162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 1 AAPL Newsletter American Academy of Psychiatry and the Law

September 2015 • Vol. 40, No. 3

American Medical Association 2015 selves or members of their own fami- lies. However, it may be acceptable Annual Meeting Highlights to do so in limited circumstances in Barry Wall, MD, Delegate, Ryan Hall, MD, Alternate Delegate, Jennifer emergency settings … oMr faoyr short- Piel, MD, J.D. Young Physician Delegate term, minor problems.” was pro- posed to be defined as an action is ethically permissible when qualifying conditions are met. Thmeaeyxample given for the usage of was “Physicians may disclose personal health information without the specif- ic consent of the patient to other health care personnel for purposes of providing care or for health care operations.” Although these changes were proposed, there was still con- cern regarding word usage in the code as well as the process by which the code was being presented to the House of Delegates. Until the mod- ernized code is approved, the current existing AMA code of medical ethics The American Medical Associa- content and the presentation format is still in effect. tion’s (AMA) June 2015 Annual of the medical code of ethics more Among other general highlights, Meeting in Chicago focused on poli- appropriate for 21st-century medi- AMA delegates passed resolutions cy, medical education, health initia- cine. Major revisions proposed at limiting non-medical exemptions for tives, and elections for leadership this meeting were to further define childhood vaccines; advancing mili- positions. Dr. Steven Stack, an emer- terms such as “must,” “should,” and tary medical policies for transgender gency medicine physician from Ken- “may” to make it more evident what individuals (a resolution by a psychi- tucky, was installed as President and discretion physicians have when deal- atrist from the Gay and Lesbian Med- Dr. Andy Gurman, a private practice ing with ethics situations and to ical Association), supporting a two- orthopedic hand surgeon from Penn- address medico-legal concernsmwuistht year grace period for implementation sylvania, was elected President-Elect. these terms. Use of the word “ ” of ICD 10 for purposes of CPT cod- Dr. Patrice Harris, a child and foren- was proposed to indicate that an ing, supporting study by AMA on sic psychiatrist, who is a member of action is ethically required and physi- means to prevent violent acts against AAPL, was re-elected to her second cians cannot use individual judgment health care providers; and a call for term on the AMA Board of Trustees or discretion. The example provided more transparency and education sur- (BOT), where she currently serves in in the report was “Physicians who rounding Maintenance of Certifica- the position of BOT Secretary and testify as fact witnesses in legal tion. In addition, the BOT issued a will soon become the BOT’s Chair. claimSshmouuldst deliver honest testimo- report regarding background checks The AMA Council on Ethical and ny.” was proposed to indicate for firearm purchases, which refer- Judicial Affairs (CEJA) presented an action or obligation that is strong- enced and closely mirrored the Amer- reports on Ethical Practice in ly recommended as a matter of pro- ican Psychiatric Association policy. Telemedicine and Prescribing and fessional ethics, but which may have However, there was debate on the Dispensing Prescription Medication some exceptions such as special cir- floor as to whether the policy would Samples. Both reports were referred cumstances or consideratiosnhso.uTldhe require background checks for all back for additional modifications. examples for the usage of purchases and transfers or only for CEJA also presented its second offi- were “Physicians should routinely purchases (e.g. may be limited times cial revised version for the modern- inquire about physical, sexual, and where transfers for safety such as ization of the medical code of ethics. psychological abuse as part of the with a suicidal patient should not be Code modernization, which started in medical history,” and “In general, delayed). The report was referred 2008, is supposed to make both the physicians should not treat them- (continued on page 2)

American Academy of Psychiatry and the Law Newsletter September 2015 • 1 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 2

American COVER STORY Academy of Psychiatry American Medical raised by a delegate not related to and the Law Association AAPL is that social media is becom- continued from page 1 ing more prevalent in forensic work in general, as well as in clinical work, Editor as a way to reduce waste, fraud, or back to the BOT for more study. abuse. It was the contention of that Charles Dike, MD, MPH, FRCPsych Resolutions which had specific delegate that if CEJA does issue an Associate Editors forensic psychiatric themes included; opinion on use of social media Mental Health Crisis Interventions Philip Candilis, MD regarding patients, CEJA needs to resolution, Maintaining Mental Steven H. Berger, MD keeps in mind the potential benefit to Health Services by States resolution, Susan Hatters Friedman, MD society from physicians’ use of social and Prevention of Unnecessary Hos- media, as well as the potential harm Neil S. Kaye, MD pitalization and Jail Confinement of to the patient. The AAPL delegation Former Editors the Mentally Ill. These resolutions requested that if CEJA does issue an encouraged the AMA to support iden- Victoria Harris, MD, MPH (2003-2008) opinion on this topic, it should issue tification, referral and treatment of Michael A. Norko, MD (1996-2003) two separate opinions (one on clinical the mentally ill along with education Robert Miller, MD PhD (1994-1996) situations and one for forensic situa- of law enforcement as a way to try to Alan R. Felthous, MD (1988-1993) tions) or at least acknowledge that reduce incarceration of the mentally Robert M. Wettstein, MD (1983-1988) clinical use of social media may dif- ill. Many of the recommendations Phillip J. Resnick, MD (1979-1983) fer from use in forensic settings. No made were consistent with the recent- Loren H. Roth, MD, MPH (1976-1979) direct forensic concerns were raised ly announced APA initiative with Officers in the cultural sensitivity discussion local governments called: ‘Stepping President which focused more on how to define Up’ to Reduce the Number of People and teach the topic. Graham Glancy, MB, ChB, FRCPsych, with Mental Illnesses in U.S. Jails. FRCP(c) AAPL Delegate Dr. Barry Wall President-elect again served as Co-vice-chair for the Emily Keram, MD “This year, the topics of psychiatric caucus. In addition, he Vice President again worked with the medical stu- Googling one’s patients dent section on resolutions regarding Christopher Thompson, MD Vice President solitary confinement in adults. Dr. (e.g. using social media Wall’s work and input with the med- Barry Wall, MD Secretary ical student section was influential in to obtain information) shaping the approved resolution Susan Hatters Friedman, MD regarding children at the last meeting Treasurer and cultural sensitivity and how the medical student section Douglas Mossman, MD will approach correctional issues in Immediate Past President were discussed.” the future. Robert Weinstock, MD AAPL Alternate Delegate Dr. Ryan Hall served as an election teller, The AAPL Newsletter is published by In addition to the House of Dele- which required him to assist in over- AAPL, One Regency Drive, PO Box 30, gates activities, CEJA also hosted an seeing the election process and certi- Bloomfield, CT 06002. Opinions open forum to obtain input from fying the votes. expressed in bylined articles and members. This year, the topics of Young Physician Delegate Dr. Jen- columns in the Newsletter are solely “Googling one’s patients” (e.g. using nifer Piel again served as the Chair those of the authors and do not neces- social media to obtain information) sarily represent the official position for the Young Physicians section’s and “cultural sensitivity” were dis- of AAPL or Newsletter editors. Internal Resolution Committee (see cussed. The primary concern in the Manuscripts are invited for publication attached photo). social media discussion was patient in the Newsletter. They should be The AAPL Delegation would also privacy if a physician obtained or dis- submitted to the editor via email to like to announce the Council’s covered information using social [email protected]. appointment of a new Alternate Dele- media. The discussion included The Newsletter is published in gate, Dr. Linda Gruenberg, and a new January (deadline for submission is examples of the doctor- patient rela- Young Physician Delegate, Dr. Tobias November 15), April (deadline Febru- tionship being potentially damaged Wasser. Dr. Ryan Hall has rotated out ary 1), and September (deadline July 1). due to information discovered, ques- of the AAPL’s Young Physician Dele- tions if information in social media www.aapl.org gate position but will remain active in was different from information print- organized medicine. AAPL thanks Dr. ed in newspapers, and how state- © 2015 AAPL. ALL RIGHTS RESERVED. Hall for his leadership skills within maintained controlled substance data- bases could be affected. A point (continued on page 27)

2 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 3

FROM THE EDITOR

On The Question Of Being An Expert thereby prompting the psychiatrists to learn about them. I can almost hear Psychiatrist sharp criticism from colleagues in Charles C. Dike MD, MPH, FRCPsych academic institutions, large private practice groups who still get visits from drug reps, or the proactive solo The visit of patient asked if her blood pressure practitioner who diligently seeks out the Pope to the which I had just taken, was in keep- new knowledge; “that is the reason USA generated ing with the “newly released” guide- for obtaining CMEs,” they assert. In a rare sort of lines about normal blood pressure. I reality, however, many of our col- frenzy that had not been aware that earlier that leagues are often caught unawares by crossed socioe- morning there had been discussion in new medications or new research in conomic and the news about precipitous termina- pathophysiology, pharmacology, psy- political divide tion of research on blood pressure by chotherapeutic interventions, neuro- rarely seen the NIH due to robust findings sug- science, genetics, and so on, that these days in the US. gesting that what we currently con- guide development of new biopsy- Of particular note however, is the sider normal blood pressure for age chosocial treatment. observation that one of the most pow- was too high. Of course, practicing psychiatrists erful men in the world, leader of over It wasn’t until much later when I eventually become aware of new 1.2 billion Catholics worldwide, cele- had a chance to read the New York developments in the field, often when brated mass regularly, a basic activity Times that I understood what she had researching treatment alternatives for of ordinary (please excuse my use of been talking about. Translation? A lot patients unresponsive to usual treat- this word) Roman Catholic priest- of our patients are informed and up to ment. Additionally, they are often the hood. Surrounded by numerous Car- date. With multiple news media and first to recognize side effects to new dinals and junior priests, it would social media network, patients get medications not yet listed in the com- easily be understood and successfully information as soon as (sometimes pendium of instructions or the med- argued that at the level of the Pope - even before) they are published. A ication insert. By virtue of their ongo- his experience, age, authority, and so practicing physician/psychiatrist can- ing interaction with patients, includ- on - he did not have to celebrate not afford to rely on old clinical ing grappling with the challenges of mass. He could delegate it to junior information alone. managing complicated illnesses priests, his mere presence alone being Along those lines, a psychiatrist refractory to medications, working sufficient. colleague in solo private practice con- with other professionals involved in Please allow me to digress. A gen- fided in me his embarrassment when the patients’ care and working with eral surgeon friend of mine in private a new patient informed him she was some difficult family dynamics or practice recently told me she was on Viibryd, a new antidepressant pre- other socioeconomic realities that about to lose hospital privileges to scribed by her general practitioner. At negatively influence their patients’ perform surgery because she had not the time, the psychiatrist had not illness, these practicing psychiatrists yet met yearly goals to maintain priv- heard of Viibryd but he was smart maintain their expertise and clinical ilege; she would need a certain num- enough to immediately quell his ris- acumen. ber of hernia repair, thyroid, gallblad- ing knee jerk response to the patient Its is difficult to explain how psy- der, breast and other specified surgery that she must have made been mistak- chiatrists who have not treated in order to be considered up to date en because Viibryd was not an antide- patients for years and struggled with and therefore, safe to practice, regard- pressant. You can imagine his sur- the challenges discussed above could less of the fact she has been in prac- prise when he later checked and, sure still be considered experts in psychia- tice for 20 years and is a seasoned enough, Viibryd was there! As new try. When my surgeon friend men- surgeon by all account. Not meeting psychotropic medications come on tioned earlier learned of this situation, the required amount of surgeries the market, it is sometimes difficult she was nonplussed. However, she meant she would no longer be consid- for psychiatrists long in private prac- recovered quickly and quipped; ered proficient; she could no longer tice, especially if not in a large group “What does it matter, you are not real claim to be an expert in these surg- practice, to become aware of them, doctors anyway, are you? Otherwise, eries some of which she could practi- understand their mechanism of how could anyone accept expert cally carryout with eyes closed. Quite action, important drug-drug interac- advice from a non practicing doctor understandable. Even I would not be tion and side effects. In the old days in a field that is rapidly evolving?” I comfortable subjecting myself to her (should I say good or bad old days?), did not believe myself bright enough knife if the data showed her numbers pharmaceutical representatives served to respond to her tongue-in-cheek to be that low! a critical function for these psychia- comment/question, so I let hang in In my own practice, I was sur- trists by making them aware of the the air. prised one morning when my first new drugs they were promoting,

American Academy of Psychiatry and the Law Newsletter September 2015 • 3 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 4

PRESIDENT’S REPORT

Everything You Need To Know ry Project,” was published in the Canadian Journal of Psychiatry3-7. A About NCR/Insanity Acquittees - team of researchers across the nation was set up to study and accurately But Were Afraid To Ask describe the characteristics of all Graham D. Glancy, MB, ChB, FRCPsych, FRCP (C) those found NCR-MD immediately following the Winko decision referred For my third and final newsletter into the community with a variety of to above. They looked at 1800 article in the series I was about to conditions. Typically these condi- accused persons, who are the total of write a review of the year from my tions would include reporting to the accused persons found NCR-MD viewpoint, when my eye was drawn hospital at specified intervals, living between 2000-2005 in the three most to a series of articles in the Canadian in supervised accommodations, populous provinces of Canada, name- Journal of Psychiatry. These articles abstaining from drugs and alcohol, ly Ontario, Québec, and British are so central and quintessential to and not owning any weapons, Columbia. These papers make com- forensic psychiatry that I felt it my amongst others. Once under this pelling reading, and I will try to sum- duty to draw the attention of our scheme, the accused is generally fol- marize some of the key findings. members to these articles3-7. lowed up by forensic services. This Recently in Canada there has been In Canada “not guilty by reason of follow-up might include a significant an upswing in publicity regarding insanity” (NGRI) has been referred to stay in hospital, often with declining three or four sensational cases where as not criminally responsible due to the accused either claimed or were mental disorder (NCR–MD) since our “However another strik- found NCR-MD. This led one laws were struck down by the esteemed journalist to call me regard- Supreme Court of Canada (SCC) in ing finding may be sig- ing an article on the increased num- the case of R v Swain2. The SCC in ber of accused using the NCR-MD this case made the decision that it nificant in that in defense. I was able to reassure him was unconstitutional for an accused that in fact the rate remained very person to be held “at the pleasure of Ontario 100% of review low and this was confirmed by the her majesty” and gave Parliament the study, which confirmed that in task of modernizing the law, which boards were attended by Ontario only 0.95 cases per thousand duly ensued in 1992. The test a prosecutor, whereas in decisions resulted in a NCR-MD remained a modified McNaughton finding, although it was a significant- test but the language was modernised Québec only 7.3% of ly higher proportion in Québec (6.08 and the scheme of gradual release per thousand). There is no evidence into the community was clarified. boards had a prosecutor that this rate is increasing, and in The new language codified the estab- Ontario I was able to discuss these lished scheme of having provincial present.” findings with the Chair of the Review review boards regularly reviewing the Board, the Honorable Justice Schnei- accused (this is the term used to der, who noted that the figures have describe the person from the initial levels of security from maximum to been stable over the last approximate- court assessment until they are minimum, with excellent outpatient ly 10 years, and in fact suggested a absolutely discharged) and set a clear care once the accused is discharged recent decline in the last year. test that an absolute discharge was with conditions. This outpatient care Despite some linguistic and cultural warranted unless there was evidence commonly includes regular contact, differences, the epidemiology of peo- that the accused remained a signifi- outreach services by community psy- ple in Québec and the other provinces cant threat to the safety of the com- chiatric nurses and social workers, is quite similar. A possible explana- munity. This latter phrase was clari- administration of medication, and tion for this disparity may be that fied in the case of R v. Winko where- supported housing. It might include Québec tends to use the NCR-MD in it was ruled that there must be early intervention, which could schema as a kind of Court mental affirmative evidence of this threat for include recall to Hospital, if the situa- health diversion. The provincial the accused to be detained or to be tion warrants. It has commonly been delivery of care has a somewhat dif- given a discharge with conditions1. It said that this is the “platinum key” to ferent model in Québec in that the is important to note that all provinces psychiatric services. It has been sug- follow-up tends to be delivered less and territories in Canada operate a gested that the legislative changes by specialist forensic services federal criminal code. The code made the NCR-MD option more throughout the province than in the allowed the review board the provi- attractive to people charged with rela- other provinces. sions to detain an accused in a mini- tively more minor offenses. One of the most important find- ings is that 72% of persons found mum, medium or maximum-security A recent series of papers, which (continued on page 7) hospital or to discharge the accused represented the work of the “Trajecto-

