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April 2017 • Vol. 42, No. 2 vulnerable to its grasp may have per- Forensic Psychiatry Review Course: sonal insecurities, perceived injus- tices, psychological deficits, or a his- October 23-25, 2017 tory of delinquency.3 A study from AAPL 48th Annual Meeting: Boston Children’s Hospital regarding mental health of young Somali October 26-29, 2017 refugees in United States and Canada noted that moderate levels of trauma Hyatt Regency Denver and discrimination are associated with support for both non-violent and at the Colorado Convention Center violent activism, but personal and social factors determine which type is Denver, Colorado chosen by an individual. PTSD symp- toms were associated with openness to illegal and violent activism, possi- bly due to cognitive and behavioral changes. They additionally noted a correlation between support for vio- lent activism with social marginaliza- tion and time on the Internet. Mean- while, post-traumatic growth and social bonds to both North American society and their Somali community were protective.4 How do heightened American immigration concerns affect the prac- tice and role of the forensic consul- tant? Forensic psychiatrists can be involved in an asylum application by providing diagnostic information that may support an applicant’s claims, along with how culture and mental Asylum Evaluations in the Terrorism Era health symptoms may relate to Danielle Kushner MD, Human Rights Committee deficits in credibility or delays in an 5 The global refugee crisis has led to heightened concerns regarding application. With today’s heightened reached the highest level since World radical Islamic terrorism developing concern about terrorists entering the War II, primarily due to the ongoing in the United States. The fight against country, forensic evaluations of asy- Syrian conflict. According to United terrorism has inevitably impinged lum seekers will become more scruti- Nations High Commissioner for upon international human rights, nized and key evaluation topics of Refugees (UNHCR) by the end of demonstrated most recently by malingering and cultural issues will 2015, 65.3 million individuals were Trump’s new Executive Order on become even more crucial. forcibly displaced worldwide as a Immigration.2 Asylum seekers and Research outlines three explanato- result of persecution, conflict, gener- refugees have become doubly victim- ry models for malingering in an eval- alized violence, or human rights vio- ized: persecuted at home and margin- uation context: pathogenic, crimino- lations, 5.8 million more than the pre- alized abroad, as they are increasing- logic, and adaptational. Pathogenic vious year. Of the total number of ly unable to enter safe countries due malingering describes an individual displaced persons in 2015, 21.3 mil- to a variety of restrictive measures. who has genuine psychopathology, lion were refugees and 3.2 million More individuals hold radical but whose symptoms are not entirely were asylum seekers.1 views than are willing to engage in consistent with the malingered diag- Simultaneously, recent domestic violent action. The process of radical- nosis. The criminological model terrorism incidents, such as the Orlan- ization is multi-factorial. For exam- involves those with antisocial tenden- do and San Bernardino attacks, have ple, research has shown that those (continued on page 2)

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American COVER STORY Academy of Asylum Evaluations given cultural barriers for testing and little additional documentation or Psychiatry continued from page 1 contacts. and the Law Culture is another important topic cies for secondary gain, while in the to be addressed in asylum assess- adaptational model, the feigner is try- Editor ments, especially as some researchers ing to increase his or her chances to Susan Hatters Friedman, MD have found DSM 5 diagnoses, such succeed in adversarial circumstances.6 as PTSD, not cross-culturally valid. Associate Editors One of the most prevalent diagnoses Consultants may also be asked to dis- Philip Candilis, MD in asylum applications, PTSD, is par- cuss cultural issues related to the Ryan Hall, MD ticularly susceptible to malingering Stephen Herman, MD applicant’s behavior and treatment. due to the high incidence of comorbid Neil S. Kaye, MD Linguistic translation needs to be symptoms, fewer objective findings, Joseph Simpson, MD, PhD examined closely for euphemisms or and high incidence of secondary gain. Renée Sorrentino, MD mechanisms of collective avoidance. Joel Watts, MD Memory difficulty in trauma is anoth- Yet, other researchers have argued er controversial topic, but research AAPL Photographer that using cultural formulations in continues to grow regarding validity Eugene Lee, MD forensic psychiatry can emphasize of memory in trauma. The dual repre- stereotypes and stigmatization of eth- Former Editors sentation model shows that involun- nic groups.5 Evaluators must remem- Charles Dike, MD, MPH (2008 – 2016) tary memories, such as flashbacks or ber their own objectivity especially in Victoria Harris, MD, MPH (2003-2008) nightmares, occur spontaneously, this heated political climate. Michael A. Norko, MD (1996-2003) while verbally accessible voluntary Robert Miller, MD PhD (1994-1996) Traditional risk assessments for memories are more difficult to Alan R. Felthous, MD (1988-1993) violence, such as the HCR-20 and retrieve.7 As with any challenging Robert M. Wettstein, MD (1983-1988) SAVRY, are appropriate for psychi- diagnosis, additional collateral of pre- Phillip J. Resnick, MD (1979-1983) atric patients, but have not been Loren H. Roth, MD, MPH (1976-1979) morbid functioning, collateral reports, found to be helpful for evaluating or testing data are important to help radicalization. Psychometric scales Officers support the evaluator’s opinion. Yet, and assessment tools currently used President for some asylum seekers, collateral Michael A. Norko, MD information may be non-existent (continued on page 32) President-elect Christopher R. Thompson, MD Vice President Philip J. Candilis, MD CALL FOR AWARD NOMINATIONS Vice President Jagannathan Srinivasaraghavan, MD Secretary Isaac Ray Award Jessica Ferranti, MD Treasurer The Isaac Ray Award, established in 1951, recognizes a person who has made Douglas Mossman, MD outstanding contributions to forensic psychiatry or to the psychiatric aspects Immediate Past President of jurisprudence. It is a joint award of the APA and the American Academy of Emily Keram, MD Psychiatry and the Law that honors Isaac Ray, M.D., one of the original founders and the fourth president of the American Psychiatric Association. The AAPL Newsletter is published by Deadline for Nominations: June 1 AAPL, One Regency Drive, PO Box 30, Bloomfield, CT 06002. Opinions expressed in bylined articles and Manfred S. Guttmacher Award columns in the Newsletter are solely those of the authors and do not neces- The Manfred S. Guttmacher Award, established in 1975, recognizes an sarily represent the official position outstanding contribution to the literature of forensic psychiatry in the form of a of AAPL or Newsletter editors. book, monograph, paper, or other work published or presented at a professional Manuscripts are invited for publication meeting between May 1 and April 30 of the award year cycle. in the Newsletter. They should be sub- Deadline for Nominations: June 1 mitted to the editor via email to [email protected] The Newsletter is published in January (deadline for submission is November 15), April (deadline Febru- Learn more about how to make ary 1), and September (deadline July 1). a nomination at: psychiatry.org/awards www.aapl.org © 2017 AAPL. ALL RIGHTS RESERVED.

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EDITOR’S COLUMN “The More You Tighten Your Grip… summer, providing possibilities for cross-pollination of ideas, not only The More Star Systems Will Slip with others at the intersection of men- tal health and the law (forensic psy- Through Your Fingers” chologists and attorneys) but also cross-pollination with our internation- Susan Hatters Friedman MD al counterparts. Looking forward to Welcome to to her urn shaped like a large Prozac this, we will read about (and see pho- the April pill (reportedly her favorite posses- tographic evidence of) the recent newsletter. This sion), nothing about Carrie Fisher Asia-Pacific IALMH Chapter meet- year has seen a was conventional. Despite the fraught ing. You will also find ideas for men- lot of changes in relationships with her parents torship in research. An in-depth our world. While throughout her life, she emerged an review of Neurolaw from AAPL’s working over- outspoken, brave, and witty advocate 2016 course and an update from seas, new immi- for mental health. For many, she AAPL’s representative to the APA gration policies humanized mental illness and addic- round out this issue. Hope to see you in the United tion in women, despite facing stigma all at the APA Guttmacher Lecture States are the primary topic people herself. Her story, not just of Axis I next month! have raised with me. I hear frequent disorders, but also of overcoming dif- tales of colleagues rebooking their ficult developmental upbringing, international trips so as to avoid the often, yet unbidden, draws parallels potential to be detained at airports in to my female forensic patients strug- our country. And I hear worries of gling with the same trifecta and end- American colleagues who are either ing up in very different circum- not of European extraction or who stances. Resilience and humor, food The AAPL Awards Committee have non-American accents—worries for thought. would like your help. We would about leaving either to visit family I hope that you will find expand- be interested in receiving nomina- internationally or to attend a confer- ing knowledge while reading this tions by June 1 for the following ence, and if they will be allowed re- issue of the AAPL Newsletter. Enjoy awards: entry. the timely articles from various com- - For AAPL mem- If you happen to be following the mittees about topics ranging from the bers who have provided outstand- titles of these editor columns, and Women’s March on January 21st to ing service to AAPL, e.g., through you happen to be a Star Wars fan, transgender legal issues, to terrorism committee membership. you’ll recognize an iconic, (and a and asylum evaluations. Reading the – For AAPL favorite) Princess Leia line. That’s vast range of committee articles, one because, reflecting on both the immi- cannot help but be reminded of members over the age of 60 who gration ban and the recent sudden important work that our AAPL com- have made significant contribu- death of Carrie Fisher, one of the mittees are doing—on contemporary tions to the field of forensic psy- great celebrity mental health advo- and critical issues. You will also con- chiatry. cates, this line found itself foremost sider primary prevention of criminal – in my mind. justice system involvement upon For APA members (who may not When she died, I was mid-way reading Dr. Norko’s president col- be AAPL members), who have through listening to Carrie Fisher’s umn. This newsletter issue also fea- made distinguished contributions reading of The Princess Diarist on tures articles about addiction, a new to the teaching and educational audio-book— hearing about her and dangerous drug of abuse (kratom) functions of forensic psychiatry. teenaged affair with the dashing but and marijuana legalization. Discus- – For non- married Harrison Ford. Additionally, sions of other mental health law here- AAPL members who have con- a fortnight previously having attended in include updates on Tarasoff, the tributed to AAPL. the midnight premiere of Rogue One, Goldwater rule (in the Fellows Cor- her sudden death was particularly vis- ner), and the impacts of Sex Offender – For out- ceral. Playing a formidable woman registries. Also, the Faces of AAPL, standing faculty member in fel- saving the galaxy from evil by day, Ask the Experts, and Child Column lowship program. behind the scenes she struggled with present their, as usual, intriguing dis- mental illness and substances. From cussions. Please send your nominations to her unabashed discussions of living The International Association of Jeffrey Metzner, MD, Chair of the with bipolar disorder and addiction in Law and Mental Health (IALMH) Awards committee at both her writing and public speaking, meeting is upcoming in Prague this [email protected].

