September 2016 Rev3.Qxp September 2016 8/29/16 12:00 PM Page 1 AAPL Newsletter American Academy of Psychiatry and the Law

166980 AAPL News September 2016_rev3.qxp_September 2016 8/29/16 12:00 PM Page 1 AAPL Newsletter American Academy of Psychiatry and the Law

September 2016 • Vol. 41, No. 3 AAPL at the APA Awards excellence in forensic psychiatry through its core principles of being Ryan C.W. Hall MD dedicated to enhancing practice, teaching, and research. It was noted that we currently have more than 1,800 members in North America and around the world and that through our annual meetings, we frequently facilitate the exchange of ideas and practical clinical experience through publications and regularly scheduled national and regional meetings. A separate newsletter article will cover the Guttmacher Award, but again we want to acknowledge and recognize Dr. Kenneth L. Appelbaum, Dr. Jeffrey L. Metzner, and Dr. Robert L. Trestman for receiving this honor at the 2016 meeting. This year’s winner of the Isaac Ray Award was Dr. Elissa P. Benedek. The Isaac Ray Award was At the recent APA meeting in the US Department of Justice. He established in 1951 to honor one of Atlanta, Georgia, several AAPL has also been involved in the Nation- the original founders and fourth Pres- members were recognized at the 60th al Prison Project and was involved in ident of the APA, Isaac Ray, and hon- Convocation of Distinguished Fel- the first and third editions of APA’s ors psychiatrists who have made out- lows, as was the AAPL organization guidelines for psychiatric services in standing contributions to forensic as a whole. Current APA President, correctional facilities. psychiatry or to the psychiatric and former AAPL president, Renée Dr. Donna M. Norris was also rec- aspects of jurisprudence. The Isaac Binder presided over the ceremony in ognized with the Distinguished Ser- Ray Award is co-sponsored by which several senior AAPL members vice Award (established by the APA AAPL. Dr. Benedek is an adjunct received special presidential com- Board of Trustees in 1964 to honor Clinical Professor at the University of mendations. individuals and/or organizations who Michigan. Her career in forensic psy- In alphabetical order, AAPL mem- have contributed exceptional merito- chiatry has spanned over 50 years, bers who were recognized by special rious service to the field of psychiatry with a focus on research and policies presidential commendation include: and/or the American Psychiatric impacting child abuse, trauma and Dr. Larry L. Faulkner, who is the Association). Dr. Norris specializes neglect, as well as ethics in psychia- president of the American Board of in child and forensic psychiatry. She try. She was the second female presi- Psychiatry and Neurology. His is also the past APA secretary-treasur- dent of APA in 1990 and has also notable past work includes being er, the first woman and first African- served on the APA’s Board of Dean at the University of South Car- American APA speaker of the Assem- Trustees. She is also a past recipient olina and a past president of the bly and secretary of the American of the Guttmacher Award. American Academy of Psychiatry and Psychiatric Foundation. She was rec- Last, but certainly not least, we the Law. ognized for her contributions to psy- need to acknowledge the Assembly Dr. Jeffrey L. Metzner, who is a chiatry, including advocacy for the Warren William’s Speaker’s Award. Clinical Professor of Psychiatry at the mental health needs of underserved Although the awards were not pre- University of Colorado. He is notable populations and the advancement of sented directly at the Convocation, for his work on psychiatric care pro- women in leadership roles. they were listed in the program. This vided in jails and prisons, as well as The organization of AAPL as a award was established in 1984 in advising judges, special masters, whole received the Organizational memory of past speaker Warren monitors, state departments of correc- Distinguished Service Award. AAPL Williams, MD, and is administered tions, city and county jails, as well as was recognized for its leadership and (continued on page 2)

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American COVER STORY Academy of AAPL at the APA Awards Psychiatry and the Law continued from page 1 by the APA Area Councils to recog- and Professor of Public Policy at the Editor nize outstanding recent or current University of Virginia. He was rec- Susan Hatters Friedman, MD activity/contribution in the field of ognized for several of his achieve- Ending the Associate Editors psychiatry and mental health. The ments, such as work on Philip Candilis, MD founder of AAPL, Jonas R. Rappe- Tobacco Problem: A Blueprint for the Ryan Hall, MD port, was a recipient of the award this Nation; his work on juvenile justice Stephen Herman, MD year. Dr. Rappeport is a distin- reform; and his work on the Commis- Neil S. Kaye, MD guished life fellow of the American sion on Mental Health and Law Joseph Simpson, MD, PhD Psychiatric Association. He graduat- Reform for the Chief Justice of Vir- Renée Sorrentino, MD ed from the University of Maryland ginia. Joel Watts, MD School of Medicine, as well as com- Although not directly affiliated AAPL Photographer pleting his training there. His acade- with AAPL, other notable events at Eugene Lee, MD mic appointments have included the the Convocation included former University of Maryland School of First Lady Rosalyn Carter, who spoke Former Editors Medicine, University of Maryland on her longstanding work toward Charles Dike, MD, MPH (2008 – 2016) Victoria Harris, MD, MPH (2003-2008) School of Law, and Johns Hopkins mental health treatment and improve- Michael A. Norko, MD (1996-2003) University School of Medicine. ments for patient care; The William Robert Miller, MD PhD (1994-1996) Besides being a founder and past C. Menninger Memorial Convocation Alan R. Felthous, MD (1988-1993) president of AAPL, he has also been lecture, which was given by Tom Robert M. Wettstein, MD (1983-1988) a president of the Maryland Psychi- Frieden, MD, MPH, current Director Phillip J. Resnick, MD (1979-1983) atric Society. He has also won the for Centers for Disease Control and Loren H. Roth, MD, MPH (1976-1979) APA Isaac Ray Award for Contribu- Prevention; and the Human Rights Officers tions to Law and Psychiatry. Award which was awarded to David President Richard J. Bonnie, JD friend of Satcher, MD, PhD, served as the for- Emily Keram, MD AAPL, who is the Harrison Founda- mer Surgeon General of the United President-elect tion Professor of Law and Medicine States from 1998 to 2002. Michael Norko, MD Vice President James Knoll, IV, MD Vice President Susan Hatters Friedman, MD Secretary Christopher Thompson, MD Treasurer Douglas Mossman, MD Immediate Past President Graham Glancy, MB

The AAPL Newsletter is published by AAPL, One Regency Drive, PO Box 30, Dr. Donna Norris receives her award First Lady Rosalyn Carter addresses the Bloomfield, CT 06002. Opinions from Dr. Renée Binder. audience. expressed in bylined articles and columns in the Newsletter are solely those of the authors and do not neces- sarily represent the official position of AAPL or Newsletter editors. Manuscripts are invited for publication in the Newsletter. They should be submitted to the editor via email to [email protected] The Newsletter is published in January (deadline for submission is November 15), April (deadline Febru- ary 1), and September (deadline July 1). From left to right, First Lady Rosalyn Carter, Saul Levin, MD, MPA, APA CEO and Med- www.aapl.org ical Director, Jacquelyn Coleman, CAE, AAPL Executive Director, Jeffrey Janofsky, MD, © 2015 AAPL. ALL RIGHTS RESERVED. AAPL Medical Director, Rahn Bailey, MD, APA Membership Committee Chair

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FROM THE EDITOR “I Saw a City in the Clouds” American Psychiatric Association president Dr Renée Binder, at this Susan Hatters Friedman MD year’s APA meeting, among others. The work that our colleagues repre- Welcome to is 20 days. [2]) Add to that, a lot of senting AAPL are doing in the APA the September us save up our vacation time for Assembly and at the American Med- issue of the “later”. But then, we have a hard time ical Association are described in their AAPL Newslet- using it, worrying about coverage or own articles as well. We’re also excit- ter. September our services or our patients if we take ed to share articles from colleagues in not only signals a longer trip. But somehow, our col- related disciplines, with Criminology the end of sum- leagues in other countries are able to Professor James Oleson writing about mer and heading routinely take longer leave, attend High Intellect Crime, and Law Pro- back to school, international conferences, even take fessor Michael Corrado writing about but also, of sabbaticals, and still be quite produc- preventive detention in Europe. Inter- course, time to register for AAPL. tive. nationally as well, Dr Joel Watts This year’s program in Portland Research demonstrates benefits of writes about Canadian law. Dr Jeff promises not to disappoint, with its vacation. It turns out that relaxing Janofsky, Medical Director, describes courses, panels, workshops and new and pulling away from one’s work the Moore case, and one might expect research. over vacation are positive for one’s to “watch this space.” As I’m sitting down to write this health and wellbeing even after vaca- The incoming Rappeport fellows column, for it to be in your hands by tion. [3] One study found that middle for 2016-17 are introduced in this September and well in advance of the aged men at high risk for coronary issue. You’ll find two thoughtful Fel- AAPL meeting, I’ve just returned heart disease have decreased risk of low’s Corners, from current forensic from a much-needed summer girls- mortality with the frequency of annu- psychiatry fellows—about forensic trip to Europe with my daughter. And al vacations. [4] However, working evaluations in a second language, and for once in a great while, a vacation during vacation negatively affects about taking the stand. Please do without a conference in the middle! health and wellbeing after return. [3] encourage your fellows to make con- Perhaps unsurprisingly, I’ve been (Those of us know who we are. Seri- tact if they would be interested in doing some reflecting about the per- ously, statistically speaking, how writing for the Newsletter. As well, sonal importance of taking a break. often can proofs possibly arrive when this issue holds multiple thought-pro- Summer has always been a time I one is on the way to the airport?) voking committee articles, with top- associate with relaxation with family While we as forensic psychiatrists are ics ranging from child abuse report- and fun in favorite locations. Time to lucky to have a fantastic career, and a ing, risk management, modelling nurture the soul and to refuel, before welcoming professional home with habits, biases, elder abuse, to what heading back to the grind. But some interesting colleagues and intellectual toxicology screens may miss, and the of us forensic psychiatrists just might stimulation, I’ve been informed that well regarded Ask the Experts col- be workaholics…. AAPL meetings don’t technically umn. I’ve written previously about the count as “vacation” for some reason. Hope you enjoy reading this issue potential benefits of taking a sabbati- One should come to AAPL, but also of the Newsletter—perhaps not cal [1], but vacations are important take a vacation. Just some food for counting that as your “vacation” too. Attending a conference lecture thought. though. See you in Portland! by Professor Tom Gutheil as a young In this edition of the Newsletter, resident, I was struck that his con- President Dr Emily Keram discusses References: tracts include that he will be unavail- the theme of Trauma and Transforma- 1. Friedman SH. No worries, mate: A foren- able to testify in the month of August. tion. Dr. Charles Dike (this year’s sic psychiatry sabbatical in New Zealand. J And yes, it has stuck with me since, AAPL program chair) writes about Am Acad Psychiatry Law 2013;41:407-411. that this highly productive leader in the upcoming lunchtime speakers— 2. Ray R & Schmitt J. No-vacation nation. our field thinks vacation is important make sure to get your lunch tickets Center for Economic and Policy Research. 2007. enough that it is routinely spelled out early. Jackie Coleman’s illuminating 3. deBloom J, et al. Effects of short vaca- in his contracts with attorneys. Executive Director column provides tions, vacation activities, and experiences Vacations increase, rather than guidance about how presentations are on employee health and well-being. Stress decrease, productivity, and it seems chosen for AAPL, and how our future Health 2012;28:305-318. that other nations are on to this. Inter- submissions might improve in order 4. Gump BB & Matthews KA. Are vaca- nationally, the US lags behind in to increase chances of acceptance. tions good for your health? The 9-year mor- vacations for its workers [2], that is, You’ll find this issue full of amaz- tality experience after the multiple risk fac- regarding the minimal paid vacation ing AAPL member accomplishments tor intervention trial. Psychosom Med time received by law. (For example, and awards, including the Guttmacher 2000;62:608-612. the European Union’s vacation floor award and AAPL’s award given by

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PRESIDENT’S REPORT Trauma and Transformation that determine whether this transformation will have positive or negative Emily A. Keram MD consequences for the individual and the collective. In selecting my theme, I have been brought me into contact with people Trauma and Transformation, I hope to honored to serve who experience similar or related share some of what I’ve learned and nd in as the 42 traumatic events very differently. For to encourage AAPL members to President of the example, while treating veterans of explore the impact of trauma on their American Acade- Iraq and Afghanistan, I have been forensic cases, their own lives, and my of Psychiatry involved in the cases of over a dozen the communities in which they live and the Law Guantanamo detainees, six of whom I and with which they identify. (AAPL) and look evaluated face-to-face. I have I am extremely fortunate and forward to pass- worked with patients who contem- grateful to have Charles Dike, M.D., ing the baton to the extraordinarily plated or attempted Suicide by Cop as my Program Chair. Dr. Dike capable hands of Michael Norko, and patients who, in their role as law immediately understood what I am MD, in October. enforcement officers, have shot attempting to communicate by the Among the humbling opportunities behaviorally disordered mentally ill selection of my theme. I would like to the AAPL Presidency brings is the subjects. I have worked with discuss some of the ways in which prospect of distilling years of forensic lawyers, paralegals, and judges who the theme will be represented at the experience into a theme that underlies are negatively impacted by their Annual Meeting. the Annual Meeting and the Presiden- exposure to traumatic material while Two of our luncheon speakers tial Address. In my final President’s at the same time registering and man- demonstrate the transformative poten- Report, I will discuss the selection of aging my own response to the same tial of trauma on the individual. Zak my theme, Trauma and Transforma- disturbing evidence. Ebrahim, who will be speaking on tion. Through repeated experiences of Thursday, is the son of El-Sayyid Without design, my clinical and hearing related trauma narratives Nosair. In 1990, Mr. Nosair shot and forensic careers have focused on trau- from different viewpoints I have wit- killed the leader of the Jewish ma and its aftermath. This work has nessed the impact of trauma on the Defense League in Brooklyn, New occurred across disparate settings. I individual and society, both in the York. While in prison, Mr. Nosair have been a staff psychiatrist at the immediate aftermath of the event and helped plan 1993 bombing of the Santa Rosa Community Based Outpa- in the longer term. I have been aided World Trade Center. Mr. Ebrahim tient Clinic for almost 20 years, treat- in this journey by the opportunity to will share his memories of growing ing veterans from WWII to the cur- treat individuals at the VA and in my up in a radicalized family and his rent conflicts. For many years my private practice over many years and rejection of its ideology. Emmanuel forensic cases primarily involved through different tasks over the life Jal, who will speak on Friday, is a allegations against law enforcement cycle. Similarly, because of the former child soldier from Southern of excessive force, wrongful death, evolving rules of the Military Com- Sudan. Mr. Ebrahim will discuss his and inadequate training stemming missions and policies on indefinite rescue and rehabilitation from his the from their contacts with mentally ill detention, I have worked on some trauma of his early life. He has trans- subjects. As a result of providing detainee cases for many years. formed from child soldier to artist mental health training to law enforce- Years spent working with the same and musician and founder of Gua ment officers I established a small patients and on the same cases, as Africa, a charity that assists individu- private practice treating first respon- well as my own reactions as an als, families, and communities devas- ders. I volunteer with the First American living through the post- tated by war and poverty. Responder Support Network, a non- 9/11 era, have repeatedly exposed me In addition to presenting trauma’s profit that, among other activities, to two important aspects of trauma. transformative effect on individuals, I offers a week-long, peer support dri- The first relates to the chaos created wanted to share my experience of ven retreat to traumatized first in its immediate aftermath. The sec- understanding traumatic events from responders. For the past twelve years, ond, and most important, is the pow- different viewpoints and the potential I have consulted as an expert witness, erful force unleashed by traumatic these events have to transform com- judge’s expert, and physician monitor disruption that challenges and munities, nations, and public policy. in a number of cases involving Guan- changes our individual and societal Law enforcement contacts involving tanamo detainees. Finally, I have identity in often astonishingly funda- use of force demonstrate trauma’s been an expert witness in cases mental ways. tendency to drive people to the involving domestic terrorism. I have developed a profound extremes of reaction. I have learned Practicing across such a wide appreciation for the transformative that addressing and ameliorating the range of demographic, occupational, potential of trauma. Consequently, I aftermath of trauma requires the diffi- and geographic contexts has often have become interested in the factors (continued on page 8)

