Winter 2021 • Vol. 46, No. 1 2020 AAPL Presidential Address self, and work-life imbalance. Studies show that medical errors are higher for individuals with burnout. On the other Dr. William J. Newman, MD: Promoting hand, higher levels of empathy are a Wellness in Forensic Psychiatry protective factor against burnout. Britta K. Ostermeyer, MD, MBA, DFAPA National data shows that 45% and 54% of physicians in 2011 and cognitive impairment, fatigue, depres- 2014, respectively, reported burnout. sion, anxiety, and visual changes. In Although a 2013 Stanford University particular, Neuropeptide-Y (NPY), survey of physicians yielded only a synthesized in the hypothalamus, is 26% reported rate of burnout, three becoming increasingly understood years later burnout had increased as having an important role in stress, to 39% despite Stanford’s burnout anxiety, and resiliency. Chronically prevention efforts. The Stanford study stressed individuals have higher serum also looked at professional fulfillment NPY levels than patients diagnosed and found that 24% of physicians with PTSD or MDD. reported fulfillment in 2013, which Dr. Newman shared that he was subsequently decreased to 14% in stalked by a former patient who had 2016. Dr. Newman highlighted that serious plans to kill him. Severe, reported burnout rates increased even chronic stress due to stalking often is though Stanford as an institution is followed by inflammatory conditions, very committed to burnout prevention. including cancer. He was diagnosed On the topic of helping to promote with metastatic cancer some time after wellness and preventing burnout, Dr. Newman, AAPL’s 46th President, experiencing severe and chronic stress Dr. Newman explained the Stanford was introduced by Charles Scott, MD. due to the stalking. model, called “Well MD Center.” Dr. Newman is Professor and Interim Burnout, defined as emotional, phys- Its priorities are: (1) “The Culture of Chair in the Department of Psychiatry ical, and mental exhaustion caused by Wellness,” meaning that leadership is and Behavioral Neurosciences at the prolonged stress, has been classified engaged; (2) “Efficiency of Practice,” St. Louis University School of Medi- by the World Health Organization as ensuring that physicians have the cine in St. Louis, Missouri. an occupational phenomenon. Of note, resources they need to practice at the In his introduction, Dr. Newman while medical students start with high- top of their license; and (3) “Personal stated that we tend to speak very little er levels of resilience than other grad- Resilience,” which facilitates building about well-being despite being psy- uate students, after medical school, one’s own self-appreciation and how chiatrists, and that this topic has been physicians experience burnout at a to recognize one’s limitations as well an infrequent part of presentations at higher rate than other matched profes- as strengths. AAPL. He has had personal experi- sionals. It is a real concern for organi- Physicians are an unusual group, ences that led him to focus more on zations to place the onus for wellness psychiatrists an unusual subset of wellness and staying healthy. onto physicians, as they are already physicians, and forensic psychiatrists He explained that while acute stress prone to self-reproach. In his opinion, make up an even more unusual sub- in response to danger is important and physician burnout must be addressed class. A 2014 Canadian survey found adaptive, a prolonged stress response through a variety of systemic changes that 62% of physicians self-identify is maladaptive and leads to negative within medicine. “It’s not enough to as having “Type A personality,” 53% long-term emotional and physical focus on individual physicians fixing agreed that they are a “workahol- sequelae. Chronic stress causes themselves or addressing this problem. ic,” and 35% agreed that they are a inflammatory processes which can There really need to be some big-pic- “control freak.” He commented that in cause a host of medical conditions, ture goals.” Factors promoting burnout particular “within forensic psychiatry including cancer, cardiovascular include sleep deprivation, perfection- probably a lot of people would identi- disease, and neurological conditions. ism, demands, financial struggles, fy with these descriptors.” Brain inflammation due to peripheral unreasonable expectations, negative Identified maladaptive physician pro-inflammatory cytokines crossing relationships, lack of support, high traits include neuroticism, anger, and the blood-brain barrier can lead to workload, call, overstretching one- (continued on page 2)

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 1 COVER STORY American Academy of of this group, he has learned to identi- Psychiatry Presidential Address continued from page 1 fy more with the term “work engage- and the Law ment,” which is defined as “a positive, pride. We as forensic psychiatrists may fulfilling, work-related state of mind Editor that is characterized by vigor, dedica- Joseph R. Simpson, MD, PhD have identified ways to channel neu- roticism, such as being detail-oriented tion, and absorption.” According to Dr. Associate Editors and somewhat obsessive. Anger in Malissa Clark (a 2020 AAPL pre- Philip J. Candilis, MD physicians may not necessarily surface senter), workaholism includes feeling Ryan C. W. Hall, MD as temper outbursts but is more likely compelled to work because of internal Stephen P. Herman, MD pressures; having persistent thoughts Neil S. Kaye, MD to manifest as impatience and intoler- Britta K. Ostermeyer, MD, MBA ance. Physicians must learn to recog- about work when not working; and Karen B. Rosenbaum, MD nize anger and think through ways to working beyond what is reasonably Renée M. Sorrentino, MD address it, much like in a CBT-type expected, despite the potential for Joel Watts, MD model. Lastly, pride in itself is not negative consequences and impact on personal relationships. Interestingly, AAPL Photographer unhealthy but may become problemat- Eugene Lee, MD ic when it comes across as arrogance Dr. Clark found that workaholism is and begins to impact others negatively. only moderately correlated with actual Former Editors Dr. Newman noted, “One thing I often hours worked, and that it has more Susan Hatters Friedman, MD (2016-2018) tell my trainees is that in forensic to do with the way one interprets and Charles Dike, MD, MPH (2008-2016) psychiatry I think it’s a good thing to relates to one’s work. Workaholism is Victoria Harris, MD, MPH (2003-2008) highly correlated with Type A person- Michael A. Norko, MD (1996-2003) be confident but you have to stop short Robert Miller, MD PhD (1994-1996) of being arrogant, “and that’s a chal- ality and perfectionism; early studies Alan R. Felthous, MD (1988-1993) lenge...Take your work seriously but show it likely correlates with narcis- Robert M. Wettstein, MD (1983-1988) try not to take yourself too seriously.” sism, which does not have to do with Phillip J. Resnick, MD (1979-1983) He further suggested it is important to the amount that somebody works, but Loren H. Roth, MD, MPH (1976-1979) obtain feedback from others, including the way it is impacting them person- Officers constructive criticism. “Being open to ally. President that, I think, is a major part of devel- Next, Dr. Newman shared insights Liza H. Gold, MD oping throughout your career.” about the psychology of hate, which is President-elect Dr. Newman noted that forensic generally viewed as a distraction from Susan Hatters Friedman, MD psychiatrists are unusual in part due internal feelings such as helplessness, Vice President to unique challenges. Looking at the inadequacy, and shame. It provides Hal S. Wortzel, MD job description, there is (1) a heavy a temporary release of such internal Vice President emphasis on public speaking, which discomfort. Knowledge and educa- Britta K. Ostermeyer, MD creates significant anxiety in about tion are the most effective tools for Secretary one-third of the U.S. population; addressing hate. There are increasing Karen Rosenbaum, MD (2) exposure to chronic stress, both reports about the long-term physical Treasurer internally and externally, via real and emotional impacts of hate, related Stuart A. Anfang, MD and self-imposed deadlines; (3) great to chronic stress and its impact. “The Immediate Past President potential for punishment for any Dalai Lama gives a very nice quote to William J. Newman, MD career imperfections, such as failing this point: ‘Don’t let the behavior of The AAPL Newsletter is published by an exam; and (4) repeated exposure to others destroy your inner peace.’” AAPL, One Regency Drive, PO Box potentially traumatizing content with a Dr. Newman listed useful habits that 30, Bloomfield, CT 06002. Opinions high risk of vicarious trauma, defined can counteract chronic stress and re- expressed in bylined articles and columns as experiencing repeated or extreme duce inflammation, including a healthy in the Newsletter are solely those of the exposure to aversive details of the diet, regular exercise, enough sleep, authors and do not necessarily represent relaxation, engagement with family, the official position of AAPL or traumatic events(s), which may lead to Newsletter editors. PTSD. Dr. Newman pointed out that travel, mindfulness, job satisfaction, Manu­scripts are invited for publication in our 2020 AAPL program included a yoga, Netflix, and knitting. He pointed the Newsletter. They should be sub­mitted presentation by Dr. John Bradford on out that “every individual has to deter- to the editor via email to NewsletterEdi- this topic. mine what makes a healthy Wellness [email protected] Dr. Newman moved on to discuss Wheel for them. While it is different The Newsletter is published in workaholism, which was first de- for different people, it is some combi- Winter (deadline for submission is nation of elements for each person.” November 15), Spring (deadline scribed in the 1970s by psychologist March 1), and Fall (deadline July 1). Dr. Wayne Oates as “the compulsion It is very important to foster good relationships, while relieving oneself www.aapl.org or the uncontrollable need to work incessantly.” While Dr. Newman of those that do not bring positive © 2021 AAPL. ALL RIGHTS RESERVED. reflected that he probably is a member (continued on page 7)

2 • Winter 2021 American Academy of Psychiatry and the Law Newsletter PRESIDENT’S REPORT

able to combine the advantages of AAPL Post-COVID: online education with the social and educational advantages of being in Pivoting to a New Normal the same place at the same time with Liza H. Gold, MD colleagues. For example, the Annual I hope this pandemic, but also into the future. Meeting call for submissions usually issue of the To that end, with the support and yields far more proposals for presen- newsletter finds assistance of Executive Council tations than can be accommodated. If everyone safe and members, and again, Jackie Coleman, online CME courses are successful, well. By the time her staff, and the second iteration of courses might become a primarily on- you read this, I the Virtual AAPL Task Force, we are line learning modality, thus allowing also hope we will developing “AAPL OnLine.” Some more panels, workshops, and other be turning the of these new endeavors are likely to presentations at the Annual Meeting. corner on a year be very successful; others maybe not In addition, AAPL will be adver- of loss, hardship, and uncertainty. so much. But there can be no doubt tising our online offerings to mem- My heart goes out to all who have that trial and evaluation of innovative bers, nonmembers, and all psychi- struggled to meet the challenges this online offerings will result in AAPL atric residencies. Topics in forensic year presented, especially our AAPL being able to advance its educational psychiatry are often of great interest members who have been providing mission in new ways as part of the to nonforensic clinicians, and many frontline care despite the personal “new normal.” psychiatric residencies do not have a risks to themselves and their fami- Projects currently underway in- forensic fellowship program. Online lies. I have never been prouder of my clude: offerings could result in significant- medical colleagues and the health care • Organization of “open house” ly increased attendance and elevate professionals with whom we work, as committee meetings, coordinated AAPL’s profile, which might lead to they have risen to meet an unimag- with Forensic Fellowship Train- increased membership and increased inable challenge. ing Directors, for fellows (and recruitment of forensic fellows. Although we are not “post-COVID” others) to have an opportunity to Certainly, for the next two years yet, eventually and together we will explore and meet with commit- or so, AAPL’s ability to translate the get there. But what will the “new tees in which they might have an unique teaching talents and expertise normal” look like? The need to adapt interest; of our members to online offerings to the pandemic has resulted in many • Development of live-stream will be critical to the strength of the changes, including some profound online courses and other types of organization. So I encourage mem- changes in perspective. Some of presentations for CME credit; bers to propose additional innova- these were not optimal. For example, • Organization of members-only tions. Please get in touch with any many of us look forward to the AAPL Town Hall meetings to address is- ideas or proposals you might have Annual Meetings as a highlight of our sues and current events affecting ([email protected]); no idea or professional year. There is no doubt AAPL and forensic psychiatry; suggestion will be rejected without that not being able to hold our Annual • An “Expert Lecture” series, consideration! Meetings in person in October 2020, live-streaming a member present- In 2020, we did not have control of and now again in October 2021, are ing a 60-90 minute lecture for many aspects of our lives. We fell into losses. CME credit; our current circumstances unprepared But necessity being the mother of • Development of the capability for the changes and challenges we invention, 2020 Program Chairs Ryan to access on-demand materials, have been forced to confront. How- Wagoner and Trent Holmberg, Exec- such as recordings of courses and ever, we can have control in defining utive Director Jackie Coleman and meetings, podcasts, and other AAPL’s “new normal,” especially her staff, and the “Virtual AAPL Task digital modalities; in regard to our primary mission of Force” headed up by Annette Hanson • Redesign of the AAPL website, education. Your suggestions for in- organized an excellent live-streamed the “Digital Face” of AAPL, to be novation and your evaluations of our Annual Meeting. Renée Sorrentino, more dynamic and interactive, for online endeavors will be invaluable our 2021 Program Chair, is well on members and nonmembers. in determining which of these will her way to building on that experi- The most obvious advantage of on- help AAPL thrive through and after ence. Our in-person Annual Meetings line learning (aside from being able to these difficult times. I know AAPL is will resume as soon as possible, hope- attend in your pajamas) is time flex- up to the challenge. I leave you with fully in New Orleans in 2022. In the ibility. Before the pandemic, almost Hurin’s words of hope (J.R.R. Tolk- meantime, AAPL can and must have a all of AAPL’s annual activities took ien, The Silmarillion): “Aure entulu- robust online presence for the organi- place in one hectic week at the Annual va! Day shall come again!” zation to thrive, not only through the Meeting. Going forward, we will be

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 3 MEDICAL DIRECTOR’S REPORT

Jonas was a true giant of forensic Jonas R. Rappeport, in Memoriam psychiatry. He mentored all of us. Jeffrey S. Janofsky, MD May he rest in peace. — Renee Binder I am devot- for a psychiatrist – that’s a ques- ing my AAPL tion for an ophthalmologist!” I have been thinking about Jonas Medical Direc- — Peter Ash overnight and concluded that the tor’s column to best way I could characterize Sad news to waken to here in the Jonas was as a master build- the memory of UK. His personal qualities epito- Jonas R. Rap- er. The goal for Jonas as leader mized the unique characteristics and for those around him was to peport, who died of the very special organization on September 8, build a new medical specialty. If which he created. you want to do this follow his 2020 after a long — John Baird illness. (1) He was a founding father plan. Start by creating a new or- of AAPL and was AAPL’s first Pres- Jonas was a “mensch” in every ganization, AAPL, with a singular ident and first Medical Director. (2) sense of the word. He was a role goal, continuing education for the Jonas was an important figure to many model, a wonderful teacher, a practitioners of the dark arts of of us. He was my teacher, mentor, and good friend, and a devoted spouse. forensic psychiatry with a yearly friend. After AAPL announced Jonas’ I knew him in many of these roles conference and its own profession- death I received anecdotes from all and admired him in all. I turned to al journal. Soon follow this up by over the world describing how Jonas him many times for support and creating a committee dedicated to was important in helping others in advice and he was always patient advancing sub-specialty training in this new specialty, and as soon their professional and personal lives. and generous. I will miss him as these fellowships were suffi- I thought the best tribute to Jonas greatly. ciently up and running develop would be to print excerpts from those — Elissa Benedek your own certifying exam and a comments, which I have edited for Like many others, I owe my foren- darn good one it was. And most content and space: sic career to Jonas. I had 2 areas important insist from the very I will never forget the time I was of special relationship with Jonas, beginning that only psychiatrists doing grand rounds at the Uni- photography and the Michael Re- could be full members of AAPL versity of Maryland and Jonas ese Hospital. In about 1990, Jonas and further that they had to be and Joan showed up at the talk in approached John Beahrs and me members of APA, potentially matching orange shirts and black at an AAPL meeting. He noticed AAPL’s best friend, and at the pants, and took me right from that we each carried cameras. He same time its biggest obstacle to there to the Orioles game at Cam- asked us to help him take photos at recognition. And, finally when the den Yards. He was a great guy. the AAPL meetings. John dropped time came you had to give up your — Paul S. Appelbaum off after a couple years, but I own darn good exam in favor of continued as Assistant Photog- more important recognition. That Jonas was so helpful to me in rapher. When I would describe was a hard one. But you cannot my early years in AAPL and so my appointment as the Assistant be a master builder just by having supportive later when we were Jonas, people knew what I meant. ideas in your head. You had to developing the website for AAPL. In my forensic work, I learned to have the positive personality I relished his wit - he had so many answer only the question asked. attributes, political adroitness, and wonderful ways of putting things. As the Assistant Jonas, I learned the absolute dedication to accom- My favorite was his advice about to do only the assigned task, not plish the goal. Jonas had all this risk management: “When in doubt, more. He did let me know that he plus personal warmth, an ability shout!” (Get a second opinion, appreciated my doing my assigned to listen and to formulate ideas formal or informal, and docu- tasks. Jonas did his internship at clearly and positively. All were ment it). The first time I cited his Michael Reese Hospital in Chi- part of his makeup. Jonas was a saying in a chapter draft, the editor cago in about 1950. He met Joan help to most all who sought out his wrote, “Love It!” next to it. I still there. She was a psychiatric nurse. help and support, and the most he say it whenever I am teaching I did my internship at Michael ever asked of anyone in return was residents about risk management Reese in 1972, and then psychia- arranging a good fishing trip. situations. Another favorite was try residency there, too. I enjoyed — Joe Bloom when he talked about the “nature reminiscing about Michael Reese and quality of the act” clause in with Jonas and Joan on several I interviewed Jonas for an article the M’Naghten Rule. “The nature occasions. Nothing lasts forever. in the Journal of Forensic Psychi- of the act? What? The defendant Now Michael Reese Hospital and atry in 1997, when I worked in thought he was shooting at a tree, Jonas are both gone. the UK. He suggested we talk in not a man. That’s not a question — Steve Berger (continued on page 5)

4 • Winter 2021 American Academy of Psychiatry and the Law Newsletter MEDICAL DIRECTOR’S REPORT

In Memoriam Society events, at AAPL, at APA, I first met Jonas in 1979 at the continued from page 4 at GAP, at committee meetings, in Del Coronado meeting. I was so his woodshop, and once fishing for impressed that I followed Joe his hotel bedroom in Denver at an bluefish. He made it possible for Bloom’s advice to me to join AAPL meeting. He spent part of me to survey Maryland psychi- APPL and pursue certification in the time sat propped up on his bed atrists for my PhD dissertation forensic psychiatry. It was the best and part of it getting dressed. He research. It seemed he spent every thing I ever did in my profession- was generous and helpful through- evening on the phone doing work al career. We will all miss Jonas. out to someone he had never heard for all the committees and organi- What a visionary and kind mentor. of who was asking him a series zations for which he volunteered. What a sad loss. of slightly impertinent questions. No one was more generous than — Robert P. Granacher, Jr. What made the strongest impres- Jonas in donating time and energy sion on me was the complete lack to the betterment of the profession, One of the giants, fallen; he was of pretension in a figure who was and his most prolific channels of the seed crystal for AAPL so many regularly described as the doyen of influence were organized psychia- decades ago. US forensic psychiatry. try and mentorship. Jonas did not — Thomas G. Gutheil — Alec Buchanan keep his opinions to himself. He had a way of telling you that you Jonas was very kind and nurturing I remember Jonas not only for were wrong without giving offense to all of us up-and-coming young- his foundational contributions or insisting you come around to er forensic psychiatrists. AAPL to forensic psychiatry and his his point of view. By 1982, when will be emptier without him. remarkable capacity to change we were teammates with Jim — Bruce Harry his mind, but also as a welcoming Cavanaugh and John Monahan in mensch for all seasons. May his the evaluation of John Hinckley, A rare kind of genius and founding memory be a blessing to us all as Jonas treated me as a colleague. greatness. “Reasonable medical we continue to learn to change our I like to think that Jonas took me certainty is not what I thought it own minds. under his wing, as he has so many was. It is neither reasonable nor — Harold Bursztajn others, and then set me free to find certain.” His words and deeds remain with us. I will always remember Jonas as a my way in the world. — James L. Knoll, IV warm, kind, supportive, inspiring We will all miss him, his kindly leader who blazed the trails that smile, and the way he emanated May we all have the positive im- we now traverse. His spirit and love. pact that Jonas had... influence lives on in each one of — Park Dietz — Jeffrey L. Metzner us. That is a wonderful gift from I am so sad and sorry too. I had a generous man. May he rest well the privilege of sharing Jonas’ APPL’s loss is Heaven’s gain. We in peace. birthdate October 16, so we’ve will miss him. We are sad. — Michael Champion exchanged birthday greetings over — Richard Rada So sorry to hear that Jonas has the years. He meant so much to died. He was a large and important many of us and was such a spiri- Lost a very good man. Worth figure in our field. tual and instrumental force in the remembering for a long time. — Brian Crowley development of AAPL, indeed of — William H. Reid our forensic psychiatry discipline. Jonas was the father of AAPL and — Alan Felthous (continued on page 6) the father figure to generations of AAPL members, many of whom he nurtured and mentored. I first met Jonas the evening before the 1971 APPL meeting in Pittsburgh, and he invited me to look him up if I were ever in Baltimore. Herb Thomas gave me his number, and when I moved to Baltimore as a medical student in 1972, Jonas invited me to his home to meet his family. For the next 10 years, we were in weekly contact, at his Court Clinic, at lectures he gave at Hopkins and the University of Maryland, at Maryland Psychiatric Dr. Rappeport, AAPL’s first president, cutting the cake at our 40th Annual Meeting celebration in Baltimore.