4 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 5

MEDICAL DIRECTOR’S REPORT

Justice Kennedy Takes On Solitary hetadalmany technical defects, O'Keefe . designed a randomized trial to Confinement In The Correctional System study "to parse out the effects of seg- Jeffrey S. Janofsky MD regation from those of other prison environments."4 The researchers fol- lowed four groups for one year: "Sentencing essary temporarily in some instances inmates in general population and judges, moreover, he concluded that, "the judiciary may inmates in segregation, each group devote consider- be required, within its proper jurisdic- further divided into those with and able time and tion and authority, to determine without severe mental illness. Results thought to their whether workable alternative systems disproved the researcher's hypothesis task. There is no for long-term confinement exist, and, that inmates, with or without mental accepted mecha- if so, whether a correctional system illness, would experience significant nism, however, for should be required to adopt them." psychological decline in segregation. them to take into account, when sen- Although clearly dicta, Kennedy's Instead both the mentally ill and non- tencing a defendant, whether the time thinking around the use of long term mentally ill segregation groups in prison will or should be served in segregation in correctional settings is showed a reduction in symptom solitary. So in many cases, it is as if a instructive for all of us who practice severity. The author's emphasized judge had no choice but to say: 'In in correctional settings and/or who several flaws in their own study, imposing this capital sentence, the are interested in public policy. including problems with generaliz- court is well aware that during the In 2012 the APA published its ability across correctional systems many years you will serve in prison Position Statement on Segregation of writing, “We do not claim, nor before your execution, the penal sys- Prisoners with Mental Illness. The believe, that these data definitively tem has a solitary confinement Position Statement and its back- answer the question of whether long- regime that will bring you to the edge term segregation causes psychologi- of madness, perhaps to madness “Results disproved the cal harm." itself.' Even if the law were to con- Study of best practices for segrega- done or permit this added punish- researcher's hypothesis tion of prison inmates remains an ment, so stark an outcome ought not important issue that is difficult to to be the result of society’s simple that inmates, with or study. Future work on this issue is unawareness or indifference." crucial, however, in order to allow So wrote Justice Kennedy in a without mental illness, Justice Kennedy and other jurists to concurring opinion in Davis v. determine whether workable alterna- 1 would experience signifi- Ayala . Ayala was found guilty of tive systems for segregation exist, and was sentenced to death for a cant psychological and, if so, whether a correctional sys- triple homicide. The Court held that tem should be required by the Court any federal constitutional error that decline in segregation.” to adopt them. may have occurred by excluding Ayala’s attorney from part of a Bat- References: son hearing was harmless error. 1. Davis v. Ayala 576 U. S. ____ (2015). While Justice Kennedy joined the ground material support Kennedy’s http://www.scotusblog.com/case- majority opinion in all respects, he opinion. The Position Statement files/cases/chappell-v-ayala/ (accessed July 2, 2015 wrote separately on an issue that had, notes that prolonged segregation for 2. Metzner & Fellner: Solitary Confine- "no direct bearing on the precise legal inmates with severe mental illness ment and Mental Illness in U. S. Prisons: A questions presented" in the case. should be avoided, and that if an Challenge for Medical Ethics, 38 JAAPL Based on Ayala's counsel's statement inmate with severe mental illness 104–108, 2010 during oral argument that his client requires segregation access to out of 3. American Psychiatric Assoication Posi- had "served the great majority of his cell mental health treatment and tion Statement on Segregation of Prisoners with Mental Illness. more than 25 years in custody in unstructured recreation time should 3 http://www.psychiatry.org/File%20Library/L 'administrative segregation' or, as it is be provided . et al earn/Archives/Position-2012-Prisoners-Seg- better known, solitary confinement," A recent study by O'Keefe, . regation.pdf (accessed July 2, 2015) Justice Kennedy went on to describe not cited in Kennedy's concurring 4. O'Keefe ML, Klebe KJ, Metzner J, the history of solitary confinement. opinion, tends to disprove Kennedy’s Dvoskin J, Fellner J, Stucker A.: A longitu- Justice Kennedy reviewed the exist- reasoning, at least for segregation of dinal study of administrative segregation. 41 ing legal and scientific literature, inmates for one year or less. Noting JAAPL 49-60, 2013. including Metzner & Fellner’s work that past studies on the deleterious in JAAPL2. While acknowledging mental health effects of segregation that solitary confinement may be nec- have been cross sectional studies that

American Academy of Psychiatry and the Law Newsletter September 2015 • 5 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 6

ASK THE EXPERTS

Ask The Experts outcome of the case. However we Neil S. Kaye, MD, DFAPA, and Graham Glancy, MBChB, FRCPsych, FRCP must be clear as forensic psychia- trists, the AAPL ethical guidelines I want to personally thank Bob strictly prohibit working on a contin- Sadoff, MD, who has co-authored this that my opinion is truly unencum- gency basis. column with me since 2008. His bered. Since I have already been paid In certain cases it may be reason- friendship and mentoring has been a in full, there is obviously no possible able to accept a case at an hourly rate critical influence in the development connection between my testimony lower than the usual rate that one of my own career. As Bob steps and being paid, and thus I am impar- generally charges. A case that is down, I welcome Graham Glancy, tial with respect to the trial outcome. especially worthy, or where it is clear MD as my new co-author. Graham is However, to answer the question that the client will not be able to well known to AAPL members and more directly: There is nothing that afford the psychiatrist’s usual fee has served as President of AAPL. He prevents you from reducing your bill, schedule may fall into this category. brings a new international view to the should you so desire. In some cases I In certain cases involving issues of column and I look forward to writing will agree to a fee reduction based on social justice it is not unreasonable to together. how I feel about the case and my work pro bono. relationship with the lawyer. I also Returning to the question at hand, Neil S. Kaye, MD, DFAPA and will ask the lawyer what her reduc- Tom Gutheil, MD reminds us that Graham Glancy, MBChB, FRCPsych, tion in billing will be and may agree although forensic psychiatry can be FRCP (C), will answer questions to match that in some way. Forcing stimulating and fascinating, it is also from members related to practical the lawyer to give back to her client way of making a living. One must issues in the real world of Forensic seems logical, if I am being asked to pay attention to the business aspects Psychiatry. Please send question to do likewise. of the practice. That does not mean [email protected]. that one should be ruthless, but rather A. Glancy: that our relationship with lawyers is This information is advisory only Firstly would like an important component of the busi- for educational purposes. The authors to say how hon- ness. Sometimes in a case one finds claim no legal expertise and should ored I am to step that one has billed over the original not be held responsible for any action into the shoes of estimate. However if, as in the case taken in response to this educational the great Dr. at hand, the outcome is poor, one advice. Readers should always con- Robert Sadoff, may be tempted to write off the last sult their attorneys for legal advice. one of the pio- part of the account or offer a profes- neers of forensic sional discount. This maintains your psychiatry. Dr. Sadoff has been relationship with the lawyer who is Q.: I worked really hard on a losing instrumental in shaping forensic psy- likely already somewhat disappoint- plaintiff case. They lawyer has asked chiatry as we know it today, so it is ed. From a business point of view me to reduce my bill due to the poor with great trepidation that I try and this may be worthwhile in the long outcome. Is this allowed? replace him as Dr. Kaye’s co-author run. on this column. I am reminded of the quotation A. Kaye: My I have to agree with Dr. Kaye from the torah that Dr. Sadoff used in real advice is to regarding the importance of spending his high school valedictorian speech, avoid getting into time on the initial stages of the refer- “everything is foreseen, yet the this kind of situa- ral so as to avoid difficulties later. It choice is given”. As long as we are tion. First, I is at least helpful, if not essential to careful to follow our ethical guide- require a retainer distill one’s initial discussion with the lines we can make certain choices. when I first get lawyer into a written retainer agree- the case and my ment, which will request an agreed Take Home Point: retainer agree- upon retainer fee prior to beginning Relationships with lawyers are ment makes the following clear: I the case. Time spent at this juncture always a combination of personal and require payment in full for all work of the referral avoids a lot of nasti- professional. There is a risk in trying done prior to testimony. I also ness and potential misunderstanding to please a referring lawyer of losing require payment for my expected time later on. I concur that having a impartiality and objectivity. Yet, in court (billed by the day on most retainer fee in hand facilitates our role there is a reality in running your busi- cases) in order to get me to come to in maintaining objectivity and hon- ness, as to what decisions are good court. I explain to the lawyer that esty. business decisions but still consistent paying me in advance is not just my Many lawyers in civil cases take a with the ethics code of our profes- requirement, but also helps her case. case on a contingent basis, whereby sion. I am easily able to explain to the jury they are only paid according to the

6 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 7

CHILD COLUMN

Whose Embryo Is It? wanted any embryos created to be Everything You Need implanted in a surrogate mother and To Know Stephen P. Herman MD should be raised by a husband and continued from page 4 wife – not a single parent. A court The case start- ruled in his favor. NCR-MD had previous psychiatric ed like this: A Where is a solid argument here? It Chicago physi- hospitalizations. In fact most had seems as though judges are flying by two or more prior admissions. This cian, diagnosed the seat of their robes. The ethical with cancer, suggests that the psychiatric system implications are enormous. However, failed these patients and that we need asked her uniform standards are lacking. boyfriend to pro- to consider ways to prevent the situa- A Michigan couple fought for tion becoming so dire as to lead to vide sperm so that years over the fate of their frozen embryos could be criminal charges. This might include embryos after their divorce. The ex- measures such as better outreach ser- created to be used after her cancer wife wanted more children; the ex- treatment. The boyfriend agreed. vices, more availability of emergency husband did not. The judge ruled in or safety beds, and as the authors There was no written contract. She the man’s favor, saying that he had a had made no demands on her suggest, better training of violence right not to have the embryos implant- risk assessment for general mental boyfriend, promising to assume all ed, since he did not want them. health workers. This is also reflected expenses. However, she and her in the finding that Québec has a boyfriend broke up. Despite advice “For some divorcing cou- lower offense severity than the other from an attorney, the couple had not provinces. For instance homicide or signed a co-parenting agreement, and ples, the issues of frozen attempted murder makes up 7% of so after the breakup, the conflict the offenses across the board, but began. embryos might be yet an- only 3.2% in Québec. Interestingly The ex-boyfriend did not want the recent criticisms of forensic psychia- embryos used, while the woman did. other factor to consider.” trists in the press, and even by the The case was litigated. A lower court provincial psychiatric association, ruled in favor of the woman, saying have been the most vociferous in the her position outweighed the man’s. In the coming years, courts might province of Québec. It is evident that An appeals court disagreed, saying rule in favor of men who do not want two thirds of the offenses were that standard was not tenable. Instead, embryos used. But why is this a offenses against the person. It is also the lower court should consider a bal- stronger argument than a woman’s of note that family members are most ance of interests. In the lower again, right to have the embryos implanted? at risk of being the victims of vio- the judge again ruled in favor of the There are no guidelines. The issue lence, followed by mental health doctor, saying she and her now ex- seems to be up to a judge faced with workers. This is in contradistinction boyfriend had made an oral agree- an almost impossible situation. Stan- to the public viewpoint that strangers ment. dard recommendations seem to be to are frequently the victims of violence Each side’s attorneys made argu- consult with an experienced divorce perpetrated by the mentally disor- ments. The man’s attorney said no attorney and try to sort it all out. The dered. embryos should be implanted if one arguments can be strong for either It would be of no surprise to our party is in opposition. The woman side. readers that 94% of the proband suf- disagreed, writing that her ex- This conflict is the ultimate in cus- fered from a psychotic spectrum dis- boyfriend had at one time agreed to tody disputes. Can this be a forensic order and a third of these had comor- the plan. The case is still pending. issue? There will probably come a bid substance abuse. I was surprised As we know, scientific advances day when we will be asked to get that only a third had comorbid sub- have moved reproductive technology involved. The forensic expert should stance use disorders, a figure that is far along from what was ever stay away from offering a specific actually lower than the comorbidity dreamed before. For some divorcing opinion. We are not trained to do this. in individuals suffering from major couples, the issues of frozen embryos However, we can evaluate each parent mental illness. It is possible that the might be yet another factor to consid- and provide psychiatric profiles to the presence of substance abuse increases er. More and more attorneys are fac- court. This could help judges under- the blameworthiness of the accused ing this dilemma with their clients. stand the context of parents’ choices. and perhaps led to guilty verdicts. The law is way behind. There is not a Some may argue, however, that there Previous impressions had suggest- judicial presumption or solid case law is no role for us here. There are no ed that accused persons spend less to provide guidance. easy answers. But it is an area of time in the NCR-MD schema in A Tacoma couple produced two extreme interest. More behavioral Québec than in other provinces. The embryos through a surrogate. The research is needed. findings of this p(crojnetcint urevdeoanlepdatgheat8) couple divorced. The ex-husband What do you think?

American Academy of Psychiatry and the Law Newsletter September 2015 • 7 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 8

PRESIDENT’S REPORT - Continued

Everything You Need stance abuse and personality disorder against the person. The authors note To Know also contributed to the decision to dis- that these figures should be compared continued from page 7 charge somebody with conditions. with the general recidivism rate in the All these factors would be taken into same time period, which would be indeed there were significant inter- consideration using a structured pro- 34%; and even more startlingly, provincial differences. After one year fessional judgment instrument such as against an inmate population treated the HCR -20, which was generally for mental disorder and released, who 74% of people were still under the 8 review board in Québec, compared used by clinicians and presented in have a recidivism rate of 70% . This with 92% in Ontario. The difference evidence to the board. does demonstrate that the NCR-MD after five years was more striking, In part four of the series, the schema provides services that seem to demonstrating that 19% of NCR-MD recidivism rates were presented and manage people quite well and not cases in Québec compared with 58% discussed. The three year recidivism only serve the needs of the accused in Ontario were still under the review rate post index offense is 10% in but significantly reduces the recidi- board. British Columbia was inter- Ontario and 21.5% in Québec, that is, vism rate and thereby protect the pub- mediate regarding all these findings. twice as high. This is likely reflec- lic. There was also a measurable differ- tive of the fact that accused persons Factors that predicted recidivism ence between those who were still from Québec have the lowest severity included number of previous offens- detained in custody (meaning in a of criminal offense originally, were es, substance use disorders, and rates hospital) in that after 5 years; only of personality disorder. A severe 23% were in hospital in Québec com- “It is interesting to note index offense had an inverse relation- pared with 79% detained in Hospital ship with recidivism. These findings in Ontario. that the HCR-20 was suggest the clinicians and review There are also significant differ- boards, as noted above, are giving ences in the practices of the Review generally used by the weight to the right factors in predict- Board between the provinces. For ing whether the accused is a signifi- instance in Québec only 65% of the clinicians in coming to cant threat to the safety of the com- accused were represented by counsel, their conclusions related munity. compared with 96% in Ontario. Con- In conclusion I would advise all sidering that accused persons in to significant threat and forensic psychiatrists to review these Québec are discharged from hospital articles in detail. In this article I have more quickly and received absolute risk management.” attempted to summarize some of the discharge more quickly, it could be more salient findings. The findings argued that they do not really need a were reassuring in that accused per- lawyer. However another striking sons under the MD –NCR schema finding may be significant in that in under the review board for a shorter seemed to be receiving excellent ser- Ontario 100% of review boards were period of time, and generally reof- vices, which, contrary to some asser- attended by a prosecutor, whereas in fended with a relatively minor tions, significantly reduce recidivism Québec only 7.3% of boards had a offense. In fact the figures showed to lower levels. It was also reassur- prosecutor present. It is possible that that people who had committed a ing to note that both clinicians and this was one of the reasons for the severe offense had only a 6% recidi- review boards, who are essentially in more measured, conservative vism rate involving an offense of any agreement, are taking the salient fac- approach of Ontario. It is interesting kind. In fact the recidivism rate of a tors into account in coming to their to note that the HCR-20 was general- severe violent offense within three conclusions. ly used by the clinicians in coming to years was an extremely low 0.6%. It is of note that following absolute dis- References their conclusions related to signifi- 1. Schneider, R., Glancy, G., Bradford, J., cant threat and risk management. In charge the recidivism rate rose to 22%. Despite the fact that these SeibJeonumronragleonf, tEh:e AWminekriocavns ABcriatdisehmCyoolfum- 87% of cases there was agreement bPisay.chiatry and the Law between the clinical recommenda- accused persons were noted to be . 28(2), 206-12, tions and review board decision. doing well, cooperating with treat- 2000 Factors that appeared significant in ment, and were judged not to be a 2. Glancy, G. & Bradford, J: CanJoaduirannal of Landmark Cases: R. vs. Swain. effecting the decision of a discharge significant threat to the safety of the the American Academy of Psychiatry and community at the time of their the Law with conditions included a lack of . 27(2) 1-7, 1999 past offenses, a less severe index absolute discharge, after discharge they are often not given the services 3. Crocker, A.G., Nicholls, T.L., Seto, M.C., offense, and the presence of a mood Côté, G: The National Trajectory Project of disorder diagnosis. There was a and structure of the review board Individuals Found Not Criminally Responsi- schema and this leads to an upswing strong trend, which did not reach sig- ble TonheACccaonuandtiaonf JMoeunrntaallDoifsPorsdyecrhiiantrCyana- nificance, that the absence of sub- in recidivism. This recidivism is not da. necessarily a serious violent offense (continued on page 9)