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PRESIDENT’S REPORT Primary Prevention of Criminal These individuals are often as frus- trating to community clinicians as Justice Involvment they are to the courts. Services are offered, medications supplied, sub- Michael A. Norko MD, MAR stance treatment available and people continue to get arrested for manifesta- If we concep- The last four of the five intercepts tions of their mental illness and/or tualize criminal all describe tertiary prevention; they substance use disorders. Clinicians justice system include programs such as jail diver- might be relieved that their patient involvement sion; drug, mental health and commu- was arrested, and at least relatively (CJSI) as an nity courts; assertive community safe and abstinent for a while. Courts adverse condition treatment (ACT), intensive case man- are relieved to send people to the for which indi- agement, and correctional re-entry; forensic hospital for 60-90 days for viduals with seri- and special mental health probation restoration, so that the communities ous mental ill- or parole. The first intercept, which will have some respite from their ness (SMI) in the community are at primarily involves the crisis interven- troublesome behavior. some risk, then we can think of pri- tion team (CIT) approach, can be But this is not how we ought to mary, secondary and tertiary preven- considered secondary prevention. spell relief. tive measures for CJSI among clients The most important public health We need to develop and teach dif- of public mental health care systems. technology is, however, primary pre- ferent and better skills to our frontline Tertiary prevention aims to reduce the vention. Munetz and Griffin referred community clinicians to equip them negative impact of established condi- to this as “the ultimate intercept” and to be more successful at primary pre- tions by restoring function and reduc- described it as involving “best clini- vention. At the very least this will ing condition-related complications. cal practices” (Ref 1, p 545). It is also require 1) proper assessment of risk; Secondary prevention aims to diag- now referred to as Intercept Zero.3 2) risk management to the extent that nose and treat an existing condition in Munetz and Griffin thought that few this is possible in a system of care; 3) its early stages before it results in sig- people would be intercepted early effective treatment to reduce risk; and nificant morbidity. Primary preven- because few communities are able to 4) ongoing training, supervision and tion aims to avoid the development of make these services available and consultation by forensic psychiatrists an adverse condition. easily accessible to those who need and psychologists. The Sequential Intercept Model1 them. Even these interventions, though, was developed as a way to conceptu- My experience tells me that even are not enough because they tend to alize efforts to move people with SMI with willing, well-intended, and assume that criminal behavior by out of the cycle of CJSI by means of active collaboration between mental individuals with SMI is a direct result stages of interventions described as health and criminal justice systems, of psychiatric symptoms and, if “filters” or intercepts. The five inter- and even with a well-developed pub- symptoms are well managed and cepts are: 1) law enforcement and lic mental health system, too many basic needs are met, these individuals emergency services; 2) post-arrest people continue to experience most of are unlikely to commit a criminal detention, initial hearings and pretrial the intercept stages. Nearly every offense. However, extensive research services; 3) post-initial hearings: jail, week, people with SMI are admitted has found that the same criminogenic courts, forensic evaluations and to our forensic hospital for restoration factors that predict arrest for the aver- forensic commitments; 4) reentry of competence to stand trial (CST) age adult criminal also predict arrest from jails, state prisons, and forensic with low level misdemeanor charges for SMI adults.5 Criminogenic factors hospitalization; and 5) community on low bonds or a promise to appear. refer to those personal factors that corrections and community support My colleagues in other states report increase risk of criminal behavior, services. An excellent review by that they have been seeing increases including antisocial behavior, person- Heilbrun and colleagues describes the in CST evaluations and restoration ality, cognitions and associates. literature on community alternatives admissions as well. Waiting lists and Many offenders, SMI or otherwise, at these various intercepts.2 Many lawsuits are common struggles for often have deficits in interpersonal jurisdictions in the United States have forensic system directors. In skills and in cognitive skills (like utilized this model in designing inter- response, more than a dozen states problem solving, planning, and future ventions within partnerships between have already developed programs for thinking) that need to be addressed to public mental health and judicial sys- CST restoration in jails, because they promote prosocial behaviors. Thus, tems. A quick internet search on do not have the capacity in their hos- criminogenic needs are targets for “sequential intercept mapping” will pitals to accommodate the influx of intervention to prevent involvement produce examples from all over the such individuals (including the Los (or further involvement) in criminal country of jurisdictions that have Angeles program described in the activity and can be employed in com- engaged this process. January Newsletter4). (continued on page 8)

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EXECUTIVE DIRECTOR’S REPORT Sometimes Embracing Change ter the weather” I have a hard time justifying why the “what” was there Jacquelyn T. Coleman, CAE in the first place, since the expression seems perfectly clear without it. This This list is by no means complete. As forensic is a hard one for me and I haven’t psychiatrists, you made up my mind. Went missing. What happened to dis- know the impor- I have been saving for last a rela- appeared? On my bad list. tance of using tively new expression that I just love correct language. – gaslighting. I know it has been Slew: This is now an acceptable word I was brought around a while and is a recognized in all major media. Why? up by a strict phenomenon, but in the current politi- constructionist. cal climate it is really gaining ground. Massive: Everything is massive now, My father According to Wikipedia, and yes, I even if it has no mass. allowed no slang in our house. know it’s not Roget’s Thesaurus, but I Among the words he abhorred were can lift it: Decimate: Don’t even get me started. “stupid,” “meaningful,” and “rele- “Gaslighting is a form of manipu- vant.” Yes, it was a long time ago.We lation that seeks to sow seeds of Here is a sentence that recently had to express ourselves clearly and doubt in a targeted individual or gave me pause, and I do not mean in say what we meant. He put a Roget’s members of a group, hoping to make a good way: “We are going to use Thesaurus in my hands when I was targets question their own memory, this presentation to homage…” OK, barely able to carry it. perception, and sanity. Using persis- that one made me gag. So it’s no accident that I view with tent denial, misdirection, contradic- As such: This meaningless expres- alarm new words and expressions tion, and lying, it attempts to destabi- sion was given to us by Washingtoni- that creep into our language. Howev- lize the target and delegitimize the ans. Yes, the term has been used for a er, I have gradually come around to target’s belief… long time, in the proper way, but it’s the point of view that language is liv- “Instances may range from the not a short cut for telling us what you ing and people can be very creative. I denial by an abuser that previous abu- mean. If you have ever submitted to haven’t given up on my belief that sive incidents ever occurred up to the the Journal, you may have noted that sloppy is sloppy and if you are going staging of bizarre events by the you lost all your “as suches.” The to invent a new expression, it should abuser with the intention of disorient- Managing Editor is allowed some be “meaningful” and “relevant.” Ooh, ing the victim… privileges…. I am going to be punished for that! “The term originates in the system- A fact (or is it a factoid): impact What are the sources for new atic psychological manipulation of a used to be a noun. I believe I was in words and expressions? Washington victim by the main character in the on the creation of “impact” as a verb. is first on the list. Government relish- 1938 stage play Gas Light, known as Early in my career as a journalist, I es inventing new words, for obfusca- Angel Street in the United States, and interviewed the Governor of Ver- tion of course, but also for a way to the film adaptations released in 1940 mont. He was the first person I ever be in the clique where only they and 1944. In the story, a husband heard say “we don’t know how that is know the code. The media, especially attempts to convince his wife and going to impact…” street reporters on local channels, do others that she is insane by manipu- I am not hopeless however. I can come up with the weirdest things, and lating small elements of their envi- tolerate spoken expressions that are they spread like wildfire. A third ronment and insisting that she is mis- funny or in my judgement creative. I source is the so-called silicon valley, taken, remembering things incorrect- think the expression “own it” has a no longer a geographic entity. Having ly, or delusional when she points out nuance that makes it an acceptable been forced to interact with many these changes. The original title stems replacement for “it’s your responsi- software and hardware designers over from the dimming of the gas lights in bility,” but NOT if it’s used in every the years, I cannot say that they actu- the house that happened when the sentence for everything, as if I can ally speak English, whereas I can husband was using the gas lights in have any influence over that. usually understand what the Washing- the attic while searching for hidden “I can’t even” is kind of fun, espe- ton types and the media are trying to treasure. The wife accurately notices cially when accompanied by a wide say. But I need to acknowledge that the dimming lights and discusses the eye roll. Another one I like is “Is that some of my favorite word columnists phenomenon, but the husband insists even a thing?” often point out that words we think she just imagined a change in the Speaking of constantly changing are new were really used by Shake- level of illumination.” language, I am still struggling with speare and other famous writers a I’d love to hear your favorite and “no matter” versus “no matter what.” long time ago. not-so-favorite words and expres- The “what” is losing its grip. When I I am going to indulge in a few sions. You do not need to write to me comments about my likes and dislike. analyze expressions such as “No mat- (continued on page 8)

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MEDICAL DIRECTOR’S REPORT The Tarasoff Pendulum Swings we will keep an eye on it. Plan: We will continue Risperdal, Back: Expansion of Washington Depakote and [bupropion].