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MEDICAL DIRECTOR’S REPORT Texas, Intellectual Disability and the ments in adaptive functioning, was not appropriate. We then applied this Death Penalty - Moore v. Texas analysis to several cases, including Moore’s. Jeffrey S. Janofsky MD I have previously written in this column about the APA’s and AAPL’s 6 On June 6, standard in Ex parte Briseno that the amicus brief in Hall.7 In that brief we 2016 the United Texas Appellate Court had adopted in updated the Supreme Court on States Supreme prior cases for Atkins claims. The changes in the professional under- Court granted cer- Appeals Court held that it was up to standing of Intellectually Disability. tiorari in Moore v. the Texas legislature to change the The majority and minority opinions 1 Texas. AAPL, law, not the Court. Using the Briseno both quoted extensively from our along with the standard, the Texas Appeals Court brief. Constitution Pro- then analyzed the presence of Intel- AAPL has only signed on to one ject, and the Southern Center for lectual Disability based on IQ scores other amicus brief asking for certio- Human Rights had filed an amicus that were not statistically corrected. rari in the Supreme Court. The 2 brief supporting certiorari. The Texas Appeals Court also did not chance that the Supreme Court will The question the Court accepted consider adaptive functioning at all. accept any case is very low. The for appeal was whether, in determin- The Texas Appeals court found that Court receives approximately 7,000 ing whether an individual may be Moore was not Intellectually Dis- to 8,000 petitions for a writ of certio- executed it was a violation of the abled and reimposed the death penal- rari each year, and hears only about Eighth Amendment and the Court’s ty. Moore appealed to the U.S. 80 of those cases.8 I hope AAPL’s 3 decisions in Hall v. Florida and Supreme Court. certiorari amicus brief played even a 4 Atkins v. Virginia to prohibit the use part in the Court's acceptance of this of current medical standards on intel- important matter. lectual disability, and to require the AAPL will almost certainly review 5 “The Texas Appeals use of outdated medical standards. and participate in the writing of an Moore was convicted of being the court found that Moore amicus briefs on the merits in this shooter in a botched 1980 robbery. matter. I will keep you informed of He was found guilty and sentenced to was not Intellectually our progress. death that same year. He has been on Texas’ death row ever since. He has Disabled and reimposed References: had several direct and habeas appeals 1. USSC, Docket number 15-707, and has been twice re-sentenced to the death penalty. Moore http://www.scotusblog.com/case death. During his latest habeas appealed to the U.S. files/cases/moore v texas/ appeal Moore raised many claims, 2. http://www.scotusblog.com/wp including a claim that the Eighth Supreme Court.” content/uploads/2016/04/Bobby James Amendment barred his execution Moore v Texas amicus.pdf 3. 134 S.Ct. 1986 (2014) because he was Intellectually Dis- 4. 536 U.S. 304 (2002) abled. The Texas trial habeas court AAPL’s amicus brief reviewed the 5. http://www.scotusblog.com/wp concluded that Moore met the defini- history of the diagnosis of Intellectual content/uploads/2016/04/Moore Petition.pdf tion of Intellectual Disability under Disability both pre and post Atkins, 6. 135 S.W.3d 1 (Tex. Crim. App. 2004) the current guidelines of the AAIDD how the Court in Atkins relied on 7. AAPL Newsletter. September 2015, (American Association on Intellectual DSM-IV-TR’s now outdated defini- Vol. 39, No. 3, page 5 and Developmental Disabilities) and tion of Intellectual Disability, and 8. http://www.supremecourt.gov/ under both the DSM IV and the DSM how subsequent Courts before Hall faq.aspx#faqgi9 5. The Court found that both Moore’s tended to rely on strict IQ cutoffs to MUSE & VIEWS impairment in adaptive functioning define Intellectual Disability. We then and his corrected IQ score placed him reviewed the DSM 5 approach, which What’s in a Name? in the range of mild Intellectual Dis- expressly states that diagnosis of A Florida woman was arrested in May for ability. The Court found that he was Intellectual Disability should be shooting a missile at an occupied car. A closer therefore barred from execution under based on both clinical assessment and look at the police report shows the woman’s Atkins and Hall. standardized testing of intelligence, as legal name, Crystal Metheney. When contacted by a reporter regarding the detained woman’s The Texas Court of Criminal well as evaluation of adaptive func- unique name, an employee for the Polk County Appeal reversed. The Court held that tioning. We wrote that the Texas Sheriff’s office replied, “Sir, this is Florida. the state habeas trial court erred by Appellate Court's exclusive reliance We have a lot of interesting names here.” relying on current medical standards on statistically uncorrected IQ tests Source: www.eonline.com rather than the twenty-two year old alone, without also analyzing impair- Submitted by William Newman MD

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ASK THE EXPERTS AAPL: Ask the Experts-2016 being an advocate now-is that not correct doctor?” The point is that Neil S. Kaye MD, DFAPA when you are retained as an indepen- Graham Glancy MB, ChB, FRC Psych, FRCP dent expert you are not an advocate for the patient. It is reasonable to Neil S. Kaye, MD, DFAPA and Graham Clearly, the role of the forensic defend your position, sometimes vig- Glancy, MB, ChB, FRC Psych, FRCP psychiatrist as defined by the SCO- orously, but you are not the advocate. (C), will answer your questions from TUS includes advocacy. Further, any The use of the adverb vigorously members related to practical issues in good expert knows that in order to be means intellectually vigorous, not the real world of Forensic Psychiatry. persuasive, one must be passionate physically or emotionally. It is Please send question to and that proper emotional modulation always important to try to keep your [email protected]. during any presentation improves the equilibrium and to maintain a profes- listener’s experience. sional manner, even in the most try- This information is advisory only for The real key here is to marry these ing of circumstances. educational purposes. The authors two approaches. Be impartial in claim no legal expertise and should reaching an opinion but once that Take Home Points: not be held responsible for any action opinion is reached, it is appropriate to Advocacy for your opinion is dif- taken in response to this educational advocate for that opinion with passion ferent than advocacy for the defen- advice. Readers should always con- and verve. dant in a criminal matter or for a par- sult their attorneys for legal advice. ticular side in a civil matter. It is A. Glancy: always appropriate and professional Q.: What is the role of advocacy? This question to advocate for your impartially becomes even reached opinion and on behalf of our A. Kaye: more pertinent in profession. Advocacy is an Canada since the important part of health advocate is the role of the one of the 7 roles My group is looking for forensic psychia- expected of a examples of attorneys' trist. However, physician according to the CanMEDS resisting their own retained one must be framework. The central role of med- aware of the ical experts in the samples include: expert's input. We don't AAPL Ethics communicator, collaborator, manager, mean the cases where the Guidelines that insist on striving for scholar, and professional. In some expert turns down the case objectivity and impartiality in reach- respects being a health advocate is a as meritless, but ones ing an opinion. Many AAPL mem- role that the forensic psychiatrist where, say, the expert bers thus are uncomfortable being should be expected to take in certain thinks something is essen- placed in an advocacy position. situations. For instance when advo- However, the SCOTUS in Ake v. cating for services for the the mental- tial to the opinion but the Oklahoma (470 US 68) ruled that an ly ill in correctional facilities, or for attorney feels it puts a bad indigent defendant is entitled to an other important to initiatives in light on the case or the par- expert psychiatric witness to assist in healthcare for our client base it is ties, or where the expert's the defense. The majority opinion in appropriate for us be a health advo- suggestion for a template Ake was penned by Justice Marshall. cate. Writing for the Court, Marshall said: In his role as president of AAPL, or outline of the best struc- “without a psychiatrist’s assistance to Dr. Larry Faulkner made a convinc- ture for the direct examina- conduct a professional examination ing case for instituting subspecialty tion is resisted or dis- on issues relevant to the insanity status in forensic psychiatry. Dr. John missed. Extended content defense, to help determine whether Bradford and I and took on this role is welcome, as well as that defense is viable, to present testi- in Canada. This is a type of advocacy approaches that members mony, and to assist in preparing the that should be encouraged. cross-examination of the State’s psy- At one point in a particularly vitri- have used. Examples chiatric witnesses, the risk of an inac- olic cross-examination a lawyer asked (which will be attributed curate resolution of sanity issues is me about a statement made in an arti- only at the request of the extremely high. This is so particularly cle regarding advocating for services sender) may be sent to when the defendant is able to make for our population. When I answered, [email protected]. an ex parte threshold showing that his perhaps unwisely in retrospect, that sanity is likely to be a significant fac- the article was meant as advocacy, he Thanks in advance. tor in his defense.” craftily countered “just like you’re

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EXECUTIVE DIRECTOR’S REPORT Ramping Up past were not accepted this year in order to allow for new topics. Addi- Jacquelyn T. Coleman CAE tionally, the course’s appeal to the entire membership is also considered The May Semiannual Meeting saw their ratings. It is possible for a sub- when determining which courses to the introduction of the draft Annual mission to receive very high marks accept. Meeting program to the Education for quality and still not be accepted. For topics this year, the favored and Program Committees and the As I mentioned above, in addition to categories of submission were correc- Executive Council. the rating, the number of presentations, criminal issues, and “Special It will be available by the time you tions submitted on the topic is impor- Topics.” The last is a category I read this. Dr. Dike’s article in this tant. The Program Chair may prefer a would like to see refined, but it is same issue is about the lunch speak- similar offering with a different sometimes hard to figure out where a ers, a very exciting group. approach, or perhaps there are a lot particular submission belongs. In I am going to tell you about the of submissions featuring the same 2013, the Education Committee program itself. key speakers, or the program is lack- changed its topics to conform to the We had 232 abstracts, the second- ing in some topic and preference is list used by the American Board of highest in our history (2014, Chicago given to a submission on that topic. Psychiatry and Neurology to help was the highest.) With an overall acceptance rate of members choose topics that conform Needless to say, there was heavy 50-60 percent, and adding these other to the expectations of what they will competition for the available slots factors, you can see how high-quality be tested on. and the Program Committee and Dr. presentations don’t always make the I hope this article highlights the Dike had their work cut out for them. cut. There are a number that are quality of the presentations you will A bit about the process: when the clearly going to be accepted, and hear in October, but it should also abstract submission deadline is there are a number that are clearly highlight, for those whose submis- reached, the abstracts are assigned going to be rejected, but it’s in the sions didn’t make it this year, that randomly to members of the Program middle where the agonizing decisions competition is fierce, and each year Committee. Scientific Papers and have to be made. You can ask any will be different. Don’t be discour- Research In Progress are judged sep- former Program Chair about that! aged. arately from other submissions. This This year, we are looking at a pro- year, each member of the Program gram with a 57 percent acceptance Committee had over 30 abstracts to rate overall. However, since most rate, within a three-week period. One posters are accepted and as many as Medical Transcription numerical rating is given for each possible scientific papers and abstract. The range is 1-7, with 7 research-in progress submissions are • 35 years’ exp in Psychiatry, being the best. Comments are accepted, the key numbers for most Forensic Psychiatry, and encouraged. presenters are the following: Only Psychology After the ratings are made, the 25 panels were accepted, 28 were Program Chair sifts through all the rejected. For workshops, 16 were • 140 wpm, 180 wpm submissions, considering quality, the accepted and 31 rejected. There has real time number of submissions on the topic, been a consistent problem with many and the pertinence of the topic to the workshop submissions: the require- • Accurate, dependable field and to the meeting itself (if the ment for active audience participation President has designated a theme). in a learning activity. “Questions and • Verification of content You may know that committees answers” and “discussion” do not integrity are required to make a submission qualify as audience participation for a every two years. Committee submis- workshop. Submissions should be • HIPAA compliant encryption sions are rated on the same basis as very specific about what the active used to send and receive all other submissions. The accep- learning activity will be. The ques- tance rate for committees’ submis- tion that is on the submission form data sions is better than the rate for sub- for a workshop that asks the nature of missions as a whole. audience participation does NOT • Excellent references This year, for the first time and at mean who should be in the audience! available the recommendation of the 2014 Pro- There were 8 courses submitted gram Committee, the Education and 4 of those didn’t make it. There Laura Arntz, 503-260-6506, Committee decided to make available are never more than four courses on request the ratings and comments accepted because they would take too [email protected] for submissions that were not accept- much time from the program. Some or find me on LinkedIn ed. Twenty-one submitters asked for courses that were well-received in the

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PRESIDENT’S REPORT - CONTINUED

Trauma and lished a Blue Ribbon Committee on Transformation Improving Police Response to Per- sons with Mental Illness. Chief Louis Interested in advertising continued from page 4 Dekmar, who initiated the committee, AAPL Newsletter cult tasks of learning and validating will outline its goals for nationwide in the ? different reactions to the same trau- advancement this area. Please email matic events, finding common I hope you will find meaning and [email protected] ground, and holding to the middle. inspiration in the Annual Meeting Our third luncheon speaker, theme of “Trauma and Transforma- or call 800-331-1389 Christy Lopez, J.D., is a Deputy tion.” I look forward to hearing your for more information. Chief in the Civil Rights Division of thoughts about the program in Port- the U.S. Department of Justice. Ms. land. Lopez heads the Special Litigation Section’s police practice group, NCCHC to Celebrate 40th National Conference in Las Vegas which has primary responsibility for The National Commission on Correctional Health Care will celebrate its 40th annual national con- conducting “pattern-or-practice” ference October 22-26 at the Paris Hotel in Las Vegas. At the five-day conference – the country’s investigations of law enforcement largest conference for correctional health professionals – clinicians, administrators and others will agencies. Ms. Lopez led the team that gather to learn about latest advancements and best practices in delivering health care behind bars. Health professionals working in the nation’s jails, prisons and juvenile detention facilities face investigated the Ferguson Police unique issues and challenges. For four decades, NCCHC has provided an opportunity for them to come Department and is the primary drafter together, learn from experts and one another, discuss common challenges and share solutions. of the Ferguson Report. She also led Approximately 75 people attended the first conference, which helped to spur the national movement to improve correctional health care; a record crowd of close to 2,000 is expected at the 40th. investigations of the Chicago Police “For 40 years, NCCHC has been the source of quality education for health care professionals work- Department, the New Orleans Police ing in the country’s correctional facilities,” said Nancy White, MA, LPC, chair of the Education Commit- the Los Angeles Sheriff’s Depart- tee. “Our 40th conference not only marks a milestone in NCCHC’s history, but also celebrates the orga- ment, the Newark (New Jersey) nization’s reach and impact.” White is the American Counseling Association liaison to the NCCHC board of directors. Police Department, and the Missoula, This conference also marks the 25th anniversary of the organization’s Certified Correctional Health Montana investigation, which was the Professional (CCHP) program, the largest certification program in this field. Currently more than 3,400 Division’s first investigation focusing professionals are CCHP-certified. th on the collective law enforcement Special activities to commemorate these anniversaries, along with the 40 anniversary of the Estelle v. Gamble decision, are also being planned. Estelle v. Gamble was the landmark Supreme Court response to allegations of sexual case that in 1976 established prisoners’ right to health care. assault. The conference features eight in-depth preconference seminars and more than 100 concurrent ses- I wanted to provide an opportunity sions, and offers up to 32 hours of continuing education credit. Topics on the agenda include hepatitis C, HIV, mental illness, substance abuse and the NCCHC health care standards, which help facilities use for AAPL members to learn more resources efficiently while improving quality of care. The exhibit hall will feature hundreds of products about the law enforcement policies and services to support correctional health care. and procedures and national efforts All conference activities take place at the Paris Hotel in Las Vegas. For more information, visit by law enforcement agencies to www.ncchc.org/national-conference-on-correctional-health-care. improve their response to mentally ill citizens in crisis. On Thursday Tri-State AAPL’s First Winter Conference in Miami evening it will be my pleasure to pre- Title: Revisiting Court Ordered Outpatient Treatment, Competency, EED, Sex Offender sent a Presidential Symposium, Evaluations, Psychiatric Malpractice, the Insanity Defense, and Peer Review of Forensic “Police Response to Persons with Evaluations: Civil & Criminal When: Friday, December 9, 2016 - Sunday, December 11, 2016 Mental Illness.” In 2012, the Portland Where: The Betsy South Beach Police Bureau and the United States Department of Justice entered a set- The meeting objective is to provide specific presentations on forensic cases, discussion of relevant topics in forensic psychiatry, and advance best practices in forensic evaluations through a peer review tlement agreement following several process in an informal and social tropical setting. If you are interested in presenting a topic or foren- high-profile incidents. The agreement sic case for peer review, please contact Eric Goldsmith at (212) 486-2754 or via fax (212) 486-2758 resulted in the creation of the or e-mail at [email protected]. Bureau’s Behavioral Health Unit, Registration: members of which will describe its Registration in the amount of $50.00 is due by November 1, 2016. (no fee for spouses/partners) four tiers of police response to the Visit www.aapl.org to download the registration form or contact the AAPL Executive Office at mentally ill: Crisis Intervention Train- 800-331-1389 or [email protected] for more information. ing, the Enhanced Crisis Intervention Please Note: Registration is limited so please send your check out early. In addition, as there is Team, the proactive Behavioral a peer review component to this conference Tri-State AAPL asks that you maintain confidential- Health Response Team, and the Ser- ity to what is presented. There will be no recordings or tapings made of the presentations. vice Coordination Team. On a nation- Room reservations: al level, the International Association There are no requirements to stay at The Betsy. However, a discounted room rate of $275/night (plus of Chiefs of Police (IACP) has estab- $20 daily resort fee) at The Betsy can be made by calling the hotel directly at (305) 531-6100 and specifically ask for IN HOUSE Reservations and reference Tri-State AAPL Room Block.

