad treatment of many areas of the law, an in-depth exploration of particular areas of interest is encouraged when needed. It is not intended as legal advice, but rather as a groundwork to prepare the reader to engage with their own legal counsel in seeking guidance in their work.
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In society’s need to explain and understand aberrant behavior, whether by individuals or groups, it often turns to the mental health professions and, increasingly, the broader array of behavioral sciences. Drawing on experiences in the... more
In society’s need to explain and understand aberrant behavior, whether by individuals or groups, it often turns to the mental health professions and, increasingly, the broader array of behavioral sciences. Drawing on experiences in the areas of homicide, workplace violence, and insider threat, this talk will explore the strengths and weaknesses that the behavioral sciences bring to the development of policies aimed at addressing these major societal problems.
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Organizational and occupational psychiatry represents the extension of psychiatric knowledge and skill to the day-to-day functioning of individuals in the workplace and their organizations, with the goal of helping both to function... more
Organizational and occupational psychiatry represents the extension of psychiatric knowledge and skill to the day-to-day functioning of individuals in the workplace and their organizations, with the goal of helping both to function better. To this end, psychiatrists have played an important role both in the treatment of workers and consultation to organizations since the early part of the 20th century.
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The authors provide an overview of what is known about workplace violence and discuss how to deal with issues of workplace violence that arise in clinical practice. They review myths and facts about workplace violence, including research... more
The authors provide an overview of what is known about workplace violence and discuss how to deal with issues of workplace violence that arise in clinical practice. They review myths and facts about workplace violence, including research on prevention. Legal issues relating to the psychiatrist as employer and the Americans with Disability Act are presented. General principles of violence assessment are reviewed and the authors then discuss the psychiatrist as consultant to the workplace and as clinician treating a victim or perpetrator of workplace violence. Three cases illustrate the general principles provided.
Research Interests: Psychology, Psychiatry, Mythology, Violence, Homicide, and 12 moreMedicine, Workplace, Humans, United States, Female, Pubmed, Workplace Violence, Male, Incidence, Adult, Sex Factors, and Duty to Warn
In this issue of the Journal, Swanson et al. explore the demand for and utilization of psychiatric advance directives (PADs), and discuss some of the barriers to their greater acceptance. This author suggests that PADs may be more widely... more
In this issue of the Journal, Swanson et al. explore the demand for and utilization of psychiatric advance directives (PADs), and discuss some of the barriers to their greater acceptance. This author suggests that PADs may be more widely accepted and utilized if they are viewed as tools for maximizing individual autonomy, with an emphasis on optimizing rather than merely restricting care.
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Workplace violence has captured the attention of the public, the media, and employers since a series of shootings at the U.S. Postal Service facilities in the late 1980s gave rise to misplaced concerns about employees, primarily... more
Workplace violence has captured the attention of the public, the media, and employers since a series of shootings at the U.S. Postal Service facilities in the late 1980s gave rise to misplaced concerns about employees, primarily disgruntled current or former employees, “going postal.” Psychiatrists and other clinicians who possess the requisite knowledge and experience to address workplace violence concerns can play an important role in assessing and managing violence risk, including addressing the misperception that individuals with mental illness are significantly more likely to be violent. A clinician who is treating the employee in question can contribute first-hand knowledge to the risk assessment process, but should not serve as the sole evaluator of risk and fitness for duty. This chapter discusses the reasons for using independent expert evaluators rather than the employee’s treating clinician alone, and the components of a thorough workplace violence risk assessment and analysis.
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Physicians who prescribe psychotropic medications to children face unique legal and ethical challenges. The issues of competency, consent to treatment, patient autonomy, and confidentiality are important in this work, just as they are in... more
Physicians who prescribe psychotropic medications to children face unique legal and ethical challenges. The issues of competency, consent to treatment, patient autonomy, and confidentiality are important in this work, just as they are in adult medicine. The child and adolescent psychopharmacologist must also deal with the complex influences of family dynamics, child development, divorce, and custody as well as the involvement of parents, school personnel, and social service agencies in the treatment process. The fact that much remains to be understood in child psychiatry, the probabilistic rather than certain outcomes of medication trials, and the uncertain effects of new treatments on developing nervous systems all add additional layers of complexity.
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Research Interests: Medicine, Electrocardiography, Electroconvulsive therapy, Prospective studies, Humans, and 12 moreBlood Pressure, Anesthesia, Heart rate, Clinical Sciences, Aged, Middle Aged, Electrocardiogram, Cardiovascular Risk Factor, Randomized Block design, Neurosciences, Esmolol, and Diastolic Blood Pressure
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As highly visible representatives and guardians of society, law enforcement officers (LEOs) are very public figures. Injury or death in the line of duty, whether due to accidents or intentional acts of violence, is an occupational hazard... more
As highly visible representatives and guardians of society, law enforcement officers (LEOs) are very public figures. Injury or death in the line of duty, whether due to accidents or intentional acts of violence, is an occupational hazard for LEOs. Targeted assaults on police officers, referred to as ambushes in previous literature, are a particularly perplexing problem with significant implications for society at large. In the summer of 2016, the latest in a series of high‐profile acts of violence aimed at police occurred, leading to increased examination of the acts themselves and their causes. This article examines recent trends in assaults on LEOs, focusing on predatory rather than reactive attacks, and applies a threat assessment model to a case of targeted violence against police. We use State of Washington v. Christopher Monfort (2015), a prosecution for arson, assault with intent to murder, and murder, as a case example, to examine how the threat assessment model, and the concepts of affective versus predatory violence help in understanding targeted violence against LEOs, assessing its risk, and managing it. Copyright © 2016 John Wiley & Sons, Ltd.