State Psychiatrists' Duties to Later DeMeerleer and Schiering Protect Third Parties mended their relationship when DeMeerleer's mental condition had Jeffrey S. Janofsky MD improved. They ceased their relation- ship for good on July 16, 2010. There In Volk v. relationship with Rebecca Schiering, was no subsequent contact with Dr. DeMeerleer1, in a the mother of three sons. During that Ashby. 6-3 decision the year DeMeerleer exhibited volatile On July 17, 2010 DeMeerleer Supreme Court of behavior, and took firearms to the entered the Schiering's home and the State of Wash- location of where his truck had been killed Schiering and one of her sons. ington significant- vandalized. DeMeerleer's family Another son escaped. DeMeerleer ly expanded the intervened, removed the guns from committed suicide. duty of outpatient DeMeerleer's house and then Schiering's mother and surviving psychiatrists towards third parties informed Dr. Ashby the DeMeerleer's son sued Dr. Ashby, alleging failure whom their outpatients might harm, thoughts had "progressed from suici- to follow the standard of care. Ashby even if the outpatient made no threat dal to homicidal." denied any failure of the standard of to a specified potential victim. The DeMeerleer's relationship with care and moved for summary judg- APA's Committee on Judicial Action Schiering progressed. In 2009 Schier- ment because DeMeerleer’s behavior had helped draft an unsuccessful ami- ing became pregnant with DeMeer- was not foreseeable, and because Dr. cus brief written by the Washington leer's child. However during the preg- Ashby did not owe DeMeerleer's vic- State District Branch and other med- nancy DeMeerleer lost his job and tims a duty of care. Ashby argued that ical societies in support of limiting assaulted Schiering's nine year old there could be no foreseeability with- such a duty. This case essentially cre- autistic son. Schiering moved out and out actual threats by DeMeerleer ates a strict liability standard for terminated the pregnancy. DeMeer- towards the victims, and that no such Washington State psychiatrists whose leer contacted Dr. Ashby's clinic in threats had been made at any time patients harm third parties "serious distress" and was referred to during treatment. Ashby further DeMeerleer had begun treatment a community mental health clinic (the argued that the only available actions with psychiatrist Dr. Howard Ashby opinion does not make it clear that he might have taken were to seek in September 2001. At Dr. Ashby's whether DeMeerleer was in treatment civil commitment or warn any poten- initial evaluation he diagnosed with Dr. Ashby from 2005 until 2009, tial victims or the authorities of DeMeerleer with bipolar disorder and nor on what date DeMeerleer restart- DeMeerleer’s potential danger to oth- prescribed Depakote. DeMeerleer ed treatment with Dr. Ashby. ers. Ashby claimed immunity for fail- provided a written list of bothersome In April 2010 DeMeerleer had his ure to hospitalize or to warn under a experiences including "delusional and last visit with Dr. Ashby. According Washington State statute. Ashby filed psychotic beliefs," as well as other Dr. Ashby's note from that meeting: supporting affidavits from DeMeer- beliefs indicating a lack of remorse leer's family members and friends for others. DeMeerleer's wife provid- Jan indicates that his life is sta- attesting that DeMeerleer had had no ed written documentation of DeMeer- ble, he is reconstituting gradual- unusual behaviors and had made no leer's dangerous rages as well as his ly with his fiance[e]. They are threats around the time of the homi- dreams of going on killing sprees. taking marriage classes, he can cides/suicide. However Ashby did not In 2003 DeMeerleer found out his still cycle many weeks at a provide an expert psychiatric report wife was having an affair. She time. Right now he is in an about the standard of care. divorced him soon after. DeMeerleer expansive, hypomanic mood, In response, the Plaintiffs argued reported suicidal ideations as well as but sleep is preserved. He has a that under Petersen v. State2, once a homicidal thoughts towards his wife, bit more energy and on mental special relationship existed between a but assured Dr. Ashby that he would status, this shows through as he mental health professional and his not act on them, and he did not. is a bit loquacious but logical, patient, the mental health professional DeMeerleer told Dr. Ashby about goal oriented and insight and owed a duty of reasonable care to any "revenge thoughts and fantasies," but judgment are intact. He states foreseeable victim of the patient. did not report an identifiable victim. when depressed he can get Plaintiffs argued that Dr. Ashby Dr. Ashby continued medication and intrusive suicidal ideation, not breached the duty owed by failing to psychotherapy. that he would act on it but it perform a risk assessment on In 2005 DeMeerleer began a new bothers him. At this point it's DeMeerleer and failing to provide not a real clinical problem but (continued on page 7)

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MEDICAL DIRECTOR’S REPORT

The Tarasoff Pendulum recognize a cause of action for med- for the ability of psychiatrists to accu- continued from page 6 ical malpractice without a physician rately predict future violence. Howev- patient relationship. The Supreme er Dr. Mossman actually wrote that intensive psychiatric treatment for Court affirmed the trial court's sum- while violence risk assessment had DeMeerleer with more frequent clinic mary judgment decision with regards advanced since the Tarasoff decision, visits. Their theory was supported by to any claim of medical malpractice. predictions about whether a specific an affidavit from a forensic psychia- However the Supreme Court went patient would be violent or not in the trist, who also opined that Dr. Ashby's on to explain that Washington law future could not be made accurately, failures were a, "causal and substan- imposes an alternative duty, that of because of the low base rate of vio- tial factor" in causing the harm to medical negligence, which occurs lence. The case was returned the trial occur. when there is a special relationship court to resolve the medical negli- The trial court granted Dr. Ashby between the mental health profession- gence claim. summary judgment, finding that there al and patient. Citing Petersen, Tara- The dissent pointed out that 3 4 was no data indicating that DeMeer- soff II and Lipari v. Sears , the Court Petersen was a case where psychia- leer had made threats towards Schier- explained that once a mental health trists had the ability to control their ing or her sons, and that therefore professional and a patient establish a patient because the patient in Ashby had no duty to warn Schiering. treatment relationship, either outpa- Petersen had been involuntarily hos- Volk appealed to Washington's tient or inpatient, the professional pitalized, and that the psychiatrists in Appellate Court. Volk argued that "incurs[s] a duty to take reasonable Petersen had an ability to exercise Petersen did not require actual threats precautions to protect anyone who continued control of their inpatient. towards a specific victim before a might foreseeably be endangered by This was not the case here as duty could be imposed on a psychia- the patient's condition” [emphasis in DeMeerleer was never an inpatient 5 trist. Asbury argued in part that the original]. The Court noted that the under Asher's control. The dissent Washington State legislature settled psychiatrist is not necessarily noted that the majority imposed duty the public policy in 1987 when it required to control the patient's future on psychiatrists without regard for adopted RCW 71.05.120(2) that limit- actions, but was under a duty to "take this "control principle" which was ed the duty owed by mental health reasonable precautions" to lessen the novel and incorrect under Washington professionals to third parties only to dangerous propensities of the patient. State Law. The dissent further noted those reasonably identifiable persons These precautions are to be informed that the majority was essentially actually threatened by a patient. The by "professional mental health stan- adopting new language from Sec. 41 Court of Appeals held that the legisla- dards." The Court also noted that it of the Third Restatement of Torts tive limits placed on the Petersen explicitly rejected California’s post that, rather than requiring a control- decision applied only when an invol- Tarasoff approach that had limited ling relationship before imposing a untarily committed inpatient was that victims must be readily identifi- duty to exercise control, explicitly released. The Appellate Court able before liability can be imposed state that control is not necessary in 7 reversed the summary judgment opin- on treating psychiatrists. mental health contexts. The dissent ion in part. Both sides appealed to the Based on the facts of this case, as pointed out that this language has not Washington State Supreme Court. well as Dr. Ashby's concession that a been adopted by any State that has The Washington Psychiatric Asso- special relationship existed between considered it. ciation argued in their amicus brief to himself and DeMeerleer, the Court There is no Federal issue here so the Washington Supreme Court that held that the special relationship current Washington Law now impos- the 1987 legislation should apply to requirements were met. Once the the- es what I believe is an unworkable both in both inpatient and outpatient oretical duty was found to exist, the strict liability duty on psychiatrists to settings, and that the broader duty question remained whether the injury somehow protect society in general imposed by the Court of Appeals, was reasonably foreseeable and this is from potential harm, even when no which created a strict liability stan- a question of fact to be decided by the specific threat was made towards any- dard, was both inconsistent with the jury. The Court held that the plain- one. To correct this problem the legislative mandate of 1987 and con- tiff's forensic psychiatrist's affidavit Washington State Psychiatric Society trary to common sense. "created a genuine issue of material could ask for a re-hearing, and failing The Washington State Supreme fact as to whether, based on the stan- that could lobby the legislature to Court ultimately held that under dards of the mental health profession, pass another limiting statue, explicitly Petersen this is a medical negligence the harms experienced by Schiering rejecting the holding in this case. case and not a medical malpractice and her family were foreseeable." The In Maryland, in response to such case under Washington law. The majority relied in part on a misread- potential expansion of psychiatrists' Court noted under medical malprac- ing of Douglas Mossman's paper, The duty to third parties, the Maryland tice the psychiatrist owes a duty to his Imperfection of Protection through Psychiatric Society successfully lob- 6 patient and that Washington does not Detection and Intervention. The bied for legislation that created a duty majority wrote that the paper stood (continued on page 8)