8 • September 2016 American Academy of Psychiatry and the Law Newsletter 166980 AAPL News September 2016_rev3.qxp_September 2016 8/29/16 12:00 PM Page 9

FELLOWS CORNER

Taking a Stand members of the jury nodding and tak- out.” I had not anticipated the urge to ing notes. I gave myself an internal defend the entire psychiatric profes- Jacqueline Landess MD, JD high five. I tried my best to explain sion when called to the stand. my role in the case and how I came Certainly, there are limits to what It was the night to my opinion. I had weighed materi- we do and the opinions we render. before my first als from both the defense and the We cannot go back in time and jury trial. I ner- prosecution, examined interviews observe or interview a defendant at vously read and with other parties and of course inter- the time of the crime. We are left reread my opinion viewed the defendant himself, in with the pieces of a puzzle that we in the case, search- reaching my conclusion. I was as must gather and attempt to align, ing for inconsis- objective and unbiased as I could be; much like a detective, in rendering tencies or flaws in addition, this had been a court- the most reasonable, medically proba- which might open me up to an attack ordered evaluation, meaning I was ble and unbiased opinion that we can. by the opposing counsel. As an attor- not hired by the defense or the prose- So if we do these things, the assump- ney, I was no stranger to the adversar- cution. Then the dreaded cross-exam- tion is that we arrive at a close ial nature of the legal system, but I ination came. approximation to the “truth” of what had never been put on the stand and The first comment from the district occurred, while acknowledging the cross-examined, at least not in “real attorney was a snarky remark about limitations of human knowledge and life.” I ordered take-out as I pored our failure to connect prior to the expertise. What bothered me the over my report, and observed that it trial, despite my attempts to reach most, I realized, was that no aspect of somehow felt like my last meal. I her. It became immediately clear that my opinion was acknowledged as tried to rationalize the situation. I her sole purpose was to discount my legitimate or “truthful” by the oppos- thought, “Well, look. The guy is opinion and methods, by any means ing counsel, despite the 50-plus hours going down for murder either way. necessary. As the cross-examination I had put into the case. Despite my The only difference your opinion may progressed, we gradually digressed own countertransference toward the make is to allow him a sentence other from the central issues in the case, at defendant, which was certainly not than life without parole. Even if the least from a psychiatric standpoint. I positive. Despite the efforts I made to jury doesn’t agree with your opinion, was asked to comment on aspects of weigh each piece of evidence equally it’s no sign of failure on your part.” I the case that I could not; for instance, in rendering my opinion. struggled a bit with these thoughts at one point I was asked how long it I realized that perhaps my job that and feelings, and reflected upon the would take to kill someone by stran- day was not only to advocate for my case. gulation. As I admitted that I did not opinion and educate the jury, but also It was my first murder case. The know, the district attorney appeared to advocate for the field of psychiatry defendant’s crime did not evoke to smirk. I found myself wondering and understanding of mental illness. much sympathy, though he was clear- why I had even attempted to render As a psychiatrist, I know mental ill- ly not a psychopath or even antiso- an opinion in this case, when it ness and the disruption and devasta- cial. He had, by his own admission, appeared that the level of respect for tion that accompanies its symptoms. I made a series of reckless decisions that opinion was about as great as my have witnessed psychosis and the which culminated in methampheta- desire to sit on the stand for three impact that psychosis has upon rea- mine intoxication and, in my opinion, hours. Despite the rigors of cross- soning, decision-making, insight and a resulting psychosis. His memory for examination, I stood steadfast in my judgment. I appreciate that any act the murder was relatively clear, opinion that the defendant had been must be understood in context of that though he could not identify a psychotic at the time of the murder. person’s cognition, emotions, and motive. The crime appeared to be As I walked away from the court- environment. I also have faith in the senseless and no matter how vigor- room, I felt frustrated and foolish. law and the necessity of laws to rule ously I culled through the records in How had I imagined my role as a and govern human behaviors. It is a the case, I could not readily under- forensic psychiatrist? I am obligated difficult task to influence and con- stand why this man had murdered a to deliver an opinion that is truthful vince a layperson that these are not person he loved, seemingly without and promotes justice while still merely vague and unsupportable provocation. I did, however, believe respecting the rights of the individual. beliefs I hold, but scientifically reli- that he had diminished capacity to I am to maintain my humanity in the able and valid concepts. It is even premeditate the act, given his psy- face of acts and crimes which often more challenging to accomplish this chotic state at the time of the crime. defy human understanding. I thought when your words are distorted, The day of the trial came. I felt I had done those things. But why then motives inferred, and the legitimacy relatively confident with the direct did I feel like I had failed on some of your profession questioned during portion of my testimony. While level? The not-so-subtle message sent a rigorous cross-examination. explaining the concept of substance- by the DA was “garbage in, garbage induced psychosis, I noticed several (continued on page 28)

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FROM THE WORLD OF CRIMINOLOGY High-IQ Offenders: Too Much of a index group also reported higher inci- dence rates (i.e., the number of Good Thing offenses reported per person among those reporting an offense) than did J.C. Oleson JD, PhD, Associate Professor of Criminology, the control group. This finding, too, is University of Auckland inconsistent with a model that assumes an inverse, linear relation- The criminal genius is an extraor- seemed to be enough to overwhelm ship between IQ and crime. dinarily popular figure in literature their intelligence and incline other- One explanation for the finding and film: Crime and Punishment’s wise law-abiding youths to crime. might be found in Travis Hirschi’s Rodion Raskolnikov, Sherlock On the other hand, the gifted are influential theory of social bonds as Holmes’ Professor Moriarty, The not a unitary class. On the IQ distrib- an explanation for delinquency and Ususal Suspect’s Keyser Söze, The ution, the exceptionally gifted (with crime.7 Hirschi proposed four ele- Girl with the Dragon Tattoo’s hacker- an IQ of 160) are as divergent from ments of the social bond: attachment, heroine Lisbeth Salander, and The the bright (with an IQ of 115) as are consisting of closeness to others, Silence of the Lambs’ Dr. Hannibal the bright from those with borderline especially parents; commitment, con- “The Cannibal” Lecter. Although not mental retardation (with an IQ of 70, sisting of self-interest that has been usually satisfying formal diagnostic accompanied by other diagnostic cri- invested in social conformity; criteria, such characters are often teria). Educational psychologist Leta 1 involvement, consisting of engage- characterized as elite psychopaths. Hollingworth proposed an optimal ment in conventional activities that Of course, there are real-world ana- intelligence: although children with limit offending opportunities; and logues to these fictional villains: 125-150 IQs have much in common belief, consisting of assent to conven- Catch Me If You Can author Frank with average peers and can establish tional social norms. In 44 semi-struc- Abagnale, the 1924 thrill killers satisfying relationships, children with tured follow-up interviews, members Nathan Leopold and Richard Loeb, IQ scores of 150+ often struggle to 5 of the index group articulated themes Unabomber Theodore Kaczynski, form attachments with others. Could that aligned closely with the four University of Alabama shooter Pro- super-optimal intelligence cease to components of the social bond. fessor Amy Bishop, and NSA operate as a protective factor and Specifically, many expressed weak- whistleblower Edward Snowden all begin to function as a risk factor? ened attachment, citing examples of possessed above-average intelligence In a study of self-reported offend- stigmatization, isolation, and alien- (operationalized as IQ). Yet, despite ing, an international index sample of ation. Some expressed weakened the public’s fascination with the crim- high-IQ adults possessing 130+ IQ commitment, indicating skepticism inal genius in newspaper pages and scores (N = 465; mean IQ = 148.7) about the value of conventional mea- silver screens, little is known about reported higher – not lower – preva- sures of achievement. A few actual high-IQ offenders. lence rates for 50 of 72 measured expressed weakened involvement, The linkage between intelligence offenses than controls (N = 756; noting that they had engaged in crim- and crime has been studied since mean IQ = 115.4). Indeed, for seven inal actions during periods of unem- Lombroso, and although many socio- of the nine offense types measured in ployment or had rejected licit oppor- logically-trained criminologists have the study—sex, violence, drug, prop- tunities to engage in crime. And regarded the association with “a curi- erty, white-collar, professional mis- many expressed weakened belief, ous mixture of faith, indifference, and conduct, and miscellaneous crimes— 2 indicating that independence of contempt,” there is now a general prevalence rates (i.e., the percentage thought, legal hypocrisy, and/or post- consensus that low intelligence (as of the sample reporting an offense) of conventional moral reasoning led IQ) is related to delinquency and the index group were higher than them to think in socially discrepant crime. Indeed, “[t]here is likely not those of controls. For white-collar ways. another individual level variable that crimes, property offenses, and profes- People with high IQs are, by defin- is so consistently associated with sional misconduct, rates were signifi- ition, a small group (only 2% of the crime and other forms of antisocial cantly higher. Controls reported high- 3 population is expected to possess a behaviors than IQ.” Specifically, er prevalence rates only for vehicular 130+ IQ), and they very well might – offenders appear to have a mean IQ and justice system offenses. Overall, as the linear model of IQ and crime score approximately 8 to 10 points the lifetime prevalence rate for aggre- predicts – be less predisposed to anti- lower than non-offenders. Above- gated offenses was almost 10% high- social behaviour. But individuals who average intelligence, on the other er for the index group than it was for have high IQs and superior executive hand, is widely regarded as a protec- the control group: 93.8% versus 4 function, and do turn to crime, pos- tive factor. This understanding 84.7%. This finding is not what sess the cognitive abilities to become accords with several studies of gifted would be predicted by a model that successful criminals.8 Cyril Burt delinquency (IQ = 115+) in which assumes an inverse, linear relation- observed that bright delinquents, only severe emotional disturbance ship between IQ and crime.6 The (continued on page 30)

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FROM CANADA A Review of Canadian Mental deprived of their freedom without possibility for treatment to reduce his Health Acts risk.1 All Canadian mental health acts Joel Watts MD, FRCPC, DABPN (Forensics) include a criterion concerning a Civil mental health legislation Civil Commitment “harm” that the patient could inflict directly affects access to psychiatric In Canada, a person who is com- on himself or on others. Four juris- treatment for the most vulnerable mitted involuntarily must: dictions limit this criterion to “physi- people in our society.1 Akin to the • Have a disease or a mental dis cal harm” (Ontario, Quebec, autonomy states enjoy in the United order that is defined by law; Nunavut, and the Northwest Territo- States to craft mental health legisla- • Present a probability that they ries). Although Quebec refers to “immediate and severe danger”, tion for their citizens, provinces in will harm themself or another 3 Canada have jurisdiction on the pro- person because of their disorder, according to some authors , this defi- vision and organization of the public or present a risk of mental or nition is sometimes extended to non- health care system (including of physical deterioration; physical harm. Similarly, in Ontario, course psychiatric care). They also • Be deemed incapable of making some decisions from the Consent and establish their own criteria and laws the decision to be hospitalized Capacity Board seem to interpret psy- allowing families, police and caretak- or to receive treatment. chological harm as a form of physical ers to intervene with regard to per- harm. New Brunswick and Yukon sons incapable of recognizing their specifically refer to psychological own mental health needs. While in “According to the Cana- harm. However, for many years, principle, federal law tries to ensure dangerousness criteria in civil com- that all mental health services are dian Psychiatric Associ- mitment statutes have been expand- provided equally throughout the ing, and many courts have ruled that country, significant differences exist ation (CPA), involuntary these principles are consistent with the Canadian Charter of Rights and amongst provinces with regards to 1 civil commitment. Often, legislation hospitalization must be Freedoms. evolves only as a result of local high linked to a thorough At present, seven Canadian profile and rare events. provinces refer to “dangerousness” as Around the world, the aim of com- assessment of the patient “significant physical or mental deteri- mitting a person to hospital is to oration” (British Columbia, Alberta, reduce their dangerousness and to and an appropriate treat- Saskatchewan, Manitoba, Ontario, and, under specific conditions, Nova offer treatment. The power of the ment.” state follows the parens patriae prin- Scotia and Newfoundland). In ciple – the duty to help citizens inca- Ontario, for a patient to be committed pable of taking care of themselves. All Canadian jurisdictions use for more than 72 hours, the physician Civil commitment is also in line with “mental disorder” as a definition, but must indicate that the patient is inca- the duty of the state to protect its citi- Quebec and Ontario define this quite pable to consent to treatment, and zens against dangerous persons (so loosely. In other provinces, the defin- needs treatment. Again, courts in called “police powers”). According to ition is more specific and sometimes Ontario and Manitoba have found the Canadian Psychiatric Association linked to the necessity of treatment these physical or mental deterioration (CPA), involuntary hospitalization (British Columbia, Saskatchewan, criteria consistent with the Canadian must be linked to a thorough assess- Manitoba, Ontario [with regards Charter of Rights and Freedoms. ment of the patient and an appropriate specifically to the “deterioration” cri- Treatment Authorization and treatment. The CPA recognizes, how- teria], Nova Scotia, and Newfound- Involuntary Treatment orders ever, that many Canadian provinces land). British Columbia and Manito- Being able to treat a patient who is (among others Ontario and the North- ba even excluded some patients from involuntarily hospitalized is a major west Territories), do not link civil involuntary commitment, such as preoccupation of clinicians who don’t commitment and treatment; this those affected by an Antisocial Per- want to be simple jailers. What results in an involuntary hospitaliza- sonality Disorder, for which there is should we do with a patient who is tion without treatment due to the lack little to no recognized treatment.3 To too dangerous to be released yet of consent from the patient. Some be committed involuntarily in refuses a treatment that would allow authors argue that a person’s freedom Saskatchewan, Nova Scotia, and them to eventually regain their free- is further limited where the law does Newfoundland, the patient must be doms? not allow the possibility of linking incapable of consenting to treatment. In five Canadian provinces, the the commitment and the treatment of This criterion prevents a patient who state delegates a representative whose patients (who are often also inca- is “fully capable” from being responsibility is to authorize the treat- pable).2 (continued on page 29)

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RAPPEPORT FELLOWSHIPAWARD 2016-2017

Britta Ostermeyer, MD, MBA and Susan Hatters Friedman, MD, Co-Chairs, Rappeport Fellowship Committee

This year again, the committee has selected six outstanding Rappeport Fellows! The prestigious AAPL Rappeport Fellow- ship was named in honor of AAPL's founding president, Dr. Jonas Rappeport, MD. It offers the opportunity for outstanding senior residents with a dedicated career interest in forensic psychiatry to receive mentorship by senior forensic psychiatrists. In addition, fellows will receive a scholarship to attend the AAPL forensic psychiatry review course and annual AAPL meeting in Portland, Oregon. The Rappeport Fellowship Committee is pleased to announce the six Rappeport Fel- lows for 2015-16 are as follows: Dr. Lara J. Cox, Dr. William Conner Darby, Dr. Christopher Fischer, Dr. Ariana Nesbit, Dr. Jason Quinn, and Dr. Rocksheng Zhong.

Dr. Lara J. Cox Dr. Cox is starting her second year of fellowship in child and adolescent psychiatry at the New York University School of Medicine, where she also completed her training in adult psychiatry. Over the course of this coming year, she will be rotating through the outpatient clinics at Bellevue Hospital Center and the NYU Child Study Center, as well as completing an elective in the New York City juvenile justice system. She is interested in trauma-informed mental healthcare delivery in juvenile justice settings, as well as in the overlap between trauma-related symptoms and disruptive behaviors including conduct disorder. Dr. Cox has given several presentations on trauma and conduct disorder, including talks at the 2016 Annual Meeting of the American Psychiatric Association and the 60th Annual Con- gress of the Asociácion Española de Psiquiatria del Niño y el Adolescente in San Sebastián, Spain. She has also published a paper on the neurobiology of conduct disorder. Before residency, Dr. Cox completed the five year Clinical Scientist Training Program at the University of Pittsburgh, earning a master’s degree in clinical research in addition to her medical degree. She first became involved with the American Psychiatric Association as a medical student there, serving on the national board of the Psychiatry Student Interest Group Network for several years. She went on to be elected as the Resi- dent Fellow Member Trustee on the APA’s Board of Trustees, serving as the trustee-elect from 2013-2014 and a full voting member of the board during her year as the trustee in 2014-2015. Dr. Cox will finish her child psychiatry fellowship in June 2017 and plans to complete a fellowship in forensic psychiatry thereafter, with the eventual goal of working in the juvenile justice system. Her Rappeport mentor is Dr. Joseph Penn. Dr. William Conner Darby Dr. Darby is a fourth year psychiatry resident at UCLA. He has an interest in the ethical challenges that arise practicing at the interface of psychiatry and law. He has applied this interest to multiple presentations at national meetings for the APA, AAFS, ASAP, and now AAPL on such topics as involuntary outpatient commitment, physician-assisted suicide, the death penalty and mental illness, capacity determinations in adolescent populations, and disability evaluations. Dr. Darby is second author on a paper on capital punishment for the mentally ill, two textbook chapters: one on forensic psychiatric ethics and the other on diminished capacity and responsibility. He is co-developer with Dr. Robert Weinstock on the ethical model of Dialectical Principlism which he applied to a paper on informed consent for potentially dangerous patients that won The Shirley Hatos Twenty First Century Psychiatry Prize awarded for the best original paper by a UCLA affiliated resident. Dr. Darby is currently a member of three AAPL committees. He plans to complete a forensic fellowship next year and to pursue a career in academic forensic psychiatry. His Rappeport mentor is Dr. Emily Keram. Dr. Christopher Fischer Dr. Fischer is a Child and Adolescent Psychiatry fellow at the University of Southern California. He completed his General Psychiatry residency training at the University of California, Los Angeles Neu- ropsychiatric Institute. He received his MD from the University of California, San Diego. Prior to medical school, Dr. Fischer received a Masters of Science in Financial Analysis from the University of San Francisco. He has written articles on juvenile adjudicative competence, juveniles as defendants, neuropsychiatric risks of concussions, factitious disorder, malingering, and deception detection. With- in AAPL, he is a member of the Child and Adolescent Psychiatry and the Law, Human Rights and National Security, and the Liaison with Forensic Sciences committees. In addition to Psychiatry, he is also passionate about international affairs, having worked abroad and studied Russian, Spanish, and German. In the future, he looks forward to combining his interests in international affairs, Forensic Psychiatry, and Child Psychiatry. He is honored to receive the Rappeport fellowship and is excited about beginning his fellowship training in Forensic Psychiatry this coming year. His Rappeport mentors are Drs. Jessica Ferranti and Susan Hatters Friedman.