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Research Interests: Cognitive Science, Terrorism, Violence, Mental Health, Social Support, and 15 moreDisaster Management, Medicine, Disaster Preparedness, Disasters, Humans, Bioterrorism, Natural disaster, Clinical Sciences, Harvard, Community Networks, Occupational therapy services in mental health services, Post Disaster Planning, Community Based Mental Health Services, Community health services, and Disaster planning
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Research Interests: Psychiatry, Psychotherapy, Informed Consent, Medicine, Psychosomatic Medicine, and 13 moreHumans, Disclosure, United States, Confidentiality, Malpractice, Liability, Psychiatric Clinics of North America, Duty to Warn, Psychology and Cognitive Sciences, Medical and Health Sciences, Health Insurance Portability and Accountability Act, HIV infections, and Referral and consultation
Research Interests: Medicine, Electrocardiography, Electroconvulsive therapy, Prospective studies, Humans, and 12 moreBlood Pressure, Anesthesia, Heart rate, Clinical Sciences, Aged, Middle Aged, Electrocardiogram, Cardiovascular Risk Factor, Randomized Block design, Neurosciences, Esmolol, and Diastolic Blood Pressure
The problem of violence in our society has received increasing attention from the public and mental health professions in recent years, and assessing the risk of violence has become a core skill for mental health clinicians and forensic... more
The problem of violence in our society has received increasing attention from the public and mental health professions in recent years, and assessing the risk of violence has become a core skill for mental health clinicians and forensic specialists alike. In fact, mental health practitioners in all clinical settings are tasked with assessing and managing their patients’ risk of violence. Although research on the nature of violence and factors that increase the likelihood that a person will commit violent acts has grown in the past several decades, there is no single standard protocol or tool for assessing the risk of violence. This chapter reviews the key risk factors for violence that are supported by research, examines the relationship between mental disorders and violence, and describes approaches that mental health professionals can use to assess the risk of violence.
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More than any other clinical intervention, civil commitment is subject to strict legal requirements and oversight. Although the rules and processes vary by jurisdiction, the legal proceedings in all jurisdictions are designed to balance... more
More than any other clinical intervention, civil commitment is subject to strict legal requirements and oversight. Although the rules and processes vary by jurisdiction, the legal proceedings in all jurisdictions are designed to balance the autonomy interests and constitutional rights of the patient against the state’s legitimate exercise of authority. This chapter reviews the legal principles underlying civil commitment and describes how those principles are applied in different ways, using examples from various jurisdictions. Using a case vignette, it explores a common scenario in which an emergency room physician who must make a decision regarding a patient’s need for hospitalization obtains a psychiatric consultation, and it follows the civil commitment process as it would play out in one jurisdiction. By its nature, civil commitment is both a clinical intervention and a legal process, and the chapter addresses some of the clinical challenges encountered in the course of involuntary hospitalization.
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Violence in the workplace emerged as an occupational safety issue in the late 1980s, became a cultural and media phenomenon in the 1990s, and has now settled in as a chronic workplace concern. While other workplace security and safety... more
Violence in the workplace emerged as an occupational safety issue in the late 1980s, became a cultural and media phenomenon in the 1990s, and has now settled in as a chronic workplace concern. While other workplace security and safety threats have arisen during this period, two years after the terrorist attacks of September 11, 2001, workplace violence was ranked as the leading security concern in a survey of employers. ABOUT THE AUTHOR Ronald Schouten, MD, JD, is Associate Professor of Psychiatry, Harvard Medical School, Director, Law & Psychiatry Service, Massachusetts General Hospital. Address correspondence to: Ronald Schouten, MD, JD, 15 Parkman Street WAC 812, Boston, MA 02114; rschouten@partners.org; 617 726-5195. The author disclosed no relevant financial relationship.
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The first 15 chapters of this book have described, and hopefully simplified, the major legal issues that are inherent in the practice of the mental health professions. However, there are a number of important issues that do not fit neatly... more
The first 15 chapters of this book have described, and hopefully simplified, the major legal issues that are inherent in the practice of the mental health professions. However, there are a number of important issues that do not fit neatly into the preceding chapters and do not require a full chapter themselves, but are important to the clinician because they are so common and can cause considerable consternation. These issues, covered in this chapter, include record keeping, requests for release of information in a variety of contexts, patients’ requests for evaluation of fitness to return to work or carry firearms, and testimony at depositions and trials.
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This chapter describes the complex medicolegal issues surrounding the rules of confidentiality and privilege and their multiple exceptions. It lays out the underpinnings of confidentiality, then addresses its various exceptions, such as... more
This chapter describes the complex medicolegal issues surrounding the rules of confidentiality and privilege and their multiple exceptions. It lays out the underpinnings of confidentiality, then addresses its various exceptions, such as waiver, duty to protect third parties, civil commitment, and mandated reporting of child abuse, elder abuse, and intimate-partner violence. Psychotherapist–patient privilege is discussed, first with regard to its origins and then with regard to its exceptions, including various forms of waiver. Practical examples illustrate these concepts for the reader to make it easier to understand these ubiquitous, but at times perplexing, concepts and to illustrate the nuances of various aspects of the law. Practitioners should note that there is considerable overlap between confidentiality and testimonial privilege, and the division of this chapter into two sections creates, in some ways, an artificial divide between two closely related concepts.
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The goal of this book is to help clinicians at all levels of training negotiate the complex legal issues that are an inherent part of modern clinical practice. This chapter provides an introduction to the origins of “law” in its many... more
The goal of this book is to help clinicians at all levels of training negotiate the complex legal issues that are an inherent part of modern clinical practice. This chapter provides an introduction to the origins of “law” in its many forms, the structure of the legal system, and fundamental legal principles that are of special relevance to mental health practitioners and that will recur throughout the book. It discusses concepts that are foreign to most clinicians that have a great impact on mental health practice: the adversarial process, sources of laws, constitutional principles, the concept of legal precedents, and the ethics of the legal system.