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PRESIDENT’S REPORT

Primary Prevention the potential for tremendous public recovery in forensic mental health care. AAPL Newsletter 42 (1): 18, 33, 2017 continued from page 4 health advances in the mental health and justice systems. 11. Dorkins E, Adshead G: Working with offenders: challenges to the recovery agen- munity forensic mental health.6 A References: da. Advances in Psychiatric Treatment 17: recent encouraging development has 178-187, 2011 been the creation of a forensic hospi- 1. Munetz MR, Griffin PA: Use of the tal version of START NOW (avail- sequential intercept model as an approach to able in the public domain7) from decriminalization of people with serious Sometimes mental illness. Psychiatric Services 57: 544- Robert Trestman and colleagues at the 549, 2006 continued from page 5 University of Connecticut Health 2. Heilbrun K, DeMatteo D, Yasuhara K, et Center, in collaboration with mem- al.: Community-based alternatives for jus- to point out that many of the words I bers of the Forensic Division of the tice-involved individuals with severe mental used in this article, not the highlight- National Association of State Mental illness – Review of the relevant research. ed ones, were once new and different. Health Program Directors (NASMH- Criminal Justice and Behavior 39: 351-419, Finally, many thanks to the printer PD). START NOW uses a cognitive- 2012 of the Newsletter, whom I know is behavioral and motivation interview- 3. Trial Court Community Justice Project going crazy with all my quotes and ing-focused treatment approach to issues report on mental health and addic- ellipses. offenders with behavioral disorders tion. Massachusetts Bar Association and has demonstrated positive out- Lawyers e-journal. December 22, 2016. The Tarasoff Pendulum comes in several correctional https://www.massbar.org/publications/e- studies.8 The hope is that forensic journal/2016/december/12-22/news-from- continued from page 7 clinicians in hospital settings will be the-courts. Accessed January 28, 2017 interested in employing the program 4. Ochoa KC, Simpson JR: To jail or not to to third parties under very limited cir- and conducting evaluation or research jail: trial competency restoration for misde- cumstances, gave explicit instructions on its effectiveness with that popula- meanants. AAPL Newsletter 42 (1): 29, 35 on how to discharge that duty, and 2017 created immunity for mental health tion. START NOW has already been 8 5. Skeem JL, Peterson JK: Major risk fac- professionals who act in good faith. used with good effectiveness in Con- 9 10 necticut in a community program at tors for recidivism among offenders with California and Nebraska have the fifth intercept, involving specialty mental illness" Council of State Govern- adopted similar limiting statutes and probation/parole, case management ments Report. (2011) Available at: Washington State could do the same. http://works.bepress.com/jillian- and clinical supports.9 peterson/21/. Accessed January 28, 2017 References: What we need next is to develop 6. Rotter M, Carr WA: Reducing criminal 1. Volk v. DeMeerleer. Case number 91387- 1, December 22, 2016, Supreme Court of the capacity to utilize the programs recidivism for justice-involved persons with the State of Washington cited by Rotter & Carr and by Trest- mental illness: Risk/needs/responsivity and man with clients in the community http://www.courts.wa.gov/opinions/pdf/9138 cognitive-behavioral interventions. 71.pdf who are not yet (or at least not cur- SAMSHA’s Gains Center for Behavioral 2. Petersen v. State, 100 Wn.2d 421, 671 rently) involved in the criminal jus- Health and Justice Transformation, 2013. P.2d 230 (1983). tice system. I am encouraged by the https://www.prainc.com/wp- 3. Tarasoff v. Regents of Univ. of Cal., 17 current enthusiasm for collaboration content/uploads/2016/02/ReduceCrimRe- Cal. 3d 425,435, 551 P.2d 334, 131 Cal. among the AAPL committees devoted cidRNR.pdf. Accessed January 28, 2017 Rptr. 14 (1976)). to community, hospital and correc- 7. Available at http://health.uconn.edu/cor- 4. Lipari v. Sears, Roebuck & Co., 497 F. tional forensic practice. I am also rectional/programs-and-services/start-now- Supp. 185, 188 (D. Neb. 1980); 5. Petersen, 100 Wn2d. at 428 program/. Accessed January 28, 2017 encouraged at the potential for devel- 6. Mossman D: The Imperfection of Protec- opment of a forensic recovery com- 8. Trestman RL: START NOW: Develop- tion Through Detection and Intervention: mittee within AAPL, under the lead- ment of a Skills-Based Psychotherapy for Lessons From Three Decades Of Research ership of Sandy Simpson.10 I am par- Forensic Psychiatric Hospital Settings. Joint on the Psychiatric Assessment Of Violence ticularly intrigued at the notion Simp- Conference of the Southern States Psychi- Risk. The Journal of Legal Medicine, son cites of the “moral agenda” of atric Hospital Association and the NASMH- 30:109–140, 2009. DOI: recovery for forensic patients – learn- PD Forensic Division, September 3, 2016. 10.1080/01947640802694635 Available at: 7. Restatement (Third) of Torts: Liability ing to live better so as not to re- for Physical and Emotional Harm§ 41 (Am. offend.11 http://www.nasmhpd.org/sites/default/files/S TART%20NOW%20NASMHPD%20Foren- Law lnst. 2012) (Third Perhaps members of these commit- Restatement) sic%20Division%20Presentation_Trest- tees can continue to help develop pro- 8. Courts and Judicial Proceedings, Sec. 5- man.pdf. Accessed January 30, 2017 609 (b), Annotated Code of Maryland grams and training for public mental 9. Frisman L, Lin HJ, Rodis E, Grzelak J: health systems to encourage primary 9. Cal. Civ. Code § 43.92 http://codes.find- Final Report: Evaluation of the ASIST Pro- law.com/ca/civil-code/civ-sect-43-92.html prevention of CJSI. This is an area gram. September 14, 2011 (available upon 10. Neb. Rev. St. § 38-2137 ripe for AAPL members’ leadership in request) http://nebraskalegislature.gov/laws/statutes. education and implementation, with 10. Simpson S: Proposal: A committee on php?statute=38-2137

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ASK THE EXPERTS Ask the Experts 2017 traumatic material, the dosage model, or expressing forensic empathy, con- Neil S. Kaye, MD, DFAPA tributes to symptoms. Often old scars Graham Glancy, MBChB, FRCPsych, FRCP(C) are opened by new material. This is especially the case when other things Neil S. Kaye, MD, DFAPA and Gra- being avoidant. in one’s life contribute to stress and ham Glancy, MB, ChB, FRC Psych, That being said, I also hope that anxiety. One aspect that may be par- FRCP (C), will answer questions each and every one of us is affected ticularly important for forensic psy- from members related to practical by the stories we hear from evaluees chiatrists is the viewing of pornogra- issues in the real world of Forensic regarding their trauma. To fail in this phy in photographic or particularly in Psychiatry. Please send questions to endeavor would be inhuman and video form. In the case of John [email protected]. impede our goal of truly hearing what Bradford, he was involved in a partic- is being expressed during the evalua- ularly gruesome serial murder case, This information is advisory only, for tion. Empathic listening does have a where the victims were video record- educational purposes. The authors role in forensic psychiatry, so long as ed, and 15 years later he was claim no legal expertise and should it is not used inappropriately to dis- involved in two cases that involved not be held responsible for any action arm an evaluee in the effort of obtain- video evidence in quick succession. taken in response to this educational ing information that would not other- The consequences can range from advice. Readers should always con- wise be shared. the full range of posttraumatic symp- sult their attorneys for legal advice. The role of consultation with a col- toms to burnout. Forensic psychia- league to help manage the emotions trists tend to work in isolation and Q. Recently I started doing Compen- stirred up by a specific case can be assess case after case. They may sation & Pension Exams evaluations invaluable. Supervision has been part well be particularly at risk of devel- for Veterans. I’m finding the material of our educational foundation and is oping these syndromes. As well as grueling. How do I manage this? integral to our learning and growth as the well-known symptoms above, this psychiatrists and as forensic scien- can lead to a change in one’s world- A. Kaye: There tists. Discussion with a colleague view, and also to cynicism and lack is no doubt that about your feelings can help you of caring, which are likely protective forensic work can emotionally; it can also help you to mechanisms. frequently entail see the case in a more objective and One particularly interesting aspect emotionally dis- impartial light. arises in child pornography cases. We turbing and drain- discussed this issue amongst our col- ing material. In A. Glancy: If a leagues in Toronto, in our Journal many ways, this forensic psychia- Club. One psychiatrist, Dr Jeffrey is not unlike clin- trist as eminent McMaster, was asked to view a video ical work. One difference is that in and experienced of the kidnapping and sexual assault the clinical setting, dealing with as former Presi- of a young girl. He raised his reluc- transference and countertransference dent of AAPL, Dr tance to view the video with his col- is often part of the therapeutic process John Bradford, leagues, and we all agreed that view- and so it is often acknowledged and acknowledges ing the video would not further his addressed. This is perhaps less com- experiencing sec- understanding of the client or his risk monly confronted in the forensic ondary trauma, rest assured you are assessment. He, therefore, wrote a world. not alone. Dr Bradford has gone pub- letter to the retaining counsel who I think it is important for every lic and lectured on this topic to foren- presented this to the judge. The forensic psychiatrist to be aware of sic psychiatrists and other profession- judge was indignant, making the her/his own sensitive areas, blind als. What you mention is the forme point that he had to view the video, spots, biases, and Achilles’ heels. As fruste of secondary trauma, the first why shouldn’t the forensic psychia- an example, if you are against the sign of this syndrome. Professor trist. Dr McMaster replied that it was death penalty, don’t do capital cases. Cheryl Regehr has researched this repeated exposure to this material, If you are emotionally vulnerable to topic in emergency services personnel which is common for forensic psychi- child issues, you shouldn’t do sexual and has found that 20-50% of these atrists who do these types of cases all abuse cases. I highly recommend workers suffer from secondary trau- the time, that could make one vulner- screening cases before you sign on to ma. It arises when repeatedly work- able to secondary trauma. make sure you can stomach the mate- ing with clients who discuss traumatic Regarding self-care, it is important rial that may be presented. It is events, when the worker is responsi- to try and be aware of the stresses on always better to turn down a case ble for serious outcomes, and often ourselves. It is also important to with which you are not comfortable when the worker is under stress and have a support network, or supervi- than to try to get through it while working alone. Repeated exposure to (continued on page 21)