8 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 9

FACES OF AAPL

Cheryl Regehr, PhD for their annual meetings. Planning lence and the fatalistic sense that there for all aspects of an airport emergency was no way out emerged as a critical By Philip Candilis, MD allowed for a comprehensive view of part of the mind-set of defendants who problems that might arise for her as felt they would die if they did not pro- The inspiration chief executive officer of a major uni- tect themselves with deadly force. for public service versity. Whether leading a social work was critical for Studying trauma in emergency ser- research center, a sexual assault cen- the Provost of the vice workers was a related element of ter, or a major international university, University of her work, as Cheryl explored the fac- Professor Regehr has found the multi- Toronto, a long- tors influencing recovery from the ple perspectives of forensic work time friend to the stresses of public safety. What effects instructive in analyzing complex American Acade- does exposure have among those social and communitarian issues. “It’s my of Psychiatry and the Law. Winner responding to emergencies, and is easy to hold a singular theoretical and of AAPL’s 2004 Amicus Award, Pro- there a related effect on public safety? political view,” she says. The chal- fessor Cheryl Regehr grew up in a It is not inconceivable that PTSD and lenge lies in seeing complex human family that served as a haven for fos- related symptoms will have an impact behavior from the perspective of many ter children with special needs – chil- on decision-making in a crisis. In constituents and stakeholders. AAPL dren who benefited enormously from work presented over the past two Amicus Cheryl Regehr does exactly the teaching and social work back- years at AAPL, Dr. Regehr identified that. grounds of her parents. Now a social influences of clinicians’ PTSD on sui- work scholar and educator herself, Dr. cide risk assessments as well as Regehr has made a career of forensic among police officers and paramedics. Everything You Need mental health and fosters a university To Know environment that nurtures students “Studying trauma in continued from page 9 focused on community and societal needs. emergency service work- 60(3):96-98, 2015 Trained in emergency and forensic 4. Crocker, A.G., Nicholls, T.L., Seto, M.C., mental health, Dr. Regehr studied ers was a related ele- Côté, G., Charette, Y., Caulet, M: The both victims and perpetrators of sexu- National Trajectory Project of Individuals al violence – writing her doctoral dis- ment of her work...” Found Not Criminally Responsible on sertation on factors that contributed to Account of Mental DisordTehreinCaCnaandaidaan. Part 1: Context and Methods. the resilience of rape survivors. Early Journal of Psychiatry 60(3):98-106, 2015 attachment, quality of relationships, Dr. Regehr’s contributions to 5. Crocker, A.G., Nicholls, T.L., Seto, M.C., and cognitive orientation all mattered AAPL are long-standing. First pre- Charette, Y., Côté, G., Caulet, M: The to those recovering from sexual senting in 1988, Cheryl appears regu- National Trajectory Project of Individuals assault. larly to present results or participate Found Not Criminally Responsible on Moreover it was the structure Account of Mental Disorder in CTanhaedCa.aPnar-t on panels. Her work has appeared on 2: The People Behind the Label. offered by the community that con- eight separate occasions in the AAPL dian Journal of Psychiatry 60(3):106-117, tributed to a better outcome. Support Journal. AAPL’s strength is that it lies 2015 systems, counseling, and educational in the frequent start of important ideas 6. Crocker, A.G., Charette, Y., Seto, M.C., efforts joined personal factors to influ- in the clinical realm that then develop Nicholls, T.L., Côté, G., Caulet, M: The ence the choices available to survivors into research that is itself applicable to National Trajectory Project of Individuals and underscore the importance of sys- clinical practice, she says: “There are Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part temic solutions to broad concerns like few organizations that exhibit that 3: Trajectories andThOeuCtcaonmaedsiaTnhJroouugrnhatlhoef sexual violence. connection between research and Forensic System. In student health for example, practice.” Psychiatry 60(3):117-127, 2015 Provost Regehr advocates preventive One project that stands out in Dr. 7. Charette, Y., Crocker, A.G., Seto, M.C., education on sexual violence, robust Regehr’s work is a collaborative pro- Salem, L., Nicholls, T.L., Caulet, M: The mental health services, supports for ject with current AAPL President Gra- National Trajectory Project of Individuals Found Not Criminally Responsible on those harmed, and procedural fairness ham Glancy, analyzing Battered Account of Mental DisorTdheer iCnaCnandaiadna. Part for the accused – a systems-based Woman’s Syndrome (BWS) defen- 4: Criminal Recidivism. process that values individual and dants who had killed their partners. Journal of Psychiatry 60(3):127-135, 2015 community integration. Their analysis of the elements of the 8. Villeneuve, D.B., Quinsey, V.L., Predic- Traceable to her work in emer- defense required by the Canadian tors of general and violent recidivism gency management, Dr. Regehr draws Criminal Code led to a better under- among mentallyThdeisCoradneardeidaninJmoautrensa. lCorfim on her leadership of the clinical team standing of the factors distinguishing PJussytcicheiaBtreyh2av2.(4):387-410, 1955 at Toronto’s Pearson Airport, where BWS cases from others. The pro- most APA members recently landed longed nature of intimate partner vio-

American Academy of Psychiatry and the Law Newsletter September 2015 • 9 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 10

FELLOWS CORNER

Extremism, Radicalization, and Terror: our assessment? Could premature or inaccurate timing increase the risk of Can Psychiatry Help? radicalization? One may consider Mustafa A. Mufti, MD doing standardized risk assessment such as HCR-20 on patients who may appear at risk, however its application On August 8, bia.edu/i/a/document/9386_WhitePa- in violent extremism may not be as 2015, a “normal” per_2_Extremism_030809.pdf) stat- specific as in the population it was appearing young ed, “Extremism is a complex phe- normed. couple in Missis- nomenon, although its complexity is Literature suggests that there is no sippi was arrested often hard to see. Most simply, it can single cause or route responsible for for attempting to be defined as activities (beliefs, atti- engaging in violent extremism. Radi- travel abroad to tudes, feelings, actions, strategies) of calization is a process of change, hard join the Islamic a character far removed from the to observe clinically. However, some State of Iraq and ordinary. In conflict settings it mani- individuals may be predisposed to the Levant (ISIL). Muhammad Oda fests as a severe form of conflict this change. Some known risk factors Dakhalla, a 22-year-old male, and engagement. However, the labeling of for extremism include depression, Jaelyn Delshaun Young, a 20-year-old activities, people, and groups as social isolation, sense of inequality female, had no known legal history ‘extremist,’ and the defining of what and injustice, and perceived discrimi- and potentially bright futures. Ms. is ‘ordinary’ in any setting is always a nation. Researchers have suggested Young, a high school honors graduate subjective and political matter.” For that by providing support and mental and cheerleader, was what the Vicks- the purposes of this article we will health treatment in the early stages burg Post called “an all-American refer to extremism as an ideology that we may be able to prevent the entry Girl.” Mr. Dakhalla was about to start is outside the mainstream of society into the early stages of violent graduate school in Mississippi. His or religion. extremism. taekwondo instructor described him What would cause otherwise “nor- What then can we do for those as calm, attentive, and focused, mal” individuals to commit or plan an who have already been radicalized? A adding that the charges did not fit his act of violent extremism, and is there National Public Radio report indicat- character at all. any way to identify these individuals? ed that more than 60 Americans have It appears that that these two Most individuals with extreme views been accused of joining or supporting young adults’ political and religious never go on to commit a shooting in ISIL. If they are incarcerated with no views led them to being radicalized— church or school, or become living effort toward de-radicalization, we willing to pledge their allegiance to a bombs. What is the most common risk their going further down this path known terror organization. Charged characteristic among individuals who or even “infecting” other inmates. with making supportive statements commit terroristic acts? Unfortunate- The process of de-radicalization is regarding ISIL, Ms. Young was ly, for prevention purposes, the most one that is being studied both at home allegedly pleased to learn about the common characteristic seems to be and throughout the world. Programs attack on Marines in Tennessee, while their apparent normality within soci- in United Kingdom, Denmark, Saudi Mr. Dakhalla allegedly indicated that ety. Arabia and the United States are he was willing to fight for ISIL. The McGilloway and colleagues (Int working to help solve this issue. question that comes to mind is what Rev Psychiatry, 27:39–50, 2015) Kruglanski and colleagues (Political drove this young couple to this point? spoke of how the criminal justice Psychology, 35:69–93, 2014) note What, if anything, caused them to be framework concentrates efforts on that many of these programs have a vulnerable to this degree of radical- small numbers of convicted terrorists. multifaceted approach. They consist ization? They suggested that we should look of intellectual, emotional, and social We have all been witnesses to into ways to approach this as a popu- components. In Minneapolis, Judge numerous unfortunate incidents lation-based public health concern. Michael Davis ordered Abdullahi where a person’s or group’s political, Taking that into consideration, what Yusuf, another self-professed ISIL racial, or religious extremist views are potential risk factors for violent candidate, to attend a rehabilitation led them to acts of violent extremism extremism? What could and should program after he pled guilty to and terror. The public’s immediate we do if we feel one of our patients is attempting to join ISIL. We have yet response is, “They must have been heading down the path of radicaliza- to learn about the outcome of this crazy.” There is debate among schol- tion? Perhaps we could obtain collat- program, but I am hopeful it will shed ars regarding the degree to which eral information from family or some light on this problematic issue. mental health issues plays a role in friends or even go to the extent of the radicalization process—a subject notifying law enforcement agencies. Mustafa A. Mufti, MD is a forensic for forensic psychiatric inquiry. Cole- However, if there is no imminent risk fellow at University of Pennsylvania man and Bartoli, in “Addressing of harm, can we break confidentiali- fellowship program Extremism,” (http://www.tc.colum- ty? What if we were not accurate in

10 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 11

ALL ABOUT AAPL - Committees

Reflections of an Israel Defense Forces .009% per year, or slightly less than 1/10,000. This is somewhat lower Military Psychiatrist than the suicide rate among US Ziv Ezra Cohen, MD, Trauma and Stress Committee active duty personnel of 1.87/10,000.5 In 2006, the IDF insti- “You have to allow me to serve,” was fourteen following a terrorist tuted restrictions on service members he said. “Everyone in my family attack in which a car was driven into taking their weapons home on week- end leave after noting that most sui- was a paratrooper. I know I can do a group of students. The patient 6 it, too,” Yoni implored. After com- endured prolonged and painful physi- cides occurred on these visits. The pleting advanced training with cal rehabilitation. Her current symp- suicide rate was subsequently Israel’s elite paratroopers, Yoni’s toms thus represented a reactivation reduced by half. Although certain officers noted him to be sullen, with- of pre-existing PTSD. psychiatric risk factors for suicide drawn, and poorly motivated, and While American service personnel are common between the US and referred him for psychiatric evalua- enter the military with higher rates of Israeli militaries, sociocultural risk tion. adverse childhood events than their factors differ. For example, suicide 1 in the US military is associated with As a grandchild of Holocaust sur- civilian counterparts, in the Israeli 7 vivors, a first generation American setting, global stress index scores for low psychosocial adaptation, where- born to Israeli veterans of the Israel adolescents are significantly higher as in the Israeli military it has been associated with excessive motivation Defense Forces, a medical student in than US norms and correlate with 8 New York City during 9/11, and a periods of political-military conflict.2 to serve. psychiatry resident during the Iraq Intergenerational trauma is also com- The nexus between civilian trau- and Afghanistan wars, I had long mon in Israel, with many soldiers ma and military trauma in Israel is been interested in the impact of trau- having primary family members who particularly apparent. Given Israel’s ma on individuals and society. Moti- sustained Holocaust related trauma,3 size (about the size of the state of vated by this interest, from 2011- combat trauma, or mass violence. New Jersey) and the nature of mod- 2012 I had the opportunity to serve This, in turn, affects soldiers’ subjec- ern warfare, the “front” and the in the Israel Defense Forces (IDF) tive experience of the stresses of mil- “rear” are more conceptual than real- Medical Corps, Mental Health itary service, and may manifest in ities. Family members worry about Branch, as a military psychiatrist, adjustment disorders, anxiety disor- soldiers’ safety and soldiers worry where I encountered Yoni. ders, or reactivation of PTSD. about their civilian family members Similar to the US Armed Forces, who may be subject to rocket fire or the bulk of a military psychiatrist’s “Intergenerational trau- suicide bombers. This is captured by work in the IDF involves evaluation, Israel’s Memorial Day, which is offi- triage, and treatment of soldiers and ma is also common in cially named, “Day of Remembrance officers. Much of the clinical case- for the Fallen Soldiers of Israel and load is “bread and butter” psychiatry, Israel, with many sol- Victims of Terrorism.” In Israeli col- e.g., anxiety and depression, unrelat- lective consciousness the distinction ed to the military environment. diers having primary between fallen soldiers and fallen cit- In many cases, however, the mili- izens is blurred. tary environment may be associated family members who Like in the United States, where with exacerbation of pre-existing in 2014 the DOD estimated that sustained Holocaust 4.3% of women experienced unwant- mental health issues. Individuals 9 with personality disorders may find it related trauma,3 combat ed sexual contact in the military, the difficult to adapt to the demands of past several years in Israel have seen the military and develop adjustment trauma, or mass vio- growing awareness of military sexual disorders or those with pre-existing trauma. A recent report by the IDF depression and anxiety may worsen. lence.” Advisor on Women in the Military Although operations associated trau- found as many as 1 in 8 women sol- diers experienced unwanted sexual ma may result in posttraumatic stress 10 disorder (PTSD) symptoms, the mili- Given the easy access to firearms, contact in 2013. A specialty clinic tary psychiatrist must remain on the there is always a concern for suicide. for victims of sexual trauma in the alert for other sources of trauma. A The IDF reported that 15 soldiers IDF serves the needs of these sol- soldier posted to a base on Israel’s died by suicide in 2014; the number diers. border with Gaza complained of has fluctuated between 7 and 28 in Since 1998 gay men and women insomnia due to anxiety about the the past 5 years.4 Although the exact have been allowed to serve openly in constant rain of Hamas rockets. On standing force in the IDF is classi- the IDF, and since 1999 the IDF has had a progressive policy towards exploration, it emerged that the fied, the publicly available estimate (continued on page 26) patient had slept poorly since she of 160,000 suggests a suicide rate of

American Academy of Psychiatry and the Law Newsletter September 2015 • 11 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:57 PM Page 12

RAPPEPORT FELLOWSHIP AWARD 2015-2016

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

The prestigious AAPL Rappeport Fellowship was named in honor of AAPL's founding president, Dr. Jonas Rappeport, MD and offers the opportunity for outstanding senior residents with a dedicated interest in psychiatry and the law to devel- op and groom their knowledge and skills. The Rappeport Fellows will receive a scholarship to attend the AAPL forensic psychiatry review course and annual AAPL meeting in Ft. Lauderdale, Florida. Each fellow is also assigned a senior AAPL forensic psychiatry preceptor to guide their activities and training during their fellowship year. The Rappeport Fel- lowship Committee is pleased to announce the six Rappeport Fellows for 2015-16. The Fellows are Miguel Alampay, MD, JD , LT, MC, USN, Vivek Datta, MD, MPH, Brian Holoyda, MD, MPH, Darlinda Minor, MD, David A. Nissan, MD, LT, MC, USNR, and John P. Shand, MD.