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Rapid advances in neuroscience have broad implications for our understanding of human behavior. The …
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The contemporary doctrine of informed consent is one of the most important developments in modern medicine. Informed consent as we know it today is a fundamental principle of medical ethics, an essential aspect of clinical care, and a... more
The contemporary doctrine of informed consent is one of the most important developments in modern medicine. Informed consent as we know it today is a fundamental principle of medical ethics, an essential aspect of clinical care, and a legal obligation enforced through case law, regulations, and statutes. A new concept when it was adopted in the middle of the 20th century in the United States, it has become an essential part of modern clinical care. This chapter explores the history and development of the doctrine of informed consent, as well as its application in clinical practice. Using a case vignette involving a common clinical situation, we examine the components of the informed-consent process, with a focus on the evaluation of decision-making capacity.
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Sexual harassment is a major concern in the modern workplace. Society has given more attention to this problem since the 1991 Senate confirmation hearings of Supreme Court Justice Clarence Thomas, during which Justice Thomas adamantly... more
Sexual harassment is a major concern in the modern workplace. Society has given more attention to this problem since the 1991 Senate confirmation hearings of Supreme Court Justice Clarence Thomas, during which Justice Thomas adamantly denied the allegations that he had engaged in sexual harassment. Public opinion was split on the credibility of both Justice Thomas and Professor Anita Hill, his accuser, as well as on the significance of the issue. Congress addressed the problem of sex-based discrimination in the Civil Rights Act of 1964.l It states, “It shall be an unlawful employment practice for an employer. . . to discriminate against any individual with respect to his compensation, terms, conditions, or privileges of employment because of such individual’s race, color, religion, sex, or national origin. . ..” In 1980 the Equal Employment Opportunity Commission issued its guidelines on sexual harassment.’ The Commission defined sexual harassment as:
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Negli ultimi decenni la violenza sul posto di lavoro ha rappresentato un’importante preoccupazione per la popolazione e per i lavoratori americani. Sebbene il terrorismo internazionale sia stato al centro della politica estera e dei... more
Negli ultimi decenni la violenza sul posto di lavoro ha rappresentato un’importante preoccupazione per la popolazione e per i lavoratori americani. Sebbene il terrorismo internazionale sia stato al centro della politica estera e dei media, la violenza sul posto di lavoro ha continuato a rappresentare la preoccupazione principale dei lavoratori (Pinkerton Consulting and Investigations, 2003). Il termine violenza sul posto di lavoro evoca immagini di lavoratori armati e scontenti che gettano scompiglio, uccidendo e ferendo i colleghi e, nella maggior parte dei casi, uccidendosi o restando uccisi nel corso dell’arresto da parte della polizia. Contrariamente alla percezione pubblica ed al ritratto dei media, gli episodi di violenza sul posto di lavoro che richiamano un tale stereotipo sono diminuiti sin dal 1994 (Bureau of Labor Statistics, 2006a), cosi come il tasso complessivo di crimini violenti negli Stati Uniti; molto piu comune e un assortimento di comportamenti che sono legittimamente inclusi sotto un’ampia definizione di violenza o aggressivita sul posto di lavoro: aggressioni non fatali, atti di bullismo, molestie (sessuali e non sessuali), abuso verbale, minacce di origine nota o anonima, e procurare dei falsi allarmi. Anche gli atti di terrorismo con armi convenzionali, chimiche, biologiche, radiologiche o nucleari possono essere inclusi tra gli episodi di violenza sul posto di lavoro, essendo questi ultimi obiettivi comuni degli attacchi di terrorismo (Schouten et al., 2004).
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What are some of the important legal and/or ethical issues that arise in managed care programs that we need to understand as healthcare professionals? Cite at least two of these key concepts, and provide a relevant example for each,... more
What are some of the important legal and/or ethical issues that arise in managed care programs that we need to understand as healthcare professionals? Cite at least two of these key concepts, and provide a relevant example for each, showing how the concept relates to healthcare.? Define fraud as it relates to healthcare. What is the difference between fraud and abuse? Conduct an Internet search and find at least one example of fraud and/or abuse that took place in a healthcare setting. Present your example here for the group. What is the key learning objective from this example?
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Physicians who prescribe psychotropic medications to children face unique legal and ethical challenges. The issues of competency, consent to treatment, patient autonomy, and confidentiality are important in this work, just as they are in... more
Physicians who prescribe psychotropic medications to children face unique legal and ethical challenges. The issues of competency, consent to treatment, patient autonomy, and confidentiality are important in this work, just as they are in adult medicine. The child and adolescent psychopharmacologist must also deal with the complex influences of family dynamics, child development, divorce, and custody as well as the involvement of parents, school personnel, and social service agencies in the treatment process. The fact that much remains to be understood in child psychiatry, the probabilistic rather than certain outcomes of medication trials, and the uncertain effects of new treatments on developing nervous systems all add additional layers of complexity.
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Research Interests: Psychology, Cognitive Science, Behavioral Sciences, Terrorism, Homicide, and 15 moreExpert testimony, Medical Ethics, Medicine, Behavioural Sciences, Humans, United States, Mental Disorders, Insanity Defense, Anthrax, Clinical Sciences, Biological Warfare, Psychotic Disorders, Patient Advocacy, Phenomenon, and Duty to Warn
Organizational and occupational psychiatry represents the extension of psychiatric knowledge and skill to the day-to-day functioning of individuals in the workplace and their organizations, with the goal of helping both to function... more
Organizational and occupational psychiatry represents the extension of psychiatric knowledge and skill to the day-to-day functioning of individuals in the workplace and their organizations, with the goal of helping both to function better. To this end, psychiatrists have played an important role both in the treatment of workers and consultation to organizations since the early part of the 20th century.
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To protect individuals who can no longer make the decisions and carry on the activities of adult life, society has provided processes including the appointment of alternative decision makers, traditionally referred to as guardians of the... more
To protect individuals who can no longer make the decisions and carry on the activities of adult life, society has provided processes including the appointment of alternative decision makers, traditionally referred to as guardians of the person (for personal decisions such as medical treatment) and conservators of the estate (for financial decisions). When a person has lost capacity, appointing an alternative decision maker can be problematic, as the person may not have previously expressed preferences regarding health care or financial matters, and there may be disagreement among interested parties such as family members. Advance directives, such as health care proxies, help alleviate these problems by providing a method for the person in question to document his or her preferences and appoint someone to act on their behalf in the event of incapacity. This chapter discusses traditional protections for incapacitated persons, advance directives, and capacities to engage in various de...