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 5 EDITOR’S COLUMN

and other groups, this is preaching AAPL Post-2020: More Reasons to Get to the choir. But for those who are new to AAPL, or who for whatever Involved reason have remained on the sidelines, Joseph R. Simpson, MD, PhD we encourage you to start partici- The world idential Address from AAPL’s first pating – join a committee, submit a is increasingly virtual Annual Meeting, as well as proposal for one of the 2021 AAPL complex. Scientific summaries of the Meeting’s featured virtual events, or write an article for advances accumu- speeches: Dr. Giamberdino’s talk on this newsletter. After the juggernaut late at a dizzying the substance abuse recovery journey, of 2020, the benefits of being part of pace. Keeping and Dr. Clark’s talk on workaholism an active, responsive and supportive up with the latest and how to have a better relationship professional organization are hard to technology in with work. You’ll also want to read overstate. computers and Dr. Burrows’ contribution from the On a different note I would like cell phones seems like practically a Early Career Committee on physician to thank those AAPL members who full-time job in itself. (Being helped burnout, and the proposal for a new filled out our brief survey. The results with tech by your children—or even Wellness Committee by Drs. Perkins suggest that the state of the Newsletter grandchildren—may be somewhat and Newman. is strong. While we welcome future embarrassing, but for many it is now Through that committee and other feedback and suggestions, for now just a fact of life.) Individuals, regions initiatives, AAPL is developing we plan to continue on pretty much and nations are more and more inter- resources for maintaining and increas- as before. Despite 2020 and the years connected for good and ill. The US ing your wellness. Participation in preceding it, technological changes political scene has reached a level of AAPL is a great way to remain con- haven’t completely swept away all the turmoil not seen for half a century. nected; it provides opportunities for old media paradigms yet, and we will The COVID-19 pandemic and networking and for a collegial expe- not be eliminating the print version several other national and internation- rience. These benefits are in addition any time soon. al developments in 2020 have made to the opportunities to increase your these recent trends in human affairs professional knowledge and expertise crystal-clear. To take just the scientific by attending AAPL educational events In Memoriam arena, whereas previously it typically and reading its publications. The em- continued from page 5 took at least 10 years to produce a phasis on wellness, and on improving Jonas could just easily say he or successful vaccine, several companies diversity and equity within the orga- we were wrong about something made COVID-19 vaccines, using nization, promises to add even more as insist on a truth or opinion. different approaches, in less than one value to your membership in AAPL. He fathered a profession. year. Meanwhile, the governments of You need not limit yourself to — David Rosmarin China, France and the US have ac- engagement with one professional knowledged their interest in using ge- body; you might want to consider He was enormously supportive to netic engineering or other biological volunteering with others (always us all and brought me into AAPL. methods to improve the performance keeping AAPL as your first priority, He played a major role in the of military personnel – or as some of course). There are numerous large establishment of our modern field. more sensationalistic media outlets and small professional organizations We will miss him. like to say, creating “super-soldiers.” to get involved in, such as the APA, — Howard Zonana The events of 2020 have been dif- the AMA, the AAFS (see the report ficult and stressful for many of us, in by Drs. Freitas and De Crisce in this References: our personal or professional lives, or issue), and the NCCHC, as well as (1) Kelley J. Dr. Jonas R. Rappeport, both. Of course, an impact in one do- state and local medical and psychiat- retired forensic psychiatrist who main of life almost always influences ric groups. In addition to educational worked on cases of attempted presi- others. By what could only have been benefits, many of these organizations dential assassinations, dies. Baltimore coincidence, AAPL’s immediate past monitor the legal and regulatory land- Sun. September 9, 2020. www.balti- president, William Newman, chose scape for our profession, endeavoring moresun.com/obituaries/bs-md-ob-jo- “Wellness in Forensic Psychiatry” as to improve bills that seek to change nas-rappeport-20200909-2imb- the theme for his presidential year. regulations on psychiatry, and to pre- v47htbcvner7cr4jv6zyv4-story.html And a fortuitous coincidence it turned vent bad bills from becoming laws. (accessed 10/22/2020) out to be. In this first post-2020 issue Forensic psychiatry can be a very (2) Janofsky JS, Tellefsen C. Jonas R. of the AAPL Newsletter, you will isolating specialty, particularly if one Rappeport, MD: Founding Father of find several articles addressing issues practices it exclusively. For those the American Academy of Psychiatry related to physician wellness and of you who already understand the and the Law. J Am Acad Psychiatry burnout. There is Dr. Newman’s Pres- benefits of engagement with AAPL Law 35: 290-293, 2007

6 • Winter 2021 American Academy of Psychiatry and the Law Newsletter FEATURED SPEAKERS

“Working Hard or Workaholic? Fostering Presidential Address continued from page 2 a Healthy and Productive Relationship aspects to one’s life unless they are out with Work” by Malissa A. Clark, PhD of necessity. Compartmentalization— Renée M. Sorrentino, MD not bringing stressful work aspects home—is a very worthwhile endeavor, In keeping with this year’s AAPL correlated with workaholism, and especially for forensic psychiatrists. Annual Meeting theme, Malissa A. was a risk factor for cardiovascular Studies show fewer inflammatory Clark, PhD, presented on the topic conditions. proteins and lower stress hormones in of “Working Hard or Workaholic? “Work engaged” is distinct from individuals with strong social support Fostering a Healthy and Productive workaholism. Work engaged refers networks. He emphasized that peer Relationship with Work.” Dr. Clark to an individual who is pulled as support is beneficial for addressing is Associate Professor of Industrial/ opposed to pushed to work and is burnout and workaholism as it can Organizational Psychology at the Uni- generally related to positive work mitigate the risks of chronic stress. versity of Georgia. According to Dr. outcomes. Having personally experienced severe, Clark and her research group, about Dr. Clark pointed out, however, that chronic stress and supported others one-fifth of us spend 60 hours or more one can be “too engaged” which can who have been stalked, he stated per week working, one-half of us feel lead to exhaustion and poor outcomes that it is important for him as AAPL overworked, and 77% of us fail to use over time. Dr. Clark addressed the President to develop an AAPL peer all of our earned paid time off. This impact of COVID-19 on work hours. support system for members to share “hustle” culture, highlighted by Elon Remote work in general tends to in- work experiences and provide support Musk’s proclamation of working an crease work hours. However, studies to each other. 80-hour work week, is embedded in examining work hours in the setting Dr. Newman explained that a dis- our society. But working long hours of COVID-19 have found that most cussion on burnout and stress should is only one component of “workahol- people have maintained their pre-pan- include a conversation about resilien- ism,” a term coined in the 1970s by demic work hours. cy, which is the process of adapting Wayne E. Oates, who authored the In conclusion, Dr. Clark identified well in the face of adversity, trauma, book Confessions of a Workaholic. an approach to fostering a healthy and tragedy, threats, or significant stress. Workaholism, or a marked compul- productive relationship with work. He also introduced the concept as sion towards work, consists of four Psychological detachment, a strategy referred to as “grit,” which stands for key dimensions: excessive hours or to decrease our cognitive ruminations “perseverance and passion for long- time beyond expectations, persistent, and rest for the next week is one ap- term goals,” and that this may be a uncontrollable thoughts about work, proach. Others included physical de- more useful tool for individuals to an inner pressure or compulsion tachment such as frequent, scheduled build with. He recommended a book towards work, and experiencing nega- break and psychical activity. Competi- by Dr. Angela Duckworth, who has tive emotions when not working. tive sports were the most effect sports been identifying and studying suc- Dr. Clark’s research included the activity in terms of reducing work-re- cessful and resilient individuals with development of a brief self-assess- lated stress. The number of steps “grit.” ment tool to evaluate one’s relation- traversed per day was correlated with Finally, he talked about endocrinol- ship with work. They found that greater end-of-the-day satisfaction ogist Hans Selye, who was one of the behavioral and motivational dimen- and work-life balance. Individuals earliest researchers on chronic stress. sions correlated with individuals who who were forced to take breaks and Dr. Selye said, “It’s not stress that were “perfection striving” compared days off were found to have higher kills us. It is our reaction to it” and, to individuals who were motivated job satisfaction and improved work “Adopting the right attitude can con- by perfectionist concerns or fears performance and delivery. In summa- vert a negative stress into a positive that their work would be criticized. ry, workaholism is associated with one.” These statements go hand-in- Research examining the outcomes more negative outcomes compared hand with “grit;” reframing the ways of workaholism include a variety of to being work engaged. Both can be in which one experiences work can be negative outcomes. Dr. Clark summa- detrimental and have the potential to the difference between work satisfac- rized the following outcomes: lower cause negative outcomes. tion and workaholism and burnout. life satisfaction, greater burnout, poor Dr. Newman ended his 2020 emotional and mental health, lower Presidential Address by relating that job satisfaction, relationship stress AAPL has been his professional home and greater work-family conflict. throughout his career, and sincerely Interestingly there was no significant thanked AAPL members for allowing relationship between workaholism him to serve as AAPL President. and work performance. Sleep was

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 7 FEATURED SPEAKERS

took oral naltrexone. Anthony Giamberdino, MD: When he eventually made it to Step Nine, he made direct amends to peo- Trudging the Road to Happy Destiny ple including to his colleagues at the Karen B. Rosenbaum, MD private practice job he had to leave, On the final day of AAPL’s 51st an- cet it was an “instant love affair” with and to his residency program. The nual meeting held over Zoom in lieu opiates and it was easy to continue his chairman of the anesthesia program of Chicago due to the pandemic, anes- habit through the fentanyl that was there offered him a three-month po- thesiologist Dr. Anthony Giamberdino left over from cases at work. He soon sition as a resident, and he gratefully spoke candidly about his “experience, became a daily user and managed to accepted it. He said he needed his strength and hope” in the tradition of live and work this way for a year. He ego to be broken so that he could be a twelve-step meeting, and explained explained that at this point, he had lost humble and teachable again. that he is a “recovering drug addict all illusion of control over his addic- A colleague eventually vouched for and alcoholic.” He works with the Illi- tion. Despite having a new adopted him and he was able to get the job nois Professional Health Program and baby, a private practice position with where he currently remains, west of has practiced anesthesiology for thirty an academic appointment, and a life Chicago in St. Charles, IL. He said years in the Chicago area. By telling that looked great on the outside, he that he was honest at his interview his own inspiring story, he focused on felt miserable inside. and said that with the grace of God physician wellness, the theme of the He said he tried every strategy to he is becoming someone who will meeting. “fix” himself. He did not reach out not use again. He was able to get his He explained that by telling his for help because he lived in fear of board certification when he had five story, he hoped to increase under- the consequences and he worried he years of proven abstinence. He also standing in case attendees ever find would lose his career and his mar- had to rebuild the trust in his marriage themselves, or their friends, family, riage. He also did not know anyone in and was able to do that and raise three or colleagues in a similar situation, recovery to speak to. children with his wife. The title of his and so that attendees could potentially When he was finally asked by work talk is from the Big Book of AA, and help a colleague in a similar situation to attend a meeting in which he was he feels that every day he is “trudging reintegrate their career. confronted about his using, he drove the road of happy destiny.” (1) Dr. Giamberdino explained that to a forest preserve and tried to kill Today Dr. Giamberdino is 31 years he had a good childhood and that he himself with a lethal injection, but sober and still goes to two meet- initially used “weed” and alcohol as instead woke up in an ICU two days ings per week; he has a sponsor and a teenager and in college mainly as a later with multiple complications. A sponsors others in the program. He reward, and for a long time even when doctor on the team recognized that explained that when someone shows using daily, he was able to juggle his his problem was due to substances up, does the right thing and is hon- use while being an excellent student. and discharged him to a program in est in this program, they naturally He was also a musician in a rock band Atlanta for physicians. become a leader. He is currently the growing up. In college, he did well In Atlanta, he learned the twelve medical director at the surgery center on the MCAT and decided on medical steps of Alcoholics Anonymous, start- and has been for fourteen years. He is school in the Chicago area where he ing with admitting he was powerless a leader in church, serving on coun- became AOA and compartmentalized over drugs and alcohol and that his cils and various committees. He also his using and drinking. He said that he life had become unmanageable. He maintained his affiliation with IPHP married his wife before his last year in became willing to do whatever they and is currently on the advisory board. medical school and stayed in Chicago told him to do. He explained that the While raising his children, he coached for residency where she was attending next eleven steps outlined a plan of on soccer and baseball teams and was graduate school. He said that initially action, which was a relief. involved with outdoor education and because he was working 80 hours per After spending three and a half other trips. week, the alcohol use toned down. months in the treatment center in Dr. Giamberdino explained that However, there were two significant Atlanta, he had to face the Illinois unfortunately over the past five or ten life events that occurred while Dr. licensing board. He was told that with years, healthcare has become more Giamberdino was in residency that professional aftercare and supervision, corporatized, with negative effects. accelerated his addiction. His mother he would be able to work again as an For example, he said that several tragically died after battling a long ill- anesthesiologist. He said he worked funding sources have been withdrawn ness and while cleaning, he found 100 the Twelve Steps and went to meet- from the IPHP. He has noticed that it Percocet pills in her medicine cabinet. ings, completed an aftercare program, is now harder for a recovering physi- Also, in residency, his wife was diag- and was able to secure advocacy cian to get a second start. He lamented nosed with choriocarcinoma after a from the Illinois Professional Health that it is a “terrible, tragic irony” that miscarriage and started treatment. He Program (IPHP). He complied with we have a healthcare system where said that once he started using Perco- random drug screenings as well and (continued on page 9)

8 • Winter 2021 American Academy of Psychiatry and the Law Newsletter Anthony Giamberdino There were numerous questions for spiritual program, not a religious one, continued from page 8 Dr. Giamberdino after his talk. He and that someone only needs to find a explained that sometimes recovering “higher power.” In addition, the only our job is to help and heal people, physicians could potentially run into requirement for AA membership is a but the system will not allow us to do patients at AA meetings, but worrying desire to stop drinking and/or using. that for ourselves. He said that when about that should not keep a physi- He explained that just as a diabetic the opportunity arises, it is rewarding cian from AA. The culture in AA is will risk going into DKA if they stop to help people in this situation, but that everything is anonymous and insulin, someone with addiction could they have to want to get better and be confidential. There are always other risk relapse if they stop going to meet- willing to do anything. meetings to go to, especially now that ings. He acknowledged that although Dr. Giamberdino clarified that peo- everything is on Zoom. Currently, a there are other recovery programs out ple with good recovery are grateful person can go to a meeting anywhere there, AA is the only program that and take full responsibility for their in the world. he knows of that has a decades-long prior behavior. Physicians in recov- Dr. Giamberdino further explained track record of success. ery admit the consequences of their that AA saved his life, and IPHP saved In conclusion, Dr. Giamberdino’s past behaviors and are willing to his career. He said that sometimes he heartfelt presentation emphasizes the comply with any reasonable request has a thought of using again like most importance of physicians, especially to ensure the safety of their practice people in recovery, but he explained psychiatrists and forensic psychia- and patients. He explained that people that a sponsor told him that the key trists, understanding the program of with addiction cannot fix themselves is thinking it through and playing the Alcoholics Anonymous so that we but that there is help available and it tape forward. He knows that using can educate our patients, colleagues, is important to ask for it. He said that will eventually lead him to the back of friends, family members, and the he is living proof that there is a life a pickup truck with an IV in his foot, courts when necessary on the benefits beyond addiction, and that it is more so he does not take the first drink. He of the program, and dispel any myths fulfilling than his wildest dreams. He explained the common triggers using that could keep people from getting said that despite the difficult road, his the acronym HALT (Hungry, Angry, the help that they need. story needed to be what it was so that Lonely, Tired) and that ties into the importance of physician wellness and Reference: he could be speaking to us on October th 25, 2020. self-care. He explained that AA is a (1) Alcoholics Anonymous Big Book-4 Edition (2001)

SEEKING CLINICIANS AND FELLOWS FOR RESEARCH PARTICIPATION (COMPENSATED) Forensic Psychiatrist Joseph Penn Is New Chair of NCCHC Board We seek participants for a study of clinical decision-making in forensic evaluations. Participants must be clinicians in the U.S. with a terminal Chicago – Joseph Penn, MD, CCHP-MH, has been elected doctoral degree (e.g., M.D., Ph.D., Psy.D.) and some form of field experience chair of the National Commission on Correctional Health Care in forensic evaluation (supervised or unsupervised). Those currently in Governance Board. supervised practice (post-docs, fellows, residents) are eligible. He is director of Mental Health Services for the University of Participants review online case materials and conduct a mock criminal re- Texas Medical Branch (UTMB) Correctional Managed Care sponsibility evaluation (prior criminal responsibility evaluation experience program, which provides health care services in approximately not required). Approximately 60-90 minutes to complete. 90 adult and juvenile correctional facilities throughout the state Participants receive $150.00 in compensation. of Texas. He is also a clinical professor in the UTMB Depart- ment of Psychiatry. To participate, follow the link below (or paste into your Internet Browser): Dr. Penn has served on the NCCHC board since 2003 and https://iup.co1.qualtrics.com/jfe/form/SV 4Gi8ZAwf5oAzPgx was previously board chair in 2008-2009. He is currently the Questions my be referred to the co-Pls: American Academy of Psychiatry and the Law board liaison; previously, he was liaison of the American Academy of Child Anthony Perillo, Ph.D. ([email protected]) and Adolescent Psychiatry. He has chaired the accreditation and Jennifer Perillo, Ph.D. ([email protected]) juvenile health committees, served on multiple task forces to Indiana University of Pennsylvania revise NCCHC standards, and served on the editorial board of Department of Psychology The Journal of Correctional Health Care. He also is a physician 1020 Oakland Ave. surveyor for NCCHC. Indiana, PA 15705 Dr. Penn is triple board-certified in general psychiatry, child and This project has been approved by the Indiana University of Pennsylvania adolescent psychiatry, and forensic psychiatry by the American Institutional Review Board for the protection of human subjects Board of Psychiatry and Neurology. ([email protected]; 724-357-7730