(continued on page 13)

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RAPPEPORT FELLOWSHIPAWARD 2016-2017

Dr. Ariana Nesbit Dr. Nesbit is a fourth-year resident in General Adult Psychiatry at the Cambridge Health Alliance/Har- vard Medical School. She attended medical school at the University of Vermont, where she was inducted into the Alpha Omega Alpha Honor Medical Society. She won awards for her research, for outstanding academic achievement in the basic sciences, and for excellence in psychiatry. Dr. Nesbit developed an interest in law and ethics while in medical school, and she first explored the field of forensic psychiatry during an elective rotation with Dr. Debra Pinals. Dr. Nesbit has co-authored multiple forensic textbook chapters on treatment refusal and involuntary treatment. She has also written about or presented on topics that include the neurobiology of pedophilia, civil commitment for substance use disorders, and prearraigned arrestees. She serves on the Cambridge Health Alliance’s Program Evaluation Com- mittee, Ethics Committee, and Institutional Review Board. Dr. Nesbit is also a member of the Forensic Hospital Services and Ethics Committees of the American Academy of Psychiatry and the Law. She is spending her fourth year of residency working towards a Master of Bioethics Degree from Harvard Medical School. His Rappeport mentors are Drs. Ryan Hall and Renee Sorrentino. Dr. Jason Quinn Dr. Quinn is currently beginning his fifth (PGY-5) year of his psychiatry residency at the University of Toronto, focussing on his interest in Forensic Psychiatry. He is interested in the interaction between public policy and mental health. In response to changes to the Canadian Criminal Code, he published an article in JAAPL reviewing how international jurisdictions have attempted to address the issue of justice for victims of offenders found Not Criminally Responsible. He has presented on this topic and others in a variety of large group contexts. He also has an interest in teaching and has lectured to the undergraduate medical students at U of T as part of their pre-clerkship curriculum. Dr. Quinn plans to apply for a PGY-6 year in Forensic Psychiatry at a Canadian institution. His Rappeport mentors are Drs. Gary Chaimowitz and Britta Ostermeyer. Dr. Rocksheng Zhong Dr. Zhong is a rising fourth-year resident and Clinical Research Scholar in the Department of Psychia- try at the Hospital of the University of Pennsylvania. He obtained his A.B. in Psychology from Har- vard College and M.D. and M.H.S. from Yale School of Medicine. His interests revolve around the intersection of psychiatry, cognitive science, law, and ethics. He has written and presented papers on decision-making in moral dilemmas, pediatric resuscitation practices, and defendants’ remorse in criminal justice. Dr. Zhong is currently involved in the development of a model graduate medical curriculum on clinical informed consent. After residency, he plans to continue his training as a fellow in forensic psychiatry. His Rappeport mentor is Dr. Cathy Lewis.

The American Academy of Psychiatry and the Law is pleased to announce the 30th Annual Rappeport Fellowship competition. Named in honor of AAPL's founding president, Jonas R. Rappeport, MD, the fellowships offer an opportunity for outstanding residents with interests in psychiatry and the law to develop their knowledge and skills.

The meeting will be held in Denver, CO from October 26-29, 2017. Immediately prior to the Annual Meeting, Fel- lows will also attend AAPL's Forensic Psychiatry Review Course, an intensive, comprehensive overview of psychiatry and law. At the Annual Meeting, Fellows are encouraged to attend the many excellent educational sessions, and to meet with AAPL preceptors, who can assist them in exploring interests in psychiatry and the law. Travel, lodging, and educational expenses are included in the fellowship award, and a per diem will be paid to cover meals and other expenses.

Residents who are currently PGY-3 in a general program, or PGY-4 in a child or geriatric subspecialty training program and who will begin their final year of training in July 2017, are eligible. Canadian PGY-5 general psychiatry residents and Canadian PGY-6 child residents are eligible. The Rappeport Fellowship Committee will accept two nominations from each residency program. Nominations must be postmarked byApril 1, 2017. Contact the AAPL Executive Office for more information.

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FELLOW’S CORNER The Use of a Second Language in tion in the second language as long as they are proficient. Making profes- Forensic Evaluations sional inferences from a mental status examination and about an evaluee’s Wilhem Rivera MD and Carla Rodgers MD state of mind are at the core of the Evaluating bias, adds collateral information, and matter for forensic experts. We hope persons from var- allows the expert to exercise some that a recent survey circulated to the ious linguistic judgment when processing the inter- AAPL membership will help clarify backgrounds is an preter’s information. Although some of the issues that arise in con- important skill experts in transcultural psychiatry ducting these specialized evaluations. for forensic psy- have cautioned forensic evaluators References: chiatrists. about performing evaluations with a 1. Ryan C. (2013). Language use in the According to the limited knowledge of a language [2, United States: 2011 American community 2011 US census, at p. 634], two recent studies have service reports. US dept. of Commerce. US there are over 60 million people in reported that thinking in a foreign Census Bureau. the United States who speak a lan- tongue reduces decision-making bias 2. Rosner, R (ed). (2000). Culture and Eth- guage other than English at home. by reducing the emotional reactions nicity, Principles & Practice of Forensic that occur when receiving informa- Psychiatry 2nd. Boca Raton, Fl, CRC Press Over 22% of these are not able to 3. North, T. (2012). Statement before the speak English well, or at all [1]. Even tion in one’s primary language [7,8]. Senate Homeland Security and Government among the speakers of the top ten Having an expert interpreter along Affairs Committee, Subcommittee on Over- other languages, English-speaking with an understanding a foreign lan- sight of Government Management, the Fed- ability varied greatly. Less than half guage may consequently provide for eral Workforce, and the District of Colum- of those who spoke Korean, Chinese, improved quality of information. bia Washington, D.C.www.fbi.gov/news/tes- or Vietnamese, for example, spoke Some commentators caution that timony/a-national-security-crisis-foreign- English “very well.” The proportion evaluations performed with untrained language-capabilities-in-the-federal-govern- of those who spoke English “very interpreters, like a non-proficient ment, last accessed March 7, 2016 well” among Russian, Spanish, evaluator, may lead to failure in iden- 4. CIA Values Language Capabilities French Creole, Arabic, and Tagalog tifying thought distortions and delu- among Employees. 2010. www.cia.gov/news-information, last speakers ranged from 52-67% [1]. sions because of the tendency to omit accessed March 7, 2016 This leaves a large proportion who sensitive material. [9] A systematic 5. Education and the Language Gap. has difficulty communicating with review of patient language proficien- December (2010). Secretary Arne Duncan’s others, especially when they come in cy and interpreter services showed remarks at the Foreign Language Summit. contact with the legal system. that conducting an evaluation in a U.S. Dept. of Education. Some commentators consider non-primary language can lead to an 6. Rosner, R (ed). (2000). Culture and Eth- working with evaluees from different incomplete or distorted mental status nicity, Principles & Practice of Forensic linguistic backgrounds a part of the examination. Psychiatry 2nd. Boca Raton, Fl, CRC Press new field of “Transcultural Forensic There are no formal studies that 7. Keysar, B., Hayakawa, S., An, S.G. Psychiatry.”[2] Consequently, foren- assess bilingual practices in forensic (2012). The Foreign Language Effect: psychiatry. The closest we’ve come is Thinking in a Foreign Tongue Reduces sic evaluators who speak a foreign Decision Biases, Psychological Science language are part of the field’s evolv- studying how interpreters help the 8. Corey, J.D., Costa A., (2015). The For- ing sensitivity to language as an evaluation of mental status and diag- eign Language Effect on Moral Decisions: expression of culture, and offer a ser- nosis. Two studies about professional Ciencia Cognitiva: Center for Brain and vice to those who may have been interpreters point out that they can Cognition, Universitat Pompeu Fabra, Spain marginalized by the legal system. The nonetheless improve clinical care 9. Bauer, A., Alegria, M. (2010). The need for bilingual professionals has more than untrained interpreters, that Impact of Patient Language Proficiency and been recognized by US agencies like mental status exams are the same Interpreter Service Use on the Quality of the FBI, CIA and the US Dept. of when compared with interviews by a Psychiatric Care: A Systematic Review. Education, which have issued mission bilingual psychiatrist, and that expert NIH Public Access Psychiatric Services statements that recognize the need for interpreters may improve disclosures 10. Karliner, L., Jacobs, E., Chen, A., Mutha, S. (2007). Do Professional Inter- bilingual performance and instruction [10,11]. preters Improve Clinical Care for Patients [3-5]. In our experience, most English- with Limited English Proficiency? A sys- When evaluating a limited English speaking psychiatrists who perform tematic Review of the Literature. Health proficiency (LEP) individual, there is an examination in another language Research Educational Trust a special benefit in understanding the will use an interpreter, even if they 11. Jacobs E., Sadowshi, L., Rathouz, P. foreign language. This is because have some second language profi- (2007). The Impact of an Enhanced Inter- understanding the evaluee’s primary ciency. However, others feel they preter Service Intervention on Hospital language decreases decision-making gain more by conducting the evalua- Costs and Patient Satisfaction. Journal of General Internal Medicine

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MEANWHILE INTERNATIONALLY… The Double Track in Continental od during the late nineteenth century when a movement to individualize European Criminology the treatment of criminals ran up against the problem of the so-called Michael Louis Corrado, Arch Allen Professor of Law, Emeritus, University “persistent,” or incorrigible, offender. of North Carolina Law School Criminologists who claimed training in social science or in psychology had M. v. Ger- In the 2009 case of hibition) was a principle that the argued that the classical approach to many1 the European Court of Human Court believed should apply to pre- punishment was ineffective and that Rights upheld the German notion of a ventive, as well as to punitive, sen- individual treatment entrusted to “double track,” under which danger- tences. experts promised a more effective ous criminals could be given a deter- And the Court also found a prob- approach to crime. This argument minate term in prison as retributive lem in the fact that there wasn’t much pointed away from the classical idea punishment, to be followed by an to distinguish the conditions during of the fixed punishment proportional indeterminate term of preventive the retributive or punitive term of the to the crime and toward an indetermi- detention that would last as long as sentence from the conditions during nate sentence of individualized treat- the prisoner remained dangerous. The the preventive term. If there was no ment that would change the character Court found that there was nothing distinction between the two terms, of the criminal for the better. But, inherently wrong with the idea of then the second term would have to they added, some criminals could not punishment followed by preventive be considered punishment just like be corrected. They had been corrupt- detention, and pointed to similar the first term, and the Court held that ed from birth, or by previous stays in practices in a number of other Euro- that also violated the Convention. prison; they were beyond salvation, pean countries. Preventive detention had to be clearly and for them only segregation was The law had been challenged distinguishable. appropriate, segregation that would before the European Court by a The detainee’s appeal was granted, (failing some miraculous recovery) detainee. The German government and Germany (and much of Europe) last the rest of their lives.2 had defended the law as an “escape began a period of soul-searching on The first fruits of this “progres- valve” which allowed it to keep the the question of the double track. sive” approach to crime were seen in sentences for ordinary prisoners low, Ensuring that the second track would reforms proposed in the 1880s and indeed, among the lowest in Europe. be significantly different from the 1890s in Switzerland, France, and Those criminals that inspired the first would be expensive, for one Norway, reforms providing for segre- greatest fear among the public would thing. But its also true that punish- gation instead of punishment for per- be given over to the double track, to ment is traditionally surrounded by sistent offenders. The general single- remain in prison indefinitely, and limitations: in addition to non- track idea of segregation for persis- ordinary criminals could be given retroactivity, the accused is protected tent offenders entered into the crimi- mild sentences proportional to their by the requirements that there be a nal justice systems of various coun- crimes. In this way popular outrage criminal act and that punishment be tries in Europe – including the dicta- was contained and at the same time proportional to the crime, to name torships in Hungary, Spain, and the prisons were not overburdened. just two. Importing the non-retroac- Yugoslavia. A 1909 draft proposal in But although the European Court tivity prohibition on punishment into Germany followed this lead but was idea had no problem with the of the preventive detention raised this ques- never enacted into law. double track, it found a couple of tion: should preventive detention The double track itself, a compro- problems in the way the law was enjoy all the same limitations that mise between the measures provided implemented. For one thing, Ger- punishment does? Take the require- for by classical retributive theory and many had increased the maximum ment of proportionality: the possibili- those provided for by positivist pre- length of preventive detention from ty of tacking on a period of preven- ventive theory, put punishment ten years to make it indefinite, and tive detention means that that limita- together with preventive detention, had done so retrospectively. Prisoners tion is worthless. It will be up to the and appeared first in New South already sentenced to preventive judge in every serious case whether Wales in Australia in 1905. Criminals detention when the maximum had the proportionality restriction applies having previously committed several been ten years were now liable to to you or not. The fate of the double serious offenses would be given the remain detained indefinitely. The track in Germany is now up in the air. ordinary sentence of punishment to Court held that this retroactive exten- The double track had been intro- be followed by detention at “His sion of the period of detention violat- duced into German law by the Nazi Majesty’s pleasure.” The compromise ed the European Convention on government in 1934, but the idea did approach was followed, within ten or Human Rights: “no retroactive sen- not originate with Nazi (or with Fas- so years, in other parts of Australia tence increases” (something that for cist) ideology. Its history goes back at and elsewhere in the British Empire.3 us comes under the ex post facto pro- least fifty years before that to a peri- (continued on page 16)

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MEANWHILE INTERNATIONALLY…CONTINUED

The Double Track fied, then the sentence was required (Article 66 of the German Criminal (for a), or permitted (for b), to be Code) is distinguished from the com- continued from page 15 aggravated up to five years for minor mitment of mentally ill offenders to In the 1930 Rocco Code adopted crimes, and up to fifteen years for psychiatric hospitals (Article 63 of by the Fascist government in Italy, felonies. But in addition, if “the pro- the Code). “[P]reventive detention the double track appeared once more. tection of the public requires such a requires that the perpetrator is There was no hint that a mental or measure,” the court had to pass a sen- responsible for his criminal behavior. psychological defect was required, tence of preventive detention – which The idea behind this measure is to and hence no provision for placement could be indefinite.5 protect the public from habitual in mental hospitals. (Commitment of After World War II many things offenders.”7 The ECHR and the Ger- the dangerous mentally ill was and changed in Germany and in Europe. man Constitutional Court have said remains a separate issue.) For those For one thing effective constitutional that detention in preventive detention labeled “habitual offenders,” “profes- courts were introduced to enforce the facilities must be distinguishable sional offenders,” or “offenders with human rights provisions of constitu- from detention in prisons, and one criminal tendencies,” there was a pre- tions, and the European Court of way in which that might be done sumption of social dangerousness, Human Rights took on the job of would be to provide therapy for and judges were required to imple- enforcing the European Convention detainees. but up to the present there ment the double track. Although the on Human Rights. But the double has been no serious requirement of presumption was abolished after the track did not disappear from German treatment.8 Though the detainees are, fall of the Fascist regime, the double criminal law, or from Italian criminal in theory, to be given assistance in track remains in the statute book to law, or from the law of many other adjusting to life outside prison, these be implemented on a case by case continental European countries. One are institutions designed first and basis. thing that did change in Germany foremost to protect the public from Marco Pelissero, Professor of Law was the outside limit on the period of dangerous offenders. at the University of Turin, has written detention: Detention, which had been that the use of the double track in for an indefinite period in some References: Italy has declined drastically in Italy cases, was given a ten-year limit. 1. ECHR Application number 19359/04, 17 since the Second World War, and the Then, in the late 1990s, the Ger- December 2009, no. 45. The Court found (¶ ECHR’s decision in the M. v. Ger- man legislature brought back the pos- 70) that at least seven other member states many case may result in its abandon- sibility of indefinite detention, and of the Council of Europe had “systems of ment. That is not to say, though, that preventive detention in respect of convicted the detention of prisoners sentenced offenders who are not considered to be of preventive measures are out: in many under the earlier maximum of ten unsound mind:” Austria, Denmark, Italy, ways – including notably the preven- years was extended indefinitely. The Liechtenstein, San Marino, Slovakia and tive aspects of the “anti-mafia” legis- prisoner known as “M.” (German law Switzerland. lation – Italy has replaced the double reports do not publish the full names 2. Enrico Ferri, The Positive School: Three track with a multiplicity of preventive of defendants), complained about this Lectures Given at the University of Naples, measures, many of them within the retroactive imposition of an indefinite Italy on April 22, 23 and 24, 1901 (1901; criminal penalties.4 An example of sentence, and brought the case to the trans. Ernest Untermann), chapter one. such a measure would be the Ameri- European Court of Human Rights, 3. N. S. Timasheff (1939-1940), “The can institution of the “three strikes” which upheld his appeal and repri- Treatment of Persistent Offenders Outside law: the dangerous offender is held manded Germany on several fronts, of the United States,” 30 Am. Inst. Crim. L. longer, but under the guise of punish- & Criminology 455, 458 (1939-1940). as we have seen. 4. Marco Pelissero (2013), “The Doppio ment rather than prevention. According to Joerg Kinzig, Direc- Binario in Italian Criminal Law,” in Pre- Germany followed the lead of tor of the Institute for Criminology at venting Danger, supra, pages 107-125. Italy’s Fascist government with the the University of Tuebingen, the situ- 5. Hermann Mannheim (1935), “German 1933 Act Concerning Dangerous ation in Germany today is very much Prevention of Crime Act, 1933,” 26 J. Crim. Habitual Criminals. The require- in flux. The federal legislature and L. & Criminology 517, 520-22 (1935). ments for preventive detention, under the legislatures of each of the Ger- 6. Joerg Kinzig (2013), “The ECHR and the Act, were these: man states have passed legislature the German System of Preventive Deten- a. there was a third conviction for providing for the construction of new tion,” in Michele Caianiello and Michael a serious crime, and the defendant detention facilities to provide the nec- Corrado, Preventing Danger: New Para- digms in Criminal Justice (2013), pages 71- gave the general impression of being essary distance between conditions a dangerous habitual criminal, or 95. under the punitive sentence and con- 7. Kinzig, page 76. b. there were three offenses (with ditions under the preventive 8. The German court has held that the pre- 6 or without conviction) and the defen- sentence. It is worth pointing out ventive detention provisions did not main- dant gave the impression of being a that the commitment of dangerous tain the “constitutionally required” distance dangerous habitual criminal. offenders to preventive detention between preventive detention and prison If those requirements were satis- (continued on page 28)