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The contemporary doctrine of informed consent is one of the most important developments in modern medicine. Informed consent as we know it today is a fundamental principle of medical ethics, an essential aspect of clinical care, and a... more
The contemporary doctrine of informed consent is one of the most important developments in modern medicine. Informed consent as we know it today is a fundamental principle of medical ethics, an essential aspect of clinical care, and a legal obligation enforced through case law, regulations, and statutes. A new concept when it was adopted in the middle of the 20th century in the United States, it has become an essential part of modern clinical care. This chapter explores the history and development of the doctrine of informed consent, as well as its application in clinical practice. Using a case vignette involving a common clinical situation, we examine the components of the informed-consent process, with a focus on the evaluation of decision-making capacity.
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More than any other clinical intervention, civil commitment is subject to strict legal requirements and oversight. Although the rules and processes vary by jurisdiction, the legal proceedings in all jurisdictions are designed to balance... more
More than any other clinical intervention, civil commitment is subject to strict legal requirements and oversight. Although the rules and processes vary by jurisdiction, the legal proceedings in all jurisdictions are designed to balance the autonomy interests and constitutional rights of the patient against the state’s legitimate exercise of authority. This chapter reviews the legal principles underlying civil commitment and describes how those principles are applied in different ways, using examples from various jurisdictions. Using a case vignette, it explores a common scenario in which an emergency room physician who must make a decision regarding a patient’s need for hospitalization obtains a psychiatric consultation, and it follows the civil commitment process as it would play out in one jurisdiction. By its nature, civil commitment is both a clinical intervention and a legal process, and the chapter addresses some of the clinical challenges encountered in the course of involun...
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The legal considerations for threat assessment and management practitioners are many and varied. Constitutional, statutory, regulatory, and common law considerations all play a role in the legal landscape for professionals engaged in the... more
The legal considerations for threat assessment and management practitioners are many and varied. Constitutional, statutory, regulatory, and common law considerations all play a role in the legal landscape for professionals engaged in the discipline. This chapter focuses on key legal issues that affect the practice of threat assessment and management, with an emphasis on the U.S. legal system and primary relevance to those countries that follow the Anglo-American legal tradition. While the chapter provides a broad treatment of many areas of the law, an in-depth exploration of particular areas of interest is encouraged when needed. It is not intended as legal advice, but rather as a groundwork to prepare the reader to engage with their own legal counsel in seeking guidance in their work.
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Background: Frontline healthcare workers (HCWs) are at risk of developing post-traumatic stress disorder (PTSD) due to the nature of their work and, due to the additional stress and mental fatigue brought on by the COVID-19 pandemic, this... more
Background: Frontline healthcare workers (HCWs) are at risk of developing post-traumatic stress disorder (PTSD) due to the nature of their work and, due to the additional stress and mental fatigue brought on by the COVID-19 pandemic, this risk has increased significantly. A proper understanding of the risk factors for PTSD in this context is crucial to the development of both preventive and corrective measures that will improve the psychological and emotional health of HCWs and reduce their predisposition to PTSD in the short and long term. This study was conducted to determine the prevalence and associated risk factors of PTSD among frontline HCWs in Riyadh, Saudi Arabia, during the COVID-19 pandemic. Methods: This cross-sectional survey study examined responses from emergency medical services personnel (paramedics, nurses, and physicians) in eleven large public hospitals in Riyadh, Saudi Arabia, between June 01 and July 01, 2020. The total number of respondents was 613. The PTSD C...
Violence risk assessment is an important and challenging task undertaken by men-tal health professionals and others, in both clinical and nonclinical settings. To date, computational linguistic techniques have not been used in the risk... more
Violence risk assessment is an important and challenging task undertaken by men-tal health professionals and others, in both clinical and nonclinical settings. To date, computational linguistic techniques have not been used in the risk assessment pro-cess. However they could contribute to the current threat assessment process by al-lowing for early detection of elevated risk, identification of risk factors for violence, monitoring of violent intent, and determi-nation of threat level. We analyzed a sam-ple of communications to judges that were referred to security personnel for evalua-tion as constituting potential threats. We categorized them along multiple dimen-sions including evidence of mental illness, presence and nature of any threat, and level of threat. While neither word count-based or topic models were able to effec-tively predict elevated risk, we found top-ics indicative of persecutory beliefs, para-noid ideation, and other symptoms of Axis I and Axis II disorders. 1
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The first 15 chapters of this book have described, and hopefully simplified, the major legal issues that are inherent in the practice of the mental health professions. However, there are a number of important issues that do not fit neatly... more
The first 15 chapters of this book have described, and hopefully simplified, the major legal issues that are inherent in the practice of the mental health professions. However, there are a number of important issues that do not fit neatly into the preceding chapters and do not require a full chapter themselves, but are important to the clinician because they are so common and can cause considerable consternation. These issues, covered in this chapter, include record keeping, requests for release of information in a variety of contexts, patients’ requests for evaluation of fitness to return to work or carry firearms, and testimony at depositions and trials.
Research Interests:
In this issue of the Journal, Swanson et al. explore the demand for and utilization of psychiatric advance directives (PADs), and discuss some of the barriers to their greater acceptance. This author suggests that PADs may be more widely... more
In this issue of the Journal, Swanson et al. explore the demand for and utilization of psychiatric advance directives (PADs), and discuss some of the barriers to their greater acceptance. This author suggests that PADs may be more widely accepted and utilized if they are viewed as tools for maximizing individual autonomy, with an emphasis on optimizing rather than merely restricting care.