Vivek Datta, MD, MPH Dr. Datta is Chief Resident for Education at the University of Washington Medical Center, Seattle, where he directs the Neuropsychiatry Consultation Service. Born in London, England, Dr. Datta com- pleted his Medical Degree with Distinction at the University of London. He was a Visiting Research Fellow in Psychological Medicine at the Institute of Psychiatry at the Maudsley, London and Clinical Lecturer in Psychiatry at Deakin University School of Medicine, Australia. After a short stint as House Physician and Surgeon at Barnet and Chase Farm Hospitals, London, he came to the US as a Frank Knox Memorial Fellow to complete his MPH at Harvard. During his residency training he has won numerous awards including the PRITE Fellowship of the American College of Psychiatrists, the IMG Fellowship of the American Association of Directors of Psychiatry Residency Training, and the Diversity Leadership Fellowship of the American Psychiatric Association. As part of the latter, he serves as a member of the APA’s Council on Psychiatry and Law and Committee on Judicial Action. He is interested in forensic neuropsychiatry and his current research explores criminal responsibility and legal defenses for criminal behavior in frontotemporal dementia. Upon com- pletion of residency training, he will begin his Forensic Psychiatry Fellowship at UCSF.

Brian Holoyda, MD, MPH Dr. Holoyda is a 4th year resident in General Psychiatry at UC Davis Medical Center. Dr. Holoyda developed an interest in forensic psychiatry during medical school, attending his first AAPL meeting in his third year and completing an elective rotation with Dr. Phillip Resnick in his fourth year. As a resident Dr. Holoyda has been vigorously active in pursuing forensic training and research experience. He has co-authored multiple papers and book chapters on a variety of forensic topics, including two first-author publications for the AAPL journal. He has presented at numerous conferences in the Unit- ed States, as well as internationally in Canada, the United Kingdom, and Austria on topics including bestiality, cult members who commit murder, and competency to stand trial in misdemeanor defen- dants. Dr. Holoyda is spending his fourth year of residency researching sex offenders who are hospitalized within the Cali- fornia state hospital system. He will then attend forensic psychiatry fellowship at UC Davis. His current academic interests exist at the intersection of group psychology and forensics and include cults, religious extremism, terrorist organizations, and mass suicide and homicide. In the future Dr. Holoyda hopes to develop a career in academic forensic psychiatry through which he can provide treatment, build a forensic practice, and continue to research and write on forensic topics.

David A. Nissan, MD Dr. Nissan is a 4th year psychiatry resident at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. Dr. Nissan attended the University of Rochester through a Naval Reserve Officer Training Corps scholarship, in his senior year serving as the Battalion Commander. As an undergraduate he was awarded the DeKiewet research fellowship to study Alzheimer’s Disease, specifically the folding prop- erties of synthetic peptides as a model for amyloid-β. He graduated Suma Cum Laude, double major- ing in biochemistry and history, and was elected to the Phi Beta Kappa honor society. Dr. Nissan attended medical school at Weill Cornell Medical College, where he was elected the President of his medical school class, selected for the Alpha Omega Alpha honor society, and was awarded the Leonard Tow Humanism in Medicine Award. Dr. Nissan began psychiatric residency training at NYPH-WCMC in 2012, and in 2013 was awarded a Janssen Resident Psychiatric Research Scholar award to study the demographics and impact of treatment-over-objection, and has presented this work at poster sessions at the APA meetings in 2014 and 2015. Dr. Nissan is currently serving as a Co-Chief Resident, and after completing residency in the spring of 2016 will return to active duty in the United States Navy. (continued on page 13)

12 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 13

RAPPEPORT FELLOWSHIP AWARD 2015-2016

Once again this year, we received a high number of outstanding applicants who competed for the six Rappeport Fellow- ship Awards. The committee noted that there are many excellent residents with an interest in forensic psychiatry, which is outstanding for our field of Forensic Psychiatry. We would like to thank the members of the Rappeport Committee, all Rappeport preceptors, and our AAPL Council for their continuing support of this superb training opportunity!

Miguel Alampay, MD Dr. Alampay was raised in both the US and Asia. After graduating Magna Cum Laude from George- town, Dr. Alampay continued on to Georgetown’s Law Center where his academic focus was mainly on intellectual property and healthcare regulatory work. During this time, Dr. Alampay had the privi- lege of working with organizations such as Catholic Charities, the Whitman Walker Clinic, the VITA Program, and Klores & Associates. He has counseled clients in the areas of immigration, public bene- fits for HIV+ GLBTQ (Gay, Lesbian, Bisexual, Transgender, Queer) patients, tax law for low-income families, and catastrophic medical malpractice. Following law school, Dr. Alampay commissioned as an officer in the United States Navy and began medical school at the Uniformed Services University of the Health Sciences. He received his MD in 2012 and began his psychiatry training at Walter Reed. He was elected Chief Resident for the 2015-2016 academic year. Before that he served as Deputy Chief the prior year and was also Vice Presi- dent of Walter Reed’s intern class. His scholarly contributions include work in neuromodulation, traumatic brain injury, post-traumatic stress, forensics, eating disorders, and humor in mental healthcare. His work has been presented in both national and international fora. He was recently named the Washington Psychiatric Society’s Resident of the Year for 2014, and completed the Institute for Contemporary Psychotherapy and Psychoanalysis’ Fellowship in Contemporary Forms of Psychotherapy. He currently serves on the Board of the Washington Psychiatric Society, APA’s Council on Psychiatry and the Law, and the board of the District of Columbia Bar’s Lawyer Assistance Program. In addition to being a Rappeport Fellow, he is concurrently a GAP Fellow, and American Psychiatric Leadership Fellow. He is currently admitted to prac- tice law in Maryland and the District of Columbia; and is licensed to practice medicine in Virginia.

Darlinda Minor, MD Dr. Minor is currently serving as an Administrative Chief Resident at the George Washington Univer- sity Psychiatry Residency Program. In addition, she has served on various committees (Teaching, Recruitment, Retreat Planning, Newsletter) in the residency program, and spearheaded many quality improvement projects. During her third year, she completed a yearlong forensic psychiatry rotation at the District of Columbia Department of Corrections. Dr. Minor has also created another forensic psy- chiatry rotation conducting juvenile evaluations in the Maryland Correctional Department. At the 2014 American Academy of Psychiatry and the Law (AAPL) annual meeting, she co-presented on four projects, including a panel presentation on liability in college suicides. She will also be co-presenting on several projects in the 2015 AAPL annual meeting. She has co-authored an article on decisional capacity in Amy- otrophic Lateral Sclerosis, which was published in the Journal of American Academy of Psychiatry and the Law in June 2015. She currently serves on the Suicidology Committee of AAPL and has contributed a newsletter article for AAPL on behalf of the committee in January 2015. Upon graduation, Dr. Minor will be pursuing further training in forensic psychi- atry as a fellow at the Case Western Reserve University.

John P. Shand, MD Dr. Shand is Clinical Chief Resident at Case Western Reserve University. Dr. Shand has been serving on the Ohio Psychiatric Physicians Association’s Ethics Committee (OPPA) for the past two years, and has written several articles for their quarterly newsletter on ethical issues as they relate to psychiatry and social media. In addition, he has addressed the stigmatization of mental health issues and patients, mental health parity, stigma related to film, and psychiatry and the law in journals including The Lancet Psychiatry, JAAPL, Journal of Humanistic Psychiatry, and Australasian Psychiatry. He has co- authored in the Wiley Encyclopedia of Forensic Science on topics of Therapeutic Jurisprudence and Civil Commitment, and has given a panel discussion at the APA on American Horror Film and Psychi- atry. He has given numerous poster presentations on claims of amnesia in a court mental health clinic at venues including MWAAPL, AAPL, APA and the IPS, and has presented to the Cleveland CL-Society on the topics of factitious disorders, limbic encephalopathy, and erotomania. Dr. Shand plans to pursue a forensic fellowship, followed by a long career, in Forensic Psychiatry. He is honored to be a Rappeport Fellow.

American Academy of Psychiatry and the Law Newsletter September 2015 • 13 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 14

ALL ABOUT AAPL - Committees

APA Assembly Report patients and others who may benefit from being better informed about par- Cheryl D Wills, MD, Alternate Delegate ity. The U.S. Department of Labor has expressed willingness to investigate The APA Assembly Met in Toron- diversity, fair reimbursement, parity, any insurance plan that is not in com- to, Ontario from May 15 – 17, 2015. etc. and has implemented them into pliance with the Mental Health Parity The APA has implemented new the Strategic Plan for the organization. and Equity Act. A Confidential Prac- branding in an effort to distinguish it The APA Assembly responded to tice Questionnaire has been developed from other professional mental health member concerns about MOC to make it easier for psychiatrists to organizations. The logo, which fea- requirements by forming an Assembly report unfair reimbursement practices. tures the ancient serpent-encircled rod Workgroup on MOC and collaborat- The new DSM-5 consumer guide, of Asclepius superimposed over two ing with other APA leaders to commu- titled Understanding Mental Disorders hemispheres of the human brain, con- nicate concerns to the American was released on May 1, 2015. It is a veys the role of a contemporary psy- Board of Psychiatry and Neurology. resource that is designed to help the chiatrist as a physician who cares for These encounters ultimately resulted public understand the nature of mental all aspects of a patient’s health – in the APA requesting that the ABPN disorders and offers clinical and sci- mind, brain and body. APA advocate to the American Board of entific information that may be used CEO/Medical Director, Saul Levin, Medical Specialties (ABMS) to elimi- to augment discussions that psychia- M.D., M.P.A. said that the new logo nate part IV of the MOC require- trists have with patients and families will be used to represent the organiza- ments. The APA also is piloting a pro- about mental health. tion along with the APA seal which ject designed to facilitate completion There have been a number of includes Benjamin Rush, the year of the MOC process in several enhancements added to Internet 1844, and 13 stars that represent the regions. resources for APA members. There is 13 founders of the organization. The President and CEO of ABMS, an updated phone directory that The APA Board of Directors has Dr. Lois Nora addressed the Assem- requires a member to enter a user- reviewed a reorganization plan for the bly. She is a neurologist who comes name and password on the APA web- APA that is scheduled to commence from a family of physicians who rou- site to access it. The AAPI.org web- in November 2015. The plan, which tinely debate topics such as Mainte- site of the American Psychiatric Press, has guiding principles of inclusivity, nance of Certification among them- Inc. has also been updated. By Octo- diversity and effectiveness makes it selves (and with others). She stated ber, 2015, there should be links on the possible for each state to have two that her comments to the Assembly APA website to all of the APA product representatives funded to attend the were framed by “thoughtful letters” line websites to make it easier for fall Assembly Meeting. The plan was that she had received from 87 psychi- members and others to access introduced, in part, to increase the atrists. “Board certification is of the resources. A “find a psychiatrist” link overall diversity of the Assembly profession, by the profession, and for will be added to the website and will membership in terms of gender, eth- the patients” and encourages innova- serve as a centralized place for indi- nicity, age, professional practice inter- tion in assessment, including reducing viduals to find psychiatrists. It will ests, regional diversity (e.g. urban and the financial burden by permitting provide a timely referral mechanism rural), etc. The extent to which this remote proctoring and having flexibil- that allows each APA member to opt component of the plan succeeds will ity in what is accepted as lifelong in and to fine tune the data that is list- depend on how the district branches learning. She opined that each physi- ed under his or her name. choose to appoint delegates to the cian should be substantively engaged The APA continues to partner with Assembly. in quality improvement in his or her American Professional Agency for In 2014, the APA had its second specialty or subspecialty and part IV endorsed professional liability ser- consecutive year of increased growth of the Maintenance of Certification vices. The plan has been reviewed in membership. There was a 4.4% addresses this need. The ABMS and the following enhancements will increase in total members, a 3.1% believes there cannot be a true MOC occur: Coverage limits for punitive increase in dues-paying members, Program without continuous quality damages will increase from $25, 000 2.3% increase in early psychiatrist improvement. to $250,000 and licensing board members, 4.6% increase in resident Mental health parity has been gar- defense coverage will be increasing members, 26.6% increase in interna- nering considerable resources to edu- from $5,000 to $50,000. Also, med- tional members and a 37.1% increase cate the public. The brochure and ical payment coverage will increase in medical student members. It is poster, titled “Fair insurance Cover- from $25,000 to $50,000. Additional- hoped that this trend will continue. age: It’s the Law,” is available in both ly, a consent to settle clause will be The APA has been cognizant of English and Spanish on the APA web- added to policies so that litigation will member concerns about Maintenance site. Members are encouraged to not be settled without the psychia- of Certification (MOC), preparing for examine and to disseminate the trist’s knowledge. the changing healthcare environment, resource to health care professionals,

14 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 15

ALL ABOUT AAPL - Committees

Social Media Comes to AAPL lowing the various activities of the conference easy. Tyler Jones, MD Chair, Computer Committee 2. Consider using a session hashtag. In a conference the size of AAPL The 46th Annual Meeting is just asked, via email from Dr. Hanson, to there will be numerous sessions around the corner. It’s time to meet provide consent in advance for video over 3.5 days. A session hashtag old friends and share new ideas. This streaming. We will be using Meerkat, that includes the day and number latter notion is the cornerstone of a a video streaming platform for Twitter code on the final program makes conference. And while presentations to broadcast those select presenta- finding tweets of interest easier. are always informative and presenters tions. We will be putting together a 3. Tweet with care. By default, tweets engaging, some of the best ideas are schedule of streamed sessions for the are publicly available and while shared between presentations. The AAPL website and the hashtags for this is a benefit to reaching a salons, ballrooms, hallways, and foy- the conference and the individual ses- broader audience not everyone will ers are important spaces for attendees sions to be used to follow the discus- be ready for their presentation to to talk and contribute ideas, meet sion. If you’re interested in participat- reach a wider world. If the presen other presenters, or discuss contents ing and have not yet been asked, ter requests their talk not be tweet of a presentation they missed. please contact Dr. Hanson or me. ed, be respectful of that. And be Social media is being used at other If you are not familiar with Twitter, aware that your tweets live on. conferences to make that experience I would like to offer a brief primer on Even if you delete them, screen even better. In particular, Twitter, using Twitter at conferences. Firstly, shots can and do still exist long which uses 140 character messages, you will need a Twitter account from after. Messages should be profes photo, or video to provide a medium twitter.com. Set up is quick and can sional and educational. to connect more effectively. Using be done in 15 minutes. There are sev- 4. Attributions matter. By starting Twitter during a conference, people in eral apps for your smartphone of your tweets with the presenters’ the audience can share ideas, provide choice. For the iPhone, I use Tweetbot username you ensure they are cred opinions and analysis of presentations but the official Twitter app will also ited for the information. If you in real time. Questions can even be suffice. On the Android, Plume and don’t know their Twitter username asked by the audience or suggested by Fenix are consistently reviewed highly. be sure to clearly state who is members who are not able to attend speaking. the conference. This provides faster 5. Tweet new information, behind the feedback and makes information more “Using Twitter during a scene stories or photos. accessible. For our conference orga- conference, people in the 6. Keep it simple. Although Twitter nizers Twitter can be used to know allows comments of 140 charac what’s working or not, while it’s hap- audience can share ters. If you limit yourself to 100, pening rather than waiting until after your followers can retweet with the event for feedback. ideas, provide opinions their own comments. Since there are often several ses- 7. Follow everyone. Follow other sions happening at once, using Twitter and analysis of presenta- live-tweeters, new followers of is one way to share what you’re learn- yours, fellow tweeters whose user ing in a session to other members as tions in real time.” names appear in the event feed. well as a larger audience. Similarly, The idea behind utilizing this tool you can read tweets from sessions is to find ways to broaden the reach of you weren’t able to attend during or Here are some pointers for getting our organization to international afterwards. starting using Twitter in general and, members and to promote membership To that end, Dr. Annette Hanson particularly in the context of a confer- in the organization. We hope that by had a wonderful idea to bring Twitter ence. beginning to introduce the use of to our annual conference. And the 1. Twitter uses hashtags (keywords social media we can simply engage AAPL council has agreed to support preceded by a #) that allow for oth people inside and outside of the con- this experiment. This year we’re ers to find and follow tweets associ ference, to have conversations, and encouraging live-tweeting and the ated with the conference. We will deepen our already strong sense of video streaming of certain select pre- be using the hashtag #AAPL2015 community. By using Twitter we can sentations. We will have volunteers and the main account set up is be our own best advocacy group on from the Computer and Technology @AAPL2015. It will be important what we’re doing. and other committees moderating for all who are interested in tweet Please watch the aapl.org website questions from the Twitter audience ing to use the above hashtag and for advance notice of the schedule of and using their own Twitter accounts be consistent. Everyone following presentations to be live-streamed. You to stream some of the presentations. the hashtag #AAPL2015 will see can also join our feeds: Presenters have already been any tweet that uses it, making fol- @AAPL2015,@clinkshrink, and @tylergjonesmd. American Academy of Psychiatry and the Law Newsletter September 2015 • 15 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 16