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ALLABOUT AAPL

APA/AAPL Manfred S. Guttmacher Award Lecture of personality disorders (e.g., borderline personality disorder may be pre- APA Annual Meeting 2016 sent in 10-12% of incarcerated men and greater than 20% of incarcerated Abhishek Jain MD females). Dr. Trestman emphasized the importance of understanding and At the 2016 American Psychiatric attributed current APA President, and managing accreditation standards, Association (APA) Annual Meeting past AAPL President, Renée Binder particularly in a complex environ- in Atlanta, Georgia, the annual Man- as playing an instrumental role in this ment. fred S. Guttmacher Award was pre- change. Dr. Trestman described the drastic sented to Kenneth Appelbaum MD, Similar trends were not readily reduction of research in correctional Robert Trestman MD, PhD, and Jef- apparent in Dr. Appelbaum’s review settings. Prisons were primary sites frey Metzner MD for their “Oxford of the Institute on Psychiatric Ser- for research through the early 1970s; Textbook of Correctional Psychiatry.” vices annual meeting programs in for example, about 85% of new drug Established in 1975, the Guttmach- 2014 and 2015. He pointed out that trials were conducted in prison at that er Award annually recognizes an out- the American Journal of Psychiatry time. However, through appropriate standing contribution to forensic psy- (AJP) included three papers related to ethical concerns that were raised, chiatry literature. The award is co- the criminal justice system in 2015, such as Beecher’s 1966 New England sponsored by the APA and AAPL, which is an increase from no papers Journal of Medicine article, the pen- and supported by a grant from Profes- in 2014. However, outside of a dulum has perhaps swung to prison- sional Risk Management Services review of this Guttmacher Award- ers being “overprotected” from (PRMS), Inc. winning textbook, there have been no research. For instance, over the past As award recipients, Drs. Appel- AJP publications related to correc- 15 years, less than 30 randomized baum, Trestman, and Metzner also tional settings or the criminal justice controlled trials have been conducted delivered the Guttmacher Lecture, in system thus far in 2016. in correctional settings. Yet, efforts, which they cogently outlined psychia- Dr. Appelbaum identified key such as revised ethical considerations try’s role in the correctional system, areas to further develop the field of and research standards in prison pop- including ongoing treatment needs, correctional psychiatry: recognizing it ulations, have not come to fruition. future research directions, and as a field of growing complexity; Dr. Trestman highlighted that spe- involvement in policy initiatives. research and expanding its evidence- cialized research needs in this popula- Dr. Appelbaum highlighted that base; refining guidelines and stan- tion include neuroimaging, and neu- “correctional psychiatry is truly com- dards of practice; rehabilitation; roendocrinology, and overall more ing into its own as a subspecialty.” reforms to the criminal justice sys- studies in epidemiology, assessment He discussed that, over the years, tem; and respecting frontline clini- methodologies, psychotherapy, phar- psychiatric issues in jails and prisons cians. He estimates that 1500 to 2000 macotherapy, co-occurring disorder have had limited attention, despite psychiatrists are needed in the correc- management, and risk reduction that 15-20% of inmates are estimated tional system, however currently only approaches. to meet the criteria for severe mental 341 (less than 1%) of the 35,089 APA Dr. Metzner presented “The Role illness. As is oft stated, more psychi- members self-identify as working in of Professional Organizations in atric patients are incarcerated than correctional or forensic facilities. Establishing Standards of Care in hospitalized - which is frequently cor- Dr. Trestman discussed “The Edu- Correctional Health Care.” In the related with de-institutionalization cational and Research Needs for Cor- 1970s, the American Medical Associ- and state psychiatric beds being rectional Psychiatry.” He first sum- ation (AMA) found that jail health reduced from 558,000 in 1955 to marized their textbook’s wide-ranging services were inadequate, disorga- 35,000 in 2010. applicability, such as to clinical nized, and unstandardized. The AMA Dr. Appelbaum also described a trainees, more advanced practitioners, and other organizations collaborated slight increase in 2016 APA presenta- and administrators. Unique clinical and established a program that even- tions on topics related to correctional considerations include population tually became the National Commis- psychiatry. Searching terms “prison,” characteristics (e.g., 70-80% of sion on Correctional Health Care “jail,” “corrections,” “inmate,” inmates have substance use issues) (NCCHC). Dr. Metzner described the “detention,” and “incarceration” in and dual reporting responsibility NCCHC’s role in establishing stan- the annual meeting programs, he (e.g., to correctional officers for safe- dards for healthcare services in jails found one symposium and one poster ty concerns). More advanced practi- and prisons. at the 2014 meeting, one workshop at tioners may appreciate nuances, such Dr. Metzner highlighted the APA the 2015 meeting, and at least three as issues surrounding levels of care Council on Psychiatry and Law’s symposia, three workshops, one sci- and pod placements, awareness of influence in areas such as restraints entific and clinical report, and one specific medication abuse, (e.g., and seclusions, staffing ratios, and lecture at the 2016 meeting. He crushed bupropion), and management (continued on page 30)

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ALLABOUT AAPL APA Assembly Report funding, so that they may advance this legislation. If enacted in its Cheryl D. Wills MD, AAPL’s Alternate Representative to the APA Assembly, entirety, the bill would, among other Debra S. Pinals MD, AAPL’s Representative to the APA Assembly things, address the prohibitive cost of second generation antipsychotics for The APA Assembly Meeting was have responded positively to the ser- patients in need. held in Atlanta, GA from May 13 – vice. The program, which is hosted The FDA is reviewing a proposal 15, 2016. The organization has com- through the Learning Management to reclassify ECT from a Class III pleted its rebranding process which System, is one of many educational (high risk) to a Class II (low risk) includes a new logo and mission opportunities available on the web- medical device. The proposal is gen- statement – “The APA represents site. Lastly, there is a webpage for erally supported by the APA which medical leadership for the mind, the APA members who have life mem- prefers that the classification change brain and the body.” The membership bership that consolidates resources apply to all mental disorders for has grown to 36,490 members – the and opportunities. New information which ECT is indicated. The propos- highest number in 13 years – and will be added to the page in response al, in its current iteration, restricts the there is a budgetary surplus due to to feedback from APA life members. class change to treatment resistant membership dues and sales of DSM-5 severe major depressive disorder with and related publications. The lease on or without bipolar disorder and indi- the APA headquarters property in “[APA President, Renée viduals who require a rapid treatment Arlington, VA expires at the end of response due to the severity of their 2017 and it will be relocating to 800 Binder] accomplished physical or mental health status. Maine Ave, SW in Washington, DC An effort by psychologists in in late 2017. many noteworthy pro- Hawaii to expand their scope of prac- AAPL Past President Renée jects during her term, tice to include medication prescribing Binder has completed her term as privileges was recently defeated. APA President. The theme of her including bringing cor- Iowa became the fourth state to per- presidency was “Claiming Our mit psychologists to prescribe psy- Future.” She accomplished many rectional psychiatry to chotropic medication on May 27, noteworthy projects during her term, the forefront of discus- 2016. The APA has hired four including bringing correctional psy- regional assistants to aid the District chiatry to the forefront of discussions sions about psychiatric Branches with their efforts to respond about psychiatric care delivery to to psychologists’ scope of practice underserved populations and recog- care delivery to under- bills. The APA takes no position on nizing AAPL’s contributions to the served populations and whether District Branches should try APA. to defeat these bills or to refine them The following activities have been recognizing AAPL’s con- by focusing on protocols for pre- developed by the APA as part of its scriber eligibility. As many as five mission to educate the members: tributions to the APA.” psychologist prescribing bills will be An education innovation lab was introduced in the next calendar year. made available to members the Annu- The APA has been interfacing with The APA has actively responded to al Meeting. The highly interactive the U.S. government regarding many several statutes that used “religious lab, which was designed to permit challenging matters that are important freedom” to cloak and sanction dis- psychiatrists to be active participants for members and patients. The White crimination. The emotional impact of in learning, contained a collaborative House has appointed a Task Force of such legislation can have a profound break space, a brain break area and a Parity Enforcement that is charged impact on patients and our practices. theater with comfortable seating. monitoring and enforcing mental The APA Program Committee chose Also, the APA’s Cultural Competence health parity. The Task Force’s first to withdraw an invitation to a presen- webpage, titled “Best Practice High- open meeting was held at the APA ter whose presentation supported the lights for Treating 6 Diverse Patient Annual Meeting in Atlanta. spirit of such legislation as the pre- Populations,” is now available to The Helping Families in Mental sentation was not grounded in evi- members seeking to contextualize Health Crisis Act (H.R. 2646), which dence-based literature. their assessment and treatment of focuses mental health resources on The APA Board of Trustees Ad individuals of various cultures. In patients and families who need it Hoc Group on Telepsychiatry has addition, APA members have free most, has bipartisan support in Con- developed a toolkit for members that access to a CME course on a trending gress. The APA and other mental contains videos on various aspects of topic that changes monthly. The e- health stakeholders are encouraging telepsychiatry, including training, mail has one of the highest open rates members of Congress to work teaching, policy and clinical matters. of APA correspondence and members through the details, including the (continued on page 21)

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ALLABOUT AAPL American Medical Association 2016 vices after Olmstead v. L.C. Further, the AAPL delegation noted that pro- Annual Meeting Highlights viding appropriate services and tran- sitions for this population should Barry Wall MD, Delegate, Linda Gruenberg DO, Alternate Delegate, occur throughout adulthood, not just Jennifer Piel MD, JD, and Tobias Wasser MD, Young Physician Delegates at the point of transition to adult services. Other resolutions that the The American Medical Associa- every AMA meeting to obtain mem- House of Delegates passed included tion’s (AMA) June 2016 Annual bers’ input on current ethical issues. several LGBT matters, including Meeting in Chicago focused on poli- The committee heard testimony on “Clarification of Medical Necessity cy, medical education and practice, the issues of dual loyalties such as for Treatment of Gender Dysphoria” health initiatives, and science and those found in the military, sports and “Updating Sexual Orientation technology. Dr. Andrew W. Gurman, medicine, hospital-employed physi- and Gender Identity Policy.” a private practice orthopedic hand cian tensions that may arise, conflicts A highly debated resolution was surgeon from Pennsylvania, was inau- of interest for mandated reporters, entitled “Religiously Affiliated Med- gurated as President of the AMA and and reporting of impaired colleagues ical Facilities and the Impact on Dr. David O. Barbe, a family practice (including the pressures to send them Physician’s Ability to Provide Patient physician from Missouri, who is Vice back to clinical practice). Testimony Centered, Safe Care Services.” The President of Regional Operations at was also heard on medical tourism authors requested a report on the Mercy Clinic, was elected to Presi- both in and out of the country. impact of denial of care, presump- dent-Elect. In addition, Dr. Patrice Telemedicine is now practiced tively limited to certain religious Harris, a child and forensic psychia- widely and has changed access to facilities, which includes difficulty trist and AAPL member, transitioned care. Since physicians and patients patients face having to travel dis- into her role as Chair of the AMA interact differently in this model, tances for access to care in certain Board of Trustees. there are different levels of account- regions due to service consolidation. The Pulse Nightclub mass shoot- ability for physicians, which became A revised adoption calls for a study ing in Orlando, which left 50 people a focus of this year’s annual meeting. of hospital consolidations in both sec- dead, occurred during the Annual New policy entitled “The Ethical ular hospitals and religiously affiliat- Meeting. This galvanized the House Practice in Telemedicine” passed and ed hospitals to assess impact on of Delegates to pass a late resolution indicated that while participating in patient access to services resulting on “Gun Violence as a Public Health Telehealth and Telemedicine, the from consolidation. Crisis.” In doing so, AMA declared physician has an ethical responsibility Two competing resolutions on that gun violence represents a public to uphold their fundamental fiduciary physician assisted suicide were heard. health crisis that requires a compre- obligation by disclosing any financial A resolution regarding “Opposition to hensive public health response and or other interests in the telehealth or Physician Assisted Suicide and solution. It also called for the AMA telemedicine application and to take Euthanasia,” which would have main- to lobby to lift the congressional ban steps to minimize any conflict(s) of tained AMA’s current stance against on gun violence research, which has interest. Guidelines advise site users physician-assisted suicide, was not barred federal funding of gun vio- to arrange for follow up care when it adopted. Instead, in the wake of sev- lence research since 1996. Even in is indicated, be proficient in the use eral states passing legislation allow- the aftermath of several recent mass of the relevant technologies in con- ing physician-assisted suicide, a reso- shootings, Congress extended the ban ducting diagnostic evaluations or pre- lution entitled “Study Aid in Dying as just last year. scribing medication, establish the an End of Life Option” was passed. After eight years of revision efforts patient’s identity, confirm that the CEJA will now take up this matter. by the Council on Ethical and Judicial teleservices are appropriate for the Of note, the American Psychiatric Affairs (CEJA), the House of Dele- patient’s individual situation, and pro- Association Council on Psychiatry gates approved the passage of a mote the continuity of care when pos- and the Law will release a resource revised AMA Code of Medical Ethics. sible. document later this year addressing The last major code revision occurred Another resolution relevant to mental capacity in end-of-life deci- in 1957, with modifications in 1980 AAPL was “Support for Persons with sion making. and 2001. The new code simplifies Intellectual Disabilities Transitioning Other relevant topics in forensic the navigation of the code and related to Adulthood,” which aims to bolster psychiatry included passage of policy opinions, making the document easier transitional services from juvenile to resolutions entitled “Electronic to apply to the daily practice of medi- adult systems for the intellectually Health Records and Meaningful cine, and reflects comments and input disabled. Dr. Wall testified in support Use,” “Reducing Firearms Violence,” from the AAPL Delegation as well as of the resolution while providing con- “Fraudulent Use of Prescriptions,” other AAPL members. text on legal and other difficulties and “Physician–Patient SMS Text CEJA holds an open forum at states face in implementing such ser- (continued on page 31)

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ALLABOUT AAPL AAPL Annual Meeting 2016 Lunch Speakers Charles Dike MD, Program Chair The Terrorist’s Son: My Path to Peace Zak Ebrahim Zak Ebrahim was only seven years old when, on November 5, 1990, his father, El-Sayyid Nosair, shot and killed the leader of the Jewish Defense League. While in prison, Nosair helped plan the bombing of the World Trade Center in 1993. In one of his infamous video messages, Osama bin Laden urged the world to "Remember El-Sayyid Nosair. For Zak, a childhood amid terrorism was all he knew. After his father’s incarceration, his family moved more than twenty times, haunted by and persecuted for the crimes of his father. Though his radicalized father and uncles modeled fanatical beliefs, the hateful ideas never resonated with the shy, awkward boy. The older he grew, the more fully Zak grasped the horrific depths of his father’s acts. The more he understood, the more he resolved to dedicate his life to promoting peace. In his book, The Ter- rorist's Son: A Story of Choice, Zak traces his remarkable journey to escape his father’s terrible legacy. Crisscrossing the eastern United States, from Pittsburgh to Memphis, from a mosque in Jersey City to the Busch Gardens theme park in Tampa, The Terrorist’s Son is the story of a boy inculcated in dogma and hate—a boy presumed to follow in his father’s footsteps—and the man who chose a different path. Transforming the Police: The Department of Justice Civil Rights Division and Police Accountability Attorney Christy Lopez Christy E. Lopez is a Deputy Chief in the Civil Rights Division of the U.S. Department of Justice. Ms. Lopez heads the Special Litigation Section’s police practice group, which has primary responsibility for conducting “pattern-or-practice” investigations of law enforcement agencies, and for filing suit or negotiating a remedial agreement where such a pattern or practice is found. Ms. Lopez led the team that investigated the Ferguson Police Department and is the primary drafter of the Ferguson Report. She is currently leading the team investigating the Chicago Police Department. She also led the investigations of the New Orleans Police Department, the Los Angeles Sheriff’s Department, the Newark (New Jersey) Police Department, and the Missoula, Montana investigation, which was the Division’s first investigation focusing on the collective law enforcement response to allegations of sexual assault. This investigation was also the Division’s first pattern-or-practice case to focus on a prosecutor’s office. Ms. Lopez was also the Deputy Chief overseeing the Division’s recent successful litigation against the towns of Colorado City (Arizona) and Hildale (Utah), in which a jury found that the towns’ law enforcement agency enforced the edicts of the a religious sect rather than the rule of law. Ms. Lopez helped formulate and draft the DOJ statement of interest in the Floyd litigation challenging the New York Police Department's stop-and-frisk practices, as well as DOJ guidance released last year on preventing gender bias in the law enforcement response to sexual assault and domestic violence. Ms. Lopez currently serves as an Advisor on the American Law Institute (ALI) Principles of Law, Police Investigations Project. Ms. Lopez has been awarded the Flame Award by the National Association for Civilian Oversight of Law Enforcement (NACOLE) for her long-term commitment to police accountability and civilian oversight. In 2015, Ms. Lopez was awarded the Department of Justice’s highest employee honor, the Attorney General’s Exceptional Service award, for her work leading the Ferguson Police Department pattern-or-practice investigation. In 2013, Ms. Lopez was awarded the Attorney General’s John Marshall Award for her work leading the New Orleans Police Department investigation and consent decree negotiation. Ms. Lopez served as a federal court monitor from 2003 to 2010 for Senior District Judge Thelton E. Hender- son of the Northern District of California. In that role, she assessed and reported on the Oakland (California) Police Department’s implementation of a federal consent decree. She authored the 2010 American Constitution Society Issue Brief, "Disorderly (mis)Conduct: The Problem with ‘Contempt of Cop’ Arrests,” and has taught law school courses on unlawful racial, national origin, and religious profiling. A California native, Christy received her B.A. from the University of California, Riverside, and her J.D. from Yale Law School. She clerked for Alaska Supreme Court Justice Robert L. Eas- taught from 1994 to 1995. She is licensed to practice law in Washington DC and California.