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In this issue of the Journal, Wall et al. describe a program designed to restore to competency mentally retarded defendants who have been found incompetent to stand trial (IST). Clearly, individuals with mental retardation vary in their... more
In this issue of the Journal, Wall et al. describe a program designed to restore to competency mentally retarded defendants who have been found incompetent to stand trial (IST). Clearly, individuals with mental retardation vary in their ability to engage in life activities and cognitive processes. For the sake of this discussion, however, I will refer to mentally retarded individuals as if they were fairly uniform in their level of ability. Wall et al. describe a detailed training program that uses a variety of strategies to improve the organizational and cognitive skills of mentally retarded defendants in order that the latter may return to the criminal justice process and have their charges adjudicated. With this population of IST defendants, the issue usually is less often “restoration” of competency and more commonly creation of competency where none existed before because of cognitive and behavioral deficits. Wall et al. clearly describe theirs as a training, rather than an edu...
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In this issue of the Journal, Swanson et al. explore the demand for and utilization of psychiatric advance directives (PADs), and discuss some of the barriers to their greater acceptance. This author suggests that PADs may be more widely... more
In this issue of the Journal, Swanson et al. explore the demand for and utilization of psychiatric advance directives (PADs), and discuss some of the barriers to their greater acceptance. This author suggests that PADs may be more widely accepted and utilized if they are viewed as tools for maximizing individual autonomy, with an emphasis on optimizing rather than merely restricting care.
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This article aims to move away from intuitive appeals that link mental disorder with violence such as terrorism, mass murder, and other targeted violence. The article synthesizes the existing evidence base regarding the relationship... more
This article aims to move away from intuitive appeals that link mental disorder with violence such as terrorism, mass murder, and other targeted violence. The article synthesizes the existing evidence base regarding the relationship between mental disorders and personality traits and (a) attitudinal affinities with violent causes, and (b) a number of violent behaviors (including mass murder and terrorism). The evidence base is mixed and the research focus changed across time: from simple and unempirical assertions of causation to an almost complete rejection of their presence to a finer grained and disaggregated understanding. Empirical research examining mental disorder in crime and violence highlights that the commission of such events is a complex synthesis of psychopathology, personal circumstance, and environment. The article concludes with several suggestions regarding future research and practice.
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The problem of violence in our society has received increasing attention from the public and mental health professions in recent years, and assessing the risk of violence has become a core skill for mental health clinicians and forensic... more
The problem of violence in our society has received increasing attention from the public and mental health professions in recent years, and assessing the risk of violence has become a core skill for mental health clinicians and forensic specialists alike. In fact, mental health practitioners in all clinical settings are tasked with assessing and managing their patients’ risk of violence. Although research on the nature of violence and factors that increase the likelihood that a person will commit violent acts has grown in the past several decades, there is no single standard protocol or tool for assessing the risk of violence. This chapter reviews the key risk factors for violence that are supported by research, examines the relationship between mental disorders and violence, and describes approaches that mental health professionals can use to assess the risk of violence.
This chapter describes the complex medicolegal issues surrounding the rules of confidentiality and privilege and their multiple exceptions. It lays out the underpinnings of confidentiality, then addresses its various exceptions, such as... more
This chapter describes the complex medicolegal issues surrounding the rules of confidentiality and privilege and their multiple exceptions. It lays out the underpinnings of confidentiality, then addresses its various exceptions, such as waiver, duty to protect third parties, civil commitment, and mandated reporting of child abuse, elder abuse, and intimate-partner violence. Psychotherapist–patient privilege is discussed, first with regard to its origins and then with regard to its exceptions, including various forms of waiver. Practical examples illustrate these concepts for the reader to make it easier to understand these ubiquitous, but at times perplexing, concepts and to illustrate the nuances of various aspects of the law. Practitioners should note that there is considerable overlap between confidentiality and testimonial privilege, and the division of this chapter into two sections creates, in some ways, an artificial divide between two closely related concepts.
The goal of this book is to help clinicians at all levels of training negotiate the complex legal issues that are an inherent part of modern clinical practice. This chapter provides an introduction to the origins of “law” in its many... more
The goal of this book is to help clinicians at all levels of training negotiate the complex legal issues that are an inherent part of modern clinical practice. This chapter provides an introduction to the origins of “law” in its many forms, the structure of the legal system, and fundamental legal principles that are of special relevance to mental health practitioners and that will recur throughout the book. It discusses concepts that are foreign to most clinicians that have a great impact on mental health practice: the adversarial process, sources of laws, constitutional principles, the concept of legal precedents, and the ethics of the legal system.
As highly visible representatives and guardians of society, law enforcement officers (LEOs) are very public figures. Injury or death in the line of duty, whether due to accidents or intentional acts of violence, is an occupational hazard... more
As highly visible representatives and guardians of society, law enforcement officers (LEOs) are very public figures. Injury or death in the line of duty, whether due to accidents or intentional acts of violence, is an occupational hazard for LEOs. Targeted assaults on police officers, referred to as ambushes in previous literature, are a particularly perplexing problem with significant implications for society at large. In the summer of 2016, the latest in a series of high-profile acts of violence aimed at police occurred, leading to increased examination of the acts themselves and their causes. This article examines recent trends in assaults on LEOs, focusing on predatory rather than reactive attacks, and applies a threat assessment model to a case of targeted violence against police. We use State of Washington v. Christopher Monfort (2015), a prosecution for arson, assault with intent to murder, and murder, as a case example, to examine how the threat assessment model, and the concepts of affective versus predatory violence help in understanding targeted violence against LEOs, assessing its risk, and managing it. Copyright © 2016 John Wiley & Sons, Ltd.