ALL ABOUT AAPL - Committees

We’re Not Alone On This Forensic tional work (figure 4). According to the survey, respon- Island: Results From The 2014 AAPL dents working in either private practice or corrections are active in AAPL Practice Survey based on committee participation. Anthony Tamburello, MD, Chair, Institutional and Correctional Twelve of those with private practice Psychiatry Committee; Camille Lacroix, MD, Private Practice Committee work reported serving on the Private Practice committee, with twenty in Working in a subspecialty can at rections work, and 26 (11.5%) do corrections serving on the Institutional times feel isolating. Being surrounded both. Thus, over 70% of respondents and Correctional Psychiatry Commit- by walls can amplify this feeling – participated in some work in these tee. There was considerable cross-par- whether they are the concrete walls of fields. Figures 1 and 2 are histograms ticipation (seven private practitioners jail or prison, or the wood and plaster of the percentage of work in private served on the Intuitional and Correc- walls of a private office. The authors practice and corrections reported by tional Psychiatry Committee), though have found that AAPL committee survey respondents. rarely was dual committee member- membership in their primary areas of ship reported. practice has been professionally sup- Another important goal of the sur- portive. “We can conclude that a vey was to identify how our commit- However, these committees only tees might be of value to both profes- meet in person for an hour once a year. considerable number of sionals in our areas and the AAPL Furthermore, we note that many of us AAPL members work membership at large. Options included have “hybrid” practices that might CME, advocacy, practice guidelines, include civil and criminal work, a mix- either in part or exclu- support, networking, practice manage- ture of private and institutional work, ment, mentorship and other (with an as well as teaching and research activi- sively in the areas of pri- option for a free-text response). For ties. The statutes and regulatory issues those reporting private practice or cor- at play in each state may be an addi- vate forensic practice or rectional work, both groups identified tional barrier to coming together as a the same top three categories as most group in these particular areas. The correctional psychiatry.” valuable: CME, practice guidelines, diversity of our work means that at and networking. Figure 5 shows the times it is difficult to cover all areas results of this question for all respon- that would be of use to members. Respondents were active in forensic dents: The Private Practice and Institution- teaching activities - both clinical and In regard to free-text suggestions al and Correctional Psychiatry Com- didactic - for medical students, resi- for committee support, several called mittees independently discussed creat- dents and fellows. Eighty-seven per- for maintenance of certification activi- ing a survey to better understand the cent (87%) of respondents working in ties. Ideas for practice guidelines in constituency of AAPL who would be corrections reported some teaching corrections included proper care for served by our committees, with a work, as did 79% of those working in the most seriously mentally ill focus on meeting the members’ ongo- private practice, compared with 73% inmates, medication-assisted treatment ing needs for educational content and of those who did little or no work in for inmates with substance-use disor- other support. either private practice or corrections. ders, and the evaluation of appropri- Together, with valuable input from Figures 3 and 4 show the teaching ateness of special accommodations in the Medical Director of AAPL, Jeff activities of those reporting substantial prison (e.g. bottom-bunk, single-cell). Janofsky, and the Executive Director, private practice (figure 3) or correc- For private practitioners, potential Jackie Coleman, we developed the 2014 AAPL Practice Survey, which was distributed to 1453 AAPL mem- bers by e-mail in October. The survey posed questions about the time spent in various clinical and forensic activi- ties and polled respondents on how they felt the AAPL committees could best serve their needs. Out of 227 respondents, 86 (37.9%) do substantial private practice work (defined as >10% of professional time), 49 (21.6%) do substantial cor- (continued on page 17)

16 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 17

ALL ABOUT AAPL - Committees

We’re Not Alone continued from page 16 AAPL COMMITEES

ADDICTION AWARDS BYLAWS CHILD & ADOLESCENT COMMUNITY FORENSICS COMPUTERS CORRECTIONAL CRIMINAL BEHAVIOR CROSS-CULTURAL DEVELOPMENTAL DISABILITY EARLY CAREER EDUCATION guideline suggestions include practice correctional psychiatry. We are often ETHICS development and telepsychiatry. involved in the education of future The limitations of this survey bear forensic psychiatrists. We frequently FORENSIC HOSPITAL SERVICES mention. The response rate of 15.6% is participate in AAPL in the form of FORENSIC NEUROPSYCHIATRY low, though not unexpected for an e- committee membership. We also FORENSIC TRAINING mail survey of busy professionals. learned that AAPL may serve these GENDER ISSUES Selection bias is a likely confounder. groups by supporting the development GERIATRIC PSYCHIATRY The initial e-mail invitation from of CME and practice guidelines rele- AAPL identified the sponsoring com- vant to private practice and correction- HUMAN RIGHTS AND NATIONAL mittees and implied that the survey al psychiatry. SECURITY was targeted towards members work- We invite those practicing in these INTERNATIONAL RELATIONS ing in these areas. A follow-up areas that have not yet joined a com- LAW ENFORCEMENT LIAISON reminder e-mail clarified that we were mittee to consider doing so. When the LIAISON WITH FORENSIC interested in input from all AAPL walls of your office make you feel like SCIENCES members. We cannot confidently con- the only forensic psychiatrist with your MEMBERSHIP clude that our results are representative particular professional problems, of the entire AAPL membership. AAPL’s practice committees are an PEER REVIEW We can conclude that a consider- excellent source of networking, men- PRIVATE PRACTICE able number of AAPL members work torship, and support. PROGRAM either in part or exclusively in the PSYCHOPHARMACOLOGY areas of private forensic practice or RAPPEPORT FELLOWSHIP RESEARCH SEXUAL OFFENDERS SUCIDIOLOGY TRAUMA & STRESS

AAPL members who are interested in serving on committees for a three-year term are invited to send a letter to the President, Emily Keram, MD through the Executive Office by November 30, 2015. Committee members must be full voting members of AAPL.

Letters should indicate particular interests or qualifications for the committee appointment desired.

American Academy of Psychiatry and the Law Newsletter September 2015 • 17 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 18

TIDBITS AROUND THE WORLD

Royal College of Psychiatrists: Forensic which at times he still struggles, even though he has developed a very suc- Faculty Annual Conference - 2015 cessful acting career for himself. Jennifer Shaw, Professor of Forensic Psychiatry, Manchester, Although he was not talking about this and John A. Baird, Consultant Forensic Psychiatrist, Glasgow aspect of his life, it was known to the audience that he had had a number of successful roles, particularly the lead The 2015 residential meeting of the attempts should be made to understand role in the film The Angels’ Share, Forensic Faculty of the Royal College gangs and address the problems asso- which was recognized by BAFTA. of Psychiatrists was held in Budapest, ciated with them. A stable relationship The next session was rather differ- Hungary from March 4-6, 2015. and a job are two of the most signifi- ent and dealt with medico legal issues Budapest is an ancient city with a rich, cant factors that can support gang arising from the trial of an elderly colourful and varied history and it is affiliates to lead more stable and pro- woman who was being prosecuted for really two cities on either side of the social lives. war crimes arising from her involve- Danube. Buda with its castle is built The next speaker followed up on ment with the Khmer Rouge during on a hill, while Pest, which is larger, is this message talking of the problem of the regime of Pol Pot in Cambodia. on flatter ground. Perhaps one of the gangs in Glasgow in the West of Scot- One of the speakers, Professor Seena most recent events of international land, where there is much more gang Fazel of the University of Oxford, had importance for which the city is activity and gang affiliation than in examined the defendant and given evi- known is the uprising of 1956, when any other parts of the UK. He made dence at her trial when the issue was the population united against Soviet the same basic point that amongst one of fitness to plead. She had devel- oppression. The movement had wide- gang members’ depravations was oped organic dementia. The ethics of spread popular support and although it invariably found and there were links trials of this kind was discussed. The was overwhelmed and crushed by to social breakdown, poor physical proceedings against this defendant and Soviet military force, it was the first health and mental illness, with the last her other co-defendants cost the coun- stage in the process that culminated of those probably linked to very heavy try $200 million dollars, which was with the collapse of communism in drug misuse. calculated as $100 for each victim of 1989. the regime of terror. Issues of cost The city is peaceful now and is “The link between his benefit, value for money and overall very popular with tourists. The confer- worth inevitably arose in discussion. ence hotel had a wonderful central mental state, his offend- This was followed by a session location overlooking the Danube. which dealt with the ethical issues of The conference itself began with a ing and his art was restrictive practices against the back- session on gangs, with four comple- ground of the European Convention on mentary and lively speakers. Opening engagingly explored.” Human Rights, a very important piece the session was Professor Decker from of legislation to which the UK became Arizona State University. He provided a signatory about fifteen years ago an overview of the concept of a gang now. The legislation itself is concise and emphasised that it is a misunder- The third speaker gave the perspec- and clearly written, with similarities to stood concept. His view was “If you tive from a high security hospital and the American Constitution, and like don’t understand your problem, you’re described the additional challenges of the Constitution the implications run not going to deal with it.” He expand- managing gang affiliates who require and run. Legal experts set out human ed upon this with many examples of inpatient care, the need for criminal rights principles as they apply to the the need to understand the context, the intelligence and on occasion additional various forms of restriction that can be behavior, the values and the role security, and again the high rate of applied to patients who are subject to served for a gang member by being psychopathology amongst these indi- the mental health act. The convention involved in a gang; they vary very viduals with their mental health prob- requires there to be safeguards in the much and generalizations about the lems often obscured by co-existing form of proportionality, entitlement nature, structure and function should criminal links, drug misuse and behav- and a system of independent review. be avoided. What was beyond doubt, ioral disturbance. One particular aspect of this was dis- however, was the mental health The last speaker was Paul Branni- cussed in relation to a high secure hos- pathology to be found amongst gang gan, a young man who spoke very pital that had introduced a smoking members and the much higher rates of candidly about his difficult early life ban throughout the whole institution. misfortune, morbidity and mortality, as he grew up in the east end of Glas- The conclusions of the exercise were with, for example, the risk of being gow, his offending, his attempts at that a complete cessation of smoking murdered being twenty times greater rehabilitation and the continuing diffi- did not have the adverse consequences among gang members than within the culties which he experiences as a con- which had been anticipated, and general population. His thesis was that sequence of his early trauma, and with (continued on page 20)

18 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 19

ALL ABOUT AAPL - Committees

International Academy of Law and custody, dual agency, capacity, PTSD th and resilience, addiction, risk assess- Mental Health XXXIV International ment, DSM-5, ICD-10, telepsychiatry, and the list goes on. Congress on Law and Mental Health The second day of the conference Marie Rose Alam, MD, International Relations Committee included topics such as the disconnect between law and psychology, the use The 2015 biannual meeting of the more information exchanged in con- of neuroscience in public safety and International Academy of Law and versation. American national security agendas, Mental Health (IALMH) took place in The meeting had an intense sched- child murder by mothers and its rela- Vienna this year between July 12th ule. It lasted six days, with events tionship to evolution, and fetal alcohol and 17th. Vienna was a perfect back- beginning at 8:15 am and ending at spectrum disorder (FASD) as a miti- drop to the conference. As if it were 6:00 pm most days. The meeting gating factor in criminal cases. Anoth- not enough that it was once the home began with a Sunday pre-conference er subject cluster addressed working of Sigmund Freud, no place sells his- session on Freud, psychoanalysis, and with survivors of torture in various set- tory and culture better than Austria. the law. Each subsequent day was tings, from death row, to pre-trial Freud’s physical home is now the Sig- divided into four sessions, with each detainees in Guantanamo. Yet another mund Freud Museum in Vienna. It is session running about 15 rooms simul- set of presentations highlighted LGBT open to the public and contains some taneously. Each room had a topic mental health and human rights issues, of its original furnishings, family theme that contained about five pre- and discrimination against vulnerable videos, and original first publications sentations over a two-hour period. The persons such as refugees, immigrants, of Freud’s work. From castles, to gar- items I will highlight below just barely and employees with mental health dens, to music, to art, to traditional impairments. The second day also and fine dining, and the longest, most included presentations discussing the varied, most creative coffee menus “... under Soviet rule, horrific past of German medicine, col- you’ll ever see, Austria has something lectively entitled “Physicians and the for everyone to enjoy. Walking into a diagnoses were created Holocaust,” and detailed the role of subway station in Vienna also makes it with symptoms that physicians in the legitimization of clear that ethics here is a daily part of murder of the mentally ill. Hundreds life. There are no ticketed gates into reflected characteristics of Nazi medical records were the subway stations, and an honor sys- reviewed in connection with interroga- tem of payment is used, with random of government oppo- tion transcripts. In addition, the history ticket checks. To top it all, Vienna is of expulsion of Jewish physicians home to the United Nations’ Interna- nents, rather than psychi- from Germany through a 1933 law tional Atomic Energy Agency (IAEA), entitled “Law for the Restoration of where John Kerry approved the Iran atric illnesses as we the Professional Civil Service” was nuclear deal during the first few days discussed. The presentation covered of the IALMH conference. understand them.” the lack of awareness and the denial of The IALMH congress took place at fascist actions in post-war German Sigmund Freud University (SFU), a medicine, as well as the initiatives that relatively new private university scratch the surface of the breadth and led to its condemnation and the whose mission is the promotion of depth of what was presented. Needless rebuilding of German bioethics. psychotherapy as a science, based on to say, the myriad of topics presented A presentation entitled “‘Eating to research, training, and other academic was enough to satisfy any palate. All Death’ in Prader-Willi Syndrome: endeavors. It provides programs in the usual suspects of a psychiatry and Have Personal Rights Gone Too Far?” both German and English. The modern the law conference were covered: reminded me of Dr. Thomas Gutheil’s feel of the SFU architecture was criminal responsibility, competency to words, “Rotting with your rights on.” matched by the non-hierarchical nature stand trial, involuntary hospitalization, The United States was well repre- of the meeting where participant outpatient commitment, seclusion and sented. Other countries included badges were noticeably bare of all restraint, therapeutic jurisprudence, France, Belgium, Germany, Austria, titles, and simply showed the partici- disability, the role of neuroscience in the United Kingdom, Spain, Portugal, pant’s name and city of origin. Initially legal matters, medical ethics, human Sweden, Switzerland, the Netherlands, it was frustrating that the habit of read- rights issues, child abuse, domestic Denmark, Italy, Greece, Georgia, Hun- ing a person’s badge did not yield the violence, antisocial criminal behavior, gary, Romania, Australia, New expected information. However, by the sex offenders, paraphilia, suicide in Zealand, Brazil, Norway, Chile, Peru, end of the meeting, it was clear that forensic settings, neuropsychological South Korea, Taiwan, India, Canada, less information on the badge meant Japan, South Africa, Namibia, Algeria, testing, mass murder, filicide, arson, (continued on page 27)