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 9 ASK THE EXPERTS recognition of one’s limits, including Ask the Experts the willingness to acknowledge ex- Neil S. Kaye, MD, DLFAPA pertise beyond one’s own. It is very difficult to walk this line, as over- Graham Glancy, MB, ChB, FRC Psych, FRCP confidence is associated with persua- Neil Kaye and Graham Glancy will and with society’s tendency to reward siveness, especially when espoused answer questions from members relat- projected confidence over humility. by a court admitted expert and hiring ed to practical issues in the real world When scientists offer caveats instead lawyers look for persuasive experts. of forensic psychiatry. Please send of absolutes, the uncertainty we are A recent New Jersey Appellate case questions to [email protected]. trained to acknowledge makes it (4) provides some guidance specific This information is advisory only, sound as if we don’t know what’s to psychiatric expert testimony. The for educational purposes. The authors really happening. This creates op- court gave a thoughtful analysis of a claim no legal expertise and should portunities for people who present as scientific report in terms of objectivity not be held responsible for any action skeptics to undermine our profession and providing a basis for an opinion. taken in response to this educational and our testimony. Although psychiatry has little in the advice. Readers should always consult The idea that there are no experts way of objective diagnostic tests, the their attorneys for legal advice. (Douthat) is overly glib (2). The issue court noted that expert reports cannot is more that modern expertise tends to be admitted if they simply repeat Q: How do you define “expert?” be deep, but narrow in their expertise. the subject’s reporting of subjective Even within a hard science such as symptoms. There must be more. The A. Kaye: epidemiology, someone who studies objective piece, then, should be what Expertise is not infectious diseases knows more about the expert brings to the table. Al- just about knowl- epidemics than, say, someone who though excellence is not necessarily edge, but also studies nutrition. Our work as forensic the standard, expert witnesses must do about the capacity psychiatrists demands both depth and more than fact witnesses–if they want to spot errors. breadth of expertise. to give opinions. The court makes its Without affirma- A major area of concern should be reasoning clear and insists on a stan- tive action, efforts that knowledge is tinged by confirma- dardized diagnostic approach, gives to be thoughtful, tion bias. When doing our work as credence to objective testing, and also and practice, most of us are more scientists we should be happier when stresses methodology in reaching an likely to fall in the former group than we find people, opinions, viewpoints opinion, which I favor and believe is the latter. Humans hunger for infor- and/or facts with which we disagree. what Daubert (5) is about. mation, but often lack the know-how This provides the opportunity to to evaluate it or the sources that we reconsider our methodology and A. Glancy: reference. This is the epistemolog- processes, and can enlighten our for- I remember ical crisis of the moment: there’s a mulations, conclusions, and ultimate very early on in lot of “expertise” around, but fewer opinions. my career being tools than ever to distinguish it from Knowledge is often thought of as called as an expert everything else. “Pure credentialism” a quantity of information. A person in Superior Court doesn’t always work. A well-creden- who “knows” a lot is often referred and being cross-ex- tialed person may not really be an to as knowledgeable. The Internet amined on my CV. expert and their ability to teach to a has become the font of knowledge In particular I was asked how many trier of fact may be woefully lacking. in today’s world. Many people turn times had I been qualified as an expert Or, their viewpoint may be tainted to the Internet for answers and in the in court and I answered that I had by significant bias or an undisclosed medical world, we are constantly been qualified on one occasion previ- agenda. faced with the idea that “Dr. Google” ously. The distinguished judge peered Real experts have experience in has the answer to all of our medical at me and, accepting me as an expert making decisions and knowledge problems. In reality, Google is a great in forensic psychiatry, stated, “Well, of how things usually play out in a example of endless knowledge with he is the only expert that we have here similar set of circumstances. This no expertise. It is no surprise that so I suppose he’ll have to do.” idea is reflected in Gladwell’s book Internet-based medical diagnosing This is a simple question that is Outliers. (1) Education, fellowship is accurate only about 50% of the very difficult to answer. I can ap- training, and clinical practice are part time. (3) While the hope for artificial proach this in two ways: First ,what of becoming an expert, but they alone intelligence remains high, there is is the legal definition, and second, cannot substitute for experience. still no substitute for an experienced how is an expert defined outside of A lack of expertise becomes espe- physician! the legal forum. cially problematic when it is com- In court, the strongest attractor of bined with extreme overconfidence, trust shouldn’t be confidence, but the (continued on page 11)

10 • Winter 2021 American Academy of Psychiatry and the Law Newsletter ASK THE EXPERTS

The admissibility of expert evidence Take Home Points: Ask the Experts The difference between knowledge continued from page 10 has been subject to various legal decisions. In Canada, the prevailing and experience is a critical distinction At the most basic level an expert decision is R v Mohan (13), which set to keep in mind. You will notice Dr. witness could be said to be somebody out four factors that should be consid- Glancy’s inclusion of his wife’s pub- who possesses the necessary expertise ered. These included the relevance of lications in his citations. There is no in a given field. Most particularly, the the evidence; the necessity of the evi- doubt he is a true expert! expert must strive for objectivity and dence; the absence of an exclusionary honesty (6, 7) and give their opinion rule; and the assurance that the expert References: in a non-partisan manner, which is was properly qualified. In the Unit- (1) Gladwell M. Outliers : the story of suc- free of conflict. Gutheil and Simon ed States, two major cases prevail, cess. New York :Little, Brown and Compa- (8) discuss the inherent tensions in the namely the general acceptance rule ny, 2008 (2) Douthat R. “In the fog of Coronavi- relationship between forensic experts (14) and more comprehensively, the Daubert decision (5). This case cited rus, there are no experts.” www.nytimes. and lawyers, stemming from the com/2020/04/07/opinion/coronavirus-sci- different roles that they adopt. Most three additional factors beyond the ence-experts.html. New York Times, Apr 7, importantly, the expert witness must general acceptance rule, which includ- 2020 adhere to the duty to provide fair, ed whether the theory or technique is (3) Park A.: Should you diagnose yourself objective, and non-partisan assistance testable and has been tested; whether online? time.com/5230797/online-symp- to the courts. In a recent Canadian the theory or technique has been tom-checkers-is-it-safe/. Time Magazine. case, the judge was charged with the subjected to peer review; and whether April 4, 2018. gatekeeper function of ensuring this, the error or potential rate of error has (4) HKS v Kensey. Superior Court of NJ, prior to admitting expert evidence been identified. Appellate Division, #A-1329-18T2 (9), as opposed to this issue going to Perhaps most importantly for foren- (5) Daubert v Merrell Dow Pharmaceuti- cals, [1993] 509 U.S. 579 weight as it did previously. A fre- sic psychiatrists is a consideration of whether we can give an objective and (6) AAPL, Ethical Guidelines for the Prac- quent role conflict is between the con- tice of Forensic Psychiatry. (2015) Retrieved cept of providing treatment and that of honest opinion that is not advocacy, from www.aapl.org/ethics.htm providing expert opinion. Strasburger considering the limits of our expertise, (7) CAPL, Ethical Guidelines. (2018) and others (10) describe this conflict and educating the courts. Retrieved from http://www.capl-acpd.org/ in an important paper, which has been Regehr (15) defines, at the basic ethical-guidelines/ enshrined in the ethical principles of level, an expert as one who pos- (8) Gutheil TG, Simon RI. Attorneys’ pres- forensic psychiatry. sesses authoritative knowledge or sures on the expert witness: early warning Interestingly, Canadian courts have basic skills. She emphasizes that the signs of endangered honesty, objectivity, and come to an awkward compromise expert’s expert possesses intuitive fair compensation. J Am Acad Psychiatry Law 27: 546-553, 1999 on this issue, differentiating between decision-making and problem solv- ing, beyond simple knowledge. She (9) White Burgess Langille Inman v. Abbott ‘litigation experts’ who may be and Haliburton Co, [2015] 2 SCR 182 forensic experts retained for the case; outlines the contrasting theories of (10) Strasburger LH, Gutheil TG, Brodsky and ‘participant experts’, for instance, whether expertise is inherited or the A. On Wearing Two Hats: Role Conflict in treating physiotherapists or rehabil- result of what Ericsson calls delib- Serving as Both Psychotherapist and Expert itation specialists (11). The role of erate practice. I argued for the role Witness. Am J Psychiatry 154: 448-456, forensic expert therefore is to under- of “deliberate practice” (16), the 1997. take a search for the facts of the case, kind that makes you sweat, but with (11) Westerhoff v Gee Estate, [2015] ONCA supported by evidence-based tests good coaching, delivering actionable 206 and come to an objective opinion. It feedback. This was supported by a (12) R. v. Lavallee, [1990] 1 SCR 852 is common in forensic practice to qualitative study that I performed (17) (13) R v Mohan, [1994] 2 SCR 9 (14) Frye v United States, [1923] D.C.Cir. review collateral information, such as interviewing some of the “Greats” of forensic psychiatry, who all sponta- 293 F. 1013 that provided by informants who may (15) Regehr C. Stress trauma in decision have relevant information. A number neously said that working 60-80 hours making for social workers. New York: of cases in Canada have reviewed this in at least the first ten years of their Columbia University Press, 2018. practice (12) and have ruled that ex- career, corresponding to Gladwell’s (16) Glancy G. The Mock trial: Revisiting perts are allowed to use what amounts 10,000 hours, helped them become a Valuable Training Tool. J Am Acad Psychi- to hearsay evidence but, if these facts an expert’s expert. Most of us strive atry Law 44: 19-27, 2016. are not proven in court, this goes to merely for “competence;” Dreyfus (17) Glancy G, Miller D. Perspectives on the weight of the expert opinion. If (18) describes a five-stage model, Excellence in Forensic Psychiatry. Int J relying on this evidence, therefore, it where the progression goes from nov- Risk Recovery, submitted. is important to communicate with the ice to advanced beginner to compe- (18) Dreyfus H and Dreyfus SE. Mind Over tence to proficiency to expert. Machine: The power of human intuition and retaining attorney and suggest that expertise in the area of the computer. New this evidence be proven prior to your York: The Free Press, 2000. final opinion.

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 11 SPECIAL ARTICLE

day after she arrived at the psychiatric Massachusetts General Hospital v. unit, but six days (four business days) CR: after she presented to the emergency Due Process Regarding Emergency room. The question before the municipal Department “Boarding” Prior to court was whether the three-business- Involuntary Psychiatric Hospitalization day time limit under Section 12(b) Ren Belcher, MD – after which the hospital must either discharge the patient or file a civil Patients in psychiatric crisis are of- involuntary psychiatric evaluation commitment petition – should start ten “boarded” in an emergency room into two distinct phases. The first, from the time a patient is admitted to or medical floor of a general hospital Massachusetts General Law Chapter an emergency room rather than the while waiting for an appropriate psy- 123 § 12(a) (“Section 12(a)”), allows time they are admitted to a psychiat- chiatric placement (1-4). The frequen- several types of mental health clini- ric hospital. The court found in favor cy and duration of boarding appear cians and police officers to transport of CR, arguing that if the clock only to have increased in recent years and hold for preliminary evaluation began when the patient arrived at a given the rise in psychiatric visits to any person whom they have “reason psychiatric facility, “a hospital could emergency rooms without concordant to believe” may be at risk of harm indefinitely detain psychiatric patients expansions in available resources (1, to themselves or others. The second in an emergency department while 5). In Massachusetts, where the pres- phase, “Section 12(b),” requires waiting for an open bed. Indefinite ent case was decided, the Department a more thorough assessment in a restraint without any due process of Mental Health (DMH) reported 481 psychiatric hospital if the admitting is, on its face, the most egregious patients boarding over 96 hours in the physician at a DMH-certified facility infringement upon a person’s fun- first year of a program designed to finds that there is a “likelihood to damental right to liberty and cannot expedite psychiatric placement (6). cause harm” if the patient is released possibly be harmonized with § 12(a).” For patients involuntarily brought – a higher threshold than that required (Ref. 13, p. 10) The court ordered that to care, boarding can be especially for the initial evaluation. “§ 12’s three day detention period problematic: delays in a medical Importantly, Section 12(b) is limited begins when a patient arrives at an hospital can add to the amount of time to three business days, while Section emergency department or psychiatric patients are detained, may aggravate 12(a) does not have a statutory time facility.” (Ref. 13, p. 11) It directed psychiatric symptoms (7), and may limit. The question of due process emergency rooms to release detained offer fewer due process protections during a prolonged Section 12(a) hold patients after three business days of than patients would receive in a was initially raised by the appellant boarding, regardless of outstanding psychiatric hospital. Relevant case CR in CR v. Massachusetts General safety concerns. history on this topic includes In Re: Hospital (13), heard by the Appellate MGH appealed this decision, and the Detention of D.W., et al, decided Division of the Boston Municipal in Massachusetts General Hospital v. in 2014 by the Washington Supreme Court in September 2019. CR had CR (6), the Supreme Judicial Court Court (8), highlighted in forensic been detained by police after exhib- reversed the lower court’s ruling: psychiary articles (9, 10), and cited in iting disruptive behavior. A Section the Massachusetts General Hospital v. 12(a) hold was initiated by police Although the § 12(a) time period CR decision. The court ruled that the and the patient was brought to the for application to and acceptance common practice of emergency rooms emergency room of Massachusetts by an authorized facility has seeking a “single bed certification” General Hospital (MGH) for invol- extended beyond the Legisla- to hold psychiatric patients under the untary psychiatric evaluation. While ture’s original expectations, the state’s initial 72-hour and subsequent in the emergency room, CR was Legislature has not yet chosen to 14-day emergency commitments (in significantly agitated. The consult- include a specific deadline despite lieu of an available psychiatric hos- ing psychiatrists determined that she its recognition of the issue. Ab- pital) violated the state’s Involuntary would require psychiatric admission, sent demonstrated constitutional Treatment Act (11). The court found and further that she would need a pri- violations, we will not impose a that involuntary detention for psychi- vate room. It took five days to secure specific requirement ourselves. atric purposes was lawful only when admission to a suitable psychiatric As applied to CR, we conclude it occurred “in certified evaluation bed on MGH’s inpatient psychiatric that the statute did not violate due and treatment facilities,” clarifying unit, during which time CR boarded process, as the § 12(a) period of that “this definition does not include in the emergency department. When confinement was no longer than hospital emergency rooms.” (Ref. 8, CR was ultimately admitted, the necessary given the difficulty of pp. 8-9) inpatient psychiatrist filed a petition finding her an appropriate place- In Massachusetts, the emergency for civil commitment and involuntary ment. (Ref. 6, pp. 34-35) commitment statute (12) divides treatment. This petition was filed one (continued on page 29)

12 • Winter 2021 American Academy of Psychiatry and the Law Newsletter IN THE MEDIA

One of the earliest case rulings All Rise, the Judge has Entered the relating to the appropriateness of tele- court, at least for civil commitment, Zoom Call was US v. Baker, 45 F.3d 837, 840 (4th Ryan C.W. Hall, MD Cir. 1995) (4). That ruling came about For this edition of In the Media, we depending on jurisdiction. Many due to the Eastern District of North are going to be looking at news arti- jurisdictions allowed for an expert or Carolina partaking in a pilot program cles related to COVID-19. On May other witness to testify via technology, related to commitment hearings using 20, 2020, the MSN website posted either by telephone, video stream, or videoconferencing. Baker raised the article “Singapore slammed for taped deposition. Many jurisdictions concern that telecourt violated his due ‘cruel’ Zoom death sentence” by AFP also allow for lower-level process- process rights under Federal statute and “Man in Singapore Sentenced to ing hearings to occur via telecourt. (18 USC § 4247d) and cited landmark Death by Hanging Via Zoom Call” by However, some court business has to case law such as Vitek v. Jones. (5) Newsweek. (1, 2) The articles dis- be conducted with the judge and the One of the issues that Baker raised cussed the case of Punithan Genasan, defendant in the same room unless the was that a key factor, especially for who is a Malaysian citizen who was defendant had waived their right to commitment hearings, was the im- sentenced to death for drug traffick- be present. For example, the Flor- pression that a respondent makes on ing. (1, 2) Due to the sentence being ida Supreme Court had prohibited the presiding judge. The court reject- handed down during the COVID-19 judges from presiding over mandated ed this claim, indicating that judges pandemic, Mr. Genasan received the telecourt civil commitment hearings. were more likely to be swayed by judge’s sentence via Zoom. Singa- The rationale provided was similar documentary and testimonial evidence pore, like many countries at the time, to the concerns raised in Singapore – of the respondent’s mental state. In had engaged in social distancing and that people needed to have access to terms of the defendant’s impression had closure of most businesses. At the judge; realize that the hearing had of a court hearing done by teleconfer- the time, the city-state of Singapore, weight/significance, for lack of a bet- ence, the court stated in its opinion: which has a population of roughly ter word; and have a sense that the ju- 5,800,000, had 29,000 COVID-19 dicial branch respected the dignity of With regard to the notion that a cases and 22 deaths from the virus. (1) the individual. As noted in the opinion respondent may lose confidence Apparently, this was the second death issued by the Florida Supreme Court in a hearing conducted by video sentence to be issued by Zoom, with in their ruling in John Doe v. State of conference, the government the first occurring in Nigeria earlier in Florida (3): properly notes that such a concern the month. (2) is, in general, largely irrelevant Watchdog groups, such as Human [J]udicial officer’s physical to the constitutionality of the pro- Rights Watch and Amnesty Interna- presence over such hearings is a ceeding. Quite often, as the gov- tional, criticized the sentencing in constituent component of his or ernment appropriately observes, Singapore as cruel and inhuman. (1, her ministerial duty to preside criminal defendants lack confi- 2) The Deputy Director of Human over a trial or evidentiary hearing. dence in a criminal proceeding Rights Watch, Asia Division, Phil (Ref. 3, p. 1032) conducted with the full panoply Robertson, was quoted as saying: of constitutional protections. In Of note, prior to the ruling related other words, there is no constitu- It is pretty astounding. The prose- to civil commitment hearings, the tional right to a hearing in which cutors and the court are so callous state of Florida also had a similar pro- the participants have confidence. that they failed to see that a man hibition on juvenile court appearances (Ref. 4, p. 846) facing capital punishment should being conducted by teleconferencing, have the right to be present in which was also referenced: Since the ruling in Baker, the APA court to see his accusers. (1) issued a Resource Document on Tele- In our view, solutions to many of psychiatry via Videoconferencing in Although the death penalty was an the troubling issues in our crimi- 1998, which supported allowing use obvious focus of the original articles, nal justice system may be found of video conferencing for conducting this column is going to primarily fo- in proper, early, individualized a commitment hearing. (6) In addition, cus on the aspects of the incorporation intervention in a young life and there have been psychiatric papers of technology into the court room and not in the mechanical and robotic discussing various states’ uses of tele- whether “telecourt” is an acceptable processing of numbers. Respect court for psychiatric treatment. For venue for judicial hearings in Amer- for individual begets respect example, an experimental trial of tele- ica in general. Prior to COVID-19, while we fear coldness and steril- court hearings in a Michigan jurisdic- there had been various policies and ity may breed contempt. (Ref. 3, tion, published in 2007, (6) estimated allowances for use of telecourt, p. 1030) that over five years telecourt usage (continued on page 30)

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 13 AAPL ANNUAL AWARDS

James Knoll, MD Stephen Billick, MD the awarded the 2020 2020 Gold AAPL award Seymour Pollack Award winner for his many for his distinguished significant contributions contributions to to the field of forensic the teaching and psychiatry. educational functions of forensic psychiatry.

The Best Teacher in a Fellowship (Howard Aaron Panner, JD is the Zonana Award) 2020 2020 Amicus Award recipient was Ryan winner for his many Wagoner, MD. This is contributions to AAPL. awarded each year to outstanding faculty members.

Alan Newman, MD received the 2020 Submit your nominees Red AAPL award for his longtime for the 2021 AAPL Awards to outstanding service to Dr. Scott at [email protected] AAPL dedication to the by June 1. Contact [email protected] organization through committees, task forces for more information or questions. and much more.