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We studied 18 patients (age range, 53-90 yr) with at least one cardiovascular risk factor who were treated with electroconvulsive therapy (ECT) and compared effects of five pretreatments: no drug; esmolol, 1.3 or 4.4 mg/kg; or labetalol,... more
We studied 18 patients (age range, 53-90 yr) with at least one cardiovascular risk factor who were treated with electroconvulsive therapy (ECT) and compared effects of five pretreatments: no drug; esmolol, 1.3 or 4.4 mg/kg; or labetalol, 0.13 or 0.44 mg/kg. Each patient received all five treatments, during a series of five ECT sessions. Pretreatment was administered as a bolus within 10 s of induction or anesthesia. Doses of methohexital and succinylcholine were constant for the series of treatments and the assignment to no drug or to drug and dose was determined by randomized block design. Measurements of systolic and diastolic blood pressure (SBP, DBP) and heart rate (HR) were recorded during the awake state and 1, 3, 5, and 10 min after the seizure. The deviation of ST segments from baseline was measured by an electrocardiogram (ECG) monitor equipped with ST-segment analysis software. The results (mean +/- SEM) show that without pretreatment, there were significant (P < 0.05) peak increases in SBP and HR (55 +/- 5 mm Hg and 37 +/- 6 bpm, respectively), recorded 1 min after the seizure. Comparable reductions (by approximately 50%) in these peak values were achieved after esmolol (1.3 mg/kg) or labetalol (0.13 mg/kg), and cardiovascular responses were nearly eliminated after the same drugs in doses of 4.4 and 0.44 mg/kg, respectively. The deviation of ST-segment values from baseline in any lead was not measurably influenced by either antihypertensive drug. SBP values were lower after labetalol 10 min after the seizure, but not after esmolol. Asystolic time after the seizure was not significantly longer with either drug.(ABSTRACT TRUNCATED AT 250 WORDS)
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The awarding of damages in civil litigation is a basic element of the civil justice system in the United States. The system is not free of problems and controversy. Cases in which Posttraumatic Stress Disorder (PTSD) is the basis for a... more
The awarding of damages in civil litigation is a basic element of the civil justice system in the United States. The system is not free of problems and controversy. Cases in which Posttraumatic Stress Disorder (PTSD) is the basis for a claim of damages pose specific problems in quantifying the harm done and attributing causation. This paper will provide an overview of the American civil litigation system and address some of the challenges confronted when PTSD and other emotional distress claims are made. In addition, it will discuss alternative methods for compensating victims of trauma that do not utilize the traditional civil litigation system.
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Research Interests: Law, Intellectual Disability, Humans, Crime, United States, and 4 moreFemale, Male, Rhode Island, and Mental Competency
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In this issue of the Journal, Swanson et al. explore the demand for and utilization of psychiatric advance directives (PADs), and discuss some of the barriers to their greater acceptance. This author suggests that PADs may be more widely... more
In this issue of the Journal, Swanson et al. explore the demand for and utilization of psychiatric advance directives (PADs), and discuss some of the barriers to their greater acceptance. This author suggests that PADs may be more widely accepted and utilized if they are viewed as tools for maximizing individual autonomy, with an emphasis on optimizing rather than merely restricting care.
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The Massachusetts Supreme Judicial Court's decision in Rogers v. Commissioner is generally regarded as an important right to refuse treatment decision requiring maximum judicial involvement in the treatment of nonconsenting patients.... more
The Massachusetts Supreme Judicial Court's decision in Rogers v. Commissioner is generally regarded as an important right to refuse treatment decision requiring maximum judicial involvement in the treatment of nonconsenting patients. Since courts and legislators in other jurisdictions have looked to Rogers for guidance on right to refuse treatment issues, and since some have adopted it as a model, it is essential for lawmakers to understand the economic realities of the Massachusetts experience and the commitment of resources required by this model. The authors review these realities, suggesting that there are distinct reasons for considering this particular model "cost ineffective" in preserving patients' rights.
Research Interests: Economics, Mental Health, Forensic psychiatry, Treatment, Medical Ethics, and 11 moreHumans, American Journal of Psychiatry, Patient Compliance, Massachusetts, Mental Disorders, Patient Rights, Cost Benefit Analysis, Patient Advocacy, judicial role, Psychology and Cognitive Sciences, and Medical and Health Sciences
Research Interests: Neurology, Neuroimaging, Epilepsy, Informed Consent, Arterial hypertension, and 15 moreElectroconvulsive therapy, Brain, Humans, Hemodynamics, Female, Heart rate, Arterial Blood Pressure, Middle Aged, Major Depression, Flow Velocity, Cerebral Blood Flow, Basilar Artery, Middle Cerebral Artery, Intracranial aneurysm, and Medical and Health Sciences
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OBJECTIVESThis report describes successful anaesthesia and electroconvulsive therapy (ECT) in a patient with an unruptured basilar artery aneurysm. ECT is associated with a hyperdynamic state characterised by arterial hypertension,... more
OBJECTIVESThis report describes successful anaesthesia and electroconvulsive therapy (ECT) in a patient with an unruptured basilar artery aneurysm. ECT is associated with a hyperdynamic state characterised by arterial hypertension, tachycardia, and considerably increased cerebral blood flow rate and velocity. These responses pose an increased risk for subarachnoid haemorrhage when an intracranial aneurysm coexists.METHODSA 54 year old woman presented for ECT.