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CHILD COLUMN Kindertransport: Southern Italian Style valid research - that the program is a success. There are only anecdotal Stephen P. Herman, MD, LFAPA, DFAACAP reports that some of the children do very well, that is, they apparently do Reggio Cal- Since 2012, he has removed over not turn to a life of crime, like their abria sits on the 40 children from their families, with fathers. edge of Italy’s only about 25% transported with their Critics argue the answer is not to “boot,” the Strait mothers. The rest are placed in foster remove the children but to improve of Messina sepa- care. According to Di Bella, none of mental health services and socioeco- rating it from those children has committed a crime. nomic conditions in this very poor Sicily. The region Now, the Italian Justice Ministry has region. For example, out of 83 towns, has a 3,500-year applied this proposal to all of Italy! only two have a social worker. history, first Authorities must prove that the chil- Most of us in this country, I sur- inhabited by Phoenicians, Trojans, dren are at risk for psychological and mise, would find this undertaking Mycenaeans, and other peoples. It physical harm by their criminal fami- appalling. It brings to mind the infa- was an extremely important region lies. mous decision by Supreme Court Jus- when under Greek rule. Under the The radical proposal has been tice Oliver Wendell Holmes, Jr., in Romans, it was called “Rhegium Juli- praised and damned. Even the Magis- Buck v. Bell (274 U.S. 200 (1927), as um,” a noble city. At different times, trate has been ambivalent at times, but cited in Imbeciles: The Supreme it was ruled by the Byzantines, Arabs, reported mob fathers have thanked Court, American Eugenics, and the Spanish, Turkish Ottomans, and him. One father expressed his grati- Sterilization of Carrie Buck, by Adam Napoleon and was overrun by Bar- tude for giving his children “[a Cohen. bary pirates, who enslaved its inhabi- chance] to live in a taintless environ- Buck was the victim of the test of tants in Tripoli. Earthquake-prone, the ment and to live in legality.” He con- the legality of Virginia’s Eugenical region was destroyed several times tinued, “I am proud to grant my chil- Sterilization Act of 1924. Her mother throughout its history and was victim dren a different future.” and daughter were also diagnosed as of a deadly British air raid during The “Ndrangheta” is one of the “imbeciles.” Bell was the superinten- World War II. It has a Mediterranean world’s most successful criminal dent of the Virginia Colony for the climate and is famous for its oranges, enterprises. It spans most of Italy and Epileptic and Feebleminded, in gardens promenades and . . . the its claws extend to South America and Lynchburg. Opened in 1910, it was “Ndrangheta”, the local Mafia. And Australia. In Italy, young adolescents the largest asylum in the United therein lies our story. receive many gifts for their participa- States. The “Ndrangheta” (pronounced n- tion and are encouraged to spend The case moved up the judicial DRAHN-ghe-ta) specializes in a mul- more time with the mob than on their ladder, reaching the U.S. Supreme titude of crimes, from selling “protec- education. Thus, Italian authorities Court. On May 2, 1927, the Court tion,” to shops and other businesses, have argued, the children need to be upheld the Virginia law, 8 to 1. Justice to drug-dealing and infiltrating every forcibly removed from this environ- Holmes wrote: “It is better for all the aspect of government. According to ment. Otherwise, they will end up like world, if instead of waiting to execute an article in The New York Times their lost comrades, imprisoned for degenerate offspring for crime, or to (Feb. 10, 2017), 11-year-old children convictions ranging from minor let them starve for their imbecility, are lookouts during murders, witness offenses to murder. society can prevent those who are drug deals, attend mob “brainstorm- This policy has been both attacked manifestly unfit from continuing their ing” sessions and are trained in using and defended by Italian mental health kind.” He concluded with, “Three Kalashnikov assault rifles. professionals and others. Psycholo- generations of imbeciles are enough.” What could be done? Magistrate gists and social workers are tapped to Carrie Buck was forcibly sterilized Roberto Di Bella had an idea some help these children recover from the four and a half months later. have considered brilliant, and others trauma of being removed from their The Nazis became fascinated with Nazi-like. Why not remove these vul- families and to allow them a “normal” the American pseudoscience of eugen- nerable children from their culture childhood. When they are 18, these ics, and the rest is history. and allow them to grow up to be young adults are free to choose where Is this comparison to the Italian decent, law-abiding citizens? The they want to live – even if it is back plan too outrageous? It is not. When Magistrate said, “Sons follow their in Reggio Calabria. the State becomes involved in the pri- fathers, but the state can’t allow that Mr. Di Bella has asked for govern- vate lives of families, the question is children are educated to become crim- ment funding to hire more specialists who determines how much and how inals.” Minors are removed after to help with the project, now very long? In the U.S., we empower child committing such crimes as gang vio- popular with the Department of Juve- protective services to remove children lence or fire-setting. Some are even nile Justice at Italy’s Ministry of Jus- from their home if they are abused or novice Mafia members. tice. It is assumed – without scientific, (continued on page 12)

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SPECIAL COLUMN Forensic Psychiatrists’ Roles the hockey masked and machete wielding villain kills sexually active in Horror Films teenagers. Wes Craven’s A Nightmare on Elm By Susan Hatters Friedman, MD, Fernando Espi Forcen, MD, PhD, Street also tells the story of a group J.P. Shand, MD, and Praveen Kambam, MD of teenagers who have nightmares Serial killers, “homicidal mani- tise puts him in the realm of The Pro- about a sexually violent predator who acs,” stalkers, the demonically pos- fessor.1 is a burn victim turned “homicidal sessed, Frankenstein and zombies are Turning to the category of The maniac” named Freddy Krueger. This but a few of the characters that cause Activist, here the forensic psychiatrist “psycho-killer” has the special ability to turn dreams into murderous us terror; however, all of these char- inappropriately uses a forensic case to 4 acters have something in common: an advance what he or she personally reality. In a sequel, Dream Warriors abnormal (or “Abbey Normal” – from sees as justice. The Hired Gun offers (1987), Dr. Neil Gordon is a child Young Frankenstein) brain. Losing to sell his or her opinion to the high- and adolescent psychiatrist who takes control of our thoughts and behaviors est bidder, while the Jack of All care of the last survivors of Elm is one of our ultimate fears. As such, Trades, like Alex Cross, engages in Street at the Westin Hills Asylum. Dr. its embodiment has become a staple practices way outside the scope of a Gordon is the only one to identify the in the horror film genre. To rival such real-life forensic psychiatrist. commonality of all the adolescent abnormal brains, we must have the inmates: nightmares about Freddy heroes who can render their power Krueger. In this film, a nun appears in impotent – enter the forensic psychia- a dream-like fashion to the psychia- trists. trist. This nun turns out to be Amanda Movie portrayals of forensic psy- Krueger, the mother of Freddy chiatrists have been categorized as: Kruger who was raped by 1000 psy- Dr. Evil, The Professor, The Activist, chopaths resulting in the evil spawn. The Hired Gun, and the Jack of All This juxtaposition of good and evil is Trades.1 Dr. Evil uses his intellect again exaggerating the idea of this and psychological knowledge to harm black and white duality. This splitting others. Although the prototype Dr. of good and evil psychiatrists is also Evil is Dr. Hannibal Lecter from what we often see in the character of Silence of the Lambs, many earlier forensic psychiatrists – either all characters fall into this category. In good or all bad. the 1920 Cabinet of Dr. Caligari, the Horror films may also be used to titular Dr. Caligari himself is an asy- chastise psychiatrists. In the 2003 lum director who is murderous by film Gothika, Halle Berry plays Dr. proxy.2,3 In the 1933 Testament of Dr. Miranda Grey, who works at a psy- Mabuse, the so-called psychiatrist is a chiatric hospital. Dr. Grey becomes hypnotist who uses his powers to possessed and requires inpatient treat- commit crimes and later goes ment by her former colleague Dr. “insane.” Even in more recent films, Halloween (1978) is the story of Graham. Dr. Grey’s husband (who is we can see Dr. Evil characters, such Michael Myers, who after killing his secretly a serial rapist) is viciously as Shutter Island’s Dr. Cawley sister when he was age 6, is held in a murdered, leaving Dr. Grey as the (played by Ben Kingsley), a forensic forensic psychiatric facility for prime suspect. While hospitalized, psychiatrist at the Ashecliffe Hospital decades thereafter. Myers is in the Dr. Grey befriends a former patient for the Criminally Insane.1 care of Dr. Loomis, a psychiatrist who claimed she had been raped at In contrast, the Professor is por- who in the end saves the day…by night. Dr. Grey learns the rapes— trayed as an omniscient expert, who hunting and eventually shooting his ignored by the psychiatrists as imag- may behave condescendingly or use patient. This forensic psychiatrist who ined claims of patients with mental junk science to explain human behav- also serves the role of hero, detective illness—were real. Psychiatry gets ior. In Alfred Hitchcock’s classic Psy- and marksman is a fine example of a schooled. And all along, the real cho, the forensic psychiatrist Dr. Fred Jack of All Trades. problem (the raping husband) was in Richmond gives a lengthy explana- Following the success of Hal- the psychiatrist’s own home, exploit- tion of Norman Bates’ “mother” over- loween, a number of similar “psycho- ing public fears about psychiatrists. taking Norman’s personality as a dis- killer” horror films were released. In Overall, many forensic psychia- sociative reaction and an explanation these films, sexually active teenagers trists are portrayed negatively in hor- for his murderous behavior. This use are gruesomely slaughtered by a ror films. We find Dr. Evil and The of Dr. Richmond’s (fictional) exper- masked murderer. In Friday the 13th, Professor lecturing about dissociative (continued on page 21)