American Academy of Psychiatry and the Law Newsletter September 2015 • 19 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 20

TIDBITS AROUND THE WORLD - Continued

Royal College reported that the rate of treatment of it was only a minority of those suffer- continued from page 18 ADHD was considerably higher in the ing from serious mental illness that USA than in the UK and the reasons had any direct access with mental although the decision was the subject for this were discussed. The outcome health services and one unexpected of judicial review, and although the in adult life was also examined and finding was that those suffering from original review found in favor of a while in childhood in most severe serious mental illness in prisons tended patient who was opposed to the ban, cases all three symptoms were present, to have higher rates of criminogenic when this matter was appealed by the the inattention, the hyperactivity and thinking, even than was found within Hospital their appeal was upheld and impulsivity and the emotional lability, prisoners as a whole. This was surpris- the complete ban on smoking was con- in the minority of cases who continued ing because in many cases it was the sidered to be compatible with the Con- to satisfy diagnostic criteria into adult serious mental illness which had led to vention. life, hyperactivity tended to lessen but the offending and the incarceration and The last session of the first day was the other main symptoms could persist. it might have been expected that the an engaging historical presentation by The final research paper of the individual would be motivated to seek Mike Jay, an author who had written a care and treatment for their illness, but biography of James Tilly Matthews, an “In both jurisdictions, it this was not found to be the case and Englishman who was caught up in the finding although seemingly valid events in Paris around the time of the was only a minority of remains unexplained. French revolution, and who on his The afternoon offered delegates a return to England created a distur- those suffering from seri- choice between a range of workshop bance in the public gallery of the sessions, and deserving mention were House of Commons which led to his ous mental illness that sessions on the community treatment arrest. He spent the remainder of his of antisocial personality disorder, a life confined in various “mad houses” had any direct access with challenging and in some ways contro- while there was brisk debate about the mental health services, versial initiative well established now state of his mind. It appears to have in west London and enjoying consider- been a case where politicians wished and one unexpected find- able success, and a session of film his confinement to continue while the clips of films from general release physicians responsible for his care ing was that those suffer- which had a prison based theme. could find nothing untoward about his On a different theme, there was a mental functioning. Perhaps unsurpris- ing from serious mental well-attended session on the Italian ingly, it was the will of the politicians painter Caravaggio, who suffered from that prevailed. A case nowadays would illness in prisons tended to mental illness and who also was be dealt with very differently, and responsible for a homicide. The link under Human Rights legislation his have higher rates of crim- between his mental state, his offending need for continued detention would be inogenic thinking, even and his art was engagingly explored. determined by a fully independent One tradition of the Forensic Facul- judicial body that would take evidence than was found within ty conference is the conference dinner, from politicians but would not be and again this was a very successful bound by it. prisoners as a whole.” evening attended by about 150 of the The second day of the conference delegates. There is always entertain- began with a morning of research ses- ment during the evening and this year sions. The topics were varied but had a for the first time the decision was common theme in examining aspects morning emphasized again the strong taken to have an “open mike”, with of the links between mental disorder, links between alcohol and offending, delegates invited to come up and real- offending and the criminal justice sys- and the risk of overlooking alcohol in ly do whatever they chose provided it tem. One paper began by acknowledg- favor of other illegal drugs when, apart entertained the company and did not ing the well-known link between seri- perhaps from cocaine, alcohol is the go on too long. This initiative was ous mental illness and violence. Sub- intoxicating substance about which we very successful, hitherto unknown tal- stance misuse was well known to be should be most concerned when ent revealed itself from the most unex- linked with an increased risk of violent attempting to reduce violent re-offend- pected quarters and no careers were offending and in those suffering from ing. brought to a premature conclusion. co-existing mental illness, the motiva- The final plenary session in the The tradition is that each year the tion of self-medication was often a dri- morning was a presentation of a venue alternates between continental ver. detailed study of the delivery of Europe and the UK and in the spring In a session on Attention Deficit healthcare to convicted prisoners suf- of 2016 we will be in Glasgow from Hyperactivity Disorder (ADHD), the fering serious mental illness. Arrange- March 2-4, 2016. As ever, colleagues frequency and the importance of treat- ments in New Zealand and the USA from AAPL will be made most wel- ment was emphasised, but it was were compared. In both jurisdictions, come. 20 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 21

ALL ABOUT AAPL - Committees

Another “Sexy” Role for Forensic “acceptable” behavior, but the same behavior would be “inappropriate” if Psychiatrists the patient repeatedly masturbates Abhishek Jain, MD, Sex Offender Committee with her door open despite clear directives from staff not to do so. General medical and psychiatric opportunistic, impulsive, predatory, Patient-to-staff sexual threats and providers might turn to their foren- paraphilic, etc.). assault can have a profound impact sic-trained colleagues to help explain Moreover, questions from col- on staff morale and the patients’ ther- issues such as sexual aggression, leagues can serve as an impetus for apeutic milieu. Most hospitals have inappropriate sexual behavior, and forensic psychiatrists to familiarize policies or guidelines regarding the sex offender treatments, particularly themselves with characteristics of prosecution of such patients. Foren- after troubling patient-related events. sexual offending behaviors and sexu- sic psychiatrists may be called upon Queries may especially arise in set- al offenders, as well as available for guidance on treatment recom- tings where these matters are not assessments and treatment, hospital mendations, sex offender evaluation, routinely a primary focus and health- policies regarding inappropriate sex- and evaluation of criminal responsi- care providers seek a better under- ual behavior, and jurisdiction-specif- bility. The uninformed psychiatrist standing to address patient-to-patient, ic mandatory duty to warn/protect should guide against automatically patient-to-staff, or even staff-to- and report abuse and the laws gov- attributing the act to mental illness. patient sexually assaultive or inap- erning them. Colleagues may also Staff-to-patient sexual aggression propriate behavior. seek guidance pertaining to docu- can be particularly distressing. In Why might our colleagues turn to mentation, online search of publicly one example in September 2014, an forensic experts for these issues? available criminal records, referrals emergency room male nurse in Ore- The answer is perhaps similar to Dr. for sex offender treatment, and police gon pled guilty to charges related to Graham Glancy’s recent response1 or social services involvement.2 sexually abusing ten women. Fol- regarding the forensic psychiatrist’s Regarding patient-to-patient sexu- lowing these allegations, the hospital role in correctional psychiatry: foren- al contact, Ford and colleagues wrote enacted various interventions, such sic experts are well versed in balanc- about the limited consensus among as the “Inappropriate Behaviors ing patient care and public safety, in US inpatient psychiatric units regard- Response” training, and developed a systematic approach for reviewing maintaining objectivity (e.g., when ing the management of sexual behav- 5 assessing violent acts), are aware of ior between patients and offered a and addressing patient complaints. unique forensic settings such as spe- A framework for responding to patient complaints may be a consid- cialized sexual offender treatment “... an emergency room 6 sites, possess expertise in the rela- eration. tionships between mental disorders male nurse in Oregon Although staff-to-patient aggres- and crime, and are trained in assess- sion are typically low base rate ing conditions such as paraphilic dis- pled guilty to charges occurrences, even one incident can orders. lead to a systemic questioning of pre- Although forensic psychiatrists do related to sexually abus- employment screening procedures, not always have direct experience hospital reporting mechanisms, and working in specialized sex offender ing ten women.” patient safety issues. Forensic psy- sites, they often have knowledge of chiatrists may be able to lend some sex offender assessment and treat- insight into understanding sexual ment through working in correctional model policy to evaluate sexual inci- predation and the limits of screening. settings, conducting forensic evalua- dents. They recommended a clear Staff education regarding boundaries tions for criminal proceedings, and definition of sexual behaviors, a bal- and the proper mechanism and chan- performing violence risk assess- ancing of patient rights with issues nels to report suspicious behavior ments. Furthermore, sex offender, such as transmission of sexually among colleagues can be particularly sexual harassment, and physician- transmitted disease, education useful. patient sexual violation laws are core regarding reproductive issues, and Overall, forensic psychiatrists topics in forensic training and are evaluation of non-consensual activi- working in general and medical set- covered in the AAPL Landmark ty.3 tings may be consulted to provide Cases. Thus, forensic psychiatrists Generally, delineating “accept- guidance on all aspects of inappro- often have perspectives that are help- able” versus “inappropriate” sexual priate sexual behavior. This presents ful to their non-forensic colleagues, behavior can be particularly chal- another application of forensic train- and can provide general background lenging and is often setting-specific.4 ing in primary clinical settings and a education, such as potential etiolo- For example, a patient with schizo- potential opportunity for collabora- tion in a multi-disciplinary team. gies of sexually abusive, problemat- phrenia masturbating in the privacy (continued on page 27) ic, and aggressive behavior (e.g. of her room might be considered

American Academy of Psychiatry and the Law Newsletter September 2015 • 21 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 22

SPECIAL ARTICLE

Reviewing Remaining Residuals might go all the way to the Supreme Court. Regarding PPACA There are extensions and ramifica- Lawrence K. Richards, MD tions in pseudopod fashion emanating from PPACA. One that didn’t get funded was the nearly half $billion Surely most physicians are aware here other than to state that Chief for Navigators. These were the future of the 2010 PPAC Act and the related Justice Roberts also wrote this government employees to be hired to SCOTUS rulings of June 2012 and PPACA opinion, which gave a help all the citizens figure out which June 2015. This paragraph reviews reprieve to those expecting a calami- HC policy was good for them. that briefly, then moves on to the ty if the high court backed King, and One proposal that got funded lesser known subjects. In spring made it legal for only the state HIX through federal startup and solvency 2010 the Patient Protection and to give out these tax credits. loans but is failing is the non-profit Affordable Care Act was passed and So, what remains? A lot. Even the Insurance CO-OPs. (“Consumer signed by President B. Obama. It has Democrats who have been most Operated and Oriented Plans.”) been referred to in the media as vocal in backing “ObamaCare” have These may have been a persuasion “Obama Care” or the Affordable from time to time said there are parts for the insurance companies to col- Care Act, and sometimes just ACA. that need fixing. Disclosure: this laborate with the PPACA. There are Little attention has been given to the author has not read the 900+ pages. twenty three and only Maine’s is patient and her/his protections. In The Media gives most of its cov- operating profitably. Massachusetts’ June 2012, SCOTUS ruled 5-4 that erage of the Republicans to those Cooperative spent over six times on the mandate forcing persons to buy talking repeal, and while polls differ, administrative expenses as it got in health insurance was a tax and there- most still show a small edge to those premiums. Illinois’ Co-op (Land of by upheld the Act. In June 2015, citizens favoring repeal—albeit this Lincoln Health) projected a net SCOTUS ruled 6-3 that subsidization edge lessened in the polls after the income of $28 Million for 2014, but of purchase of one’s health insurance King v. Burwell ruling. had a net loss of $17.7 Million. NY’s that qualified for the government tax Cooperative was the lead in enroll- credit could come from either the “... this author sees sev- ment, but still had a $35 Million loss. federal exchange or a state exchange. NY enrollment was 155,402 which During the time span between eral good features to was over 5 times its projection of those two USSC rulings, the most 30,864 for a 504% achievement, notoriety came from the problematic ObamaCare, including while three states with lowest opening of the federal Health Insur- achievement, AZ, IL and MA, hit ance Exchange, HealthCare.gov, on parity, one of the essen- about 4% of their projections. Oct.1, 2013. Since then, there have Despite all this, this author sees been other ‘happenings’ of note. tial benefits which a several good features to “Oba- These include: several states opening maCare,” including parity, one of the their own Health Insurance policy must have to be essential benefits which a policy must Exchanges (HIX) marketplace, with offered on a HIX ...” have to be offered on a HIX, and that the majority of states not doing so 80% of the money taken in per year due to fears of expanding expenses; on premiums must be paid out in pol- the Speaker of the House of Repre- icy benefits. sentatives saying regarding the 900+ There are several items connected To close, the SCOTUS June, 2012 page Act, “We had to pass it in order to the PPACA which the author finds ruling also disallowed what authors to find out what was in it;” and the more interesting and potentially of PPACA wanted as nationwide President’s statement, “If you like impacting. The two most immediate mandatory Medicaid expansion. The your doctor, you can keep your doc- are: a) there are three other “subsidy” PPACA’s form of federal financing tor” later proving to be not quite true cases already at the federal Appellate for the states’ expansion of Medicaid in all cases. Other concerns include, level. The en banc U.S. Appellate always included early major federal out of network services costs, and the Court for D.C. hearing on Halbig v. largess followed by steady withdraw- subsidy case issue on who can give Burwell will probably see that court al, leaving each state to pick up more the tax credits that subsidizes the doing its best to “punt” off the SCO- of the cost as time progressed. purchase of a policy off the HIX, TUS ruling in King since it chose to Author notes the latter is already argued in the USSC under King v. defer action until after the King rul- occurring at rates greater than expect- Burwell. ing; b) the case of the U.S. House of ed. Thus the federal government had King v. Burwell is a subject of the Representatives suing the President. to offer the subsidies on poster to be presented at the Ft. It is at the district level now, and HealthCare.gov in order to “save” the Lauderdale AAPL Annual Meeting, looking like it won’t be dismissed as PPACA! so little more will be said on that the federal government wants; it

22 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 23

SPECIAL ARTICLE

Update In Suicide Trends most basic trend is that suicide rates, Jason Beaman DO and Stephen Brasseux MD overall, are increasing. When exam- ining trends based on age, compar- isons of 2007 and 2012 with 2013 are The Centers for Disease Control groups. There was an increase in the very similar with one important and Prevention (CDC) maintains a crude rates for both the White and exception, the 35-59 age group. From database, the Web-based Injury Sta- Black groups (0.15 and 0.12 respec- 2007-2013, the rates increased for tistics Query and Reporting System tively). most age groups. However, when this (WISQARS), of violent deaths in Gender trends were not much dif- is narrowed down to 2012-2013, the order to aid in prevention efforts. ferent from 2012 to 2013. In 2013, rates decreased. This demonstrates WISQARS collects information about the crude rate for a male was 20.59 that possible suicide prevention the type of death including suicide, compared to 5.67 in females. In efforts targeting this demographic homicide and deaths by legal inter- 2012, the rate for males was 20.57 may be effecting positive change. vention. This information is collect- and 5.53 for females. When total sui- The suicide rates for the age group ed from the National Center for cides are examined, these rates have 70-74 decreased in both 2012 and Health Statistics and the National more meaning. In 2013, 32,055 2013 when compared to 2007. This Violent Death Reporting System. males committed suicide compared may reflect improved medical This article will summarize the newly with only 9,094 females. advances along with suicide preven- released data with previous years To provide a more comprehensive tion efforts. In contrast, suicide rates (2012 and 2007) in order to better picture, rates were also compared among adolescents increased in inform on suicide trends in the United with the 2007 data. Crude rates of almost all categories when 2013 is States. suicide increased in all age categories compared to both 2007 and 2012. The data was taken directly from from 2007 to 2013 with the exception This is concerning given the amount the WISQARS inquiry database of two, 40-44 (-0.06) and 75-80 of attention placed on this problem. located on the CDC’s website. Crude (-0.53). The largest increases were Race trends continue to demon- rates (per 10000) were compared for found in the 55-59 and 70-74 groups strate that the highest crude rate is all ages (without regard for race or (3.58 and 3.37 respectively). found among the white population. gender). Crude rates for race and This same category had the largest gender were then explored indepen- “As the United States increase from 2007-2013. The rate in dent of each other and independent of African Americans essentially age. The results are discussed below. becomes more assimilat- remained the same. The gender com- WISQARS separates groups based ed with other cultures, parisons provide continued evidence on age categories of 5 years, starting that males complete suicide at a much with 0-4 and ending at 85+. When the use of race classifica- higher rate than females. This trend the 2013 crude rates of suicide were is widening as demonstrated by com- compared to 2012 data, there was an tions becomes less help- paring the 2013 data to 2007 and overall increase (13.02 vs. 12.94). 2012. The highest increase was found in the ful (as seen by the large This data should not be considered 70-74 category (15.54 in 2013 versus without acknowledging its limitations. 13.9 in 2012). There was an increase number included in the The source data is not complete and in every class from age 5 through 29, often depends on death certificate with the exception of the 15-19 age other category).” data or voluntary reporting by select group (0.09% decrease). Age 30-34 states. Suicide is not always an obvi- was the only class that showed no ous cause of death and as a result, change. The rate decreased in all Suicide rates increased in all races these data may be underreported. classes from ages 35-59. The rate from 2007-2013. The largest increase While age and gender are usually increased in all classes from ages 60- was found in the White race (an steadfast categories, race is not. As 85, with the exception of the 75-79 increase of 1.91). The smallest the United States becomes more group (-0.38 change). increase was found in the assimilated with other cultures, the Trends based on race were also Asian/Pacific Islander race category, use of race classifications becomes examined. WISQARS categorizes 0.24. The rate for African Americans less helpful (as seen by the large num- race as White, Black, American Indi- and American Indians increased from ber included in the “other” category). an, Asian/Pacific Islander and Other. 4.84 to 5.38 and 10.24 to 11.69 Further evaluation and manipulation The highest increase in crude rate respectively. Rates increased for both of the data could help to understand was found in the American Indian males (2.17) and females (0.89) from the intersection of age, gender and population (11.69 vs. 11.03). There 2007 to 2013. race. This would allow focused pre- only decrease was found in the By utilizing the above data, trends vention efforts for high risk groups. Asian/Pacific Islander and Others become quickly discernable. The

