Recent events have revived questions about the circumstances that ought to trigger therapists’ du... more Recent events have revived questions about the circumstances that ought to trigger therapists’ duty to warn or protect. There is extensive interstate variation in duty to warn or protect statutes enacted and rulings made in the wake of the California Tarasoff ruling. These duties may be codified in legislative statutes, established in common law through court rulings, or remain unspecified. Furthermore, the duty to warn or protect is not only variable between states but also has been dynamic across time. In this article, we review the implications of this variability and dynamism, focusing on three sets of questions: first, what legal and ethics-related challenges do therapists in each of the three broad categories of states (states that mandate therapists to warn or protect, states that permit
therapists to breach confidentiality for warnings but have no mandate, and states that give no guidance) face in handling threats of violence? Second, what training do therapists and other professionals involved in handling violent threats receive, and is this training adequate for the task that these professionals are charged with? Third, how have recent court cases changed the scope of the duty? We conclude by pointing to gaps in the empirical and conceptual scholarship surrounding the duty to warn or protect.
This column describes the gradual integration of psychiatrists into mainstream general medical ca... more This column describes the gradual integration of psychiatrists into mainstream general medical care, from their exile as “alienists” in isolated asylums to their current roles in accountable care organizations. The authors note that a contemporary form of alienism persists and argue that conceptual parity—the idea that mental illnesses exist within the same ontological realm as other illnesses—must first be achieved before full integration can be realized. Some steps toward achieving conceptual parity, such as the development of quality measures for behavioral health care and improved training programs, are described.
The American Academy of Paediatrics endorses obtaining assent when prescribing medications for at... more The American Academy of Paediatrics endorses obtaining assent when prescribing medications for attention-deficit/hyperactivity disorder (ADHD) in older children whenever possible. Studies indicate the concept of assent may not be well understood by clinicians, possibly effecting effective and widespread implementation. We argue that though the concept of assent continues to evolve, it is critical in the context of patient-centred care, shared decision-making and in supporting minors' transition to adulthood. Based on the principle of respect for young persons, we argue that obtaining assent is an ethical imperative when prescribing medication for ADHD. We highlight the instrumental benefits of obtaining assent in the paediatric clinical encounter when prescribing medications for treatment of ADHD.
Substance Abuse Treatment, Prevention, and Policy, 2015
Moral philosophers have debated the extent to which persons are individually responsible for the ... more Moral philosophers have debated the extent to which persons are individually responsible for the onset of and recovery from addiction. Empirical investigators have begun to explore counselors' attitudes on these questions. Meanwhile, a separate literature has investigated counselors' negative attitudes towards naltrexone, an important element of medication-assisted treatment for alcohol addiction. The present study bridges the literature on counselor views about responsibility for addiction with the literature on attitudes towards naltrexone. It investigates the extent to which a counselor's views of individual responsibility for alcohol addiction are related to that counselor's views of naltrexone. Using a vignette-based survey of 117 addiction treatment professionals, the study analyzes the relationship between an addiction counselor's views about individual responsibility for alcohol addiction and using naltrexone to treat it. We find a significant difference in counselors who assign greater responsibility to a person for the onset of alcohol addiction. They agreed more strongly with several objections to naltrexone, including worries about compliance, naltrexone's side effects outweighing its benefits, naltrexone treating symptoms but not underlying causes, and the idea that medication may undermine a person's motivation to recover. Combined views of greater responsibility for addiction's onset and recovery also significantly predicted stronger agreement with objections. We conclude that there is a strong relationship between a counselor assigning higher individual responsibility for addiction and holding more negative views about naltrexone. The study also sheds light on one reason why the model of addiction as a brain disease has had limited impact on clinical practice.
Ketamine offers a promising new option for the treatment of depression, but its increasing off-la... more Ketamine offers a promising new option for the treatment of depression, but its increasing off-label use is ethically and clinically inappropriate at the moment.
: This article discusses the relationship between disease-advocacy groups and the revision proces... more : This article discusses the relationship between disease-advocacy groups and the revision process for the Diagnostic and Statistical Manual of Mental Disorders. We discuss three examples in which patient-advocacy groups engaged with the DSM-5 revision process: Autism Speaks' worries about the contraction of the autism diagnostic category, the National Alliance on Mental Illness's support for the inclusion of psychosis risk syndrome, and B4U-ACT's critique of the expansion of pedophilia. After a descriptive examination of the cases, we address two prescriptive questions. First, what is the ethical basis for patient and advocate influence on DSM diagnoses? Second, how should the American Psychiatric Association proceed when this influence comes into conflict with other goals of the revision process? We argue that the social effects of, and values embedded in, psychiatric classification, combined with patient and advocates' experiential knowledge about those aspects of diagnosis, ethically justify advocate influence in relation to those particular matters. However, this advocate influence ought to have limits, which we briefly explore. Our discussion has implications for discussions of disease categories as loci for social movements, for analyses of the expanding range of processes and institutions that advocacy groups target, and for broader questions regarding the aims of the DSM revision process.