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FACES OFAPPL Joseph Penn, MD nosed with intellectual disabilities, challenges. “If we don’t maintain substance abuse programs, and its standards,” he says, “poor outcomes Philip J. Candilis, MD historic death row. “Constitutional- and lawsuits will follow. We need level health care is provided onsite system-knowledgeable professionals AAPL’s new and via telemedicine to offenders who know the local community for representative to statewide and across the lifespan,” the best results. For all of us, there is the National Joe says; “to juveniles sentenced as a fine line between good constitution- Commission on adults, pregnant women, offenders al care and care that doesn’t break the Correctional with medical conditions (e.g., requir- bank.” As an examiner for the ABPN Health Care ing dialysis), sex offenders, and those and principal author of AACAP’s (NCCHC) is a with geriatric and neurocognitive dis- juvenile corrections guideline, Joe former Rappeport orders.” brings an academic as well as admin- Fellow who was “Forensics helps us understand istrative perspective to that tension. inspired to join AAPL by long-time roles,” Penn says, “allowing us to see Joe is most proud of his two sons, Ethics Committee chair Philip inmates as patients not just offenders. both currently in college. Oliver, a Merideth. Joe Penn himself has It is a vulnerable population with a senior, is a recording artist, singer and served on the Rappeport selection constitutional right to health care.” song-writer based in Providence. committee at Meredith’s encourage- His challenge, he asserts, is getting Elliot studies history and archeology ment. inmates what they need, not simply at Maine’s Colby College. He is an Born in Austin and growing up what they want. avid fisherman and Civil War re- near San Antonio, Dr. Penn complet- enactor. Joe himself challenges them ed medical school at the University of to competitive tennis matches, and Texas Medical Branch (UTMB). “Forensics helps us subjects his family to his aspirations International childhood OCD expert as a “wannabe DJ.” The home and mentor “Henrietta Leonard iden- understand roles,” Penn playlist is apparently a bone of con- tified ‘forensics’ as a career opportu- says, “allowing us to see tention. nity for me; and I wanted to improve After ten years as AACAP’s repre- my child forensic expertise, explore inmates as patients not sentative to NCCHC, and more recent child custody and parental rights. She just offenders.” chairman of its board, Joe’s broad was the one who nominated me for experience and training make him the the Rappeport fellowship. Phil ideal AAPL ambassador to correc- [Merideth] took it from there,” Penn Dr. Penn works proactively to tions. The Newsletter wishes him recalls. “Phil offered me basic organi- recruit and retain psychiatric staff, set well in his challenging mission. zational advice, fellowship informa- up multidisciplinary policies and pro- tion, deadline alerts, and persistent cedures, teach at the medical school, Kindertransport encouragement.” Then the fellowship improve statewide telemedicine and at Yale beckoned. EMR, and utilize CQI and Lean Six continued from page 10 “After I had done adult and child Sigma processes to improve health training,” Penn continues, “I was care delivery to the prison system. neglected, but then there is court over- ready for a real job, with my two tod- Because Joe’s mother is from Mexi- sight of that removal, and, in most dlers. My wife encouraged us to go co, Spanish is his first language. states, attempts at reunification. Chil- back to Texas.” A faculty position Family still resides in the old country. dren are not automatically removed opened up at Brown, heading the Because the DOC and UTMB are because of their parents’ political development of child and adolescent both ethnically diverse, he is clear beliefs or criminal behavior, as long forensics and juvenile corrections. that the system values his cultural as they are safe and well-cared for. After practicing for ten years in juve- upbringing and sensitivity to the com- Sons and daughters of prisoners often nile corrections, Joe assumed the role munity and its incarcerated popula- visit their fathers and this is not ipso of mental health director for the tion. facto considered a bad influence upon UTMB CMC, a medical school-uni- Joe identifies a number of areas them. versity partnership providing health for AAPL and NCCHC to address in In Italy, alleged mob fathers are not care to incarcerated adults in Texas the near future. The focus is not sim- necessarily convicted before their and in its expansive juvenile correc- ply the disturbing reality that prisons children are removed. The decision is tions system. It is the largest state have become the nation’s default made by judges. There seems to be a correctional system in the US, with mental health treatment centers. presumption that removal will assure 150,000 inmates, 108 facilities, two Restrictive housing, gender dyspho- their psychological safety, when in specialty 550-bed inpatient psychi- ria, HIV, Hep C, offenders with seri- fact, it may cause irreparable damage. atric prison units, several women’s ous mental illness, and an aging Would such a draconian plan ever be facilities, two units for those diag- inmate population provide growing instituted in this country? Let’s hope not.

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SPECIAL COLUMN Terrorism: Uncommonly Common? the mental problems such as depres- sion that are typically found in people Awareness, Approaches & Theories who choose to take their own life.2 It is also difficult to study the Kavita Khajuria, MD prevalence of psychopathology in ter- In 2016, the Globe and Mail dis- ual to adopt a role without considera- rorists, as the only persons accessible played a tidy timeline of disturbingly tion.3 Frustrated, rejected youths may would include those captured or frequent terrorist attacks. A dozen be particularly vulnerable to joining a referred for an evaluation. attacks had occurred in less than a substitute family. Research has been fairly consistent month. It ranged from the Orlando Not all agree with this. Another in finding that serious psychopatholo- attacks by a lone gunman, followed expert found that some tend to be gy or mental illness among terrorists by multiple suicide attacks elsewhere, well educated, from middle or upper is relatively rare, and not a major fac- then by a shootout, stabbings and class professional backgrounds, mar- tor in understanding or predicting ter- standoff in Bangladesh, followed by a ried, and with children.2 rorist behavior. Scholarly reviews by series of suicide bomber attacks in Many believe they have been vic- experts indicate that terrorists are not other countries. What could possibly timized by state authorities and thus pathological, rather, their evidence motivate one to conduct such activity seek revenge.2 The initial attraction is suggests terrorist “normality”, and that violence is perpetrated by ratio- and sacrifice one’s life? often to the group, rather than an 3 Despite the increased frequency of abstract ideology.3 Many recruits live nal people with valid motives. terrorist attacks over recent past in foreign countries in cultural isola- Martens (2004) notes that not all years, terrorism is not new. tion. Group relations and eventual terrorists have ASPD, yet individuals In fact, the history of terrorism is solidarity can create a situation where who become terrorists and persons as old as that of mankind.1 one may follow another’s commit- with ASPD share certain characteris- It is difficult to precisely define ment to terrorism.2 Some believe that tics. These include social alienation, terrorism, given its complexity. It modern communication has brought disturbed early socialization process- originates from the Latin term ter- disrespectful foreign influences, and es, action-oriented stimulus hunger, rere, which means to frighten.2 Defi- that their religious commitment justi- narcissistic attitudes, early damage to nitions include “Violence or the threat fies their extreme actions.2 self-esteem, defensive attitudes, of violence against noncombatants or Most involvement results from shame, fear of dependency, omnipo- property in order to gain a political, gradual exposure and socialization tent denial, escalatory events, particu- ideological, or religious goal through towards extreme behavior which larly confrontation with police, intol- fear and intimidation”1, or, “Acts of occurs in stages (i.e. Stage 1: It’s not erance of criticism, arrogance, dis- violence intentionally perpetrated on right; Stage 2: It’s not fair; Stage 3: dain, superiority, justification of their 3 violent behavior, and moral disen- civilians with the goal of furthering It’s your fault; Stage 4: You’re evil.) 3 some ideological, religious, or politi- An initial sense of dissatisfaction then gagement by dehumanizing victims. cal objective”3 breeds resentment which eventually Core deficits in psychopaths would finds a target onto which to direct the likely impair their effective function- Theories frustration. ing in a terrorist role. Terrorism, like A number of theories attempt to any other serious undertaking, explain terrorism, and range from Suicide Attacks requires dedication, perseverance, and a selflessness, many qualities of early abuse and hostility towards Suicide attacks have increased and 3 one’s parents, to frustration and the attackers view their act as martyr- which are lacking in the psychopath. aggression, low serotonin levels, an dom. Families and communities may inability to generate nonaggressive see the act as heroic and support the Personality Abnormalities & solutions to conflicts, and a perceptu- behavior.3 Profiling al hypersensitivity to interpersonal Suicide attackers tend to display a “The outstanding common charac- teristic of terrorists is their normali- cues. heightened sense of purpose, group 1 allegiance, and task focus.2 ty” and “Most terrorists are ‘normal’ in the sense of not suffering from Motives, Ideology and Pathways to 1 Radicalization Relation to Mental Illness psychotic disorders”. There is no ter- The need for identity, belonging, Mental health experts have long rorist personality, nor is there any and a sense of perceived injustice are tried to explain deviant behavior. accurate profile. Despite the lack of prevalent factors. In reality, psychopathology has significant psychopathology in the An overwhelmed adolescent may proven to be only a modest risk factor perpetrators, the psychological effects seek to define his/her identity through for general violence, and all but irrel- are far reaching, thus attempts to group membership. A quest for per- evant to understanding terrorism.3 understand and address this phenome- sonal meaning may push an individ- Suicide bombers exhibit few signs of na will likely continue. (continued on page 31)