14 • Winter 2021 American Academy of Psychiatry and the Law Newsletter COMMITTEE PERSPECTIVES

ders and their prevalence, etiologies Effects of Media on Psychiatrist and of the disorders, treatments and side effects, and dangerousness associated Patient Wellness with certain illnesses. Dr. Kambam Karen B. Rosenbaum, MD; Praveen Kambam, MD; Vasilis K. Pozios, MD; defined mental illness stigma as Ryan Wagoner, MD; and Susan Hatters Friedman, MD “the pervasive degradation, social Media and Public Relations Committee judgment, and devaluation of people because they have psychiatric symp- The Media and Public Relations portrayed, including hydrotherapy and toms or have been labelled as having Committee presented the panel Effects lobotomy for people attracted to the mental illness.” Both self-stigma and of Media on Psychiatrist and Patient same sex. public stigma exists, and there can be Wellness during the AAPL 2020 Re- Dr. Rosenbaum explained that affiliate stigma as well. An example of mote Meeting. It illustrated the ways besides character and language, other effects on behaviors of individuals is a in which various types of media can techniques are used in cinema and contagion effect, in which depictions contribute to stigma related to mental television to depict mental illness as may exacerbate harmful behaviors in illness and psychiatry and the ways in dangerous such as music, lighting, susceptible individuals. For example, which psychiatrists, especially foren- sound effects, and horror conventions. after Netflix’s first season of Thirteen sic psychiatrists, could help coun- (3) News coverage in the U.S as well Reasons Why, a series about teenage teract these messages and promote as internationally has also perpetu- suicide, aired, there was an increase patient and psychiatrist wellness. ated mental illness stigma. In 2019, in psychiatric hospitalizations for sui- Dr. Rosenbaum discussed some President Trump was quoted as saying cidality. The movie Joker (7, 8) which of the recent literature from around of mass shooters after the tragic both conflated mental illness and vi- the world examining the relationship events in Dayton, OH and El Paso, olence and offers a cultural script for between media and mental illness TX, “These people are mentally ill. violence, especially relevant for threat stigma. Media can be in the form of And nobody talks about that.” (4) A assessment, was discussed. Internet, television, radio, podcasts, study in Germany demonstrated that Dr. Pozios continued the presenta- newspapers, movies, magazines, when people read an article associat- tion, highlighting indirect pathway newsletters and other forms of print ing mental illness and violence, they effects on individuals with mental media. Media acts as a mirror of soci- were more likely to later describe a illness through media influences on ety and in turn influences society (1); person with mental illness as violent. societal knowledge, attitudes and this is especially true with social me- (5) In Japan, Aoki et al explained that behaviors. He explained the Social dia. There are multiple ways in which when the Japanese word for schizo- Cognitive Model of Stigma, in which media can use devices to negatively phrenia was changed from meaning cues lead to stereotypes that lead to portray persons with mental illness “Split-Mind Disease” to “Integration prejudice which results in discrimina- including the way in which informa- Disorder,” newspaper articles asso- tion against groups or individuals. He tion is framed. (2) If violent language ciating people with schizophrenia described various impacts of mental is used in depicting someone with and violence decreased in number. illness stigma including loss of job mental illness, this can negatively (6) Overall, research in this area has and income, loss of housing, loss impact the ways in which the public shown some improvement in decreas- of social interactions, and increased views people with mental illness. ing the stigma of mental illness in interactions with the criminal jus- Dr. Rosenbaum and Dr. Kambam countries that have made a concerted tice system. Dr. Pozios additionally both discussed a recent example, effort in this area, however there is focused on effects of media depic- examining the series Ratched, on Net- still a long way to go, especially in the tions on societal beliefs and attitudes flix, that can perpetuate stigma related United States. toward individuals in the forensic to mental illness and psychiatry. The Dr. Kambam introduced other psychiatric system, emphasizing limited series is based on the character television shows about mental illness common NGRI myths. He concluded of Nurse Ratched from the book and such as Never Have I Ever, Atypi- that progress of media depictions on movie, One Flew Over the Cuckoo’s cal, BoJack Horseman, Euphoria, forensic-related topics lags behind Nest. The series favored style over Homeland, and The Punisher. He other mental health topics and that substance. The State Hospital was explained that media has effects on there is an opportunity for forensic luxurious, with bright colors, and the both the individual, through direct psychiatrists to improve the wellness nurse’s perfectly tailored and ironed and indirect pathways, and soci- of individuals with mental illness by uniforms matched the turquoise fur- ety. Media depictions can affect an interfacing with the media. niture. However, the barbaric nature individual’s knowledge, attitudes and Dr. Wagoner discussed dealing with of treatment for mental illness was behaviors regarding mental health bad press and the impact this can have highlighted, even in the context of it matters. Knowledge-based errors on the psychiatrist. He discussed four being set in 1947. Many confound- about mental health information may tips for dealing with this, including ing diagnoses and treatments were include misconceptions about disor- (continued on page 31)

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 15 COMMITTEE PERSPECTIVES

ER Doctor-Summary: Telepsych Teleforensics: Standard of Care and consulted for possible depression and told she has attention-seeking Malpractice in Telepsychiatry-Workshop behavior. No psychiatric medi- Presented at AAPL Annual Meeting, October 27th, 2019. cations were ordered. Discharge Neil Kaye, MD; Manish Fozdar, MD; Michael Syffert, MD; Rami Abukamil, home. MD; and Donna Vanderpool, MBA, JD. Forensic Neuropsychiatry Committee and Private Practice Committee Two hours later, the family calls 911. • EMS notes: Found patient supine Electronic means of communica- ate mood and affect. The ER doctor in bed, responsive only to painful tion and incorporation of data into felt this was likely depression, and a stimuli. The family says she was the clinical practice of medicine has telepsych consult was initiated. released from the hospital today been underway for over a decade; it and delivered by ambulance in has come to be known as telemedi- • Telepsychiatrist’s note: Video this condition. cine. This same technology has been call with patient. Consulted for • The family stated that the patient used similarly in forensic psychiatry depression. Patient reliability was faking her condition and for nearly as long. In clinical work, fair. Patient presented lying in a that there was nothing medically the standard of care for telemedicine hospital bed, lucid, uncoopera- wrong. (SOC-T) is precisely the same as that tive, refusing to directly answer • Has been malnourished for past in an in-person or face-to-face setting questions when asked, and re- couple of months. (SOC), a premise of all State laws quired her nurse to repeat every- • She was unwilling to open her governing its practice. Despite this thing. She denied anxiety, depres- eyes, and when opened manually, legislative decree, there is little data sion, sadness, crying spells, loss she would clinch them closed. on care outcomes, whether they differ, of appetite, sleep disturbance, or and whether doctors believe that com- suicidal ideation, plans, or inten- She was transported to the hospital pliance with the law is even possible. tions. She could not explain why where ER notes reveal: This workshop was highly interac- she was in the hospital but denied • At the hospital, she opened her tive and used the audience response any physical issues or medical eyes willingly and began looking system (ARS) to gather data from the problems. She denied any A/V around spontaneously. She start- participating AAPL members. Seven- hallucinations or delusions. She ed to speak and answer questions ty-five percent of the responders were denied she was experiencing any correctly. board-certified, 43% have been in pain or discomfort but did appear • Differential diagnosis: confusion, practice for over ten years, 27% 6-10 to grimace a few times during the dementia, CVA, TIA, hypoglyce- years, and 30% were in their first five evaluation. She denied any past mia, UTI, pneumonia, drug abuse, years of practice. psychiatric history. delirium, dehydration, electrolyte The fictitious case used for the • No change in sleep, eating, no imbalance, depression, anxiety, workshop is an amalgam of four suicide risk, no homicide risk, intracranial hemorrhage. actual medical malpractice (med-mal) low elopement risk, no self-mu- • Head CT normal. cases provided by the presenters and tilative risk, denies aggression. • Neurologist. Multifactorial en- was chosen for the neuropsychiatric Psychomotor retardation. Affect cephalopathy. perspective but also because one of constricted. Calm. Uncoopera- • Rare alcohol consumption the leading cases in telemed-malprac- tive attitude. Thoughts logical, • Admit tice is quite similar. This article is clear with unremarkable content. intended to focus on the SOC-T issue. Speech halting. The following day: Case: A 42-year old woman, weigh- • Impression: Patient does not • Brain MRI. Abnormal Flair and ing 275 pounds, but with a 150-pound appear to suffer from a mental T2 hyperintensities within the weight loss over the prior year pre- illness, denies any depressive base of the brain most suggestive sented to the hospital ER. She had in- symptoms, denies any thoughts of of Wernicke’s encephalopathy termittent vomiting and nausea, short- self-harm, and is not an imminent (WE.) ness of breath, fatigue, and weakness. threat of harm or incapacitated • Started thiamine iv Medications were non-contributory. A due to a serious mental illness. psychiatric evaluation did not reveal • Her behavior appears volitional in However, plaintiff: anxiety or depression, and she was nature and may be a subconscious • Never recovered sent home. means of appearing dependent, • Now fully dependent Five days later, she presented again so she can be taken care of by her at the ER, alert but not oriented, with family and/or medical profession- Plaintiff’s forensic neuropsychiatric an altered level of consciousness, con- als. Discharge home with support. expert opines: fused, uncooperative, with inappropri- (continued on page 31)

16 • Winter 2021 American Academy of Psychiatry and the Law Newsletter COMMITTEE PERSPECTIVES

cognitive exercise of conceptualizing Recovery: Now, More Than Ever services as centered around the per- Eugene Lee, MD son. Consider that “[t]he social con- Recovery Committee tract that has created forensic mental health systems demands not only the Prior to fellowship, I understood from forensically-involved persons, detention and risk management of our little of “recovery” outside of addic- the psychiatrist’s impact becomes patients, but also the rehabilitation of tions. Many of my patients spoke of even more crucial to empower them those self-same patients.” (Ref. 6, p. “being” in recovery and on personal for successful behaviors. 2) Thus, working in the forensic sys- journeys punctuated with hard-earned “Recovery” may sound pleasing tem requires us to balance our public wisdom. Others “recovered,” hav- to the ear, but do we all agree on its safety role with our work as clinicians ing progressed beyond some salient principles? Certainly, the Recovery in helping people to maximize their endpoint. hat can complement (4) and augment functioning and, we hope, indepen- Recovery means different things to (5) our traditional risk assessment and dence. As a hypothetical example, different people. It can be framed in management roles. “True risk mitiga- would an insanity acquittee’s experi- terms of a person’s goals with social tion” assists (6) patients in changing ence be more patient-centered if she and occupational functioning; others and moving forward to living mean- were paying cash for a fee-for-service might narrowly focus on symptom ingful lives by understanding their life forensic hospitalization? Can the and behavioral control, medication experiences, strivings and goals, and forensic mental health system be more adherence, hospitalization rates and changing the very circumstance(s) person-centered without paying extra? lengths-of-stay. I learned in my Public driving them to have entered the Innovations we are now seeing in Psychiatry fellowship’s academic forensic psychiatric system to begin recovery-oriented services include module on Recovery (1) that the only with. peer support workers becoming more thing which cannot be recovered is Incorporating the principles of Re- mainstream in service provision. (9) time; broadly speaking, all else is covery into my own clinical practice The availability of peer support for recoverable in some form or fashion. has transformed how I approach my forensic populations appears ripe to The article “What Is Recovery?” by work as a psychiatrist. For example, grow with time. (10) Another example Jacobson (2) is, arguably, still as good even asking my patients for their is the Baer Reintegration Scholarship, a summary on the topic as can be perspectives on what recovery means which provides financial support to found. It frames Recovery as en- (or would mean) to them has proven individuals living with schizophrenia, compassing both internal conditions richly informative. I learn about their schizoaffective disorder or bipolar experienced by persons who describe core values, longer-term goals and, disorder, who are attending degree themselves as being in recovery – sometimes, philosophies on the role and certificate programs. (11) hope, healing, empowerment and (or non-role) of treatment. In my full- connection – and external conditions time work now as a prison psychia- References: that facilitate recovery – implementa- trist, I often hear about the punish- (1) Ranz J, personal communication, 2008 tion of the principle of human rights, ment of “serving time;” focusing on (2) Jacobson N, Greenley D: What Is Recov- a positive culture of healing and the recoverable here becomes all the ery? A Conceptual Model and Explication. recovery-oriented services. more relevant, realistic and, frankly, Psychiatric Services 52:482–485, 2001 In 2018, the American Psychiatric easier on me in providing correctional (3) APA Position Statement on Use of the Association strongly affirmed the healthcare. This is consistent with the Principles of Recovery. Available at: www. application of the principles of recov- suggestion that the recovery orienta- psychiatry.org/File%20Library/About-APA/ Organization-Documents-Policies/Policies/ ery to the comprehensive care and tion can (7) assuage the burdens of Position-Use-of-the-Principles-of-Recovery. treatment of individuals with mental parentalism on our side of the doc- pdf. Accessed October 11, 2020 illness, highlighting the importance tor-patient relationship. (4) Ray I, Simpson AIF: Shared Risk For- of striving for care that does not leave Power differentials among physi- mulation in Forensic Psychiatry. J Am Acad those individuals feeling powerless cian, judge and service recipient war- Psychiatry Law. 47:22-28, 2019 or disenfranchised. (3) Surely, these rant special consideration. What is the (5) Papapietro DJ: Involving Forensic Pa- principles have their place in forensic right term for this latter person bur- tients in Treatment Planning Increases Co- mental health settings. Consider your dened with numerous monikers, from operation and May Reduce Violence Risk. J patient’s repeated applications for perpetrator to patient? Even the term Am Acad Psychiatry Law. 47:35-41, 2019 conditional release from her state hos- “justice-involved person” is question- (6) Chaimowitz G: Balancing risk and recovery. International Journal of Risk and pital, or my patient feeling sad, back able, given conflicted perceptions of Recovery. 1:1-3, 2018 in prison as unable to secure compet- “justice.” In the Recovery Movement, (7) Norko M, personal communication, itive employment and stable housing the term “Consumer” is used. The October 2019 as a felon and with trouble paying his idea of the forensic consumer (8) (8) Hillbrand M, Young JL, Griffith EEH: parole and administrative fees as well. is not new and, though it might not Managing Risk and Recovery: Redefining As freedoms are increasingly stripped be universally applied, prompts the (continued on page 21)

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 17 COMMITTEE PERSPECTIVES

other health events. Symptoms of anx- Mental Health and COVID-19: iety, insomnia and (in elderly patients) a decline in cognition were the most Suicidality as an Emerging Concern common findings (12). Patricia Westmoreland, MD Data regarding the mental health Suicidology Committee effects of the pandemic has given way The coronavirus pandemic is taking of hopelessness and desperation to concern that deaths by suicide will a huge toll on our mental as well as that led to maladaptive behaviors increase because of the effect of the physical health. An editorial in the (6). Early on in the pandemic it was pandemic in inciting risk factors for Journal of the American Medical also noted that healthcare workers suicide (13). There was an increase in Association indicated that for the were severely affected by what they deaths by suicide during the 1918- entirety of 2020 there will be at least had witnessed. Frontline healthcare 1919 influenza pandemic, and among 400,000 excess deaths in the US due workers in Wuhan directly engaged in the elderly in Hong Kong during to both COVID-19 and excess mortal- diagnosing or treating COVID-19 pa- the 2003 SARS epidemic (14, 15). ity from the impact of the pandemic tients (especially those who are nurses Increased distress among individuals on other ills. (1) That number far or female healthcare workers) experi- with pre-existing mental illness may exceeds deaths from the Vietnam War, enced depression, anxiety and insom- increase risk of suicide. For individu- the Korean War and from other pan- nia (7). 50% of healthcare workers in als without pre-existing mental health demics and approaches the number Italy developed post-traumatic stress concerns, an increased risk for death of US deaths from the Second World disorder, 24% experienced depres- by suicide may result from increased War. (1) Compared to times in his- sion, and 20% experienced increased rates of depression, anxiety, and tory when people were able to come anxiety (8). PTSD due to the stressors of social together and support one another Within six months of the arrival of distancing, job loss and economic through periods of societal crisis, the COVID-19 in the US, mental health hardship, interrupted educational loss of human life on such a massive concerns increased. Over 40% of trajectories of teens and young adults, scale has been worsened by social US adults surveyed reported at least the stigma of being diagnosed with distancing and quarantining measures, one mental health condition: anxiety COVID-19 and the effect of the virus financial stressors, disruptions in or depression (30.9%), symptoms itself on the brain (12, 16). schooling as well as recreation and of a trauma related to the pandemic While reports of an increased risk religious activities (2). (26.3%), and increased substance use for suicide during this pandemic are It is estimated that for every person (13.3%) (9). Loneliness and social concerning, data regarding an in- who dies of COVID-19 there are isolation have also contributed to crease in deaths by suicide thus far at least nine loved ones who may escalating mental and physical health are sparse. Leaune et al found a slight develop prolonged grief or PTSD, concerns and themselves predict but significant increase in deaths and based on the number of deaths cardiovascular disease and premature by suicide during the emergence of thus far, over 3.5 million people could mortality (10). COVID-19 pandemic. The increase in develop major mental health needs (2, In addition to the psychological deaths by suicide was mainly reported 3). Psychological responses to prior effects of living through a pandemic, during the peak epidemic and in older pandemics have proved instructive as COVID-19 itself may induce neuro- adults. Psychosocial factors such as to what could be expected as a result psychiatric ills. Of 40,469 patients the fear of being infected by the virus of the COVID-19 pandemic. During diagnosed with COVID-19, 9086 or social isolation related to quaran- the Ebola Virus Pandemic (2014- (22.5%) patients had neuropsychiatric tine measures were the most prom- 2016), fear-related behaviors such as manifestations, the most common inent factors associated with deaths stigmatizing infected survivors and being headache (3.7%), sleep dis- by suicide (17). However, data were ignoring medical procedures impeded orders (3.4%) and encephalopathy collected fairly early in the pandemic. public health efforts as well as the (2.3%). The most common psychiat- Although suicide rates may increase recovery of survivors (4). Anxiety, ric manifestations were anxiety and as the pandemic continues, there may PTSD, and depression were found in other related disorders (4.6%), mood be room for optimism. Suicide rates at least half of those who survived Eb- disorders (3.8%); 0.2% of patients have actually been found to decline in ola or were in contact with someone had suicidal ideation (11).Those some natural disaster or crises (18). who did (5). diagnosed with COVID-19 who had This may speak to resilience, with Serafini et al traced the develop- no prior mental health history have an people finding new strengths (19). ment of stress, anxiety, and depression increased incidence of a first psychiat- However, suicide trends by race and in Wuhan, China after the emergence ric diagnosis in the 14 to 90 days that ethnicity during the pandemic may of COVID-19. Initial psychological followed their COVID-19 diagnosis, differ; a recent study found that black reactions varied from panic and col- compared to the psychological sequel- individuals residing in Maryland had lective hysteria to pervasive feelings ae suffered by patients suffering from increased deaths by suicide whereas (continued on page 34)