Research Interests: Neuroimaging, Epilepsy, Informed Consent, Arterial hypertension, Electroconvulsive therapy, and 15 moreBrain, Humans, Hemodynamics, Female, Heart rate, Arterial Blood Pressure, Middle Aged, Major Depression, Flow Velocity, Cerebral Blood Flow, Basilar Artery, Middle Cerebral Artery, Psychology and Cognitive Sciences, Intracranial aneurysm, and Medical and Health Sciences
ABSTRACT
Research Interests:
Research Interests:
We studied 18 patients (age range, 53-90 yr) with at least one cardiovascular risk factor who were treated with electroconvulsive therapy (ECT) and compared effects of five pretreatments: no drug; esmolol, 1.3 or 4.4 mg/kg; or labetalol,... more
We studied 18 patients (age range, 53-90 yr) with at least one cardiovascular risk factor who were treated with electroconvulsive therapy (ECT) and compared effects of five pretreatments: no drug; esmolol, 1.3 or 4.4 mg/kg; or labetalol, 0.13 or 0.44 mg/kg. Each patient received all five treatments, during a series of five ECT sessions. Pretreatment was administered as a bolus within 10 s of induction or anesthesia. Doses of methohexital and succinylcholine were constant for the series of treatments and the assignment to no drug or to drug and dose was determined by randomized block design. Measurements of systolic and diastolic blood pressure (SBP, DBP) and heart rate (HR) were recorded during the awake state and 1, 3, 5, and 10 min after the seizure. The deviation of ST segments from baseline was measured by an electrocardiogram (ECG) monitor equipped with ST-segment analysis software. The results (mean +/- SEM) show that without pretreatment, there were significant (P < 0.05) peak increases in SBP and HR (55 +/- 5 mm Hg and 37 +/- 6 bpm, respectively), recorded 1 min after the seizure. Comparable reductions (by approximately 50%) in these peak values were achieved after esmolol (1.3 mg/kg) or labetalol (0.13 mg/kg), and cardiovascular responses were nearly eliminated after the same drugs in doses of 4.4 and 0.44 mg/kg, respectively. The deviation of ST-segment values from baseline in any lead was not measurably influenced by either antihypertensive drug. SBP values were lower after labetalol 10 min after the seizure, but not after esmolol. Asystolic time after the seizure was not significantly longer with either drug.(ABSTRACT TRUNCATED AT 250 WORDS)
Research Interests:
Violent radicalization is a complex process that results from multiple influences and experiences across the settings and contexts of an individual’s life. No single pathway or characteristic determines who is at risk for it. Given this... more
Violent radicalization is a complex process that results from multiple
influences and experiences across the settings and contexts of an
individual’s life. No single pathway or characteristic determines who is
at risk for it. Given this understanding, no single intervention aimed at
this multiply-determined problem is likely to be successful if it is
implemented in isolation. Multidisciplinary team approaches are
increasingly seen as holding promise in the prevention and intervention
of violent radicalization in the United States and internationally.
A multidisciplinary team is typically a group of professionals who are
members of different fields of study (psychology, medicine, social work,
etc.) who provide a specific service to an individual. Team members
independently focus on the issues in which they specialize and activities
of the team are coordinated with a common goal. This paper aims
to extend current knowledge by addressing questions related to challenges
in implementing a multidisciplinary team approach with the
capacity to address violent radicalization, presenting potential solutions
to these challenges as well as highlighting one multidisciplinary team,
Community Connect, that successfully worked with youth identified as
being at risk for violence.
influences and experiences across the settings and contexts of an
individual’s life. No single pathway or characteristic determines who is
at risk for it. Given this understanding, no single intervention aimed at
this multiply-determined problem is likely to be successful if it is
implemented in isolation. Multidisciplinary team approaches are
increasingly seen as holding promise in the prevention and intervention
of violent radicalization in the United States and internationally.
A multidisciplinary team is typically a group of professionals who are
members of different fields of study (psychology, medicine, social work,
etc.) who provide a specific service to an individual. Team members
independently focus on the issues in which they specialize and activities
of the team are coordinated with a common goal. This paper aims
to extend current knowledge by addressing questions related to challenges
in implementing a multidisciplinary team approach with the
capacity to address violent radicalization, presenting potential solutions
to these challenges as well as highlighting one multidisciplinary team,
Community Connect, that successfully worked with youth identified as
being at risk for violence.
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Disasters, natural and man-made, have a considerable impact on communities. Most recently, disasters stemming from terrorist attacks have become a leading cause of concern. The importance of work in the lives of employees, coupled with... more
Disasters, natural and man-made, have a considerable impact on communities. Most recently, disasters stemming from terrorist attacks have become a leading cause of concern. The importance of work in the lives of employees, coupled with the vulnerability of workplaces as potential targets of terrorist attacks, suggests that workplaces can and should play a role in planning for, and responding to, disasters. This article addresses the role of the workplace in disasters, with an emphasis on the psychological impact of such events, by drawing upon experience and literature related to workplace violence and to other traumatic events in the workplace.
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... knowledge. Difficulties arise, however, when these theo-ries lead to legal action on the part of patients or inaction on the part of clinicians. ... as-sistant district attorney suggested that she contact Nancy Aldridge, a private... more
... knowledge. Difficulties arise, however, when these theo-ries lead to legal action on the part of patients or inaction on the part of clinicians. ... as-sistant district attorney suggested that she contact Nancy Aldridge, a private licensed therapist. ...
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In attempts to reduce the cost of mental health treatment, health insurers are turning to mechanisms for intensive oversight that fall under the rubric of managed care. These approaches have implications for the potential liability of... more
In attempts to reduce the cost of mental health treatment, health insurers are turning to mechanisms for intensive oversight that fall under the rubric of managed care. These approaches have implications for the potential liability of clinicians and managed care entities. Clinicians may be confronted with legal duties to appeal adverse decisions, to disclose the impact of managed care on patients' treatment, and in some circumstances, to continue treatment after payment has been denied. Managed care entities are being held to duties to conduct review in a reasonable fashion, and may also have a duty to disclose the limitations managed care may place on patients' access to treatment, and to select appropriate providers of care. The law in this area is in an early stage of development and is likely to be refined.
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This article focuses on psychiatric consultation in "problem employee situations," a broad term that refers to any situation in which there is conflict between an employee and the employer or coworkers. It summarizes key... more
This article focuses on psychiatric consultation in "problem employee situations," a broad term that refers to any situation in which there is conflict between an employee and the employer or coworkers. It summarizes key principles and observations that are common to psychiatric consultations in the workplace and then offers case examples that are representative of such consultations and highlights those principles. Although the focus is on psychiatric consultation to employers, an employee may seek consultation himself or herself, especially when prospects for adversarial proceedings arise. The principles described here apply in both sets of circumstances.