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FELLOWS CORNER The Goldwater Rule: matizing, and definitely unethical.” Proponents of the Goldwater rule The Tide Is Rising argue that it continues to serve impor- tant interests. Namely, it prevents the Matthew P. Lahaie, MD, JD direct impact on a non-consenting On January tor Goldwater subsequently sued the individual of a publicly made diagno- 28th, 2017, US magazine’s publisher for libel, ulti- sis. The rule prevents diagnoses that News & World mately winning $75,000 in damages. are inaccurate or without sufficient Report quoted In response, the APA in 1973 basis, as these diagnoses may be psychologist John adopted Section 7.3 in the Principles made without conducting an evalua- D. Gartner’s pro- of Medical Ethics with Annotations tion and typically are based solely on fessional opinion Especially Applicable to Psychiatry, information in the public domain. that President which states: Further, professional discussion of Donald Trump public figures’ mental health may has “malignant narcissism,” an incur- On occasion psychiatrists are erode the public’s expectation of con- able condition different from narcis- asked for an opinion about an fidentiality and confidence in psychi- sistic personality disorder. Dr. Gartner individual who is in the light of atry as a field. Such diagnoses may stated that although he had not per- public attention or who has dis- further stigmatize mental illness and sonally examined the president, he closed information about him- discourage individuals with mental had made this diagnosis by deriving self/herself through public health issues from fully participating his conclusions from observed behav- media. In such circumstances, a in civic and political life. By avoiding ior. Although he recognized the ethi- psychiatrist may share with the making such diagnoses, practitioners cal standard of the Goldwater Rule, public his or her expertise about avoid the pitfalls of parsing their Gartner stated the case of the presi- psychiatric issues in general. political and professional views. dent warranted a departure from it. However, it is unethical for a Advocates of reconsidering the This episode is the most recent in psychiatrist to offer a profes- rule argue that ethical principles may a season littered with mental health sional opinion unless he or she conflict, such as the interest in public professionals making statements has conducted an examination service and education versus respect about political figures’ mental health. and has been granted proper for a public figure, and in some cir- With so many of our colleagues hav- authorization for such a state- cumstances the “duty to warn” may ing recently proffered professional ment. override other considerations. Rather opinions publicly, has the Goldwater than diagnose the “whole person,” Rule lost its relevance? Yet, many psychiatrists and psy- assessments may be limited to the The Goldwater Rule originated chologists have offered diagnoses and public persona and public behaviors from the 1964 presidential election, psychological profiles of public fig- of an individual. Given the modern when Fact magazine surveyed over ures, both past and present. Those media’s abundance of primary 12,000 psychiatrists about GOP can- discussed have included past Ameri- sourced information, the public didate Senator Barry Goldwater’s can presidents, such as Lincoln, John- domain may offer sufficient informa- psychological fitness for the presiden- son, Nixon, and Clinton. More tion to draw reasonable conclusions cy. While some psychiatrists protest- recently, psychologist William Doher- about an individual’s public persona. ed that a response would be unethical ty at the University of Minnesota in Direct evaluation may not be neces- and others offered nuanced political June 2016 posted an online manifesto sary in many circumstances. Finally, views without psychiatric opinions, to oppose the president’s election, advocates for reconsideration note over 1,100 respondents indicated that which was signed by many mental that psychiatrists, like others, should Goldwater was unfit to serve as presi- health professionals. Psychiatrists Dr. be able to participate in civic and dent. Some claimed Goldwater had Steven Buser and Dr. Leonard Cruz political life, and that commenting on severe personality defects, including published their book “A Clear and the strengths and weaknesses of a paranoia and grandiosity. Others Present Danger: Narcissism in the Era public persona may be a part of this. opined that he had a psychosis or that of Donald Trump,” which they argued Psychiatrists and psychologists as he was striving to prove his “manli- did not offer any specific diagnoses, citizens have the right to comment on ness.” Although the American Psychi- but rather discussed the traits of the elections and candidates, while avoid- atric Association (APA) had no rele- president’s projected image. Given ing statements regarding diagnostic vant formal policy in place at the the public discourse, Dr. Maria A. impressions. But does the Goldwater time of the survey, it objected to the Oquendo, President of the APA, in Rule leave us with enough guidance? publication of the survey. Despite the August 2016 published a reminder to Is it fatally flawed? Are other existing APA’s opposition, Fact magazine the field that “breaking the Goldwater ethical tenets sufficient? Should we published the article. An upset Sena- Rule is irresponsible, potentially stig- dispense with the rule as our col- (continued on page 29)

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AAPL GOES INTERNATIONAL

Asia Pacific IALMH a brief overview of the mental health laws and services in Vietnam. Jagannathan Srinivasaraghavan, MD Trainees had ample opportunities to interact with the speakers. One The first Asia Pacific conference of Psychiatry indexed with PubMed evening there was fabulous fusion of the International Academy of Law and covered in Science Citation music of classical Indian instruments & Mental Health (IALMH) was held Reports (JCR) and Theme-Forensic and keyboard describing a bipolar in Bangalore, India from December Psychiatry Update was released by patient in a musical depiction fol- 15-17 2016. There were 46 presenta- Prof. Phillip J. Resnick at the inau- lowed by dinner. tions spread over three days of the gural session. The valedictory session at the con- conference. The first day was devoted AAPL was well represented clusion was presided by a High Court to continuing medical education pro- among the speakers. Professor judge and the speakers included the gram for psychiatrists, psychologists, Resnick delivered two lectures, one Health Minister of Karnataka. There social workers and other mental on training in forensic psychiatry and was a lot of interest expressed about health professionals. Appropriately another on child homicides by par- further developing this field as well the first day the meeting was held at ents, Steven K. Hoge presented on as forming an interest group. The the MVJ Medical College. The next competence to stand trial, Charles conference was covered in press and two days of the meeting was held at Scott on malingering (video), a YouTube video is also made. The the National Institute of Mental Navneet Sidhu on death penalty, organizers Drs. Gopalakrishnan, Health and Neurosciences, a premier Manish Pozdar on neuroscience and Chandrasekar, Sudhakar and the post- institution in India. There were 584 forensic psychiatry, Angeline Stanis- graduate students deserve a lot of delegates mainly from India and there laus on risk assessment in sex offend- credit and if forensic psychiatry were some from Vietnam, United ers and Jagannathan Srinivasaragha- becomes a specialty course in India, States, Ireland, Canada and Australia. van on boundary violations. Further AAPL can be proud to have played a The conference was organized by Dr. US-based Anand Pandurangi and significant role. Gopalakrishnan and his colleagues Antony Fernandez (AAPL member) who excelled in their hospitality and who were alumni of NIMHANS also taking care of the international speak- presented. In fact, presentations by ers. AAPL members brought a lively dis- The conference was inaugurated cussion about the possibility of start- by Honorable Justice Gopala Gowda, ing a Fellowship in Forensic Psychia- Retired Judge of Supreme Court of try (In India it is mentioned as super India. In his inaugural address, he specialty). traced mental health legislation since Brendan Kelly of Ireland talked 1912 until the recent Mental Health about mental illness and human Act and stressed the importance of rights. Julian Gojer of Canada pre- human rights of the mentally ill. The sented on neuropsychiatry of sex co-sponsors of this conference name- offenders. There were excellent pre- ly, The World Psychiatric Association sentations by Indian psychiatrists, (WPA) represented by Prof T.V. psychologists, lawyers, journalists Asokan (Zonal representative), The as well as other stake-holders. The Indian Psychiatric Society (IPS) rep- five member Vietnam delegation gave Traditional honoring of Dr. Van resented by Prof G. Prasad Rao, The World Association for Psychosocial Rehabilitation (WAPR) represented by Prof T. Murali, National Institute of Mental Health and Neuro Sciences (NIMHANS) represented by Prof. S.K. Chadurvedi (Dean) and The Indian Psychiatric Society, Karnataka Chapter, represented by Dr. Mahesh Gowda, were present and offered felicitations. I was humbled by the honor of a silk shawl and a Maharaja turban (headgear) for representing the IALMH and arranging all internation- al speakers for the conference. A spe- cial supplement of the Indian Journal Anand Pandurangi, Ashok Van, Phil and Lois Resnick (photos submitted by Dr. Van)