18 • Winter 2021 American Academy of Psychiatry and the Law Newsletter COMMITTEE PERSPECTIVES

probable SARS suffered significantly Rights and Responsibilities: higher levels of burnout and posttrau- matic stress symptoms than those who Physical, Psychological and Legal worked at similar hospitals in Ham- ilton, where individuals with SARS Peril in the “Age of COVID” were not treated. Stuart B. Kleinman, MD Not all distress reflects the presence Trauma and Stress Committee of a mental disorder, not all men- Employers are legally and ethically between January 30 and February 3, tal disorders impair or significantly obligated to provide a safe workplace. 2020, found that high levels of post- impair functioning, and not every Employees are legally and ethically traumatic stress symptoms (PTSS), mental disorder that adversely affects obligated to not harm their cowork- which were defined as a PCL-5 score functioning qualifies for ADA-based ers. And, many employers are addi- of 35 or greater, were present among protection. Nevertheless, an array of tionally legally required to provide 18.4% of those in the study’s “high- SARS-CoV-2 induced mental dis- reasonable accommodation to those risk public group” and 4.4% of the orders or conditions qualify or may with an Americans with Disabilities study’s healthcare workers. The high- qualify as ADA-protected entities that Act (ADA)-defined disability. As the risk group consisted of those with may require novel types of accom- COVID-19 pandemic persists, the “confirmed or suspected COVID-19, modations, including ones for which specific nature of these obligations, and those with close contact to” forensic psychiatric input is sought. and how to fulfill them, is rapidly, and COVID-19 patients. Such accommodations, for example, in many circumstances controversial- Another early study performed in may include: ly, evolving. China (2), this one specifically of 1. Change of workplace hours due to SARS-CoV-2 is an invisible, easily distress experienced by healthcare becoming phobic of using public acquired, and rapidly spreading, phys- workers between January 29 and transportation during “rush hour,” ically and psychologically virulent February 2, 2020, found only mild or altogether. bio-threat that may produce and sig- median scores of distress among most nificantly exacerbate mental disorders. of its 1257 respondents, specifically, 2. Reassignment to a different work- Early studies of the general popu- 39% of physicians and 61% of nurses, place team due to a Stressor-Relat- lation and healthcare workers suggest 72% of whom had junior titles. Po- ed Disorder that produces concen- that a high prevalence of SARS- tentially helpful for identifying those tration-impairing fear of acquiring CoV-2, especially when there has most at risk and for whom psycholog- severe COVID-19 or disruptive been a significant COVID-19 mortal- ical protective mechanisms should be irritability that is aggravated, for ity rate, creates a meaningful risk of particularly targeted, as well as when example, by exposure to team- some developing stress response syn- considering malingering: (1) those mates who, in fact, or in rumor, do dromes. Although methodologically working in Wuhan, as opposed to oth- not regularly wear a mask when limited in multiple ways, these studies er regions of Hubei and beyond, and frequenting high-risk venues such have important implications for (2) nurses, as opposed to physicians, as bars and large social gatherings those who remain in or may return to experienced greater manifestations of outside of the workplace. non-virtual workplaces, particularly, distress. Similar geographical results for example, for healthcare workers, were found following September 11th, Illustrating how seemingly the same first responders, and those deemed 2001, in which the development of or similar accommodation requests to be serving as “essential workers,” psychological distress generally cor- may result in different outcomes, such as navy or other military per- related with individuals’ distance from both: (1) rational vigilance arising sonnel who are closely confined for the World Trade Center towers. from a medical condition that creates extended periods, and those on the The recent epidemic-like spread significant susceptibility to acquiring frontline in meat and poultry process- of “COVID-19 Fatigue” signals that SARS-CoV-2 and developing severe ing facilities. the potential to develop vocationally COVID-19 which does not reflect the Studies done in China after impairing Burnout should also be presence of a mental disorder, and COVID-19 began seriously sickening considered. Demonstrating that those (2) irrational hypervigilance that is a population centers illustrate the signif- who perform certain types of work are function of PTSD or a related disorder icant psychological harm it may cause likely at particular risk of suffering which has resulted from exposure to in certain groups and settings. such, a study (3), done of healthcare COVID-19 or any other (traumat- One study (1), in which two workers in Canada 13 to 25 months ic) stressor might provoke the same self-administered questionnaires, following the ending in Ontario of the transfer requests, but be analyzed and one of which consisted of the PTSD SARS epidemic found that those who treated differently. Checklist for DSM-5 (PCL-5), were worked at Toronto hospitals which At the time this article was writ- completed by 2091 individuals treated individuals with suspected and ten, almost 1000 workplace-related (continued on page 33)

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 19 COMMITTEE PERSPECTIVES

facilitate high quality teaching, fo- Regional Forensic Didactic Programs rensic psychiatry fellowships in New York City have shared a didactic pro- for General Psychiatry Programs: A gram for many years. This approach could be applied to residency pro- Possible Silver Lining of Socially- grams by opening existing online di- Distanced Learning? dactic sessions within an institution to Keri Ann Stevenson, MD and Tobias Wasser, MD residents from nearby institutions. Al- Forensic Training of Psychiatry Residents Committee though many current teachers have a collection of preferred teaching tools, The COVID-19 pandemic has visiting electives for clinical forensic AAPL’s Forensic Training of Resi- changed so much about our daily experience. Given that our members dents committee is capable of creating lives, and teaching psychiatry resi- are often busy with existing clinical or compiling standardized content that dents is no exception. Most residency and teaching obligations and unable to can be used to facilitate live, online programs and medical schools have travel without significant disruption to teaching so as to relieve the prepara- moved exclusively to online didactic day-to-day operations, these requests tory burden on online facilitators. The sessions in order to facilitate social may be difficult to honor and do not committee is currently developing distancing. Faculty members had represent a sustainable solution for online educational modules for resi- to adapt quickly to the new online addressing this educational gap. How- dents focusing on topics identified in format with platforms such as Zoom. ever, in the “new normal” of online the 2019 Practice Resource (e.g., civil Like most things in life, online teaching, a shared online faculty may commitment, suicide risk assessment teaching comes with its own set of be more feasible and allow programs and decision-making capacity). The advantages and disadvantages. In the to expand their forensic educational shared didactic system could supple- case of forensic training of psychiatry offerings to include more of the topics ment these ongoing efforts. residents, this shift to online learning detailed in the AAPL Practice Re- One of the biggest challenges can mean the loss of personal contact source. to implementing regional forensic while “spreading the wealth” of fac- In his 2019 presidential address, Dr. didactic programs is likely to be the ulty members to other residency pro- Richard Frierson indicated that 81% logistics of scheduling sessions with grams in need of forensic expertise. of psychiatry residency programs do multiple residency programs simulta- The AAPL Practice Resource for not have an affiliated forensic psy- neously. However, this would not be Forensic Training in General Psychia- chiatry fellowship program. (3) That impossible to coordinate, especially try Residency Programs recommends is not to say that residency programs if residency programs can be flexible that, while core topics such as civil without associated forensic fellow- in their scheduling. Financial con- commitment, confidentiality, and sui- ships are necessarily lacking in foren- siderations for those providing the cide and violence risk assessment can sically-trained or experienced faculty education would also be an important be taught by general psychiatry facul- members. However, in geographic component of any such plan. The ty members (with the aid of suggested areas where forensic experts are logistics would have to be more care- references, if necessary), the advanced scarce – see the geographic distribu- fully worked out, perhaps with each topics of psychopathy, competency to tion of ABPN board-certified foren- participating institution contributing stand trial, the insanity defense, and sic psychiatrists according to U.S. equally to a faculty member’s com- forensic issues pertaining to children census data below (2) –more advanced pensation. In addition to the obvious should be reserved for faculty mem- forensic topics that are encountered benefits to psychiatry residents and bers with formal forensic training less frequently (such as competency programs seeking to improve their or “significant first-hand experience to stand trial and the insanity defense) forensic education, a regional didac- with these topics.” (1) This recom- are likely to receive less attention. tic program may also benefit early mendation, in addition to the relative Given all of the obstacles to incorpo- career academic psychiatrists estab- discomfort many general psychiatrists rating forensic training into general lishing evidence of local and regional experience with forensic topics, likely psychiatry residency (4), finding a educational impact for promotion and presents a challenge for smaller or way to deliver high quality forensic tenure. newer psychiatry residency programs teaching to more residents would be a which do not have ready access to step in the right direction. References: forensically-trained psychiatrists, nor One vision for how to harness (1) Cerny-Suelzer CA, Ferranti J, Wasser T to experts in the community who are current COVID-related changes in et al.: Practice resource for forensic training willing to teach. (2) As such, many teaching in order to expand AAPL’s in general psychiatry residency programs. J AAPL members occasionally receive educational reach could be the for- Am Acad Psychiatry Law 47: S1-S14, 2019 (2) Wasser TD, Hu J, Danzig A et al.: Teach- requests from directors and residents mation of regional didactic programs. ing forensic concepts to residents using of nearby psychiatry programs to For example, in order to consolidate interactive online modules. J Am Acad Psy- lecture on forensic topics or to offer resources, eliminate redundancy, and (continued on page 21)

20 • Winter 2021 American Academy of Psychiatry and the Law Newsletter COMMITTEE PERSPECTIVES

Proposal: AAPL Wellness Committee References: Finn Perkins, MD and William Newman, MD (1) Brady KJS, Trockel MT, Khan CT et al. What Do We Mean by Physician Wellness? Physician wellness has been a support AAPL members’ wellness. A Systematic Review of Its Definition and growing focus within medicine. We see a persisting need within Measurement. Acad Psychiatry 42: 94–108, This has been defined “by quality of AAPL for discussion and focus on 2018 life, which includes the absence of wellness. Several members reached (2) Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction ill-being and the presence of positive out to Dr. Newman during the 2020 With Work-Life Balance in Physicians and physical, mental, social, and integrat- AAPL Annual meeting to express the General US Working Population Be- ed well-being experience in connec- interest in forming a Wellness Com- tween 2011 and 2014. Mayo Clin Proc 90: tion with activities and environments mittee to support future endeavors 1600-13, 2015 that allow physicians to develop their within the organization. Because there (3) www.psychiatry.org/psychiatrists/prac- full potentials across personal and is no existing committee of AAPL that tice/well-being-and-burnout work-life domains.” (1) The recent attends to members’ wellness, we pro- (4) Bradford J, Levin G. Vicarious Trauma literature clearly supports that physi- pose that a new committee be estab- and PTSD in Forensic Mental Health Pro- cian wellness has worsened, marked lished with the following missions: fessionals. J Am Acad Psychiatry Law 48: by burnout, decreased job satisfac- To promote a culture of wellness 315-318, 2020 tion, and increased rates of physician within the practice of forensic psychi- suicide. (2) atry; Recovery The APA estimates that two out of To organize the AAPL peer support continued from page 17 five psychiatrists have professional initiative; burnout. (3) The practice of forensic To promote the study of wellness Miscibility of Oil and Water. J Am Acad psychiatry is not immune to these within forensic psychiatry. Psychiatry Law. 38:452-456, 2010 trends. The risks associated with Wellness is promoted by the APA (9) Who Are Peer Workers? Available at: vicarious trauma, workplace trauma, and the AMA. There is an opportunity www.samhsa.gov/brss-tacs/recovery-sup- and PTSD have been specifically im- within AAPL to tailor physician well- port-tools/peers. Accessed November 5, plicated in physician wellness within ness efforts and initiatives specifically 2020 forensic psychiatry. (4) to the field of forensic psychiatry (10) Lenane Z, Tatum T, McLean C, et al: FIT Clinic Peer Support Group, Year Two: With the focus on wellness during and provide support to our fellow Easing the Burden of Reentry in Louisiana. the 2020 AAPL Annual Meeting came members. Our goal is to identify the Available at: apafdn.org/media/APA/Files/ an opportunity to have the organiza- minimum 12 AAPL members neces- Impact/Community/Helping_Hands_Grants/ tion focus more on our own wellness. sary to support creating a Wellness FIT-Peer-Support-Poster-2018.pdf. Accessed Panels illustrated the need for thought Committee. We encourage all inter- October 1, 2020 from both a personal and systematic ested members to email Dr. Perkins at (11) www.reintegration.com view. New initiatives have begun to [email protected].

Regional Forensic continued from page 20

chiatry Law 48: 77-83, 2020 (3) Frierson RL: Examining the past and advocating for the future of forensic psychiatry training. J Am Acad Psychiatry Law 48: 1-10, 2020 (4) Wasser T, Michaelsen K, Ferranti J: Developing forensic clinical experiences for general psychiatry residents: Navigat- ing the obstacles. Am Acad Number of ABPN Psychiatry Law Newsletter Board-Certified Forensic 41: 21, 26, 28, 2016 Psychiatrists per 100,000 Residents 0-0.24 0.25-0.49 0.50-0.74 0.75-0.99 >1.00

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 21 COMMITTEE PERSPECTIVES

ban on cell phones and Internet access, Sex Offender Management in limiting possible “virtual” groups or appointments. Further, many have the Pandemic bans around any place a child might Brad D. Booth, MD and Renée M. Sorrentino, MD be, significantly limiting their ability Sex Offenders Committee to engage in stabilizing social, leisure The pandemic has created a new Working from home, we have also had and employment opportunities. Thus, norm in psychiatry. This has in- to find a private work space where the while these prohibitions had been put cluded conducting virtual care via family cannot hear our patients and in with the (non-evidence-based) hope the telephone or the Internet. While had to regularly excuse our dogs for of minimizing risk, today they have telephone care provides some con- interrupting. become significant barriers to stability nection to patients, it has several While many in-person visits were and care. drawbacks. We are no longer privy to initially barred, there were some Risk assessment and management our patients’ subtle affect changes and exceptions which have been allowed. of sexual offenders can be framed on body language. We are no longer able However, this in-person contact often the Risk, Needs, Responsivity (RNR) to emote an empathetic and reassuring required an explanation to administra- model or the Good Lives model expression. We have learned to ask tion as to why this is necessary. The (GLM). (1) While controversy exists the patient to move the phone closer patient would be met with intensive about the best approach, both are or further from their mouth, depend- screening at the entrance of the hospi- difficult to undertake within the re- ing on the degree of muffling present. tal – overwhelming for some patients strictions of the pandemic. Both place Being put on hold for another call is with significant mental health issues. weight on improving interpersonal also a now routine experience. A hospital staff member would then supports (intimate and non-intimate) For those patients we see through escort the patient with security to and and gainful employment. Neither video-conferencing, both patients from our offices. Prior to entrance to can be adequately addressed during a and clinicians have struggled to learn a large meeting space, there was man- pandemic. Further, increasing mental how to use the technology. If we are datory scrubbing down of chairs and health symptoms can be a risk fac- actually able to get a stable Internet workspaces. Once the visit started, tor for recidivism in some patients. connection, there are still many hur- social distancing took precedence over (2) Quarantine has been shown to dles. Many of us now have a reflex a therapeutic distance. Mask-wearing increase mental illness (3) as has the statement, “I think you might be on and sometimes eye protection were current pandemic. (4) mute.” We have also learned to gently also mandated. Again, this suddenly The courts have been prone to im- encourage the patient to readjust the robbed us as psychiatrists of the usual pose strict limitations on community camera angle to capture more than tools to observe patients and similarly sexual offenders, particularly those above their nose, and to avoid the sun- be therapeutic. Of course, the main with child pornography offenses or ny window background. We have a topics of conversation have been, hands-on offenses. However, in the new norm in establishing boundaries, “What’s new with COVID? What recent decision of R. v. Brar, (5) the including encouraging some patients aren’t they able to do? And how is Ontario Court of Appeals highlighted to be appropriately dressed for the this worsening their mental state?” the need to balance risk management meeting. A new skill in sign language These questions have more of the tone with the reasonable freedoms of a sex has also developed for when the audio of peer support, rather than the usual offender. Mr. Brar had been convict- goes out and we have to tell the pa- doctor-patient dyad. ed of sexual assault, prostitution of a tient to disconnect and reconnect. While we would agree that these person less than 18 years of age, two Both the phone and videoconferenc- diluted patient care experiences have breaches and three counts of child lur- ing bring a challenge for finding an been “better than nothing,” they are ing. An initial court order prohibited appropriate venue for care. We have likely not as effective as the in-person Mr. Brar from using the Internet ex- now all likely had therapy sessions provision of care we all trained and cept when at work, and from owning with patients going for a walk or in became experts at. and/or using any mobile device with their cars, taking the bus, hanging out When considering care of individ- Internet capabilities. On appeal, the at the mall, or sitting in a room with uals with sexual offenses or other court noted that some degree of Inter- family members or roommates. Our sexual issues, these issues are magni- net access is unavoidable, highlighting skill is now to encourage them to fied. Some patients do not have the fi- it is needed for shopping, banking, find a more private venue for therapy. nancial means for a telephone. While and many daily activities, including Some of us may have noticed our new some homeless shelters facilitate use what forensic psychiatry would think referrals suddenly calling us by our of the office phone, the calls are usu- of as “risk reduction interventions” – first names, asking us more about our ally in the noisy common space, with e.g., finding a job or attending classes. lives and mental health… and crunch- distractions. Many individuals with Rather than a blanket ban, the court ing on chips during the appointment. sexual offenses also have a mandatory instead prohibited Mr. Brar from (continued on page 30)

22 • Winter 2021 American Academy of Psychiatry and the Law Newsletter COMMITTEE PERSPECTIVES

between protecting free speech and Performance Crimes and Social Media preventing violence. George D. Annas, MD, MPH The issues and interplay with tra- Criminal Behavior Committee ditional media and their coverage of performance killing was presented by Whether in the form of mass It remains uncertain if technology Dr. Park Dietz, who provided an anal- shooting, bombing, or other violent has exacerbated or simply exposed ysis of many high-profile performance assaults, some criminals feel the need society’s voyeuristic fascination with crimes, some of which he had worked to publicize their actions and many crime, or the extent to which criminal on directly. He pointed out the differ- of those in the public feel the need to performance and this fascination play ences between the primary motive of watch. In an age where we possess in- off one another. However, Dr. Kayla fame vs. impact. Some may pursue stant worldwide dissemination and the Fisher showed us how terrorist groups only one, while others seek varying “look at me” generation grips tightly have capitalized on both, such as degrees of both. An impact-seeking onto power, it’s no surprise that crime, the coverage of one attack causing a crime may involve one who wishes to itself, is ever more on display. spike in the number of attacks within further “a cause,” such as the Charles- The presenters of “Performance the following week. (2) Even when ton shooter who sought to start a race Crimes & Social Media” at the 2020 broadcast media limit their coverage, war, without a significant wish to be AAPL Meeting, provided the histo- social media do not; a clear problem, famous. John Hinckley, in contrast, ry, various types, and the analysis of considering that over half of the U.S. shot Ronald Reagan for fame, having many of these acts, as well as their population gets their news from the little interest in the victim, nor any interplay with broadcast and social latter. (3) Dr. Fisher reviewed the specific “political” cause. media. Dr. James Knoll summarized correlation with anti-Semitic social Dr. Dietz addressed the concept the topic and noted a case from the media postings and violent public of the media as a “vector” of crime ancient world demonstrating that such attacks, also showing how various and addressed some of the important a practice is anything but new. In 356 groups bypass rules against hate challenges that the news media face, B.C., a man known to us as “Herostra- speech by using code-phrases to avoid needing to cover important stories tus” burned down one of the Seven algorithmic detection. Also described while minimizing inadvertent glorifi- Wonders of the World, later confessing was the strange vicarious need of cation of the perpetrator. Included in he did it to become famous (1). His some citizens to document their own this discussion was the sensible obser- sentence (besides torture and execu- presence near the aftermath of mass vation that the local news may need tion), was to have his name stricken murder, such as a man taking a selfie to provide its own community with from existence such that even men- on the scene of the Westminster attack detailed information soon after such tioning it out loud would be a crime. of March 2017. events, while the national and world- Likely due to his unique punishment wide media do not. If fame or impact the historian Theopompus could not seeking ends up being the desired out- resist recording the tale, thus immor- “In an age where we come, then such a strategy could help talizing him and giving him what he blunt some of the negative effects of wanted. His example shows us that possess instant world- such crimes. Some aspects of broad- trying too hard to deflect attention wide dissemination and cast news coverage have improved, from criminals who act in the name of such as shifting attention away from notoriety may end up having the oppo- the ‘look at me’ gener- the killer and avoiding excessive use site effect. Of course, providing more of the person’s name. Whereas social attention doesn’t help, as the case of ation grips tightly onto media melds the role of producer and Bonnie and Clyde showed how media power, it’s no surprise consumer, (4) Dr. Dietz aptly com- attention could fuel public fascination mented that choosing this outlet for with the “anti-hero.” Modern perfor- that crime, itself, is ever information represents a “voluntary mance crimes have included the brief undertaking of being misled.” craze known as “Happy Slapping,” more on display.” Studying performance crime may recording videos of planned random cast light on a dark part of society. attacks on people and publishing Dr. Fisher, who also holds a law Interventions in regard to broadcast them online. Initially starting as mild degree, provided a review of case media coverage may be helpful in assaults, the craze “evolved” into more law which restricts some of the ways decreasing the “generalized imitation” escalating episodes of violence. Some- in which such types of hate speech of sensational crimes, (5) but deeper how left out of his discussion was the may be regulated in the United States, issues remain in our collective psyche. tyrannical practice of “Rick Rolling” compared to many western European Although a popular scapegoat, the which has caused severe emotional nations which can intervene more media at large are not responsible. distress in so many. But perhaps there forcefully. There is no clear winner Saying so suggests that we are all was not enough time. on who has struck the correct balance (continued on page 27)