Recent events have revived questions about the circumstances that ought to trigger therapists’ du... more Recent events have revived questions about the circumstances that ought to trigger therapists’ duty to warn or protect. There is extensive interstate variation in duty to warn or protect statutes enacted and rulings made in the wake of the California Tarasoff ruling. These duties may be codified in legislative statutes, established in common law through court rulings, or remain unspecified. Furthermore, the duty to warn or protect is not only variable between states but also has been dynamic across time. In this article, we review the implications of this variability and dynamism, focusing on three sets of questions: first, what legal and ethics-related challenges do therapists in each of the three broad categories of states (states that mandate therapists to warn or protect, states that permit
therapists to breach confidentiality for warnings but have no mandate, and states that give no guidance) face in handling threats of violence? Second, what training do therapists and other professionals involved in handling violent threats receive, and is this training adequate for the task that these professionals are charged with? Third, how have recent court cases changed the scope of the duty? We conclude by pointing to gaps in the empirical and conceptual scholarship surrounding the duty to warn or protect.
This column describes the gradual integration of psychiatrists into mainstream general medical ca... more This column describes the gradual integration of psychiatrists into mainstream general medical care, from their exile as “alienists” in isolated asylums to their current roles in accountable care organizations. The authors note that a contemporary form of alienism persists and argue that conceptual parity—the idea that mental illnesses exist within the same ontological realm as other illnesses—must first be achieved before full integration can be realized. Some steps toward achieving conceptual parity, such as the development of quality measures for behavioral health care and improved training programs, are described.
The American Academy of Paediatrics endorses obtaining assent when prescribing medications for at... more The American Academy of Paediatrics endorses obtaining assent when prescribing medications for attention-deficit/hyperactivity disorder (ADHD) in older children whenever possible. Studies indicate the concept of assent may not be well understood by clinicians, possibly effecting effective and widespread implementation. We argue that though the concept of assent continues to evolve, it is critical in the context of patient-centred care, shared decision-making and in supporting minors' transition to adulthood. Based on the principle of respect for young persons, we argue that obtaining assent is an ethical imperative when prescribing medication for ADHD. We highlight the instrumental benefits of obtaining assent in the paediatric clinical encounter when prescribing medications for treatment of ADHD.
Substance Abuse Treatment, Prevention, and Policy, 2015
Moral philosophers have debated the extent to which persons are individually responsible for the ... more Moral philosophers have debated the extent to which persons are individually responsible for the onset of and recovery from addiction. Empirical investigators have begun to explore counselors' attitudes on these questions. Meanwhile, a separate literature has investigated counselors' negative attitudes towards naltrexone, an important element of medication-assisted treatment for alcohol addiction. The present study bridges the literature on counselor views about responsibility for addiction with the literature on attitudes towards naltrexone. It investigates the extent to which a counselor's views of individual responsibility for alcohol addiction are related to that counselor's views of naltrexone. Using a vignette-based survey of 117 addiction treatment professionals, the study analyzes the relationship between an addiction counselor's views about individual responsibility for alcohol addiction and using naltrexone to treat it. We find a significant difference in counselors who assign greater responsibility to a person for the onset of alcohol addiction. They agreed more strongly with several objections to naltrexone, including worries about compliance, naltrexone's side effects outweighing its benefits, naltrexone treating symptoms but not underlying causes, and the idea that medication may undermine a person's motivation to recover. Combined views of greater responsibility for addiction's onset and recovery also significantly predicted stronger agreement with objections. We conclude that there is a strong relationship between a counselor assigning higher individual responsibility for addiction and holding more negative views about naltrexone. The study also sheds light on one reason why the model of addiction as a brain disease has had limited impact on clinical practice.
Ketamine offers a promising new option for the treatment of depression, but its increasing off-la... more Ketamine offers a promising new option for the treatment of depression, but its increasing off-label use is ethically and clinically inappropriate at the moment.
: This article discusses the relationship between disease-advocacy groups and the revision proces... more : This article discusses the relationship between disease-advocacy groups and the revision process for the Diagnostic and Statistical Manual of Mental Disorders. We discuss three examples in which patient-advocacy groups engaged with the DSM-5 revision process: Autism Speaks' worries about the contraction of the autism diagnostic category, the National Alliance on Mental Illness's support for the inclusion of psychosis risk syndrome, and B4U-ACT's critique of the expansion of pedophilia. After a descriptive examination of the cases, we address two prescriptive questions. First, what is the ethical basis for patient and advocate influence on DSM diagnoses? Second, how should the American Psychiatric Association proceed when this influence comes into conflict with other goals of the revision process? We argue that the social effects of, and values embedded in, psychiatric classification, combined with patient and advocates' experiential knowledge about those aspects of diagnosis, ethically justify advocate influence in relation to those particular matters. However, this advocate influence ought to have limits, which we briefly explore. Our discussion has implications for discussions of disease categories as loci for social movements, for analyses of the expanding range of processes and institutions that advocacy groups target, and for broader questions regarding the aims of the DSM revision process.
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Papers by Dominic Sisti
therapists to breach confidentiality for warnings but have no mandate, and states that give no guidance) face in handling threats of violence? Second, what training do therapists and other professionals involved in handling violent threats receive, and is this training adequate for the task that these professionals are charged with? Third, how have recent court cases changed the scope of the duty? We conclude by pointing to gaps in the empirical and conceptual scholarship surrounding the duty to warn or protect.
therapists to breach confidentiality for warnings but have no mandate, and states that give no guidance) face in handling threats of violence? Second, what training do therapists and other professionals involved in handling violent threats receive, and is this training adequate for the task that these professionals are charged with? Third, how have recent court cases changed the scope of the duty? We conclude by pointing to gaps in the empirical and conceptual scholarship surrounding the duty to warn or protect.