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ALLABOUT AAPL Story of a Warchild Emmanuel Jal Emmanuel Jal was born into the life of a child solider on an unknown date in the early 1980s in the war-torn region of Southern Sudan. Through unbelievable struggles, Emmanuel managed to survive and go on to emerge as a recording artist, achieving worldwide acclaim for his unique style of hip hop with its message of peace and reconciliation born out of his personal experiences. Despite his accomplishments in music and film, one of Jal’s biggest passions is Gua Africa, the charity he has founded to work with individuals, families and communities to help them overcome the effects of war and poverty. Besides building schools, the charity provides scholarships for Sudanese war survivors in refugee camps and sponsors education for children in the most deprived slum areas in Nairobi. Gua Africa is now fundraising to complete phase 2 of Emma Academy, the education center in Leer named after the British aid worker Emma McCune who rescued Jal from a life as a child soldier. In the outbreak of violence in South Sudan since December 15th 2013, Gua has changed its focus to keeping its existing schools open and ensuring their teachers are paid and students are safe. In December 2010, Jal released “We Want Peace,” as part of the wider campaign of the same name calling for peace, protection and justice for all in Sudan ahead of the January 2011 referendum, but also calling for an end to all conflicts affecting innocent people around the world. The campaign was supported by A-list artists and leading figures from diverse fields, including Peter Gabriel, Alicia Keys, George Clooney, Richard Branson, President Jimmy Carter, Kofi Annan and many more. In 2012 he organized and hosted the first of its kind Peace Dinner and Concert in Juba, South Sudan on International Peace Day, supported by H.E Dr. Riek Marchar, Vice President of South Sudan alongside leg- endary US hip hop artist DMC. Through his peace movement We Want Peace Emmanuel Jal is working alongside African artists such as Juliani (Kenya), Vanessa Mdee (Tanzania), and Syssi Mananga (Congo Brazzaville) to spread passion and awareness about Afrcia’s at risk elephant population. Through the new campaign Stand For Elephants, these artists have released the new peace anthem TUSIMAME (Let’s Stand) now available on iTunes and Mdundo. Jal still undertakes his Lose to Win Challenge, which sees him raising funds for Gua Africa, Africa Yoga Project and My Start for Windle Trust International.

APA Assembly Report who are working to reduce the incar- substance use disorders. The law also ceration rate of Americans with men- allocates funds for a forensic hospital continued from page 18 tal disorders. The orange-tie event diversion program. featured the Netflix Series “Orange MACRA the Medicare Access and The Group recommends that the APA is the New Black.” Stars of the show CHIP Reauthorization Act of 2015 is take a leadership role, on a national walked the orange carpet and partici- the new value-based reporting pro- and state level to provide education pated in a discussion about how the gram that will replace meaningful about and advocate for telepsychiatry show has introduced viewers to what use. The Center for Medicaid and as a resource to reduce problems inmates who have mental disorders Medicare Services will be moving related to access to care. may experience and how they may be towards a performance-based funding The APA On Tour program pre- treated. system. The APA plans to work with sented a panel discussion about the Awardees included House Minori- members so that they will have the mental health impact of human traf- ty Leader Nancy Pelosi (D-Calif.), ability not to be penalized under the ficking at the Annual Meeting. Traf- who advocated for the Mental Health new system. ficking affects about 20.9 million Parity and Addiction Equity Act and The APA has partnered with the people worldwide and most survivors who supports health care reform that American Professional Agency (APA, have mental health concerns. Also, integrates mental health care and pri- Inc.) to develop nine risk manage- about 87% of individuals who have mary care; Senator Al Franken (D- ment courses that will be offered to been trafficked had contact with Minn.), who introduced the Compre- APA members at no cost. Members healthcare professionals while they hensive Justice and Mental Health may receive AMA PRA Category 1 were being trafficked. The focus of Act of 2015, which decriminalizes CreditTM and those who complete the the presentation was identification mental illness and promotes use of required three hours of coursework and treatment of survivors. MH courts, Jail Diversion, and will be eligible to receive a 5% dis- On April 18, 2016, the APA and enhanced access to community based count on their professional liability the APA Foundation held the inaugur- MH care; and Florida State Senator insurance through APA, Inc. The al APEX Awards at the Mayflower Miguel Díaz de la Portilla (R-Miami- courses, which were created in Hotel in Washington, DC. The event, Dade County, 40th District) authored response to member’s request for hosted by award winning journalist, a law that authorizes judges to use such resources, may be accessed at Cokie Roberts honored individuals treatment in lieu of incarceration for can be found at who have demonstrated the highest juveniles and U.S. Veterans with gen- http://www.psych.org/psychiatrists/pr levels of mental health advocacy and eral discharges who have mental and actice/riskmanagement.

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California’s New Amended CANRA: Russian lawmakers also introduced a bill to ban child participation in beau- Further Erosion of Psychotherapist- ty pageants and penalize the law Patient Privilege breakers7. Prisons have already become our Subhash Chandra MD, Stacy-Ann Phillip MD, Douglas Tucker MD, nation’s largest de-facto mental hos- Sexual Offenders Committee pitals, and they do not have the mission or resources to provide effective California Assembly Bill 1775 is Swiss study, watching child pornogra- rehabilitative services for all inmates an amendment to the existing Child phy alone is not a risk factor for com- who need them. The large population Abuse and Neglect Reporting Act mitting hands-on sex offenses. Out of of child porn offenders created under (CANRA) which took effect on 1-1- 231 men charged with accessing ille- the new CANRA amendment will 15, and mandates certain persons gal pornographic material, 2 (1%) likely add to the existing demand for (including psychotherapists and other also involved a hands-on sex offense, correctional mental health services, mental health caregivers) to report and only two men recidivated with a and could draw resources away from suspected cases of child abuse or hands-on sex offense in a 6-year fol- those with more severe mental disor- neglect, including sexual exploitation. low-up3. In general, evidence sug- ders. This amendment expands the defini- gests that child pornography users are This new law intends to prevent tion of “sexual exploitation” to more likely to have a prior hands-on sexual exploitation by expanding the include downloading, streaming or sex offense, but evidence also demon- prosecution of those with sexual accessing child pornography via any strates that those without such prior interest in children. However, it may means, including viewing this materi- history are unlikely to commit such inhibit patients from seeking mental al on the Internet. Under the act, fail- acts in the future. Given this data, health care for problems with sexual ure to report known or suspected excessive mandated reporting may deviance, and criminalize therapists if instances of child abuse, including not only hinder the foundation of a they address child porn use without sexual abuse, is a misdemeanor1. This therapeutic relationship, but also notifying the legal authorities8. These new law has important implications unnecessarily flood an already inun- offenders are aware that disclosure of for the performance of mental health dated legal system. their thoughts can bring them severe assessments and delivery of mental Although child porn offenses are embarrassment and disgrace. This law health care in California, and it may now punished harshly, many other will further discourage potential serve as a model for other states in expressions of sexuality in children patients from seeking help, and the future. are tolerated or promoted. For exam- encourage reticence during therapy The stated purpose of child porn ple, in the popular TV series ‘Tod- since the mere possibility of disclo- laws is to reduce sexual exploitation dlers and Tiaras’ (now off-air), a 4- sure may impede the development of of the filmed or photographed victims year-old girl donned fake breasts in the confidential relationship neces- by limiting the market for these mate- one episode, and a 3-year-old was sary for successful treatment9. rials in the first place, as well as pre- dressed as a prostitute in another4. Currently, all 50 states have laws venting further transmission of the French Vogue magazine sparked out- mandating a duty to warn or protect obscene images of the victim which rage for its racy photos of a ten-year- against imminent or direct harm to would further extend the victimiza- old girl lying provocatively in a children by sexual victimization, and tion. In addition, these laws are chest-revealing dress, stilettos, and thus allow client confidentiality to be meant to prevent online child pornog- heavy makeup5. Many millions of broken10. Under the new CANRA raphy offenders from committing sex- individuals knowingly and legally amendment, reporting is mandatory ual offenses involving hands-on con- download, stream, or access videos in once the therapist becomes aware that tact with a child. Research indicates which children are depicted in this child porn has been accessed, without that roughly 1 in 8 online offenders fashion, but this is not considered to any consideration of the potential for (12%) have an officially known con- be “obscene,” and is thus not imminent or direct harm to a child. tact sexual offense history, and 1 in 2 reportable. At what point should these The law does not differentiate online offenders (55%) admitted to a images be considered “sexual between a client who downloaded contact sexual offense in the studies exploitation” under the existing child pornography recently or many that had self-report data. However, CANRA law? In September 2013, years ago, nor between individuals over a 1.5- to 6-year follow-up, 4.6% French legislators moved to ban child with ready access to children (e.g. of online offenders committed a new beauty pageants, considering them to preschool teachers) and those with sexual offense of some kind, 2.0% represent "hyper-sexualization" of no such access11. committed a contact sexual offense, minors under age 16, and proposed The Tarasoff duty to protect poten- and 3.4% committed a new child fines and jail time for violators tial victims has existed for many pornography offense2. According to a including parents and sponsors6. years, and remains challenging for (continued on page 29)

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ALLABOUT AAPL - Committees What Toxicology Screens May Miss: behaviors such as removing clothes), tachycardia, speech abnormalities Dextromethorphan (i.e. confused, repetitive, slurred), potential effect in reducing seizure Joseph C. Cheng MD, PhD, Ryan C.W. Hall MD, threshold, and dry mouth.2,5 There Psychopharmacology Committee are also reports that suggest that there is a withdrawal syndrome seen with Many forensic psychiatrists have (DXM), which is found in many frequent DXM consumption.5 had the experience of evaluating a over-the-counter cough suppressant Although many may experience a case in which substance induced psy- formulations, such as Robitussin DM euphoric effect from dextromethor- chosis is in the differential diagnosis and Coricidin. Common street names phan intoxication, much like that seen due to presenting symptoms includ- for DXM are Triple C’s, Robotrip- 6 in PCP or ketamine, some individuals ing, but not limited to, rapid onset, no ping, Robo, Red Devils, and Dex. It may exhibit aggressive and/or disrup- clear past history or unusual presenta- is commonly used by adolescents and tive behaviors that result in self-harm tion of a psychotic disorder, disorga- young adults due to its relatively low or hostile acts.5,6 There is a growing nized behavior with euphoric or reli- cost, availability (pharmacy or drug medical literature to support dex- gious themes, and disrobing behav- store, available over the counter), tromethorphan-induced self-harm iors. However, there may be no toxi- innocuous presentation (e.g. parent deaths and homicides.6,9 For exam- cology results available to support the more concerned about marijuana in ple, in 2009, Logan and colleagues diagnosis. Many times these cases adolescent’s room than bottle of 4 reported a case series of five deaths present as an “excited delirium” or a cough syrup) and simplicity of use. resulting from abuse of dextromethor- unspecified psychotic disorder, which Unlike pseudoephedrine, which has phan obtained over the Internet.10 A results in the individual being brought to be chemically modified to make more recent study by Modi, et al dis- to the hospital or having interactions methamphetamine, dextromethorphan cussed a case of suicidal and homici- with law enforcement. Often, foren- just needs to be consumed in large dal behavior in a middle aged woman sic psychiatrists become involved quantities to obtain an intoxicating abusing dextromethorphan.11 In because of an injury to or death of effect. Queries for the term “Robot- addition, there have been other stud- either the individual with the psy- ripping” on Google and YouTube ies, mostly of ER experiences, noting chosis (e.g. dying of self-harm or in yield approximately 42,000 and 2,000 unusual behaviors or disease states police custody after struggle) or search results, respectively. This sug- that were misdiagnosed. An example someone around them, such as a fam- gests how easy it for individuals to is a paper by Majlesi and colleagues ily member, was injured. Increasing- learn about its euphoric effects and looking at dextromethorphan abuse ly, due to changes in drug laws, the how to consume the compound (for masquerading as a recurrent seizure drug economy (e.g. smoke shops), example, see the YouTube video enti- disorder.2 What many of these papers and the spread of information through tled, “DXM ... Everything you ever have in common is that the initial the Internet, there is increasing use of wanted to know about presentation was often assumed to be nontraditional drugs, such as synthet- ROBOTRIPPING!”). due to another condition, that stan- ic stimulants (e.g. bath salts and flak- The medical literature concerning dard labwork did not recognize the ka), synthetic cannabinoid derivatives DXM notes that it has effects similar dextromethorphan abuse, and that (e.g. spice, K2), and abuse of over the to phencyclidine (PCP) and ketamine dextromethorphan abuse was only counter medications (e.g. deconges- when taken in higher than recom- discovered after the historian asked tants), in order to obtain a high and mended doses.4,6,7 Although levels 1 direct questions about its use. avoid detection. Many of these sub- may vary depending on individual In conclusion, dextromethorphan is stances are not screened for on rou- genetic factors (CYP450 2D6 alleles), an often underappreciated substance tine urine drug tests, are often used in some studies report PCP-like effects of abuse that can result in psychotic combination with other drugs (e.g. occurring at doses of 120mg or 5 6,7 symptoms. Given that, by the time a alcohol or cannabis), which may be 2mg/kg. Psychiatric symptoms forensic psychiatrist becomes misidentified as the significant seen with excessive DXM use include involved in a potential case of sub- causative agent. If they are detected, dissociative events (out-of-body stance induced psychosis, it may not they may be dismissed as just appro- dream state, disorientation, deperson- be possible to obtain additional or priate over the counter use (e.g. alization, fugue state), hallucinations, 2-4 more thorough toxicology screens. cough syrup). This creates the pos- delusions often linked with paranoia Therefore, forensic psychiatrists need sibility that there are more episodes and/or religious meaning, euphoria, to be aware of presentations that are of substance induced psychosis diminished concentration/confusion, consistent with dextromethorphan occurring than most physicians recog- irritability/agitation and manic 4,5 2,3,5-8 intoxication, as well as its street nize. states. Physical symptoms of names such as Robotripping and One such compound that can cre- DXM intoxication include ataxia, Triple C’s, how it is obtained and ate this dilemma is dextromethorphan nystagmus, hyperthermia (resulting in (continued on page 28)

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Personal Biases and Professional Recommendations: ical years? The solution begins with the individual educator. Attending Modeling Prescribing Habits in physicians must remain transparent Medical Education and have an obligation to disclose to the student when their clinical prac- Brian K. Cooke MD, Psychopharmacology Committee tice does not comport with practice guidelines, FDA recommendations, or When I was a medical student, I there a mistake in developing these even best practices. worked with an attending psychiatrist habits? Croskerry suggests we should iden- who, despite authoring numerous Perhaps, but perhaps not. In the tify cognitive biases (of which there peer-reviewed articles and book chap- complex world of medicine, physi- are over 100 affecting clinical deci- ters, struggled to explain why he cians learn to respect both the art and sion making) and use a “debiasing” refused to prescribe a certain antipsy- the skill of diagnosing patients and strategy to avoid them.3 chotic to a patient with schizophrenia. formulating treatment plans. There The medical learner is a sponge, This was not one of the latest medica- can be an overwhelming amount of ready to soak up the information dis- tions, touted by pharmaceutical repre- information that floods our virtual in- seminated from superiors and ready to sentatives as a magic bullet for psy- boxes, disseminating guidelines and shape future practices to what is mod- chosis. Nor was this a medication advice from the constantly evolving eled from residents and attendings. that I had seen other physicians avoid world of clinical research. We must, therefore, assess our own prescribing. While we have an obligation to clinical decision-making and prioritize Research suggested this medication incorporate these best practice guide- honesty when teaching our students. was similarly efficacious to others in lines into our work, we may also sim- Students should learn the value of the same class and with a similar list plify the process by sticking with critical thinking and the ability to of possible adverse effects. After a what works. Conversely, we learn assess the biases that affect them. nagging persistence, I soon learned from bad outcomes, which then influ- Although there is often not a correct that the reason my attending avoided ence future decision making. For answer guiding our clinical practice, this antipsychotic was because he example, the psychiatrist whose we must admit when our medication once had a patient who developed patient developed Steven Johnson choices might be based on idiosyn- neuroleptic malignant syndrome after syndrome decides to use different cratic beliefs, relied upon by heuris- this medication was initiated. mood stabilizers for his patients with tics, or contravene the management These “n of 1” stories are not bipolar disorder. In this way habits decisions made by our colleagues. uncommon in the world of medical are formed. These are the behaviors we should education. Medical students and resi- Habits are also formed when pre- strive to model for our learners when dents frequently encounter them as scribers use treatment interventions in faced by clinical uncertainty. they learn to adapt their prescribing ways that are not officially approved. habits to the attending du jour. The Patients in the emergency room too References: attending tells the team, “I once had a frequently receive neuroimaging for 1. Wong J, Motulsky A, Eguale T, et al: patient who had a remarkable soft indications. Broad-spectrum Treatment indications for antidepressants improvement after we began this antibiotics are prescribed indiscrimi- prescribed in primary care in Quebec, Cana- mood stabilizer.” The fellow explains nately. da, 2006-2015. JAMA: 315; 2230-2232, 1 2016 he once treated a patient who went A recent article from The Journal 2. Lowry F: Off-label antidepressant pre- into delirium tremens despite being of the American Medical Association scribing increasingly common. Available at detoxed with a particular benzodi- shows that off-label prescribing of http://www.medscape.com/viewarticle/86402 azepine. The resident admits that antidepressants has been increasing 8. Accessed June 27, 2016 despite what “the book says,” he and in particular for insomnia and 3. Croskery P: From mindlessness to mind- prefers starting patients with depres- pain. Furthermore, the researchers ful practice—cognitive bias and clinical decision on a specific combination of observed that the indications for pre- sion making. NEJM: 368; 2445-2448, 2013 three medications, because he has had scribing these antidepressants are great success with that regimen. often not documented in the chart.2 Since early learners and young physi- These realities of clinical medicine cians have fairly limited patient expe- put the learner in an uncomfortable AAPL 47th riences, they are easily influenced by quandary. How does the astute med- the habits of their superiors assimilat- ical student reconcile the apparent Annual Meeting ing these practices into body of med- dichotomy between what is taught in Registration now open ical knowledge. If the evidence, how- the lecture halls of undergraduate ever, suggests no inherent problems in medical education and what is taught at www.aapl.org. certain prescribing habits, then is in the clinics and hospitals of the clin-