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 23 COMMITTEE PERSPECTIVES

Similarly, the stressors of the COVID and Reproductive Forensic pandemic increase risk factors for child abuse. Additionally, with many Psychiatry families at home including for home Cara Angelotta, MD; Anna Glezer, MD; Jill Spice, MD; Nina Ross, MD; schooling, there is less opportunity for Susan Hatters Friedman, MD an angry parent to cool down. Teach- Gender Issues Committee ers are usually primary reporters of child abuse, but when seeing students Reproductive psychiatry refers to outcomes. As of October 2020, there online they are less likely to recog- the field of mental health focused on have been close to 35,000 reported nize it. (7) Reporting of child abuse women’s health from adolescence COVID-19 infections among preg- has decreased, despite evidence of through menopause, including the nant women in the United States and increasing incidence of abuse during perinatal and postpartum windows. 50 maternal deaths. (3) According to the pandemic. (7) Forensic reproductive psychiatry CDC data, about a third of pregnant includes the clinical management of women with COVID-19 are hospital- Incarcerated women these issues in forensic settings, as ized. Pregnancy increases the risk of Over 225,000 women are incarcer- well as expert opinions in legal cases. ICU admission and mechanical venti- ated in the US. (8) The CDC recom- COVID-19 has required all of us to lation, but not death, among individu- mends improved cleaning and hygiene shift the way we provide reproduc- als with COVID-19. Latinx and Black practices, social distancing, visitor tive clinical care and expert opinions; women appear to be disproportionate- restrictions, and appropriate medical it has changed the way that women ly at risk of contracting COVID-19 isolation and quarantine to reduce the engage with mental health; and it has during pregnancy. risk of COVID-19 outbreaks within impacted women’s mental well-be- Pregnancy and the postpartum correctional environments. (9) New ing, particularly during pregnancy represent a uniquely high-risk time custodial stressors emerge with these and postpartum. COVID has placed for psychiatric illness in a woman’s necessary changes such as social iso- restrictions on medical appointments, lifetime. Evidence indicates that the lation and the restriction of services, travel, and visitations. It makes it mental health burden of COVID is including mental health resources. (10) harder for women to have loved ones likely to fall disproportionately upon Incarcerated women are more likely at their side (for appointments, labor, pregnant minority women. A Philadel- to have mental health problems than or postpartum). Not surprisingly, this phia study found that Black pregnant their male peers or women in the com- impacts mental health. It also impacts women were more likely than other munity. (11) Little is known about the how women plan for pregnancies, women to report negative employment potential mental health consequences including postponing fertility treat- consequences of COVID and more of the pandemic and the recommended ment. The combination of physical worries about prenatal care, labor and interventions to mitigate the spread of and social isolation can increase the delivery, and the postpartum period. COVID-19 in correctional facilities. risks of depression during pregnancy (4) Higher rates of suicidal and self-inju- and postpartum. rious behavior may occur. (12) Incar- The pandemic has also unmasked Family Violence cerated women may mirror women and magnified inequities in social Intimate partner violence (IPV) in the community and experience determinants of health. According to refers to physical, sexual, and psy- higher rates of post-traumatic stress CDC data from October 2020, the chological aggression by current or symptoms, depression, and psychiatric COVID hospitalization rate for Latinx former romantic partners. (5, 6) IPV decompensation. (13, 14) and Black individuals is over four is a serious public health issue that Up to 5-10% of incarcerated women times the rate for non-Hispanic whites. often has serious mental and physical are pregnant when they are arrested, (1) The death rate from COVID is also health sequela. (6) The COVID-19 and often require off-site prenatal higher among Latinx and Black com- pandemic has the potential to signifi- appointments and delivery. (15) Some munities. Racial disparities in preg- cantly increase the risk of IPV for correctional facilities quarantine nancy-related mortality predate the multiple reasons. The pandemic may offenders following any off-site visits. pandemic. Black women have a more worsen individual risk factors for IPV, Additionally, many mothers were than three times higher risk of death including unemployment and other single parents before their incarcera- during pregnancy and the postpartum economic stressors, social isolation, tion. (15) Visitation suspensions may than white women. For example, and relationship conflict. (5, 6) Stay- thus disproportionately affect female Black women with at least a college at-home mandates further increase offenders and their children. Social degree are at five times greater risk of the amount of time IPV victims are in distancing may be necessary, but it pregnancy-associated death than white contact with perpetrators and de- should not require emotional distanc- women with a college degree. (2) crease opportunities for social support ing from loved ones. (16) COVID-19 may worsen racial outside of the home or the creation of disparities in pregnancy-related health other protective environments. (6) (continued on page 29)

24 • Winter 2021 American Academy of Psychiatry and the Law Newsletter COMMITTEE PERSPECTIVES

of time that medical students and res- Ignoring our Own Humanity: idents are seldom able to set limits or even recognize when their plate is full. Burnout Among Physicians One of the most difficult things David Burrow, MD I have had to learn as I began my Early Career Committee post-training career is that it is okay Michael Gungor, an American ature is having too much work, too for me to decline a case I do not have musician and author, wrote, “Burnout little time to complete it, and finding time to do well, and to decline new is what happens when you try to avoid too little reward in doing it. responsibilities or opportunities in my being human for too long.” (1) Re- These factors make sense within the clinical practice. This ability to say, search on physician burnout is compli- models used to define and understand “No, thank you,” has enabled me to cated. It is “plagued by large variabil- burnout. Research has long focused find energy, interest, and vigor for the ity in reported prevalence rates and a on three dimensions of burnout: work that I do have. lack of agreed terminology” (Ref. 2, Emotional exhaustion, depersonaliza- Whether we begin our careers in p. 160); a review of 182 studies found tion (withdrawing from, rather than academics, non-academic employ- 142 unique definitions of burnout. (2) engaging with work), and (perceived ment, private practice, or blended Despite difficulty in defining burnout, or actual) decreased personal accom- practices, we have to learn to balance most physicians have had contact with plishment. (5, 6, 8, 9) the trade-offs in autonomy, systemic another burnt-out physician by the Although EMRs were hoped to support, responsibilities, and com- time they have completed training. improve efficiency and coordination pensation, and that the balance that Indeed, as Justice Potter Stewart wrote of care, facilitate communication, and was right for colleagues and mentors regarding “hardcore pornography” in reduce the complexity of the practice may not be right for us. The increased his concurring opinion in Jacobellis v. of medicine, these benefits have large- responsibility for the business aspects Ohio, we may struggle to define burn- ly gone unrealized. Because EMRs are of practice (on which training pro- out, “But [we] know it when [we] see designed to satisfy multiple com- grams often have not focused) and it.” (Ref. 3, p. 197) Burned-out physi- peting (and often conflicting) needs, “imposter syndrome” with its feelings cians have been described as, “angry, they are often not user-friendly. Most of incompetence or inadequacy leaves irritable, impatient, [having] increased employ complicated, unwieldy, and early career physicians at risk of being absenteeism, decreased productivity poorly designed interfaces. Although overwhelmed. and [providing] decreased quality of they facilitate mobile access to the Although studies have suggested care.” (Ref. 2, p. 160) medical record, this often comes with that risk for burnout decreases with Rates of physician burnout vary expectations that physicians will work the length of a physician’s career, the among studies, specialties, and stage on documentation outside of clinical risk remains concerningly high, with of training (2, 4-8), with psychiatrists hours. Primary care physicians spend, transitions and unfamiliar clinical experiencing rates in the 30-50% on average, two hours interacting circumstances particularly increasing range. (4, 7, 8) Studies have looked with the EMR for every hour spent our risk. (5) Burnout is associated at a broad variety of potential risk with patients, including as much as with increased risk of depression, factors for physician burnout; howev- 4.5 hours during the clinic day and anxiety, substance use disorders, and er, many of these factors (such as age, 1.5 hours after clinic dedicated to the suicide. (2, 5, 6, 8) In fact, the over- gender, marital and parent status, and EMR. This is after spending 37% of lap between depression and burnout stage of training) have yielded incon- their time during patient encounters is so great that screening instruments sistent associations. (2, 5, 7, 8) also interacting with the EMR. As one for depression can reasonably be used Well-supported risk factors for physician noted, “I became a doctor to screen for burnout. (2) Burnout burnout include circumstances that in- to take care of patients. I have become also increases the risk for medical crease the volume, density, acuity and the typist.” (Ref. 2, p. 161) errors, increased physician turnover, emotional demand of work; factors Early career forensic psychiatrists increased absenteeism from work, and (such as electronic medical records are at particular risk as they transi- poorer patient experiences in care. (2, [EMRs]) which distance physicians tion from training into unsupervised 5, 6) from patients; and factors which limit practice. Throughout medical school This dark horizon, however, is not the reward (financial or otherwise) and post-graduate medical education, without its dawn. Many studies have derived from work. Conflict with or physicians largely cannot determine found that both person-directed and lack of respect from peers, increasing when or how much work to take on. organization-directed interventions bureaucracy, long working hours, in- We do the work our training programs can reduce work-associated stress creasing computerization of practice, provide, when we are told to. Even and risk for burnout. The research has and lack of clinical autonomy all have among very supportive training pro- been heavily weighted toward individ- strong associations with burnout risk. grams, there is so much material that ualized solutions (2, 6), a point often (2) One consistent theme in the liter- must be learned in such a short period raised in criticisms of the research (continued on page 32)

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 25 COMMITTEE PERSPECTIVES

Neurological, Neuropsychiatric AAPL Members Active Within The and Legal Issues” at AAFS’ 2020 annual meeting. American Academy of Forensic Sciences • Dr. Eleanor Vo, AAFS’ Psychiatry (AAFS) and Behavioral Science Section Corina Freitas MD, MSc, MBA and Dean De Crisce, MD Secretary, serves on the AAFS Membership Committee. Through AAPL Forensic Sciences Liaison Committee her participation in the AAFS The 72nd annual scientific meeting Long-Term Planning Committee, Student Academy of Forensic Sci- of the American Academy of Forensic as well as on the Membership ences, she acquaints high school Sciences (AAFS) took place in Ana- Committee. and college students with the role heim, California from February 17-22, • Drs. David Annas, Corina Freitas, of psychiatry in forensic sciences. 2020. AAFS was founded in 1948 and Jarrod Marks, representing • Dr. Karen Rosenbaum, Past Chair as a multi-disciplinary professional the SUNY Upstate Forensic of AAPL’s Liaison with Forensic organization that provides leadership Psychiatry Fellowship, had the Science Committee and AAFS’ to advance science and its application privilege to present the opening Psychiatry and Behavioral Sci- to the legal system. Today with over evening session at AAFS’ 2020 ence Section, now serves on the 6,500 members, AAFS represents all annual meeting. Their panel, AAFS Board of Directors as well forensic branches, including Psychia- entitled “Dracula, Twilight, and as on the History of the Academy try and Behavioral Science, as well as Blood Cults: Why Is It That Vam- and the Nominating Committees. Jurisprudence, Criminalistics, Tox- pires Never Die?,” led the capti- • Italian psychiatrist and AAPL icology, Pathology-Biology, Digital vated audience through a journey member Dr. Jimmy Troccoli is the Media, and other fields. AAFS fosters exploring the fascination with 2021 AAFS Psychiatry and Be- opportunities to collaborate with vampires based on cultural and havioral Science Program Chair colleagues from other forensic fields psychoanalytic theories as well and serves on the Continuing Ed- in research, education, and practice. as through past historical tales of ucation Committee as well as on Since AAFS has a role in providing sadism and mass murder. the International Affairs Commit- input to the National Academy of Sci- • Dr. Cristina Secarea, a forensic tee, which welcomes international ence, it also coordinates standards and psychiatry fellow, was the recip- forensic scientists into AAFS. offers advocacy. In addition, AAFS ient of the 2020 AAFS Richard • Dr. Jessica Morel, AAFS’ Psy- cultivates the involvement of young Rosner Award for Best Paper by chiatry and Behavioral Science members who are welcomed, men- a fellow in forensic psychiatry or Section Assistant Program Chair, tored, and encouraged to participate. psychology. Her paper entitled serves on the Continuing Educa- With “Crossing Borders” as the 2020 “Factors Influencing Adjudicative tion Committee. AAFS annual meeting theme, there Competence and Length of Time • Dr. Alan Felthous collaborated were numerous exciting opportunities to Restoration” was presented at with Italian forensic psychiatrist for interdisciplinary networking. the 2020 AAFS annual meeting Dr. Felice Carabellese and several AAPL members have demonstrated and will be reviewed for publi- other international colleagues to long-standing, notable contributions cation by the Journal of Forensic present on topics, such as “Dif- to AAFS, and this year’s accomplish- Sciences. ferences Between Readmitted ments continued that tradition. The • Dr. Dean De Crisce is the Chair and Non-Readmitted Patients following AAPL members participate of the AAPL Forensic Science Li- Discharged From Italian Psychi- or participated in the following AAFS aison Committee, which typically atric Security Facilities;” “Iden- activities: corresponds with the Chair of the tification of Risk and Protective AAFS Psychiatry and Behavioral Factors for Violent Behavior in • Dr. Richard Rosner, Past AAPL Science Section. He serves on a Population of Forensic Psy- and Past AAFS President, remains the Editorial Board of the AAFS chiatric Patient Offenders in the a member of the AAFS Past Pres- Journal of Forensic Sciences, the Apulian and Lucan Areas of Ita- ident’s Council. Other Past AAPL Membership Committee, and also ly;” and “Women and Men Who Presidents who have been active served as this year’s 2020 AAFS Committed Murders: Male/Fe- in AAFS include Drs. Park Dietz, Luncheon Session Chair. Also, he male Psychopathic Homicides.” Alan Felthous, Stephen Billick, serves as the Workshop Co-Chair • Dr. Sandra Antoniak educated Robert Weinstock, and Christo- for the upcoming 2021 AAFS an- AAFS Jurisprudence colleagues pher Thompson. Dr. Thompson nual meeting. In addition, Dr. De on the topic of “Neurodevel- serves on the AAFS Executive Crisce presented together with Dr. opment of the Transitional Committee, the Forensic Sciences Mohan Nair on “Frontotemporal Age Brain” and facilitated a Foundation Board of Trustees, the Dementia and Sex Offending: much-needed interdisciplinary educational dialogue. (continued on page 28)

26 • Winter 2021 American Academy of Psychiatry and the Law Newsletter use disorders. The report included American Medical Association 2020 information about states that permit civil commitment for substance use Virtual Interim Meeting Highlights disorders and concern about the pro- Barry Wall MD, Delegate; Jennifer Piel MD, JD, Alternate Delegate; cedures for commitment and available Sarah Baker, MD, Young Physician Delegate; and Kathryn Skimming, MD, resources for treatment in some states. Young Physician Delegate The adopted recommendations make clear that a physician or mental health recognizes that racism negatively im- The American Medical Associa- professional must be involved in the pacts and exacerbates health inequi- tion’s (AMA) 2020 Interim meeting decision for commitment; that judicial th ties among historically marginalized was held virtually from November 13 oversight is required; and the patient th communities. Without systemic and through 17 , 2020. The traditional must be treated in a medically-appro- structural-level change, health ineq- large-scale in-person was replaced by priate facility staffed by persons with uities will continue to exist, and the a large-scale virtual meeting focused appropriate training in mental health overall health of the nation will suf- on priority and urgent business for the and substance use conditions. fer.” The new policy adopted by the House of Delegates (HOD). Delegates, The AAPL delegation to the AMA HOD acknowledges that, although alternate delegates, and others provid- welcomed the addition of two Young there are many factors that drive ra- ed testimony over the virtual platform Physician Delegates: Sarah Baker, cial health inequities and structural on a full-range of issues. MD, and Kathryn Skimming, MD. To- racism, racism and unconscious bias Although the meeting focused on bias Wasser, MD, has completed his within medical service delivery and time-sensitive issues, the meeting term as AAPL’s Young Physician Del- research have caused harm and cause started with the traditional presidential egate; we thank him for his service and harm; that racism in many forms pres- speech. In her speech, President Susan contributions to the AAPL Delegation. ents a serious threat to public health; Bailey, MD, an allergist-immunologist You can find more information on that the AMA supports organizations from Texas, spoke about the challeng- the actions of the AMA House of Del- to increase funding for research to es faced by the healthcare communi- egates at the 2020 Virtual Meeting prevent or repair damages related to ty since COVID-19. She recognized at https://www.ama-assn.org/about/ racism; and that the AMA aims to pro- the tremendous loss of lives since the house-delegates-hod. beginning of the pandemic, which has mote educational programs to increase brought immense challenges and pain understanding and prevent racism. In for so many – including physicians. addition, the HOD voted to adopt new Performance Crimes She spoke about the role of physicians policy to recognize race as a social continued from page 23 as leaders and trusted sources of infor- construct that is distinct from ethnic- mation during this time, as well as the ity, genetic ancestry, or biology. With simply mindless drones, controlled resolve of our physician community. this the AMA encourage educational by the information we are exposed Following this, the HOD considered programs to recognize the harmful ef- to, without the capability of individ- a number of reports and proposed reso- fects of presenting race as biology in ual thought or choice. The truth is lutions relevant to COVID-19 and oth- medical education. far from it. And when so many of us er timely topics. Among COVID-19 Of particular interest to AAPL mem- choose – if not demand – to be in the related policies, the HOD adopted a re- bers, the HOD considered the effects of audience, how can we be surprised by port from the AMA Council on Ethical bulling among physicians. The HOD what we see on the stage? and Judicial Affairs stating that physi- adopted policy to define “workplace cians have an ethical duty to become bullying” as “repeated emotionally or References: immunized once a safe and effective physically abusive, disrespectful, dis- (1) Cartwright M. (2018, July 26). Temple vaccine is available for COVID-19, if ruptive, inappropriate, insulting, intim- of Artemis at Ephesus. Ancient History Encyclopedia. At: www.ancient.eu/Tem- they do not have a medical contrain- idating or threatening behavior target- ple_of_Artemis_at_Ephesus/ Accessed: dication. The HOD also adopted poli- ed at a specific individual or a group of 11/16/2020 cies supporting compassionate release individuals that manifests from a real (2) Jetter M. The effect of media attention for seriously ill inmates and increased or perceived power imbalance and is on terrorism. J Pub Econ 153: 32-48, 2017 infection control measures, including often, but not always, intended to con- (3) The Rise of Antisemitism on Social priority access to vaccines, in correc- trol, embarrass, undermine, threaten, Media, Summary of 2016, World Jewish tional facilities. or otherwise harm the target.” The dis- Congress Following on prior calls from the cussion focused on workplace bullying (4) Surette R. Performance crime and AMA to confront systemic racism as a type of unprofessional conduct. justice. Curr Issues Crim Just, 27: 195-216, and police force, the HOD explicitly The HOD also adopted an AMA 2015 Board of Trustees report on establish- (5) Meindl JN, Ivy JW. Mass shootings: The recognized racism as a public health role of the media in promoting generalized threat. AMA Board Member Willarda ing protocols for involuntary com- imitation. Am J Pub Health, 107: 368-370, Edwards, MD, MBA, said: “The AMA mitment for persons with substance 2017