American Academy of Psychiatry and the Law Newsletter September 2015 • 23 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 24

ALL ABOUT AAPL - Committees

Nobody Wants To Read Your Report evaluee's home. You may have started Andrew Nanton, MD, Early Careers Committee writing up summaries of records or parts of the interview before you had all the information you wanted and Ouch. It's hard to acknowledge on thing about all participants in every before arriving at an opinion. Re- those nights I'm up late writing, but legal proceeding, but you need to reading with your opinion in mind, we both know it's true: nobody is know if forensic psychological or the question then becomes: Does this thrilled to read this report. No matter psychiatric testimony is presented information help to answer the foren- how carefully crafted, nobody is lin- regularly. Explaining everything is a sic question? No? Cut it. ing up to read it like they would a reasonable default, but can be antago- new Harry Potter novel. Obviously, a nistic to a more sophisticated audi- 3. Does it tell a story? novel and a forensic report serve very ence, who will also grill you on the A report is a piece of technical different purposes, and it's hardly sur- inevitable over-simplifications you writing. It will never "tell a story" the prising that they would be received so have made. Titrate the detail of your way a novel does, but it can still ben- differently. So why mention it? explanations accordingly. efit from chronology as an organizing Because taking a moment to consider principle. A report organized by top- the reader and purpose makes a report 2. What question will this report ics such as work history and legal more effective. answer? history can make this difficult, and Our written reports are arguably Let's say, for example, you are it's worth considering on a case-by- the most important thing we do as writing a competency evaluation. The case basis if those topics make the experts. Even though reports are not central matter is the evaluee's present report in front of you harder or easier as exciting as testimony, they are the level of function. There are a multi- to understand. Collapsing several bulk of our communication to the tude of pieces of information that you headings into a more generic one to court. Lawyers and judges are busy will collect over the course of such an allow chronological organization professionals with many demands on evaluation. Ask yourself if each par- often makes sense, particularly if the their time. If you think a lawyer with ticular bit of information helps to information in those headings is low- dozens of active cases is likely to answer the question. A detailed histo- yield. clear her schedule to read your 300- ry of childhood trauma may have When you find yourself needing to page report, you might want to recon- been relevant to explore during the skip around in the timeline, try to sider some of those assumptions. The interview while you were ruling out identify a few events as landmarks. least effective report is the one that PTSD, but if it does not speak to the For example, you could give the sits unread. exact date of the evaluee's first arrest The following suggestions are “The writing advice to and then note if the arrest was before offered assuming that you are already or after their first hospitalization. dividing your report into a data sec- journalists to "kill your Even if the date is in another part of tion without interpretation of the data, babies" is relevant even the report, anticipate the reader's and an opinion section for interpreta- question about how the events are tion without introducing new data. An outside of a filicide connected chronologically. Outside of excellent source for basic report con- the opinion section of the report, you tent and structure is Grisso's 2010 1 report.” can simply include such statements as article . Despite familiarity with the context rather than offer an interpre- basics, it's easy to follow a template tation. without taking the time to consider When you reach the opinion sec- the assumptions it makes. Here are a present level of function it may not tion, the story your report needs to few items to consider when taking a belong in that competency report. tell is the story of how you arrived at step back to consider the wider con- The writing advice to journalists to your opinion. The pertinent positives text of the report: "kill your babies" is relevant even and negatives we all learned about in outside of a filicide report. It refers to medical school are relevant touch- 1. Who will read this report? cutting parts of your writing that, stones for this process. Their pres- A report cannot be all things to all despite the effort you have spent, ence or absence guided you. Your people. A judge who has presided simply don't belong in the final prod- opinion should summarize this jour- over disability hearings for 30 years uct. Perhaps you found an evaluee's ney from objective collection of is likely to be quite familiar with account of their painful divorce information to firm conclusion. How mental illness. A report for a newly- evocative, and you have written sev- did you weigh each of these against minted public defender, on the other eral paragraphs that capture the pain the whole? Include relevant discus- hand, should assume very little expo- they described. Or maybe it took you sion of past diagnoses with which sure to psychiatric jargon and con- a page to untangle the relationships you agree or disagree, and why. cepts. It's not possible to know every- between all 8 people who live in the (continued on page 26)

24 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 25

ALL ABOUT AAPL - Committees

Financial Crimes Against the Elderly: have identified signs of financial exploitation and characteristics of both A Call to Action perpetrators and victims. Recognition Sherif Soliman, MD, Chair Geriatrics Committee is of course only the first step. Every physician should be familiar with local reporting mechanisms and require- I recently had the opportunity to elder financial exploitation. Our ments. meet Professor Philip Marshall, training enables us to understand the Combatting elder financial Brooke Astor’s grandson. Mrs. Astor, psychological mechanisms that under- exploitation is a multidisciplinary the “first lady of New York,” was heir lie the relationship between the perpe- challenge. Educational programs must to the Astor fortune and spent decades trator and the victim. We can assess extend to other professionals including as a tireless philanthropist. Prof. decision making capacity of victims, attorneys, accountants, bank employ- Marshall took the courageous step of assess criminal responsibility in per- ees, financial planners, and estate filing a petition for guardianship of petrators, and identify risk factors planners. Here the focus should be on his grandmother in 2006. The petition which increase victim vulnerability. recognizing suspicious circumstances and ensuing guardianship proceedings We also have the training necessary to and unusual patterns of activity. exposed financial exploitation of Mrs. communicate this information to Elders should also be educated about Astor by Anthony Marshall and Attor- courts and to the public. I am there- common scams and suspicious behav- ney Francis X. Morrisey. It revealed fore issuing a call to action for myself ior. These thefts often occur over a that Mrs. Astor, a woman of extraordi- and my colleagues. Many including protracted period of time and are only nary means, was living in substandard Dr. Bennett Blum have already made discovered long after the perpetrator conditions while her son enriched substantial contributions to our under- has spent the money. Ideally, suspi- himself. While the petition simply standing of undue influence and cious transactions should trigger sought to protect Mrs. Astor, it set off financial crimes against the elderly. immediate investigation so as to pre- a chain of events that led to Anthony We should work to continue to vent the loss in the first place. Marshall’s 2009 conviction on 14 improve education, prevention, and The old adage, “An ounce of pre- counts including first and second prosecution of financial crimes vention is worth a pound of cure,” degree grand larceny, offering a false against the elderly. rings especially true with regard to instrument, and conspiracy. Mr. Mor- Educational programs are vital to financial crimes against the elderly. risey was convicted of five charges both prevention and prosecution. Prevention begins with public aware- including conspiracy, scheme to ness of the problem, the risk factors, defraud, and forgery. This tragic case and the signs of elder financial took elder financial exploitation from “Individuals who are exploitation. A key modifiable risk the shadows to the front pages. factor for financial exploitation is iso- Prof. Philip Marshall has devoted isolated are more likely lation. Individuals who are isolated himself to raising awareness of these to welcome contact from are more likely to welcome contact crimes. He has testified before con- from potential perpetrators and less gress, has shared his personal story at potential perpetrators likely to report perpetrators because numerous conferences, and has found- they do not want to lose the compan- ed a website, beyondbrooke.org, and less likely to report ionship. Therefore, a good prevention devoted to advancing the cause of program should include reaching out elder justice. His outstanding work in perpetrators because to elders who are isolated. Public this area has inspired me to think awareness may motivate family mem- more deeply about the role of forensic they do not want to lose bers to maintain contact with elderly psychiatry. relatives. Community and religious Elder financial exploitation has the companionship.” organizations can also be helpful in been called the “crime of the 21st this regard. The caveat is that these century.” The explosive growth of the organizations should implement poli- elder population, the unique vulnera- Signs of elder financial exploitation cies to prevent and detect elder finan- bility of this population, and the accu- should be taught as part of the geri- cial exploitation, since employees of mulated wealth over lifetimes of hard atric curriculum in medical school, such organizations have themselves work have contributed to this epidem- residency, and, of course, geriatric been perpetrators. Another potentially ic. A recent MetLife study estimated medicine and psychiatry fellowships. useful tool would be a legal frame- the financial toll at 2.9 billion dollars This should include victim risk factors work that allows financial institutions in 2010, up a staggering 300 million and signs of exploitation. Spar and to delay certain suspicious transactions dollars from their previous survey, Garb2 have identified psychological for a reasonable period in order to taken just two years prior.1 “red flags” for undue influence, a key allow for appropriate investigation. Forensic psychiatrists are uniquely mechanism of elder financial exploita- (continued on page 29) positioned to lead the fight against tion. In addition, Hall and Hall3

American Academy of Psychiatry and the Law Newsletter September 2015 • 25 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 26

ALL ABOUT AAPL - Committees

Reflections of justice. In the case of the para- http://sapr.mil/public/docs/reports/FY14_A continued from page 11 trooper with depression, coming to a nnual/FY14_Annual_Report_Appendix_A. pdf decision about his fitness for duty 10. Efraim, O: Report: 1 in 8 IDF women 11 transgender soldiers. Mental health involved not just assessing the sever- soldiers experienced sexual assault in 2013. involvement with LGBT soldiers is ity of his depression, response to YNET News. February 3, 2014. Accessed significant and ranges from support- treatment, and disability, but weigh- on June 27, 2015: ive psychotherapy to assessing gen- ing the needs of the military and the http://www.ynetnews.com/articles/0,7340,L der dysphoria and helping the soldier soldier’s self-concept as coming from -4484305,00.html a military family. Fortunately, all of 11. Shtandel, N: Homoim batsava: efshari to find an appropriate military unit. aval lo pashut. [Gay in the military: possi- An important aspect of the IDF is these interests were harmonized by ble, but not easy]. June 6, 2011. Accessed its social function. Since its found- recommending that he be assigned to on June 27, 2015: ing in 1948, Israel has absorbed 2.4 Battalion Headquarters, where he http://www.mako.co.il/pzm-magazine/Arti- million immigrants from Europe, could remain, officially, a paratroop- cle-e53cad7b0256031006.htm North Africa, and Asia.12 A new er, but removed from the stress of 12. Lipshitz, G: Country on the Move: combat. Migration to and within Israel, 1948-1995. nation needed to be formed out of Norwell, MA: Kluwer Academic Publish- the old, and the IDF was viewed as ers, 1998 important in integration.13 The IDF References 1.Blosnich JR, Dichter ME, Cerulli C, et al: 13. Azarya, V, Kimmerling, B: New immi- psychiatrist is therefore likely to Disparities in adverse childhood experi- grants in the Israeli Armed Forces. Armed encounter cultures quite different ences among individuals with a history of Forces and Society 6:455-482, 1980 from his own, requiring sensitivity to military service. JAMA Psychiatry culturally mediated expressions of 71:1041-1048, 2014 psychiatric symptoms and theories of 2. Slone M, Shoshani A: Psychiatric Nobody Wants illness. effects of protracted conflict and political continued from page 24 The IDF continues to enjoy broad life events exposure among adolescents in Israel: 1998-2011. J Traumatic Stress prestige in Israeli society, and failure 27:353-360, 2014 to complete military service carries a 3. Dekel S, Solomon Z, Rozenstreich E: 4. It's the little things stigma. A psychiatrist discharging an Secondary salutogenic effects in veterans Finally, after all of that hard work, unfit soldier may face fierce opposi- whose parents were Holocaust survivors? J there are a few other considerations tion by soldiers and their families. Psychiatric Research 47:266-271, 2013 to review. Odds are, every single per- Conversely, others called to serve 4. IDF says number of soldier suicides dou- son who reads this report will first may reject military service for per- bled in 2014, denies link to Gaza war. turn to the conclusion. Why not put it Jerusalem Post. January 2, 2015. Accessed on the first page? Yes, it lacks con- sonal or ideological reasons, and June 27, 2015: welcome exemption or discharge http://www.jpost.com/Israel-News/IDF- text there, but it will be taken out of from service. Further complicating says-number-of-soldier-suicides-doubled- context anyway. If a lawyer is look- matters, the IDF sees itself as a posi- in-2014-denies-link-to-Gaza-war-386507 ing at four different reports turned to tive social force, believing that suc- 5. Department of Defense Suicide Event different pages, is yours labeled with cessful completion of military ser- Report Calendar Year 2013 Annual Report, informative headings? Do you have a accessed on June 27 2015: report template with adjustments to vice will increase chances of future http://t2health.dcoe.mil/sites/default/files/D success in civilian life. The decision oDSER-2013-Jan-13-2015-Final.pdf font, line spacing, and margins to about whether to discharge a soldier 6. Lubin G, Werbeloff N, Halperin D, improve readability? None of these based on mental illness is therefore Shmushkevitch M, et al: Decrease in sui- things are the center of your report, often highly ambiguous and involves cide rates after a change of policy reducing but your report is not the center of weighing clinical data with addition- access to firearms in adolescents: a natu- the universe. Acknowledge that it al information from family, the sol- ralistic epidemiological study. Suicide and will be one of many sources of infor- Life Threatening Behavior 40:421-424, mation, and make it easy to use. dier’s commanders, and considera- 2010 tion of the soldier’s particular job 7. Schoenbaum M, Kessler RC, Gilman SE, and the needs of the unit. et al: Predictors of suicide and accident These are just a few considera- All these factors create the poten- death in the army study to assess risk and tions, and there's much to learn in tial for issues of dual agency. Is the resilience in service members (Army order to continuously improve our psychiatrist primarily the servant of STARRS). JAMA Psychiatry 71:493-503, reports. Many of us are familiar with 2014 forensic resources for report writing, the patient or of the military? What 8. Bodner E, Ben-Artzi E, Kaplan Z: Sol- Psychological Evaluations guides decisions when the interests such as diers who kill themselves: the contribution for the Courts2 of the soldier and of the military of dispositional and situational factors. . Another useful per- clash? In addition, the IDF psychia- Arch Suicide Research 10:29-43, 2006. spective comes from resources for trist is an agent of “society,” tasked 9. Department of Defense Fiscal Year 2014 general legal writing. Though it is with carrying out the social mission Annual Report on Sexual Assault in the somewhat less specific to our work, of the IDF, and must consider issues Military, Appendix A: Statistical Data on it's valuable to hear directly from the Sexual Assault, accessed on June 27 2015: (continued on page 27)