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Optimizing Collaboration and Achieving Standard of Care: website (http://www.mirecc.va.gov/visn19/cli A Model for Therapeutic Risk nical/assessment_tools.asp) features Management of the Suicidal Patient some usebul instruments. Use of structured measures can improve the Sarra Nazem PhD, Bridget Matarazzo PsyD, Hal S. Wortzel MD, depth of risk assessment by assuring Suicidology Committee that factors (e.g., frequency and intensity of suicidal ideation and The processes involved in the avoided by both providers and identifying reasons for living) that management of suicide risk, especial- patients), and ultimately improves the might otherwise be overlooked are ly when a provider lacks confidence patient’s sense of self-efficacy by included. Use of suicide-related mea- and comfort in the area, can be intim- allowing the patient to take owner- sures can also serve an important idating and overwhelming. Without a ship in the process.4-6 TRMSP sup- medicolegal function as the risk framework and approach to the ports both the patient’s treatment and assessment is anchored in not only assessment of suicide risk, a provider the provider’s role in suicide assess- subjective data but also quantitative can easily become lost in a litany of ment and management by providing a data yielded from reliable and valid details. Furthermore, reliance on a framework to minimize defensive measures. Scores from structured “check-list” approach to suicide risk practices that can actually cause more instruments can also be invaluable as assessment can strain the therapeutic harm2. Risk management necessitates they provide critical information relationship, resulting in a less practicing and documenting a about a patient’s baseline which can nuanced suicide risk formulation that thoughtful suicide risk assessment facilitate subsequent risk assessments lacks patient investment and collabo- that informs clinical interventions to and can be an important element for ration. The Rocky Mountain Mental mitigate risk, and the elements consideration when determining Illness Research, Education and Clin- employed in a TRMSP approach are whether hospitalization or alternate ical Center (MIRECC) utilizes a clin- easily accessible to providers across interventions are warranted. It is ical risk assessment and management disciplines and settings. Yielding a important to keep in mind that model, Therapeutic Risk Manage- suicide risk assessment and manage- although structured scales may augment of the Suicidal Patient ment process (with attendant document systematic risk assessment, they (TRMSP), that is medicolegally mentation), the TRMSP model should do not replace it. No single assess- informed and optimizes patient-cen- not only meet, but likely exceed, the ment or series of assessments are able tered care.1 In this brief article, we standard of care for assessing and to accurately predict the emergence outline the major components of the managing suicide risk. of a suicidal crisis. Therefore, the TRMSP model (augmenting clinical Clinical risk assessment can be best clinical risk assessment will like- risk assessment with structured best understood as an inductive ly combine interview and structured instruments, stratification of risk in process7 directed by the goal of col- assessment data, guided by clinical terms of both severity and temporali- lecting specific patient data to guide judgement. ty, development and documentation clinical judgment, treatment, and After conducting a clinical evalua- of a safety plan) with the goal of management. This process involves tion augmented by structured risk encouraging widespread implementa- the integration of factors that elevate assessments, the provider is next tion of a TRMSP model. or reduce the risk of a patient acting faced with estimating the patient’s Practicing clinical risk assessment on his or her intent to engage in sui- level of risk for suicide. This estima- and management that is patient-cen- cide-related behavior. Because there tion, or the suicide risk formulation, tered, supportive of the treatment is no standard of care for the predic- guides decision making surrounding process, and maintains the therapeutic tion of suicide, providers are faced suicide risk management, and ulti- alliance is at the core of therapeutic with the challenging task of how best mately informs both short and long- risk management, as conceived by to structure a suicide risk assessment term intervention approaches. Tradi- Simon and Shuman.2 Grounded with- to yield a formulation that minimizes tionally, level of risk is stratified in the goals of therapeutic assess- false-positives and false-negatives. according to severity using modifiers ment,3 the approach utilizes compo- Complete reliance on unstructured such as low, medium/intermediate, nents that are designed to increase clinical risk examinations (free-form and high. This one-dimensional strati- empathetic connections and improve clinical interviews), or those guided fication, without an accompanying collaboration between the provider chiefly by clinical experience alone,8 temporality component, lacks the pre- and patient. As a result, this frame- may result in missed aspects of risk cision necessary to accurately capture work strengthens the therapeutic rela- assessment. To minimize this possi- the nuances of suicide risk to appro- tionship, models direct and respon- bility, we argue that providers should priately guide clinical decision-mak- sive discussion about self-directed augment risk assessments with struc- ing. For example, imagine assessing a violence (which may be historically tured assessment tools. The MIRECC patient in a mental health outpatient (continued on page 27)

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Out of the Shadows: nities. Elder abuse is estimated to affect 10% of people over the age of Combatting Elder Abuse 65. This is likely an underestimate because elder abuse is vastly underre- Sherif Soliman MD, Geriatric Psychiatry Committee ported. Some reasons elders fail to Her biggest fear was going to a 96-Year-Old Miss Mary as well as a report abuse or exploitation include nursing home. 96 year-old (at the training video produced by the Office embarrassment, fear of losing inde- time of the assault) Miss Mary lived for Crime Victims, In Their Own pendence, fear of not being believed, with her 70 year-old son and his wife Words: Domestic Abuse in Later Life. and a reluctance to pursue criminal until her son’s health precluded him Elder abuse consists of physical charges particularly when the perpe- from providing care. She was then abuse, sexual abuse, financial trator is a family member. placed in a nursing home. She left exploitation, emotional abuse, and Forensic psychiatrists are uniquely the nursing home to live with her neglect. It can affect anyone regard- positioned at the interface of mental grandson, Billy, and his wife, Susan. less of socioeconomic status. In health and the law to combat elder Over the five years that she lived in 2006, Professor Philip Marshall filed abuse. Our knowledge of the psycho- their trailer, Billy and Susan forced a petition seeking to remove his logical mechanisms used to exert her to do all of the house work, took father, Anthony Marshall, as guardian undue influence can help courts and a substantial portion of her Social for his grandmother, well known New policymakers better understand and Security income, and sold off her York philanthropist Brooke Astor. prosecute exploitative relationships. assets to enrich themselves. One The petition detailed financial We can help identify risk factors and night while Susan was in the hospital, exploitation by Anthony Marshall and indicators of abuse and exploitation. Billy came home and sexually Attorney Francis X. Morrisey. They We can also help train general practi- assaulted Miss Mary. He brutally engaged in a pattern of isolating Ms. tioners to identify, document, and raped her, beat her, and threatened to Astor, deceiving her into believing report signs of abuse. Such contem- kill her. The attack lasted six hours. she was running out of money, and poraneous, high quality documenta- When he fell asleep, she called 911. selling her assets. They even forced tion can be invaluable in prosecuting She said, “Get a cop out here. I’m her to sell one of her most prized pos- these cases. We can also assist with hurt. There’s a maniac in the house.” sessions, a 1917 oil painting, Flags, victim interventions such as assessing In spite of her extensive physical Fifth Avenue, by Childe Hassam. victim impact and recommending injuries, Miss Mary’s family did not Professor Marshall’s courageous act appropriate interventions to protect believe her. At trial, the only people not only saved his grandmother from victims while preserving their autono- on her side were victim advocates. further exploitation but led to Antho- my to the extent possible. These pre- The prosecution team marshalled ny Marshall’s 2009 conviction on 14 sentations will hopefully begin a dia- medical evidence and victim support counts including first and second logue on the many ways that forensic resources to support and assist Miss degree grand larceny, offering a false psychiatrists can join the fight to pro- Mary in presenting her account of the instrument, and conspiracy. Mr. Mor- tect elders. attack. After employing multiple risey was convicted of five charges delay tactics, defense attorneys including conspiracy, scheme to References: attempted to cast Miss Mary as an defraud, and forgery. 1. Connolly, Marie-Therese (2008). A Hid- Washington Post unreliable witness. With the support The Geriatric Psychiatry and the den Crime. , January 27, 2008. of prosecutors and victim advocates, Law Committee will highlight these 2. “He Wouldn’t Turn Me Loose:” The Sex- she courageously recounted the two stories of elder abuse at the ual Assault Case Of 96-Year-Old Miss Mary details of the assault. Her nephew upcoming AAPL meeting with special (2012). Terra Nova Films. was convicted of sexual battery and guest presenters. Cheyenne Shep- http://terranova.org/film-catalog/he-would- sentenced to 40 years in prison. Miss herd, who prosecuted the rapist in nt-turn-me-loose-the-sexual-assault-case-of- Mary continued to receive support Miss Mary’s case will participate by 96-year-old-miss-mary/ from victim advocates as she coped videoconference in our workshop, 3. In Their Own Words: Domestic Abuse in with her physical and psychological and Philip Marshall will discuss his Later Life (2010). Office for Victims of wounds. She died in 2007, three compelling family experience in a Crime http://www.ovc.gov/library/video- years after the attack, in a place she workshop and course. clips.html#elderabuse 4. Grayson K. Vincent, Victoria A. Velkoff. most wanted to avoid—-a nursing The U.S. Census Bureau estimates (2010). The next four decades. The older home. In reflecting on her ordeal, that the number of Americans age 65 population in the United States. s.l. : U.S. Miss Mary noted, “I had to pay for and older is expected to more than Census Bureau. what he did.” Her tragic story is told double from 2010 to 2050, from 40.2 5. Lachs, M., & Pillemer, K. (2015). Elder first hand in an elder abuse training million to 88.5 million. This rate of abuse. New England Journal of Medicine, video, “He Wouldn’t Turn Me growth will pose new challenges to 373, 1947–56. doi: Loose:” The Sexual Assault Case Of both the legal and healthcare commu- 10.1056/NEJMra1404688

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Optimizing presentation of baseline suicidal accordant documentation, medicole- Collaboration ideation with accompanying positive gal protection would suffer. It is changes, suggests low acute risk. essential that the provider document continued from page 25 Including both severity and temporal- the suicide risk assessment (including ity in risk stratification allows the the use of structured instruments), the setting presenting with the following: provider to demonstrate awareness formulation of risk utilizing two- daily suicidal ideation with stable and consideration of risk and protec- dimensional stratification, and the intensity and frequency over the past tive factors that function to maintain collaborative development of the week; history of several suicide chronic risk over time, while also safety plan. We hope that this article attempts; recent psychiatric admis- acknowledging other short-term supplies new ideas for the provider sion (1.5 months ago) for increasing changes that can fluctuate to directly working with patients who are suici- suicidal ideation; history of substance influence risk levels acutely. dal and may be the foundation and use with sustained sobriety since dis- Many providers continue to rely impetus for new practices within cen- charge from the psychiatric inpatient upon “no harm” or suicide prevention ters of care. Interested readers are unit; engaging in outpatient treatment contracts despite no empirical evi- referred to the TRMSP website and utilizing a safety plan; recently dence demonstrating that these prac- (http://www.mirecc.va.gov/visn19/TR moved into stable housing and has tices reduce risk.13 The TRMSP M/), and article 1, 17-19. begun working at a new job. It is a model relies upon the collaborative challenging task to determine the development of a safety plan. Safety References: level of severity for this particular planning involves the hierarchical 1. Wortzel HS, Matarazzo B, Homaifar B. patient given that their history of organization of six concrete steps that A model for therapeutic risk management of multiple suicide attempts, recent can be used to help an individual the suicidal patient. J Psychiatr Pract. sobriety, and recent psychiatric cope with a suicidal crisis. Whereas 2013;19(4):323-326. admission suggest an elevated level suicide prevention contracts tell the 2. Simon RI, Shuman DW. Therapeutic of risk. Their improved housing and patient what not to do during a crisis, risk management of clinical-legal dilem- new employment, however, suggest 14 mas: should it be a core competency? J Am the safety plan offers a set of indi- Acad Psychiatry Law. 2009;37:155–61. engagement in activities that may vidualized strategies of what to do 3. Finn SE, Tonsager ME. Information- serve as protective factors. These when faced with warning signs of a gathering and therapeutic models of assess- types of cases present a potential suicidal crisis. Furthermore, by utiliz- ment: complementary paradigms. Psychol conundrum for sound clinical and ing a collaborative process, safety Assess. 1997;9(4):374-385. medicolegal decision-making. If clas- planning can be an instrumental piece 4. Ackerman SJ, Hilsenroth MJ, Baity MR, sified at high risk, we typically look to enhancing the patient’s own self- Blagys MD. Interaction of therapeutic to hospitalization as an option, which efficacy and can be a mechanism by process and alliance during psychological seems unwarranted given the fact that which patients can begin to build assessment. J Pers Assess. 2000;75(1):82- this patient is likely at their baseline their own confidence and comfort in 109. 5. Hilsenroth, MJ, Peters, EJ, Ackerman and that hospitalization may poten- being able to cope with suicidal tially be an impediment to psychoso- SJ. The development of therapeutic alliance crises. One can learn more about the during psychological assessment: patient cial improvements (e.g., unnecessary VAMC safety planning process online and therapist perspectives across treatment. hospitalization may jeopardize new (http://www.mentalhealth.va.gov/docs/ J Pers Assess. 2004;83(3):332-344. housing and employment which are va_safety_planning_manual.pdf)15 and 6. Ellis TE. Collaboration and a self-help serving to decrease desire for sui- in the articles referenced. orientation in therapy with suicidal clients. cide). Similarly, classification at low As providers, it is essential to J Contemp Psychother. 2004;34(1):41-57. risk presents other potential disadvan- weigh the medical ethical principles 7. Simon RI. Suicide risk assessment: what tages given the presence of known of autonomy, nonmaleficence, and is the standard of care? J Am Acad Psychia- risk factors; namely, medicolegal vul- beneficence16 in our decision-making try Law. 2002;30:340-344. nerability if the patient encounters a when working with patients who are 8. Simon RI. Suicide risk assessment: is significant psychosocial stressor in clinical experience enough? J Am Acad Psy- suicidal. The TRMSP model provides chiatry Law. 2006;34:276-278. the following days that reactivates the a framework to help guide suicide 9 9. Rudd M D. Fluid Vulnerability Theory: suicidal mode and acutely triggers risk management given these guiding A Cognitive Approach to Understanding the self-directed violence behaviors. In principles. Furthermore, its inclusion Process of Acute and Chronic Suicide Risk. the TRMSP model, we handle this of the patient’s perspective and empa- In: Ellis T, ed. Cognition and suicide: Theo- dilemma by utilizing a two-dimen- thy achieved within the therapeutic ry, research, and therapy. Washington, DC: sion risk stratification that denotes relationship underlies collaborative American Psychological Association; both severity and temporality (acute patient-centered care and maximizes 2006:355-368. or short-term versus chronic or long- positive outcomes for those that need 10. Simon RI. Assessing and managing term).10-12 For the patient considered and deserve the highest standard of suicide risk: guidelines for clinically based above, the baseline factors suggest risk management. American Psychiatric care. Although TRMSP likely sur- Pub; 2008. high chronic risk, whereas the current passes the standard of care, without (continued on page 28)