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 27 validated, recommends an investiga- Report of the APA Assembly tion of such cases and their outcome, Danielle B. Kushner, MD and emphasizes the need for protocols AAPL Representative to APA Assembly for the administration of ketamine and other sedating medications in The APA Assembly met virtually on Overall, the Assembly voted on emergency medical contexts outside November 7-8, 2020. Compared to the approximately twenty Action Papers. of the hospital. It recommends that Spring virtual Assembly schedule, the One of the more important pieces of these protocols should prohibit the Fall meeting was a full calendar with agenda passed included the develop- use of ketamine and other sedating all committees and councils scheduled ment of a task force to explore the medications to achieve incapacitation virtually prior to the meeting. financial and organizational impli- solely for law enforcement purposes. In the Report of the Medical cations and membership’s interests Other approved Position Statements Director, Saul Levin, MD, MPA, in changing the name of the APA to included Sexual Abuse of Migrants in discussed the organization’s recent reflect the specific medical training Immigration and Customs Enforce- administrative, political, and legis- of psychiatrists. The task force will ment (ICE) Custody; Growing Fear lative updates. He started by wel- report back to the Assembly with its Over Coronavirus Spread and Men- coming Regina James, MD, as the findings and a related action plan as tal Health Impact in ICE Detention new Chief of Diversity and Deputy part of the agenda at the Spring 2021 Centers; and Abortion and Women’s Medical Director. She previously Assembly meeting. Other import- Reproductive Health Care Rights, worked as the Director of Clinical ant approved action papers included among others. They have now been and Health Services Research at the Enhancing APA Transparency and sent to the Board of Trustees for final National Institute on Minority Health Accountability Regarding Human approval. and Health Disparities at the National and Financial Resources Allocation; Given the continued spread of Institutes of Health. Her experience Expanding Telehealth Services; and COVID-19, the APA has announced is an asset as the organization works Supporting the AMA Policy on the educational and governance meetings towards addressing equity and inclu- Independent Practice of Medicine, will continue to be virtual through sion within our profession as well as among others. Additionally, the diag- November 2021, including the Annual health disparities facing minority and nosis of Prolonged Grief Disorder was Meeting and the Fall Mental Health underserved patients. approved for addition to the DSM. Services meeting (formerly known as Key legislative updates included the Institute for Psychiatric Services). The defeat of the Dept. of Veterans Affairs 2021 Annual Meeting will be a three- prescribing pilot for VA psychologists “Given the continued day live online meeting scheduled and the ongoing opposition against spread of COVID-19, the for May 2021. The theme is Finding the redefinition of clinical psycholo- Equity Through Advances in Mind gists as “physicians” through HR 884, APA has announced edu- and Brain in Unsettled Times. the “Medicare Mental Health Access Act.” The APA has also continued to cational and governance advocate against the new proposed meetings will continue to AAFS rule on J1 visa residents that would continued from page 26 greatly impact J1 physicians. be virtual through No- Current APA President, Jeffrey vember 2021, including • Senior AAPL members Drs. Geller, MD, emphasized the impor- William Bernet, Gregory Leong, tance of combating structural system- the Annual Meeting and and Wade Myers serve on the ic racism within the APA. Dr. Geller Editorial Board of the Journal of recently authored in Psychiatric News the Fall Mental Health Forensic Sciences and promote an ongoing series on the history of Services meeting...” academic standards for forensic Structural Racism in American Psy- psychiatry research and publica- chiatry and the APA. He also estab- tions. lished the Presidential Task Force to Important forensic issues of note Address Structural Racism Through- included the passing of a Position Through the Forensic Sciences Li- out Psychiatry, chaired by APA Area 4 Statement developed by the Council aison Committee and beyond, AAPL Board of Trustee and AAPL member, of Psychiatry and Law titled Con- members have been more and more Cheryl D. Wills, MD. Additional- cerns About Use of the Term “Excited active within AAFS. We invite you to ly, President-Elect, Vivian Pender, Delirium” and Appropriate Medical explore opportunities to interact with MD, provided a brief overview of Management in Out-of-Hospital Con- the greater forensic science commu- the primary issue for her presidency texts. It states that the term “excited nity. Please join us in the Liaison with tenure, Social Determinants of Mental delirium” should not be used until Forensic Sciences community and at Health. a clear set of diagnostic criteria are the online 2021 AAFS annual scientif- ic meeting in February 2021!

28 • Winter 2021 American Academy of Psychiatry and the Law Newsletter Emerg Med 20: 690–695, 2019 MGH v. CR (2) Nolan JM, Fee C, Cooper BA et al. Gender Issues continued from page 12 Psychiatric boarding incidence, duration, continued from page 24 In rendering this decision, the court and associated factors in United States References: emergency departments. J Emerg Nurs 41: (1) COVID View Week 43, ending October relied heavily on judicial and legisla- 57–64, 2015 24, 2020. Centers for Disease Control and tive reviews of the civil commitment (3) Misek RK, DeBarba AE, Brill A. Prevention website. Accessed 10/30/2020 process, including a committee report Predictors of Psychiatric Boarding in the at www.cdc.gov/coronavirus/2019-ncov/ that determined “the three business Emergency Department. West J Emerg Med covid-data/covidview/index.html. Accessed day period is necessary to make a 16: 71–75, 2015 10/30/2020 (4) Bender D, Pande N, Ludwig M. A Liter- valid clinical determination of a (2) Racial and Ethnic Disparities Continue ature Review: Psychiatric Boarding. Public patient’s need for continued psychi- in Pregnancy-Related Deaths. Centers for Report. U.S. Department of Health and atric hospitalization.” (Ref. 6, p. 15) Disease Control and Prevention website. Human Services, 2008 The court found that this assessment Accessed 10/30/20 at www.cdc.gov/media/ (5) Zeller S, Calma N, Stone A. Effects of is neither realistically nor legally releases/2019/p0905-racial-ethnic-dispari- a dedicated regional psychiatric emergency ties-pregnancy-deaths.html achievable by any facility other than a service on boarding of psychiatric patients in (3) Pregnancy Data on Covid 19. Centers DMH-regulated psychiatric hospital, area emergency departments. West J Emerg for Disease Control and Prevention website. and that “the record presented to this Med 15: 1–6, 2014 Published 10/29/2020. Accessed 10/30/2020 court reveals no realistic alternative (6) Massachusetts General Hospital v. CR. at www.cdc.gov/coronavirus/2019-ncov/ to ED boarding itself.” (Ref. 6, p. 20) Massachusetts Supreme Judicial Court, SJC- cases-updates/special-populations/pregnan- 12844, April 14, 2020. Ultimately the court concluded that cy-data-on-covid-19.html (7) Korn CS, Currier GW, Henderson SO. releasing a patient in need of Section (4) Gur RE, White LK, Waller R et al. The “Medical clearance” of psychiatric patients 12(b) services before a Section 12(b) Disproportionate Burden of the COVID-19 without medical complaints in the Emer- evaluation can be completed “poses a Pandemic Among Pregnant Black Women. gency Department. J Emergency Med 18: risk of serious harm to the patient or Psychiatry Res 293:113475, 2020 173–176, 2000 the public.” (Ref. 6, p. 20) (5) Capaldi DM, Knoble NB, Shortt JW et (8) In Re: The Detention of D.W., G.K., al. A Systematic Review of Risk Factors for Despite reversing the lower court’s S.B., E.S., M.H., S.P., L.W., J.P., D.C., and Intimate Partner Violence. Partner Abuse 3: order to limit the time allotted for the M.P., Respondents, Franciscan Health Care 231-280, 2012 Section 12(a) process, the high court Systems and Multicare, Health System, (6) Centers for Disease Control. Intimate concluded its opinion with a plea Respondents/Intervenors, v. The Department partner violence. cdc.gov. www.cdc.gov/ that lawmakers amend the statute “to of Social and Health Services and Pierce violenceprevention/intimatepartnerviolence/ County, Appellants: Supreme Court of include a time deadline for the § 12(a) fastfact.html. Updated October 9, 2020. Washington, 90110-4, August 7, 2014. evaluation process as expeditiously Accessed October 31, 2020 (9) Appelbaum PS. “Boarding” Psychiatric as possible to clarify the statute and (7) Thomas EY, Anurudran A, Robb K et Patients in Emergency Rooms: One Court ensure the protections of the import- al. Spotlight on child abuse and neglect Says “No More.” Psychiatric Services 66: ant liberty interests at stake.” (Ref. 6, response in the time of COVID-19. The 668–670, 2015 Lancet Public Health. 5: e371, 2020 p. 35) (10) Bloom JD. Psychiatric Boarding in (8) The Sentencing Project. Fact sheet: In Washington, over 100 new psy- Washington State and the Inadequacy of incarcerated women and girls. Updated June chiatric beds were opened following Mental Health Resources. J Am Acad Psy- 2019. Available at: www.sentencingproject. the Supreme Court’s ruling In Re: the chiatry Law 43: 218-222, 2015 org/wp-content/uploads/2016/02/Incar- Detention of D.W., et al, motivated (11) Involuntary treatment act [Title 71, cerated-Women-and-Girls.pdf. Accessed by concern that with boarding out- Chapter 71.05]: Revised Code of Washing- November 11, 2020 ton. lawed, emergency rooms would have (9) Centers for Disease Control and Preven- (12) Emergency restraint and hospitalization no choice but to discharge dangerous tion: Interim guidance on management of of persons posing risk of serious harm by patients. But without a major rework- coronavirus disease 2019 (COVID-19) in reason of mental illness [Title XVII, Chapter ing of the psychiatric infrastructure correctional and detention facilities, revised 123, Section 12]: Massachusetts General nationwide, boarding will continue to October 21, 2020. Available at: www.cdc. Law. gov/coronavirus/2019-ncov/community/cor- be a burden for patients in crisis and (13) CR v. Massachusetts General Hospital: rection-detention/guidance-correctional-de- for the health system at large. Addi- Appellate Division of the Boston Municipal tention.html. Accessed November 10, 2020 tional legal challenges to psychiatric Court, 1801MH0235, September 4, 2019. boarding may be expected in other (10) Kothari R, Forrester A, Greenberg N, et states, given the precedent of the cas- al. COVID-19 and prisons: providing mental Acknowledgement health care for people in prison, minimizing es discussed here (12). I am grateful to Dr. Renée Sorren- moral injury and psychological distress in tino for her mentorship and helpful mental health staff. Med Sci Law 60:165- References comments on this article. 168, 2020 (1) Nordstrom K, Berlin JS, Nash SS et al. (11) Friedman SH, Tamburello AC, Kaempf Boarding of Mentally Ill Patients in Emer- A, et al. Prescribing for Women in Correc- gency Departments: American Psychiatric tions. J Am Acad Psychiatry Law 47:476-85, Association Resource Document. West J 2019 (continued on page 32)

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 29 All Rise ferent states have taken different per- needs and reasonable restrictions on continued from page 13 spectives. As noted, many states will liberty. It may serve as guidance for use this for lower-level proceedings. other jurisdictions. On the practi- saved over a quarter-million dollars Some states have prohibited judges cal side, such a balance would also and resulted in greater safety due to from appearing by teleconferencing allow for appropriate follow-up and less transportation, less elopement unless the accused waived his right to risk management during the current risk, and less physical encounters with be present. A question that may arise pandemic. Without such an approach, patients. In 2018, JAAPL (7) pub- is at what severity of charge or poten- many sexual offenders will go without lished an article related to telecourt, tial punishment, if any, that telecourt treatment during a time when other which noted that California, Texas, proceedings will not be allowed. As supports or coping strategies are not and New Jersey were using telecom- seen from the Singapore and Nigerian available. We have learned that the munications to assist in hearings and cases, there is the potential that even rates of intimate partner violence that the process was more efficient, the ultimate penalty may be issued have increased during the pandemic. reduced inmates’ time spent in jail, al- without the defendant ever stepping (6) If dynamic risk factors for sexual lowed out-of-state family members to foot into a physical courtroom. offending are ignored, we can antic- participate, and increased safety due ipate an increase in recidivism. One to decreased risks with transportation. References: logical answer would be to allow A survey of California courts in (1) [No Author listed] Singapore slammed sexual offenders access to the Internet 2014 (8), with only a 19% response for ‘cruel’ Zoom death sentence AFP and phones in order to engage in what rate, found that 25% of respondents 20/5/2020 www.msn.com/en-sg/news/world/ we know decreases risk: cognitive have used some form of video remote singapore-slammed-for-cruel-zoom-death- behavioral therapy targeting dynamic sentence/ar-BB14mgop accessed June 2, risk factors. Ignoring the needs of this technology in the courtrooms. The 2020 California survey found that virtual (2) Impelli M. Man in Singapore Sentenced patient population further stigmatizes technology was used frequently for to Death by Hanging Via Zoom Call. this group and highlights an age- arraignment hearings in criminal cas- Newsweek 05/20/2020 www.msn.com/ old problem in the history of sexual es, with it making up 62% for felonies en-sg/news/world/singapore-slammed-for- offenders: legal decision-making and 90% for misdemeanors. However, cruel-zoom-death-sentence/ar-BB14mgop without the use of science, a danger- when it came to sentencing hearings, accessed June 2, 2020 ous endeavor. Until the courts allow it was only used 13% of the time for (3) SC16-1852 John Doe v. State of Florida patients access to telephones and the (2017) Internet, a treatable, high-risk group, felonies and 19% for misdemeanors. th When telecourt was used for felony (4) US v. Baker, 45 F.3d 837, 840 (4 Cir. sexual offenders, will remain untreat- cases, both parties stipulated to its 1995) ed in the community. (5) Vitek v. Jones 445 U.S. 480 (1980) use approximately 40% of the time. (6) Price J, Sapci H Law & Psychiatry: When objections in felony cases were Telecourt: The Use of Videoconferencing References: raised, roughly 10% were based on for Involuntary Commitment Hearings in (1) Ward T, Yates PM, Willis GM: The Good concerns that telecourt would violate Academic Health Centers. Psychiatric Serv Lives Model and the Risk Need Responsiv- constitutional or statutory rights, 58: 17-18, 2007. ity Model: A Critical Response to Andrews, roughly 10% were based on insuffi- (7) Pearson A. Ciccone R: Judicial Telepres- Bonta, and Wormith (2011). Crim Justice ence in Involuntary Commitment Hearings Behav 39:94-110, 2012 cient or inadequate telecourt equip- (2) Stinson JD, Becker JV: Sexual offenders ment, and roughly 4% were based JAAPL Online June 2018, 46 (2) 250-252; (8) Judicial Council of California committee with serious mental illness: prevention, risk, on concerns that the telecourt equip- and clinical concerns. Int J Law Psychiatry ment may not be secure. The overall on technology: Video Remote Technolo- gy in California Courts: SURVEY AND 34:239-45, 2011 findings in the California survey FINDINGS December 2014. www.courts. (3) Brooks SK, Webster RK, Smith LE, et were that approximately 80% of the ca.gov/documents/02-_ctac-20141205-ma- al.: The psychological impact of quarantine respondents (judges) expressed satis- terials-VRTsurveyandreport.pdf. Accessed and how to reduce it: rapid review of the faction with the telecourt experience. June 3,2020 evidence. The Lancet 395:912-20, 2020 Only 2.8% expressed dissatisfaction. (4) Holmes EA, O’Connor RC, Perry VH, et Forty percent reported they believed al.: Multidisciplinary research priorities for it was equivalent to having the entire the COVID-19 pandemic: a call for action Sex Offenders for mental health science. The Lancet Psy- proceeding in a physical courtroom, continued from page 22 chiatry 7:547-60, 2020 however 52% did believe that some- (5) R. v. Brar, [2016] ONCA 724 (Can. Ont. thing was lost, but that the ultimate accessing illegal content and from C.A. 2016) outcome was not affected. participating in any manner in any (6) Campbell AM: An increasing risk of fam- In part due to COVID-19, as well as social network, online forums, or chat ily violence during the Covid-19 pandemic: people gaining more familiarity and rooms. Strengthening community collaborations to improvements in technology, issues Although a Canadian case, R. v. save lives. Forensic Science International: related to telecourt proceedings are Brar provides a thorough analysis of Reports 2:547-60, 2020 likely going to increase. To date, dif- the balance between the offender’s

30 • Winter 2021 American Academy of Psychiatry and the Law Newsletter Effects of Media ant to answer their questions about Teleforensics continued from page 15 our field and mental health, or refer continued from page 16 them to a colleague who is interested identify why forensic psychiatry por- in doing so. She further discussed her • Telepsych doctor deviated from trayals are inaccurate, educate fam- own efforts, such as answering ques- the standard of care, contributing ily, friends, the public and patients, tions on crime writer list-serves and to the permanent injury of the remember why we became forensic giving presentations for writers. plaintiff as a result of untimely psychiatrist in the first place, andseek diagnosed and treated vitamin support from colleagues and mentors. References: deficiencies. He explained that being truthful and (1) Padhy SK, Khatana S, Sarkar S: Media accurate does not sell papers or televi- and Mental Illness: Relevance to India. J AAPL members were presented with sion programs well. Unfortunately, the Postgrad Med 60: 163-170, 2014 topics to discuss and voted as follow: extremes are what are interesting to (2) Sieff EM: Media frames of mental Should an ER doctor be expected people and what sells. illness: The potential impact of negative frames. J Mental Health 12: 259-269, 2003 to diagnose Wernicke’s Encepha- Dr. Friedman closed the panel by (3) Wilson C, Nairn R, Coverdale J, Panapa lopathy (WE)? discussing the portrayal of psychi- A: Constructing mental illness as dangerous: Yes: 63% No: 37% atrists (both general and forensic) A pilot Study. Aus New Z J Psychiatry 33: in fiction and film. Irving Schneider 240-247, 1999 Should an onsite psychiatrist be described general psychiatrists as Dr. (4) Choi M: ‘We have to start building insti- expected to diagnose WE? Dippy (named after the first psychia- tutions again’: Trump again links guns and Yes: 72% No: 28% trist in cinema, in 1906 in Dr. Dippy’s mental health. Politico, 8/15/2019 accessed Sanitarium (9)) who is harmless but at: www.politico.com/story/2019/08/15/ Should a telepsych doctor be lacking in common sense; Dr. Won- trump-mental-health-background-checks- expected to diagnose WE? derful (who portrays psychiatry as gun-violence-1464977 on 10-8-20 Yes: 38% No: 62% perhaps magical but may also have (5) Dietrich S, Heider D, Matschinger H, Angermeyer MC: Influence of newspaper sex with patients); and Dr. Evil. It is clear that AAPL attendees reporting on adolescents’ attitudes toward held the on-site psychiatrist to a SOC Forensic psychiatrists in fiction were people with mental illness. Soc Psychiatry described as either being portrayed slightly higher than that of the ER Psychiatr Epidemiol 41: 318-322, 2006 doctor but also and more importantly as: Dr. Evil, The Professor, The Hired (6) Aoki A, Aoki Y, Goulden R, et al.: Gun, The Activist, or Jack (or Jill) of Change in Newspaper Coverage in Schizo- felt that the telepsych doctor was to All Trades. (10) Examples of iconic phrenia over a 20-year period. Schiz Res be held to a lower standard, despite forensic psychiatrists in film, televi- 175: 193-197, 2016 all State telemedicine laws requiring sion and novels over the years include (7) Pozios VK, Saragoza P, Kambam P. the same SOC for telemedicine and in Dr. Hannibal Lecter (Silence of the Why ‘Joker’ shouldn’t have relied on mental person care. Lambs), Dr. Peter Teleborian (Girl illness (Guest Column) October 10, 2019. Many AAPL members, especially www.hollywoodreporter.com/heat-vision/ with the Dragon Tattoo), Dr. George those with interest in neuropsychia- why-joker-shouldnt-have-relied-mental-ill- try, will immediately recognize that Huang (Law and Order: Special Vic- ness-1246869 tims Unit), Dr. Fred Richman (Psy- the evaluation of a patient for WE is (8) Friedman SH, Rosenbaum KB, ‘Joker’ usually done in concert with a phys- cho), and Dr. Molly Arrington (Primal filled with mental illness misconceptions. Fear). Clinical News. October 23, 2019. www. ical and neurological examination, Dr. Friedman also examined foren- mdedge.com/psychiatry/article/210740/ looking for the tetrad of encephalopa- sic psychiatrists in film and crime fic- mixed-topics/joker-filled-mental-illness-mis- thy, nystagmus, ophthalmoplegia, and tion in the past year, including in The conceptions ataxia. A history of poor intake, poor Sinner (11) and The Silent Patient. (9) Schneider I: The Theory and Practice of absorption of thiamine, hyperemesis, (12) Boundary violations abound, and Movie Psychiatry. Am J Psychiatry 144:966- alcoholism, starvation, gastric bypass mental illness seems to be conflated 1002, 1987 surgery, and renal dialysis are also (10) Friedman SH, Cerny CA, Soliman S, commonly implicated. A high index with violence. Dr. Friedman then ex- West SG: Reel forensic experts: forensic plored the importance of we as foren- of suspicion is required, and a brain psychiatrists as portrayed on screen. J Am MRI can be diagnostic. sic psychiatrists being aware of these Acad Psychiatry Law 39:412-7, 2011 portrayals—both for the potential for (11) Hicks C, Friedman SH, Rosenbaum Could the diagnosis of WE have further stigmatization of mental ill- KB: Trauma versus Immorality: A Review been made by a psychiatrist on ness, and also because defendants and of The Sinner. J Am Acad Psychiatry Law site? 48:412-7, 2020 jurors are much more likely to have Yes: 55% No: 45% seen our fictional counterparts than (12) Friedman SH, Magalotti S, Bodnar T. they are to know a real-life forensic Forensic Psychiatry and The Silent Patient. J Is a neuro exam the SOC for a psychiatrist. Dr. Friedman recom- Am Acad Psychiatry Law 48: 285-287, 2020 psychiatrist? mended that if forensic psychiatrists Yes: 55% No: 45% are contacted by writers, it is import- (continued on page 32)