26 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 27

COVER STORY

Meeting Highlights Another “Sexy” Role to disclosures of sexual assault in mental continued from page 2 continued from page 21 health inpatient facilities. International Journal of Mental Health Nursing. 2015, 24: 139-148. the AAPL American Medical Associ- ation Delegation. 1. Glancy, G. Correctional psychiatry and In addition, the AAPL delegation its relationship to psychiatry and the law. American Academy of Psychiatry and the International Academy wishes to recognize the American Law. 2015; 40 (2): 4, 9. continued from page 19 Association for Geriatric Psychiatry, 2. Lawn T, Mcdonald E. Developing a poli- who joined the House of Delegates cy to deal with sexual assault on psychiatric and Psychiatric section council at the in-patient wards. The Psychiatrist. Mar Palestine, Israel, Iran, Pakistan, China, most recent meeting. Given the over- 2009, 33 (3): 108-111. and Russia. Most of the presentations lap between forensic and geriatric 3. Ford E, Rosenberg M, et al. Managing sexual behavior on adult acute care inpatient were in English, but some were in psychiatry, it will be helpful having psychiatric units. Psychiatric Services. Mar Spanish and French. A presentation on the geriatric psychiatrists at the meet- 2003, 54 (3): 346-350. psychiatry in the former USSR high- ings. 4. Wright E, McCabe H, Kooreman H. lighted some of the systemic political Institutional capacity to respond to the ethi- abuse of the profession. For example, Nobody Wants cal challenges of patient sexual expression under Soviet rule, diagnoses were cre- in state psychiatric hospitals in the United continued from page 24 States. Journal of Ethics in Mental Health. ated with symptoms that reflected 711-715. characteristics of government oppo- legal community what they would 5. Patient abuse accusations against ex-ER nents, rather than psychiatric illnesses like to see in legal writing. A great nurse spurs Legacy Emanuel to change as we understand them. This allowed Legal Writ- training, policies. The Oregonian, November the government to detain such individ- isntagrtiinngPlpaoininEt insgGlisahrner's 13, 2013. http://www.oregonlive.com/port- 3. This book is a uals under the pretense of having a land/index.ssf/2013/11/patient_abuse_accu- serious mental illness simply because topic-by-topic guide, with exercises. sations_agai.html A more general style guide by the 6. Ashmore T, Spangaro J, McNamara L. they opposed the government or were ‘I was raped by Santa Claus’: Responding political dissidents. same author, who has written a num- (continued on page 28) ber of authoritative works about legal writing, is Garner's Modern American Usage4. This is an excellent desktop reference for punctuation, word choice and style. As a bonus, it is a delightful read for writing nerds and language curmudgeons. References 1. Grisso, T. (2010). Guidance for improv- ing foreOnpsiecnrAepcocertsss: JAourervniaelwofoFf ocoremnmsicon Persryocrhs.ology , Volume 2, pp. 102-115. 2. Melton, G., PetrilaP, Js.y,cPhooylothgriecsasl,eJv.,a&lua- tSiolonbsofgoirn,thCe.c(o2u0r0t7s). (3rd edition). New York: Guilford. Legal writing in plain E3.nGglaisrnher, B. (2013). (2nd edition). Chicago: University of Chicago Press. Garner's modern A4.mGearircnaenr, uBs.a(g2e009) (3rd edition). Oxford: Oxford University Press.

American Academy of Psychiatry and the Law Newsletter September 2015 • 27 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 28

ALL ABOUT AAPL - Committees

International Academy continued from page 27 WE SUPPORT YOU The third day included presenta- . s e c i

tions on epigenetics, interdisciplinary v r e S e

cross-training in law and mental c n a r u s n health, cyber-bullying, mental harm I d n

A LIBRARY OF a t

and the law, and cyberspace terrorism. n e m e g

There was a presentation cluster dedi- a

54,400+ n a

PSYCHIATRIC SPECIFIC M k s cated to ethical and legal considera- 360+ i R l a

RISK MANAGEMENT RISK MANAGEMENT n o tions in organ transplantation, while i s s e f

ISSUES ADDRESSED ARTICLES AND TIPS o r

another addressed various refugee P c i t n a l mental health problems in Lebanon t a s n a r and Jordan. In yet another presenta- T a / b Unparalleled risk management services are just one component / d

tion, we learned of a court system in , a i

of our comprehensive professional liability insurance program. n r o f i l

Rwanda where female survivors of a C n

When selecting a partner to protect you and your practice, consider I rape bring their perpetrators to justice. the program that puts psychiatrists first. Contact us today. The fourth and fifth days of the conference were ethics heavy, with various presentations regarding ethics 800.245.3333 PsychProgram.com [email protected] and end of life care, physician assisted suicide, organ donation of mentally ill persons, guardianship, and free will in More than an forensic evaluations. insurance policy Some of the highlights of this con- Actual terms, coverages, conditions and exclusions Insurance coverage provided by Fair American Insurance and ference were the thoughtful and well- may vary by state. Unlimited consent to settle does Reinsurance Company (NAIC 35157). FAIRCO is an authorized organized social events. Aside from a not extend to sexual misconduct. carrier in California, ID number 3175-7. www.fairco.com pre-conference evening reception and farewell reception, there were two major social events at renowned loca- Connect to work that tions. One evening, the group had St. matters; become part of a Stephan’s Cathedral all to itself for a company that cares. chamber orchestra performance by the

Festival Strings of Vienna. MHM/Centurion provides behavioral health and medical The program included Pachelbel’s specialty services to governmental agencies in a wide variety Canon in D Major, Vivaldi’s Violin of patient care settings, including correctional facilities, state hospitals, courts, juvenile facilities and community clinics. INDEPENDENT CONTRACTOR OPPORTUNITIES Concerto in A minor, Mozart’s MHM and its subsidiaries serve clients in 15 states across the Salzburger Symphony, and Grieg’s country. From mental health and long-term care to medical CALIFORNIA and forensic services, our employees are dedicated to providing State Hospitals Suite Aus Holbergs Zeit. Another the highest quality of care for every population they serve. Atascadero & Coalinga evening, a cocktail reception was held EMPLOYED OPPORTUNITIES MICHIGAN Commonwealth of PENNSYLVANIA for the group at the ballroom of the MI PSYCH Full-Time, 37.5 Hours/Week; No Call; No Weekends GEORGIA Ann Arbor – PT & Moonlighting Clarks Summit State Hospital city hall of Vienna, the Rathaus. This Columbus Ypsilanti – FT Danville State Hospital Inpatient Psychiatric Hospital was quite an elegant affair, with Vien- Lansing/Grand Rapids – FT & PT Torrance State Hospital NO CALL Muskegon – PT Warren State Hospital nese waltz music performed by the Valdosta Telepsych available Wernersville State Hospital Ladies’ Orchestra Tempo di Valse Outpatient; Flexible Schedule Jackson MINNESTOA Part-Time The next IALMH congress will be Outpatient; 3 Days per Week Faribault – PT Ebensberg Center Hollidaysburg Veterans Home held at Charles University in Prague in MARYLAND PENNSYLVANIA Polk Center July 2017. The exact dates are not yet Baltimore & Jessup Philadelphia – PT & Locums (Days/Evenings/Weekends) determined. If Vienna was any indica- MASSACHUSETTS Erie, Clarion, Pittsburgh, Bridgewater, South Walpole & To apply or inquire, contact: tion, it will be another beautiful event Scranton, State College & Framingham Holley Schwieterman, (866) 204-3920 Wilkes-Barre worth attending. I hope to see you all Outpatient – FT & PT [email protected] FT, PT & Locums; Retention Bonus Bridgewater there. & 3- or 4-Day Workweek Options Inpatient – FT & Moonlighting TENNESSEE MISSISSIPPI Statewide – FT, PT & PD Statewide – FT, PT & PD Telepsychiatry – Jackson VERMONT Statewide – FT, PT & PD www.mhm-services.com EOE

28 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 29

ALL ABOUT AAPL - Committees

Financial Crimes continued from page 25

These cases are notoriously diffi- cult to prosecute. Transactions often have the facade of legitimacy. Vic- tims are often reluctant to pursue criminal charges due to shame, fear both of the perpetrator and of losing PSYCHIATRISTS their independence, and emotional $191,899.84 to $218,842.78 attachment to the perpetrator. When they do cooperate with prosecution, Ann Klein Forensic Center’s Special Our Extraordinary they can often make poor witnesses. Treatment Unit Adult facility located in Benefits Include: These victims are at greater risk of Rahway, New Jersey invites you to join our • Paid Vacation team of professionals who are making a • Paid Holidays becoming ill or dying during the • Sick Days process. They sometimes suffer from difference in the health and welfare of New Jersey citizens. Our inpatient units • Personal Days neurocognitive disorders that make it • Medical Insurance are designed to treat adult males who • Dental Insurance difficult to recall details of the suspi- have been civilly committed under New cious transactions. Forensic psychia- • Life Insurance Jersey’s Sexually Violent Predator’s Act. • Prescription Plan trists can assist in determining We seek experienced Psychiatrists to • Deferred Income whether the victims were competent conduct detailed forensic evaluations. • No overnight call to enter into the contested agreements, whether the victims were vulnerable For consideration please contact: to undue influence, and whether there Dean De Crisce, M.D., Acting Director of Psychiatry are indicators of undue influence in or Merrill Main, Ph.D., Clinical Director at: (732) 499-5041 the relationship. email at: [email protected] or [email protected] Criminal prosecution is one legal EOE mechanism for protecting these vul- nerable victims. Others include civil action to invalidate contracts where the victim was incompetent to enter CONSULTATION IN PSYCHOLOGICAL ASSESSMENT BY into the agreement, durable power of AN EXPERIENCED FORENSIC EXAMINER attorney, and, in cases of extreme dis- ability, guardianship. Our practice at Richard Frederick, Ph.D. the interface of psychiatry and the law Board Certi ed in Forensic Psychology places us in a unique position to com- Board Certi ed in Assessment Psychology bat these crimes through education, prevention, and prosecution. While I Dr. Frederick will score and provide interpretive reports to psychiatrists have focused on the role of forensic for self-administered tests such as the MMPI-2, MMPI-2-RF, and PAI. psychiatry, legislators, prosecutors, Self-administered tests are available to measure many domains primary care physicians, and financial relevant to criminal and civil forensic examinations, tness for duty professionals all have a role to play. examinations, and risk assessments. These domains include basic There is no better time to get started. personality characteristics, cognitive functioning, executive functioning, posttraumatic stress, attitudes about physical functioning, References and feigned psychological problems or feigned cognitive impairment. 1. The MetLife study of elder financial abuse: crimes of occasion, desperation, and predation against America’s elders. 2011. Interpretive reports individualized for speci c referral Available from: questions. Fast turn-around time. http://www.metlife.com/assets/cao/mmi/pub- lications/studies/2011/mmi-elder-financial- abuse.pdf. Contact Dr. Frederick to determine how to best meet your 2. Spar JE and Garb AS. Assessing compe- forensic needs with self-administered psychological tests tency to make a will. Am J Psychiatry completed under your supervision. 1992 149:169-174. 3. Hall, Ryan C.W., M.D. "Exploitation of the Elderly: Undue Influence as a Form of 866-791-2724 • [email protected] Elder Abuse." Clinical Geriatrics 13.2 richardfrederick.com (2005): 28-35.

American Academy of Psychiatry and the Law Newsletter September 2015 • 29 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 30

ADS

CORRECT CARE RECOVERY SOLUTIONS

EXCITING PSYCHIATRY OPENINGS IN FLORIDA and South Carolina! :ŽŝŶƚŚĞŶĂƚŝŽŶ͛ƐůĞĂĚĞƌŝŶSpecialty HealthCare Solutions!

Working with Correct Care, you will receive lucrative benefits such as:

x Attractive Sign-on Bonus x Competitive Compensation, CME and Health Benefits. x Paid Malpractice Insurance. x Deferred Compensation Plan. x Stable and flexible work schedule while serving forensic patients.

Full-time - Part-time - Internal locum opportunities available near Port St. Lucie, Jupiter, Treasure Coast, Miami, The Keys and South Carolina.

dŽũŽŝŶƚŚĞĐŽŵƉĂŶLJ͛ƐŝŶŶŽǀĂƚŝǀĞĂŶĚŐƌŽǁŝŶŐƚĞĂŵ͕ŵŽƌĞŝŶĨŽƌŵĂƚŝŽŶĐĂŶďĞŽďƚĂŝŶĞĚĨƌŽŵEŝĐŽůĞƚ Bryson at telephone number 954-777-0163 or [email protected]

Medical Transcription:

• 35 years’ exp in Psychiatry, Forensic Psychiatry, and Psychology

• 140 wpm, 180 wpm real time

• Accurate, dependable

• Verification of content integrity

• HIPAA compliant encryption used to send and receive data

• Excellent references available

• Laura Arntz, 503-260-6506, [email protected]

30 • September 2015 American Academy of Psychiatry and the Law Newsletter 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 31

NEW MEMBERS 2015

AE MD SD Erik Lundmark, MD Allan Anderson, MD Sarah Flynn, MD Megan Della Selva, MD AL Kathleen Patchan, MD TX Jesse Martinez, Jr. Edward Wicht, MD Martin Guerrero, MD, JD Denise Perone, M.D. MI Sarah Strebeck, MD Charletta Dennis, MD Leonard Weiss, MD AZ Dorothy Gotlib, MD Roberto Sebastian, Jr., MD VA MN Navneet Sidhu, MD CA Brooke Beehler, DO Arin Abnoosian, MD Soniya Hirachan, MD VT Dan Begel, MD Simha Ravven, MD Barbara Justice, MD NC Sanaz Kalantarzadeh, MD Dan Cotoman, MD WV Gloria Kardong, MD Jennifer Kemper, MD Richard Geary III, MD Elizabeth Mahler, MD Rebecca Najera, DO NM AUSTRALIA Carla Eide, MD Jane Fitch, MBBS FRANZ CO Caleb Armstrong, MBChB Jonathan Thiele, MD NV Rahul Gupta, FRANZCP LaTricia Coffey, MD Leonard Lee, MB CT Fiona McGregor, FRANZCP Michael Chen, MD NY Gorana Milosevic, MD Katherine Michael, MD Lama Bazzi, MD Hoa Nguyen, MBBS Karen Moyer, DO Constantin Boisrond-Canal, MD Jane Phillips, FRANZCP Susannah Tung, MD Jorge Castillo, MD Sachin Rai, MD Margaret Fraser, MD Pankaj Relan, MD, FRANZC DC Scott Gershan, MD Sarah Steele, MBBS Wilhem Rivera, MD Shadia Hanna, MD Jeffrey Kerner, MD BRAZIL FL Sarah Masood, MD Plinio Montagna, MD Todd Cornett, MD Megan Mroczkowski, MD Carolyn Drazinic, MD, PhD Louise Mullan, MD CANADA Emily Lazarou, MD Hari Nair, MD Maryana Duchcherer, MD Edwin Olsen, MD, JD Kamaloshni Puthumana, MD Michelle Mathias, MD Gary Proctor, MD Amam Saleh, MD Jeff McMaster, MD Sana Qureshi, MD Douglas Saphier, MD, MPH Kulwant Riar, FRCP Carole Tessier, MD GA OH Stephanie Chapman, DO David Bienenfeld, MD ENGLAND Monifa Seawell, MD Lubna Grewal, MD Jeremy Berman, MRCPsych Steven King, MD Lucja Kolkiewicz, MBBS HI Douglas Misquitta, MD Kurt Humphrey, MD INDIA OR Natalia Raharjanti, MD IL Morgyn Beckman, MD Scott McCormick, MD Alexander Horwitz, MD IRAQ Afram Hassan, MD KS PA Michael Burke, MD, PhD Fahad Ali, MD IRELAND Mohamed Ismael, MD, MPH Paul O’Connell, MD LA Matthew Lang, DO Michael Blue, MD John Williams, MD ISRAEL Ashleigh Fleming, MD Azgad Gold, MD, PhD Tiffany Gartrell, MD RI Janet Johnson, MD Stephanie Hartselle, MD NETHERLANDS Mohammad Khan, MD Christine Montross, MD Renée Sevinga, MD Padmini Nagaraj, MD SC SOUTH KOREA MA Adam Bloom, MD Chan Hee Huh, MD Andrew Clark, MD Sandeep Gude, MD Don Condie, MD Jeffrey Raynor, MD UNITED KINGDOM Richard Taylor, MRCPsych

American Academy of Psychiatry and the Law Newsletter September 2015 • 31 162031 AAPL News September 2015_rev6.qxp_September 2015 10/30/15 4:58 PM Page 32

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 Charles Dike, MD, MPH, FRCPsych, Editor