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Taking a Stand apartment units and extensive possibilities internet. J Anal Toxicol 2009; 33(2): 99- for therapeutic treatment are being provided. 103. continued from page 9 11. Modi D, Bhalavat R, Patterson JC, 2nd. Suicidal and homicidal behaviors related to As I spoke with my colleagues and Toxicology Screens dextromethorphan abuse in a middle-aged program director after the case, I real- woman. J Addict Med 2013; 7(2): 143-4. ized I had indeed accomplished my continued from page 23 objectives. I had never lost my com- administered, and that individuals Optimizing posure or responded defensively to may be using it to avoid producing the questions asked. I had acknowl- positive urine toxicology screens (e.g. continued from page 27 edged what I did not know. I had not wanting to get high while on proba- retreated from my opinion. I had tion). Increased sensitivity to and 11. Rudd MD. The assessment and man- done my job. Perhaps it was a trial by inquiry about dextromethorphan use agement of suicidality: practitioner’s resource series. fire, but I came out intact. I came to may allow forensic psychiatrists to be Sarasota, FL: Professional Resource Press/Professional Resource the jarring realization that the concept more accurate in identifying causa- of justice is somewhat of a moving Exchange; 2006. tion when encountering substance- 12. Berman AL, Silverman MM. Suicide target, influenced by politics, percep- induced psychosis. risk assessment and risk formulation part II: tion and personal motives. Some- suicide risk formulation and the determina- times, the role of the expert witness is References tion of levels of risk. Suicide Life Threat merely a footnote in a lengthy saga 1. Paillet-Loilier M, Cesbron A, Le Boisse- Behav. 2014;44(4):432-443. already written. But this is not always lier R, Bourgine J, Debruyne D. Emerging 13. Rudd MD, Madrusiak M, Joiner TE. the case. Over the course of my fel- drugs of abuse: current perspectives on sub- The case against no-suicide contracts: the lowship year, I observed and partici- stituted cathinones. Subst Abuse Rehabil commitment to treatment statement as a pated in other trials, cases and evalua- 2014; 5: 37-52. practice alternative. J Clin Psychol tions. I became more adept and confi- 2. Majlesi N, Lee DC, Ali SS. Dex- 2006;62(2):243-251. dent in educating the court while tromethorphan abuse masquerading as a 14. Stanley B, Brown GK. Safety plan- recurrent seizure disorder. Pediatr Emerg transparently stating the limitations of ning intervention: A brief intervention Care 2011; 27(3): 210-1. to mitigate suicide risk. Cog Beh the work that we do. Though there 3. Amaladoss A, O’Brien S. Cough syrup Pract. 2012;19:256–64. will still be a sense of anticipation psychosis. CJEM 2011; 13(1): 53-6. 15. Stanley B, Brown GK, in collab- when I walk into a courtroom to testi- 4. Alam LY, Nelson A, Bastiampillai T. oration with Karlin B,Kemp JE, Von- fy, the frame has shifted. I anticipate Cough syrup psychosis: Is it under-recog- Bergen HA. Safety plan treatment the possibility that others will attempt nised? The Australian and New Zealand journal of psychiatry 2013; 47(12): 1209- manual to reduce suicide risk: veteran to discredit my profession and opin- version. Washington, DC:US Depart- ion, but I can maintain my confidence 10. 5. Miller SC. Dextromethorphan psychosis, ment of Veterans Affairs; 2008 (avail- because I performed my job with able at integrity, honesty and transparency dependence and physical withdrawal. Addiction biology 2005; 10(4): 325-7. http://www.sprc.org/library_resources and sought the truth while acknowl- 6. Logan BK, Yeakel JK, Goldfogel G, /items/safety-plantreatment-manual- edging my obvious human limita- Frost MP, Sandstrom G, Wickham DJ. Dex- reduce-suicide-risk-veteran-version). tions. tromethorphan abuse leading to assault, sui- Accessed April 26, 2014. cide, or homicide. Journal of forensic sci- 16. Gillon R. Medical ethics: four The Double Track ences 2012; 57(5): 1388-94. principles plus attention to scope. 7. Shin EJ, Lee PH, Kim HJ, Nabeshima T, Bmj. 1994;309(6948):184-188. Kim HC. Neuropsychotoxicity of abused continued from page 16 drugs: potential of dextromethorphan and 17. Homaifar B, Matarazzo B, novel neuroprotective analogs of dex- Wortzel HS. Therapeutic risk man- sentences since they did not provide a tromethorphan with improved safety pro- agement of the suicidal patient: aug- “clear therapeutic orientation.” Christopher files in terms of abuse and neuroprotective menting clinical suicide risk assess- Michaelson, “’From Stasbourg with Love’ – effects. J Pharmacol Sci 2008; 106(1): 22-7. ment with structured instruments. J Preventive Detention before the German 8. Roy AK, 3rd, Hsieh C, Crapanzano K. Psychiatr Pract. 2013;19(5):406-409. Federal Constitutional Court and the Euro- Dextromethorphan Addiction Mediated 18. Wortzel HS, Homaifar B, pean Court of Human Rights,” 12 Human Through the NMDA System: Common Rights L. Rev. 149, 163 (2012). On the Matarazzo B, Brenner LA. Therapeu- Pathways With Alcohol? J Addict Med tic risk management of the suicidal newly designed structures built in response 2015; 9(6): 499-501. to the court’s holding, see COE Press patient: stratifying risk in terms of 9. Chung H, Park M, Hahn E, Choi H, J Psychiatr Release, Bergmann v. Germany, ECHR Choi H, Lim M. Recent trends of drug severity and temporality. application no. 23279/14, 7 January 2016, abuse and drug-associated deaths in Korea. Pract. 2014;20(1):63-67. page 2: “a newly constructed centre for per- Annals of the New York Academy of Sci- 19. Matarazzo BB, Homaifar BY, sons in preventive detention, a separate ences 2004; 1025: 458-64. Wortzel HS. Therapeutic risk man- building on the premises of Rosdorf Prison 10. Logan BK, Goldfogel G, Hamilton R, agement of the suicidal patient: safety (“the Rosdorf centre”), where persons in pre- Kuhlman J. Five deaths resulting from planning. J Psychiatr Pract. ventive detention are placed in individual abuse of dextromethorphan sold over the 2014;20(3):220-224.

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A Review of Canadian Orders (CTO). Quebec also has treat- hands-on sexual offense. ment orders, but they apply more California’s new CANRA amend- continued from page 11 widely to inpatient and outpatient ment represents a significant erosion ment of a patient who is incapable to care. Usually, to be eligible for a of confidentiality in the psychothera- consent to treatment. In CTO, the patient must have had a pist-patient relationship. It will pre- Saskatchewan and Newfoundland, the minimal number of hospital days dur- dictably inhibit access to treatment by attending physician holds such ing the preceding years. In Alberta many potential patients, and its value authority, while in British Columbia, and Saskatchewan, a patient is eligi- in identifying future sexual perpetra- the director of the psychiatric depart- ble during his first psychiatric hospi- tors and their victims is doubtful. ment grants such authorization. In talization. In practice, in many juris- Unfortunately, psychiatrists and other New Brunswick, the court makes dictions, treatment orders and CTO’s mental health caregivers did not decisions for incapable patients, or are underutilized due to the perceived mount any meaningful opposition to for capable patients who refuse treat- complexities in obtaining, implement- this law, and we will now have to ment. In Quebec, the Superior Court ing and renewing them. deal with the consequences. decides for an incapable patient who As we can see, despite the so- References: categorically refuses treatment. These called universality and equality principles that theoretically underpin the 1. Digest CLCs. AB-1775 Child Abuse and jurisdictions all propose treatment in Neglect Reporting Act: sexual abuse. Avail- keeping with the principle of “the Canadian public health care system across the country, provincial juris- able at: best interest of the patient”. https://leginfo.legislature.ca.gov/faces/bill- In other Canadian provinces, a pri- dictions have varied approaches to NavClient.xhtml?bill_id=201320140AB1775. vate “substitute decision maker” sys- balancing autonomy and liberty inter- Accessed 07/06/2016. tem is used to treat a patient who is ests of individuals and intervention 2. Seto MC, Karl Hanson R, Babchishin incapable to consent to treatment. In powers of the state to help those in KM. Contact Sexual Offending by Men Alberta and Prince Edward Island, the need and protect society from danger- With Online Sexual Offenses. Sexual substitute decision maker must act in ous persons. Abuse: A Journal of Research and Treat- ment the best interest of the patient. In all 2011;23(1):124-145. References: 3. Endrass J, Urbaniok F, Hammermeister other jurisdictions, decision makers LC, Benz C, Elbert T, Laubacher A, must abide by the previous capable 1. Gray J., Hastings T., Love S. O’Reilly R. Clinically Significant Differences Among Rossegger A. The consumption of Internet wishes of the patient (wishes previ- Canadian Mental Health Acts, Canadian child pornography and violent and sex ously expressed by the patient when Journal of Psychiatry, April 2016, Vol. 61, offending. BMC Psychiatry 2009;9(1):1-7. they were capable), even if they are 222-2261 4. Henson M. Toddlers and Tiaras' and sex- not in their best interests. In Manitoba 2. Gray J., McSherry B., O’Reilly R. and ualizing 3-year-olds. Available at: and Nova Scotia, the legal test is a Weller P. Australian and Canadian Mental http://www.cnn.com/2011/09/12/opinion/he “modified best interests” test, which Health Acts Compared. Australian and New nson-toddlers-tiaras/. Accessed 07/08/2016. is a compromise between these two Zealand Journal of Psychiatry. 2010; Vol 44: 5. Allen P. France bans children's beauty principles. In reality, few patients 1126-1131. contests in bid to stop the 'hyper-sexualisa- 3. Gray J. and O’Reilly R. Clinically Sig- tion' of youngsters. Available at: have clearly expressed prior wishes http://www.dailymail.co.uk/news/article- about treatment, and the substitute nificant Differences Among Canadian Men- tal Health Acts, Canadian Journal of Psychi- 2424462/France-bans-girls-beauty-contests- decision maker decides based on the atry, May 2001, Vol. 46, 315-321 bid-stop-hyper-sexualisation-children.html. best interest of the patient. Accessed 07/11/2016. What do we do with a patient who 6. Healy M. Could Child Beauty Pageants is no longer dangerous but not yet California’s CANRA Be Banned In The USA? Available at: capable, and refuses all outpatient http://www.usatoday.com/story/news/nation/ treatment (the famous revolving door continued from page 22 2013/09/22/beauty-pageants-children-- patient)? Nine provinces have ver- ban/2842431/. Accessed 07/06/2016. clinicians to adhere to in the face of 7. Bielanko M. Russia Moves To Ban Child sions of involuntary treatment orders ambiguous dangerousness and immi- that can be applied to outpatient care. Beauty Pageants: Why America Should Be nence of harm. It has been recom- Next. Available at: In British Columbia, Manitoba, and mended that clinicians focus less on https://www.babble.com/mom/guess-which- Prince Edward Island, they are called the imminence of the threat, and more country-wants-to-ban-child-beauty- “temporary leave”, a period during on a demonstrated capacity to carry pageants/. Accessed 07/11/2016. which the patient can be brought back out the threat12. This new law will 8. B4U-ACT. Research Survey Results to the hospital if they refuse treatment reduce the ambiguity by setting a Youth, Suicidality, and Seeking Care. Avail- during a limited period as outpatient. clear but extremely low bar for man- able at: http://www.b4uact.org/research/sur- In Alberta, Saskatchewan, Ontario, vey-results/youth-suicidality-and-seeking- dated reporting of child porn offens- care/. Accessed 07/06/2016. Nova Scotia and Newfoundland, there es. Its usefulness is questionable, are more prolonged forms of this 9. Behnke DS. Disclosures of information: without any consideration of the Thoughts on a process. Available at: order called Community Treatment patient’s capacity to commit an actual (continued on page 31)

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High IQ Offenders 8. Portnoy J, Chen FR, Raine A. Biological than 3 to 4 weeks. Subsequently, in protective factors for antisocial and criminal April 2016, the NCCHC adopted 17 continued from page 10 behavior. Journal of Criminal Justice. 2013 principles to guide correctional health Oct 31;41(5):292-9. professionals in addressing issues “tactfully and wisely handled...are 9. Cyril Burt. The subnormal mind (3rd among the most hopeful cases that the ed). Oxford university press; 1955, at 182. about solitary confinement. psychologist is called upon to Drs. Appelbaum, Trestman, and study...[but Burt also warned that]... APA Meeting 2016 Metzner also addressed audience [w]rongly treated, they turn into crim- questions regarding practical issues inals of the most dangerous and elu- continued from page 17 including confidentiality, limited 9 resources, and legal challenges. sive type.” If an IQ score above a solitary confinement in correctional certain threshold (e.g., IQ 150) can Compellingly, Dr. Trestman analo- settings. For example, the NCCHC gized that trying to engage patients operate as a solvent on Hirschi’s website states, “Many national and social bonds, as the qualitative analy- and provide psychiatric treatment international organizations have rec- with limited confidentiality is akin to sis indicated, then the relationship ognized prolonged solitary confine- between IQ and protective effects a surgeon attempting to perform ment as cruel, inhumane, and degrad- surgery in an unsterile environment. might be curvilinear, switching direc- ing treatment, and harmful to an indi- tion from positive to negative. Overall, this textbook and lecture vidual’s health . . . It is well estab- emphasize the critical role of correc- James Oleson is an Associate Pro- lished that persons with mental illness tional psychiatry and its important fessor of Criminology at The Univer- are particularly vulnerable to the place in the broader field of psychia- sity of Auckland. His monograph, harms of solitary confinement. As a try. Needs exist for further mental Criminal Genius: A Portrait of High- result, federal courts have repeatedly health education, training, resources, IQ Offenders, will be published in found the solitary confinement of the research, and policies in jails and October 2016 by the University of mentally ill to be unconstitutional, prisons. California Press. and in 2012, the APA adopted a policy opposing the ‘prolonged’ segrega- References: tion of prisoners with serious mental 1. Leistedt SJ, Linkowski P. Psychopathy illness, which it defined as longer and the cinema: Fact or fiction?. Journal of forensic sciences. 2014 Jan 1;59(1):167-74. 2. McGloin JM, Pratt TC, Maahs J. Rethinking the IQ-delinquency relationship: A longitudinal analysis of multiple theoreti- cal models. Justice Quarterly. 2004 Sep 1;21(3):603-35, at 604. 3. Beaver KM, Schwartz JA, Nedelec JL, Connolly EJ, Boutwell BB, Barnes JC. Intelligence is associated with criminal justice processing: Arrest through incarcera- PSYCHIATRIST tion. Intelligence. 2013 Oct 31;41(5):277- 88, at 285. Adult Staff Psychiatrists * Inpatient * State of New Jersey 4. Ttofi MM, Farrington DP, Piquero AR, The State of New Jersey offers an excellent bene ts and compensation package. Annual salary Lösel F, DeLisi M, Murray J. Intelligence as range of $191,899.84 (Board Eligible), $203,492.70 (Board Certi ed or $218,842.78 (3 years Post a protective factor against offending: A Board Certi cation). meta-analytic review of prospective longitu- Per Diem appointments are also available, which do not receive bene ts package. Per Diem rates are dinal studies. Journal of Criminal Justice. $105.00 (Board Eligible), $110.00 (Board Certi ed) or $125.00 (3 years Post Board Certi cation). 2016 Feb 16. Ann Klein Forensic Center’s Special Treatment Unit Adult Facility, located in Rahway, NJ, invites you to join our team of professionals who are making a difference in the health and welfare of NJ citizens. Our 5. Hollingworth LS. Children above IQ inpatient units are designed to treat adult males who have been civilly committed under NJ Sexually 180. World book company; 1942. Violent Predator’s Act. We seek experienced Psychiatrists to conduct detailed forensic evaluations. 6. Mears DP, Cochran JC. What is the And effect of IQ on offending?. Criminal Justice Ann Klein Forensic Center, a 200 bed Adult facility located in Trenton, NJ, is currently seeking and Behavior. 2013 Nov 1;40(11):1280-300. Psychiatrists with a special interest in forensic evaluation and court testimony to provide quality comprehensive mental health service for individuals who require a secured psychiatric setting. Schwartz JA, Savolainen J, Aaltonen M, Requirements: Merikukka M, Paananen R, Gissler M. Board Eligible/certi cation in psychiatry from the American Board of Psychiatry and Neurology or the Intelligence and criminal behavior in a total American Osteopathic Board of Neurology and Psychiatry. birth cohort: An examination of functional Direct Contact Information: form, dimensions of intelligence, and the Special Treatment Unit Ann Klein Forensic Center nature of offending. Intelligence. 2015 Aug Dean DeCrisce, MD Elizabeth Hogan, MD 31;51:109-18. [email protected] [email protected] Phone number: 732-499-5041 Fax number: 609-777-0160 7. Hirschi T. Causes of delinquency. Uni- EOE versity of California press; 1969.

30 • September 2016 American Academy of Psychiatry and the Law Newsletter 166980 AAPL News September 2016_rev3.qxp_September 2016 8/29/16 12:00 PM Page 31

ALLABOUT AAPL AMA 2016 Meeting continued from page 19 COVERAGE FOR Messaging and non-HIPAA Compli- FORENSIC SERVICES ant Electronic Messaging.” A policy entitled “Weapons, Hospital Work- place and Patient Safety Issues” was Forensic psychiatrists face unique adopted, advocating that hospitals and risks that many malpractice other healthcare delivery settings insurance policies do not cover. restrict guns and Tasers on their We cover expert witness testimony, premises, particularly in emergency IMEs and all forensic activities. departments and psychiatric units. Drs. Piel and Gruenberg testified on “Medical Reporting for Safety DONNA VANDERPOOL, MBA, JD Sensitive Positions” that looked for VICE PRESIDENT, RISK MANAGEMENT AMA to advocate for uniform policy Chapter Contributor in Gun Violence and Mental Illness (APPI) on mandatory reporting of significant medical conditions that may pose a risk to public safety. Testimony More than an insurance policy reflected concern for the ambiguity in the meaning of “safety sensitive,” PsychProgram.com/Forensic who defines the conditions, the spe- (800) 245-3333 cialty of the reporting professional and how laws vary from state to state. [email protected] The AMA will study the issue for Insurance coverage provided by Fair American Insurance and Reinsurance In California, d/b/a Transatlantic Professional report to the House in November Company (NAIC 35157). FAIRCO is an authorized carrier in California, ID Risk Management and Insurance Services. number 3175-7. www.fairco.com 2016. Dr. Piel served as Chair of the Young Physician Section’s reference committee for the third year. For more information visit http://www.ama- assn.org/sub/meeting/index.html. COOK COUNTY HEALTH California’s CANRA & HOSPITTALSALS SYSTEM continued from page 29 Cermaak Health Services at Cook County Department of Corrections http://www.apa.org/monitor/apr07/ethics.aspx. 10. Rob Weiss M. Clinical Alert: Where Do You Stand Regarding Imminent Changes to Join ouur growing team. Client Confidentiality (AB1775)? Available at: http://www.robertweissmsw.com/clini- We are hiiring Psychiaatrists. cal-alert-where-do-you-stand-regarding- imminent-changes-to-client-confidentiality- alaries starrt at $230,000 ab1775. 11. Cathy Atkins JD. Understanding Man- everal corrrectional dated Reporting Requirements: AB 1775. sychiatric oopenings Available at: https://www.camft.org/ias/images/PDFs/Atto rneyArticles/Cathy/Understanding_Mandat- Please sendd your resumme with Correctional ed_Reporting_Requirements_AB1775.pdf. Psychiatrist in the subjectect line to: 12. Johnson R, Persad G, Sisti D. The Tara- cermakrecruuit@c@ ookcountyhhs.y org soff Rule: The Implications of Interstate Variation and Gaps in Professional Training. JAAPL Online December 1, 2014 2014;42(4):469-477.

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AAPL Newsletter PRSRT STD American Academy of Psychiatry and the Law U.S. POSTAGE One Regency Drive PO Box 30 P A I D Bloomfield, Connecticut 06002 HARTFORD, CT PERMIT NO. 5144 Susan Hatters Friedman, MD, Editor