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 31 References: Teleforensics Burnout (1) Gungor M: The Crowd, the Critic, and continued from page 31 continued from page 25 the Muse: A Book for Creators (Audible Audio Edition): M. Gungor, Michael Gun- Would telemed consult differ if it on combatting and preventing phy- gor, Woodsley Press: Audible Audiobooks. was done NOT in ER but on floor sician burnout. Although focusing Woodsley Press, 2012. as a consult or as an outpatient on improving physician resilience (2) Yates SW: Physician Stress and Burnout. consult? has been found to have short-term Am J Med 133: 160–164, 2020. Yes: 49% No: 51% benefits, it risks sending a message to (3) Jacobellis v. Ohio, 378 U.S. 184 (1964) overwhelmed physicians that they are Available at: supreme.justia.com/cases/ The above three responses show a to blame for problems that research federal/us/378/184/.Accessed November 21, nearly equal split in experts’ opinions tells us are actually largely system- 2020. on these critical SOC/SOC-T issues. ic, even as it provides skills that can (4) Shanafelt TD, Boone S, Tan L, et al.: Presenters led the audience on a Burnout and Satisfaction With Work-Life help physicians navigate challenging Balance Among US Physicians Relative to discussion on what it means for a environments. A meta-analysis found the General US Population. Arch Intern Med patient to be “medically cleared” prior that combining person-directed and 172: 1377, 2012. to doing a psychiatric consult: organization-directed interventions (5) Dyrbye LN, West CP, Satele D, et al.: can improve both the magnitude and Burnout Among U.S. Medical Students, Res- Should a Psychiatrist Proceed with duration of the anti-burn-out effects idents, and Early Career Physicians Relative an Evaluation if Consulted Prior to of successful interventions, though its to the General U.S. Population. Academic Medical Clearance? findings were limited by the fact that Med 89: 443–451, 2014. Yes: 55% No: 45% (6) Awa WL, Plaumann M, Walter U: of 25 studies, only 34% included orga- Burnout prevention: A review of interven- Does the fact that ED Doctor nization-directed interventions. (6) tion programs. Patient Ed Counseling 78: Missed the Diagnosis Exculpate Measures which improve physicians’ 184–190, 2010. the Psychiatrist? ability to cope with stressors include: (7) Chan MK, Chew QH, Sim K: Burnout Yes: 25% No: 75% remaining actively engaged in work, and associated factors in psychiatry resi- taking control of work environment dents: a systematic review. Int J Med Educ Here we see a nearly equal split and conditions, receiving support and 10: 149–160, 2019. on whether or not medical clearance encouragement from peers, increasing (8) Hardy P, Costemale-Lacoste J-F, Trich- ard C, et al.: Comparison of burnout, anxiety is necessary prior to a psychiatric autonomy and improving reward (fi- and depressive syndromes in hospital evaluation (despite most residency nancial and emotional) for work done. psychiatrists and other physicians: Results programs teaching that one doesn’t These measures can be anticipated to from the ESTEM study. Psychiatry Res 284: evaluate a person [ex.: intoxicated] be associated with downstream bene- 112662, 2020. until medically cleared) and the more fits to patients and health systems. (2, (9) Lee RT, Ashforth BE: A meta-analytic interesting finding that although 4-6) examination of the correlates of the three consulted as specialists, the audience The COVID-19 pandemic has intro- dimensions of job burnout. J App Psychol felt they were less expected to get the duced further uncertainty into clinical 81: 123–133, 1996. diagnosis than the doctor who called practice, while also driving rapid for the consult based on our expertise. expansion of tools such as telepsychi- Next was a discussion on the legal atry, which can potentially either add Gender Issues continued from page 29 standards of SOC-T and review cur- to physicians’ flexibility and ability rent case law. AAPL members voted: to seize and maintain greater control (12) Hewson T, Shepherd A, Hard J et al: of their practices, or thrust them into Effects of the COVID-19 pandemic on the Does Credentialing Imply Knowl- uncharted waters where they feel mental health of prisoners. Lancet Psychia- edge of SOC? adrift, ineffective, and pulled where try 7:568-570, 2020 Yes: 50% No: 50% they do not wish to go by currents (13) Liu N, Zhang F, Wei C et al: Prevalence and predictors of PTSS during COVID-19 Is There a Difference Between beyond their control. We may find ourselves increasingly separated from outbreak in China hardest-hit areas: SOC, Evidence-based Care, and gender differences matter. Psychiatry Res “Best Practices?” the patients and clients who were the 287:112921, 2020 Yes: 90% No: 10% reasons we entered our field, or able to (14) Vindegaard N, Benros ME: COVID-19 connect with them in increasing ways. pandemic and mental health consequences: Does SOC differ for telepsych? Two keys to physician well-being are systematic review of the current evidence. Yes: 25% No: 75% maintaining boundaries by saying Brain Behav Immun 89:531-542, 2020 “No, thank you,” to opportunities that (15) Friedman SH, Kaempf A, Kauffman S. Is there a Different Threshold for would overtax us, and reaching out The Realities of Pregnancy and Mothering Liability under Telepsych? The for help and support when we find While Incarcerated. J Am Acad Psychiatry Law 48: 365-375, 2020 discussion suggested that most ourselves struggling for things beyond (16) Otugo O, Wages B: COVID-19: the ad- members felt the answer was our reach. ditional sentence for the incarcerated. Health Equity 4:403-405, 2020 (continued on page 33)

32 • Winter 2021 American Academy of Psychiatry and the Law Newsletter believed reflected development of (2) Lai J. et al. Mental health effects of Rights COVID-19. Subsequently, these COVID-19 on healthcare workers in China. continued from page 19 symptoms were determined to JAMA Netw Open, e203976, 2020 (3) Maunder RG, Lancee WJ, Balderson KE COVID-19 claims had been filed. (seemingly solely) constitute mani- festations of a panic attack. et al Long-term psychological and occupa- These, for example, have included: tional effects of providing hospital health- care during SARS outbreak. Emerging Inf 1. Alleged wrongful reduction of 4. Claimed intentional infliction of Dis, 12: 1924-1932, 2006 a previously granted accommo- emotional distress for allegedly in- dation, specifically, reduction of adequately protecting an employee virtual workplace days from five to from contracting COVID-19, after Teleforensics two weekly, that resulted in loss of the employer was on notice that continued from page 32 employment. The plaintiff asserted the individual was particularly that the same medical condition, susceptible to acquiring this condi- “possibly,” but when forced to vote for which she had been accommo- tion. To succeed, claims of negli- answered: dated, rendered her physical work- gent and intentional infliction of Yes: 28% No: 72% place too dangerous to her health emotional distress associated with to attend. Such a case requires: a. alleged contraction of COVID-19 Is the SOC the Same in a State analysis of the degree to which a from the workplace will require Hospital as in a Medical Hospital, medical condition, in fact, causes a showing of causation that will Psychiatric Specialty Hospital, an individual to be inordinately be variably difficult to establish. Prison, and General Medical Hos- vulnerable to becoming severely ill Even if not, in fact, acquired from pital? with COVID-19; b. determination workplace exposure, belief that Yes: 69% No: 31% of the degree of risk that merits the workplace was the responsible This case reveals the complexity of an accommodation to work (fully) agent will likely generate many telemed in the ER setting and high- virtually; and c. consistently ap- such claims. Reliable genetic, lighted several limitations of knowl- plying the latter threshold. Further, i.e., phenotypic, testing of SARS- edge and cognitive biases among as a consequence of the presence CoV-2 may be invaluable in some AAPL members. The answers of the of a co-existing mental disorder, of these cases. However, obtaining AAPL members on SOC are perhaps e.g., anxiety disorder, an individ- samples for comparison, especially the most revealing and troubling. As ual’s perception of the degree of from others at the workplace, will “experts” in med-mal cases, we are threat to her well-being that her inevitably involve very significant expected to know the SOC, what it physical workplace represents may privacy and practical consider- means, how it is determined, and how significantly exceed that which her ations and hurdles. it is to be applied. Remember that the medical vulnerability objectively respondents are from the more experi- creates, potentially influencing the 5. Allegedly wrongfully subjecting enced group of forensic psychiatrists, nature of any accommodation that an employee to adverse employ- and yet many failed to get the basic may be required or granted. ment action due to an employer’s concepts correct; the disagreements purportedly believing that the are significant, and for many of the 2. Alleged wrongful termination, employee’s testing positive for questions, contradicted the law. without cause, of a non-“at will” SARS-CoV-2 indicated that the employee after she purportedly employee had exposed coworkers Discussion: Data derived from voiced COVID-19 related work- to COVID-19. our workshop, albeit from a small, place safety concerns. These were but experienced sample of forensic reported to include: a. lack of man- Employment-related harms, and psychiatrists, suggest that there are dated PPE use; b. lack of require- legal liability for such, comprise rap- significant disagreements among them ment to maintain social distancing; idly evolving, potentially serious side regarding crucial questions involving and c. a supervisor’s treating work- effects from the COVID-19 pandemic the standard of care for the practice place precautions lightly, despite that may endure for years. Forensic of telepsychiatry. These observations his purported exposure to high-risk scientific knowledge promises to be should serve as a wake-up call for SARS-CoV-2 settings. The plain- able to assist in the equitable resolu- our profession and a reminder of the tiffs in this matter also brought a tion of these controversies. ongoing need for education on this whistleblower claim under state critical topic. They also have signifi- law. References: cant relevance to the practice of foren- (1) Sun L, Sun Z, Wu L, et al. Prevalence sic psychiatry. Forensic experts are 3. Alleged wrongful termination, in and risk factors of acute posttraumatic stress required to know the law and the SOC part, for an employee’s departing symptoms during the COVID-19 outbreak in on the relevant topic. Wuhan, China. medRxiv. doi.org/10.1101/20 the workplace after he acutely 20.03.06.20032425, 2020 experienced symptoms that he

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 33 Suicidality continued from page 18 the opposite was true for their white counterparts, highlighting racial dis- parities during this pandemic (20). Encouraging physical distance while finding ways to socially connect and maintain meaningful relation- ships should be explored. Access to mental health treatment, substance use treatment and domestic violence shelters is of utmost importance, as is working on a local, state and national level to advocate for continued access to mental health via telepsychiatry and telephone. Research into how COVID-19 affects the brains of those afflicted with the virus will be key in tailoring treatment that focuses not only on the physical effects but the mental effects of the illness. Finally, de-stigmatizing the mental health con- sequences of COVID-19 not only for those who have been affected by the virus but for the millions of survivors should be our priority as we continue to move through uncharted territory.

References: (1) Bauchner H, Fontanarosa PB. Excess deaths and the great pandemic of 2020. JAMA 324: 1504-1506, 2020 (2) Simon NM, Saxe GN, Marmar CR. Men- Now hiring psychiatrists! tal health disorders related to COVID-19 deaths. JAMA 324: 1493-1494, 2020 The California Department of State Hospitals operates the largest forensic (3) Verdery AM, Smith-Greenaway E, psychiatry hospital system in the nation, offering an unparalleled quality of Margolis R, Daw J. Tracking the reach of practice while providing care to some of the most complex patients found COVID-19 kin loss with a bereavement anywhere. multiplier applied to the United States. Proc We’re hiring Natl Acad Sci USA. 117: 17695-17701, Salary: at all five of 2020 $247,644 - $296,772/year (Board Eligible) (4) Shultz JM, Cooper JL, Baingana F, et our California al. The role of fear-related behaviors in the $261,312 - $305,376/year (Board Certified) locations! 2013-2016 West Africa Ebola virus disease Napa outbreak. Curr Psychiatry Rep 18:104, 2016 Practice and Benefits: (5) Kamara S, Walder A, Duncan J, et al. • Flexible workweek options may be available Mental health care during the Ebola virus • Substantial CME allowance Coalinga disease outbreak in Sierra Leone. Bull World • Generous defined-benefit pension Atascadero Health Organ 95: 842-847, 2017 • Psychopharmacology support by leading experts (6) Serafini G. Parmigiana B Amerio A et and established protocols Patton al. The psychological impact of COVID-19 • Relocation assistance may be available Metropolitan on mental health in the general population. • Telepsychiatry available at some locations QJM: 529-535, 2020 (7) Lai J, Ma S, Wang Y et al. Factors To find out more, please associated with mental health outcomes contact Juan Arguello, DO. among healthcare workers exposed to (916) 654-2609 coronavirus disease. JAMA Network Open; [email protected] 3(3):e203976, 2020 www.dsh.ca.gov (8) Rossi R, Socci V, Pacitti F et al. Mental (continued on page 35)

34 • Winter 2021 American Academy of Psychiatry and the Law Newsletter Suicidality continued from page 34 health outcomes amongst frontline and sec- 500 Church Street, Penetanguishene ON L9M 1G3 ond-line healthcare workers during the coro- 500, rue Church, Penetanguishene (Ontario) L9M 1G3 705-549-3181 www.waypointcentre.ca navirus disease 2019 (COVID-19) pandemic in Italy. JAMA Network Open. Doi:10.1001/ JAMA network open.2020.101.85, 2020 (9) Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal Located on beautiful Georgian Bay, less than two hours from Toronto, Canada, Waypoint Centre for Mental Health Care is ideation during the COVID-19 pandemic: a 301-bed psychiatric hospital providing specialized inpatient and outpatient psychiatric care for the North Simcoe Muskoka United States, June 24-30, 2020. MMWR region, and providing forensic psychiatric care for patients throughout Ontario requiring a high secure facility. We are Morb Mortal Wkly Rep. 69: 1049-1057, currently inviting expressions of interest for full time Psychiatrists to care for Forensic mental health inpatients. 2020 Join our team of psychiatrists and general practice physicians working in a rich interprofessional care environment. We offer (10) Smith BJ, Lim MH. How the assessment, evidence-based treatment and recovery-oriented rehabilitation across a broad range of needs, including patients COVID-19 Pandemic is focusing 2020 who are in hospital under an order of the Ontario Review Board due to their involvement with the criminal justice system. As attention on loneliness and social isolation. a result, periodic reports and appearances before the Review Board is a requirement of this work. Some of Waypoint’s key Publ Health Res Practice 30:e3022008, 2020 treatment philosophies include recovery-oriented and evidence-based practices in the least restrictive environment. The goal (11) Nalleballe K, Reddy Onteddu S, Shar- is to provide the patient with as much liberty as possible while respecting the safety needs of staff and the public, and ma R et al. Spectrum of neuropsychiatric complying with legal requirements. manifestations in COVID-19. Brain Behav Immunity 88: 71-74, 2020 We are accepting expressions of interest by candidates who hold an MD or equivalent, and who hold certification in (12) Taquet M, Luciano S, Geddes JR, Har- Psychiatry from the Royal College of Physicians and Surgeons of Canada or are eligible to sit the exam. Candidates must be rison PJ. Bidirectional association between eligible for licensure in the Province of Ontario, which may include eligibility for an academic license through appointment at COVID-19 and psychiatric disorder: retro- the rank of Assistant Professor or higher at the University of Toronto. The ideal candidate will hold a sub-specialty in Forensic spective cohort studies of 62354 COVID-19 Psychiatry; other candidates will also be considered based on their experience. cases in the USA. Lancet Psychiatry doi: For information regarding current opportunities, academic licenses, and our total compensation package, please contact 10.1016/S2215-0366(20)30462-4, 2020 Chantelle Shervill, Manager Medical Affairs at [email protected] or 1-877-341-4729 x2206. (13) Moutier C. Suicide prevention in the COVID-19 era: transforming threat into op- portunity. JAMA Psychiatry. doi: 10.1001./ jamapsychiatry.2020.3746, 2020 (14) Wasserman IM. The impact of epidem- ic, war, prohibition and media on suicide: United States, 1910–1920. Suicide Life PRACTICING Threat Behav 22: 240–54, 1992 (15) Cheung YT, Chau PH, Yip PS. A revisit on older adults suicides and severe acute TELEPSYCHIATRY? respiratory syndrome (SARS) epidemic in Hong Kong. Int J Geriatr Psychiatry 23: 1231–38, 2008 (16) Gunnell D, Appleby L, Arensman E et As the practice of psychiatry intersects more with al. Suicide Risk and Prevention during the technology through the use of telemedicine, you COVID-19 pandemic. Lancet Psychiatry 7: can count on PRMS® to protect your practice. Our 468-471, 2020 (17) Leaune E, Samuel M, Oh H, Poulet psychiatric professional liability policy includes E. Suicidal behaviors and ideation during coverage for telepsychiatry at no additional emergent viral disease outbreaks before cost, as well as many other preeminent the COVID-19 Pandemic. Prev Med (141), program benefits. 106264, 2020 (18) Reger MA, Stanley IH, Joiner TE. JUSTIN POPE, JD RISK MANAGER Suicide mortality and COVID-19. A perfect storm? JAMA Psychiatry. doi: 10.1001./ jamapsychiatry.2020.1060, 2020 More than an insurance policy (19) Pfefferbaum B, Smith CS. Mental Health and the COVID-19 pandemic. New Engl J Med 383;6:510-512, 2020 (800) 245-3333 (20) Bray MJC, Daneshvari NO, Rad- PRMS.com/PartTime hakrishnan I. Racial differences in statewide [email protected] suicide mortality trends in Maryland during the Coronavirus 2019 (COVID-19) Pan- Actual terms, coverages, conditions and exclusions may vary by state. Insurance coverage provided by Fair American Insurance and demic. JAMA Psychiatry, published online Reinsurance Company (NAIC 35157). FAIRCO is an authorized carrier in California, ID number 3715-7. www.fairco.com. December 16, 2020

American Academy of Psychiatry and the Law Newsletter Winter 2021 • 35 Non-Profit Org American Academy of Psychiatry and the Law U.S. POSTAGE One Regency Drive PO Box 30 P A I D HARTFORD, CT Bloomfield, Connecticut 06002 PERMIT NO. 5144 Joseph R. Simpson, MD, PhD, Editor