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In the practice of psychosomatic medicine, the psychiatric consultant is likely to be confronted with questions at the interface of psychiatry and law. These issues generally emerge around questions of confidentiality and exceptions to... more
In the practice of psychosomatic medicine, the psychiatric consultant is likely to be confronted with questions at the interface of psychiatry and law. These issues generally emerge around questions of confidentiality and exceptions to confidentiality, assessments of a patient's ability to consent to and refuse treatment, and concerns about malpractice liability. Overall, psychiatrists should approach the care of patients clinically, while understanding the applicable laws and regulations of the jurisdictions in which they practice. In addition, clinicians should be aware of the legal and risk management resources available to them should a complex situation arise. Finally, the psychiatric consultant should make use of consultation when complex issues emerge at the interface of psychiatry and law.
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Terrorism has existed for millennia and is a phenomenon well-known to many parts of the world. Americans were forced to recognize this phenomenon, and our vulnerability to it, by two sets of events in 2001: the attacks on New York City... more
Terrorism has existed for millennia and is a phenomenon well-known to many parts of the world. Americans were forced to recognize this phenomenon, and our vulnerability to it, by two sets of events in 2001: the attacks on New York City and Washington, DC, and the anthrax mailings that followed shortly thereafter. Psychiatry, psychology, and other behavioral and social sciences have been looked to for assistance in collecting and analyzing intelligence data, understanding terrorism, and developing strategies to combat terrorism. In addition to reviewing areas in which the behavioral sciences have made contributions in addressing this problem, this article discusses the developing roles for behavioral scientists in this field.
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The accuracy and value of personality assessment for depressed patients receiving electroconvulsive therapy (ECT) is an underexplored and controversial area. However, there are data suggesting that personality traits and personality... more
The accuracy and value of personality assessment for depressed patients receiving electroconvulsive therapy (ECT) is an underexplored and controversial area. However, there are data suggesting that personality traits and personality disorders affect the ultimate outcome of depressed patients receiving a variety of somatic treatments including ECT. Despite these data, controversy continues regarding the advisability of evaluating personality functioning in patients with severe depression. This study sought to explore the stability and predictive value of self-reported personality traits in depressed patients undergoing ECT. Sixteen subjects completed a self-report test of personality functioning and the Beck Depression Inventory (BDI) before and after ECT treatment. The results showed that the majority of self-report personality traits were stable pre- and post-ECT treatment. However, major depressive disorder did significantly affect the report of avoidant, histrionic, aggressive-sadistic, and schizotypal personality traits. Treatment did not change the overall personality profile of these subjects. Furthermore, regression analysis controlling for pretreatment depression showed pretreatment borderline personality traits to be significantly related to the posttreatment depression scores (response to treatment). These findings suggest that routine administration of a standard self-report measure of personality may aid in the evaluation of and treatment planning for patients receiving ECT.
Research Interests: Psychometrics, Nonparametric Statistics, Personality Disorders, Treatment Outcome, Electroconvulsive therapy, and 14 moreHumans, Major Depressive Disorder, Female, Personality Disorder, Male, Regression Analysis, Depressive Disorder, Beck Depression Inventory, Clinical Sciences, Middle Aged, Reproducibility of Results, Treatment planning, Pilot Projects, and Personality Trait
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... is written. Although I found all these books valuable and informative, I unre-servedly recommend Daniel Harris' and Arlene Stein's provocative histor-ical revisions of gay identity and cul-ture. For ... pages, $45 Jeffrey... more
... is written. Although I found all these books valuable and informative, I unre-servedly recommend Daniel Harris' and Arlene Stein's provocative histor-ical revisions of gay identity and cul-ture. For ... pages, $45 Jeffrey Stovall, MD Dr ...
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Medical practice occurs within a legal and regulatory context. This article covers several of the legal issues that frequently arise in the general medical setting. While this article provides an overview of approaches to informed... more
Medical practice occurs within a legal and regulatory context. This article covers several of the legal issues that frequently arise in the general medical setting. While this article provides an overview of approaches to informed consent, boundary issues, and malpractice claims, it is critical for clinicians to be familiar with the specific requirements and standards in the jurisdictions in which they practice. As a general rule, it is most important that physicians recognize that the best way to avoid legal problems is to be aware of legal requirements in the jurisdictions in which they practice, but to think clinically and not legally in the provision of consistent and sound clinical care to their patients.
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... Bos-ton, Massachusetts 02114-2517. KENNETH S. DUCKWORTH, MD• Massachusetts Mental Health Center. Boston, Massachusetts 02114. ... Billy was an I l-year-old only child referred for psychiatric evaluation because of worsening grades and... more
... Bos-ton, Massachusetts 02114-2517. KENNETH S. DUCKWORTH, MD• Massachusetts Mental Health Center. Boston, Massachusetts 02114. ... Billy was an I l-year-old only child referred for psychiatric evaluation because of worsening grades and isolative behavior. ...
The awarding of damages in civil litigation is a basic element of the civil justice system in the United States. The system is not free of problems and controversy. Cases in which Posttraumatic Stress Disorder (PTSD) is the basis for a... more
The awarding of damages in civil litigation is a basic element of the civil justice system in the United States. The system is not free of problems and controversy. Cases in which Posttraumatic Stress Disorder (PTSD) is the basis for a claim of damages pose specific problems in quantifying the harm done and attributing causation. This paper will provide an overview of the American civil litigation system and address some of the challenges confronted when PTSD and other emotional distress claims are made. In addition, it will discuss alternative methods for compensating victims of trauma that do not utilize the traditional civil litigation system.
Research Interests:
... against him. The standard of proof for establishing incompetence is preponderance of the evidence.10 In Godinez v. Moran ... Address correspondence to: Ronald Schouten, MD, JD, Law and Psychiatry Service, Massachusetts General... more
... against him. The standard of proof for establishing incompetence is preponderance of the evidence.10 In Godinez v. Moran ... Address correspondence to: Ronald Schouten, MD, JD, Law and Psychiatry Service, Massachusetts General Hospital, 60 Staniford Street, Boston, MA ...