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ALLABOUT AAPL COMMITTEES Ethics at the Women’s March Philip Candilis, MD, Navneet Sidhu, MD, Ethics Committee As we return from the Women’s March on Washington, we reflect on the state of feminism in our communi- ty and our profession. Among the rolling cheers, festive atmosphere, and colorful signs were issues from across the country and across constituencies. Groups from Alaska, Maine, Florida, Ohio and elsewhere represented uni- versity women, human rights advo- cates, social workers, psychoanalysts, and physicians. Republicans and pro- lifers attended alongside Planned Par- enthood and the National Organiza- tion for Women (NOW). A sense of humor was evident in the seriousness of the day: Dumble- dore’s Army had a presence, as did a “congregation” citing Fallopians 1:2. One man walked quietly carrying a sign proclaiming simply, “My wife is pissed.” But it was a theme from the dais and NOW that caught our atten- among persons with disabilities, per- Ezra Griffith’s cultural formulation tion most of all. sons of color, or any non-dominant provided a more inclusive view of our Trans advocate Janet Mock spoke group mistreated in court or in legisla- professional mission. Although the to the crowd of an intersectional tion. However, it also advances the view of dominant and non-dominant movement that included persons from classic dominant-nondominant dis- groups may ultimately give way to the all sectors of society – even those tinction to a language of humanity in importance of perspective in general, who are not oppressed by societal general – toward an understanding of it is this broad inclusiveness that mores. Those unaffected by aggres- inequality that covers all those who moves our field toward a more unified sive political trends can still fall vic- are or may become marginalized. professional vision. tim to a kind of rigid thinking that Because we forensic practitioners Recognizable in AAPL President perpetuates inequality and social work consistently with marginalized Michael Norko’s search for truth, in injustice, she said. and stigmatized groups, intersectional- Alec Buchanan’s work on human ity should resonate strongly for us. rights in forensic practice, or in Rick Coined by law professor Kimberle Martinez’ and my claim that we serve Crenshaw in 1989, the term “intersec- social justice rather than justice alone, “It was important to tionality” was an effort, in her words, intersectionality again aligns us with recognize that discrimi- “to make feminism, anti-racist movements that are apparent on the activism, and anti-discrimination law world stage. If human rights and truth nation intersected the do what I thought they should — weren’t quite concrete enough to highlight the multiple avenues unify our professional mission before, lives of many people...” through which racial and gender perhaps intersectionality at marches oppression were experienced so that across the globe provides a goal that At the same time, NOW brought the problems would be easier to dis- is both tangible and topical. signs saying only, “intersectional fem- cuss and understand” (The Washing- inism.” In the crowd, a professor from ton Post, Sept. 24, 2015). It was RECENTLY MOVED OR Florida spoke with us about what that important to recognize that discrimi- CHANGED YOUR EMAIL meant. nation intersected the lives of many ADDRESS? Intersectionality is about more than people, particularly because even a single group’s identity or politics; it social movements could leave some Please update the Executive Office moves beyond gender and individual groups behind. with your current contact rights. This inclusiveness recognizes This is an approach that has been information at 800-331-1389 or [email protected]. oppression wherever it exists, whether evident in forensic psychiatry since

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ALLABOUT AAPL COMMITTEES Sex Offender Registration tionate to the crime, or shocking to a reasonable person. Requirements Blankenship’s appeal to higher courts rested on the court-appointed Megan Testa, MD psychologist’s opinion. Blankenship As a forensic psychiatrist who pro- as courts are not permitted any dis- argued that he had been evaluated by vides outpatient psychiatric care to cretion to apply sex offender designa- a professional who stated that he was people with mental illness who are on tion in a case-by-case manner. not a sex offender. He argued that probation and parole, I care for many During pre-sentencing investiga- because he was engaged in a “caring” individuals who are required by law tion, Blankenship was ordered to par- relationship with the victim of his to register as sex offenders. When I ticipate in a psychological evaluation. crime and a psychologist had opined sit with my patients and hear about After interviewing Blankenship, the that he presented a low risk of reof- the effects that the stigma of sex evaluating psychologist opined that fending, imposing Tier II registry offender designation has had on them Blankenship “lacked the characteris- requirements on him was “grossly as they have been working to put tics of what he considered to be a sex disproportionate to the nature of the together lives for themselves in their offender,” and that he posed a low offense and the character of the communities after release from jail or risk of sexual reoffending. After the offender,” thus constituting cruel and prison, I often wonder about the fair- evaluation was completed, but before unusual punishment. ness of the current system that his sentencing hearing, Blankenship Blankenship’s case was heard by requires automatic classification of contacted the victim of the offense the Second District Court of Appeals. individuals convicted of “sexually and was dishonest with the evaluating In a 2:1 decision the court affirmed oriented offenses” as sex offenders. psychologist about having done so. the trial court, deciding that Blanken- In 2015 the Ohio Supreme Court The psychologist reevaluated ship’s sentence did not violate the became the first state Supreme Court Blankenship. He did not change his constitution. Blankenship then to consider whether their state’s sex opinion after the second evaluation, appealed to the Ohio Supreme Court. offender registry violated an individ- and the court moved forward with The Ohio Supreme Court heard ual’s constitutional rights by violating sentencing. Blankenship’s case. An opinion was the Eighth Amendment’s protection Blankenship was sentenced to six issued on November 12, 2015. The against cruel and unusual punish- months in jail followed by five years court affirmed the lower courts in a ment. of community control. He was 4:2 decision. Travis Blankenship was a 21-year released after serving twelve days of The majority opinion was written old man when he began chatting over his jail sentence. Upon release, by Justice O’Connor. Justice French social media with a 15-year-old girl. Blankenship was automatically desig- concurred, and Justices O’Donnell After developing a relationship nated a Tier II Sex Offender by the and Kennedy concurred in judgment online, Blankenship met the girl in state of Ohio. State law required that only. Justice O’Connor acknowl- person and engaged in consensual upon release from jail Blankenship edged that sex offender designation sexual intercourse on two occasions. register at his local Sheriff’s office. was a punishment, rather than a civil He was fully aware of her age at the He was required to make his home, requirement, as applied by the state of time of the acts, and legal charges work and school addresses publically Ohio. She stated in her opinion that, followed. Blankenship was charged accessible on the sex offender reg- simply as a matter of law, Blanken- with engaging in sexual acts with a istry, and to verify his identity and the ship’s conviction itself made him a minor between the ages of 13 and 16, accuracy of this information in person sex offender, regardless of the opin- in violation of ORC 2907.04, a sexu- with the sheriff every six months for ion of any mental health professional. ally oriented offense. Because he the subsequent 25 years. Blanken- She noted that Blankenship’s reliance was more than four years older than ship appealed his case, stating a claim on the psychologist’s opinion was the minor, his charge was a felony of that Ohio’s Tier II sex offender reg- improper because Ohio law applied the fourth degree. In addition to pun- istry requirements violated his eighth sex offender/child victim offender ishments such as incarceration, fines, amendment constitutional rights. designation as an automatic conse- and community control, Blankenship By seeking to convince an appeals quence for individuals convicted of was subject to automatic designation court that his sentence constituted crimes that were statutorily defined as as a sex offender/child-victim offend- cruel and unusual punishment, sexually oriented offenses. She stated er in the state of Ohio. In Ohio’s Blankenship’s attorneys faced a high that the Tier II registration require- automatic tier-based system, Blanken- burden. In order to succeed with ments did not rise to the level of ship would automatically be designat- their claim of Eighth Amendment severity required to find the punish- ed a Tier II Sex Offender if found violation, they had to prove that the ment cruel and unusual. Finally, she guilty of the offense, without any punishment that was imposed was so stated that Ohio’s sex offender reg- evaluation of his risk of reoffending, extreme that it was grossly dispropor- istry had penological justification as a (continued on page 31)

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PHOTO GALLERY

Jennifer Piel and Deborah Kushner Kip Thompson and Britta Ostermeyer stop for a chat

Lt. Barton, Gregg Dwyer, Karen Rosenbaum, and Paul Federoff at Dick Krueger, Mike Norko, and Rocksheng Zhong (2106 Rappeport their Internet Crimes Against Children presentation Fellow) enjoy their meal

Judy Faulkner, Renee Binder, Larry Faulkner, and Jackie Coleman Charles Scott, Richard Frierson, and Peter Ash catch up over a glass catch up of wine

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PHOTO GALLERY

AAPL members enjoying the reception John Young (center) and Charlie and Barbara Meyer

Rick Martinez and Saul Faerstein at the reception Philip and Nancy Margolis with friends

Learning at the AAPL meeting Nathan Kolla catches up with Eugene Lee Photo Credits: Eugene Lee, MD and Andrew Kaufman, MD (continued on page 35)

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ALLABOUT AAPL COMMITTEES Carolina and have similar legislation Transgendered Patients and the Law: in varying stages of progress: Ken- An Update tucky, Missouri, Minnesota, Washing- ton, South Carolina, Virginia, and Aimee Kaempf, MD, Gender Issues Committee Texas. Of these states, the Texas Rough estimates are that about have laws against discrimination State Bill 6, is thought to be the most 0.3% of the US population, or almost based on gender identity. While it likely to make it from a bill into law 700,000 individuals, identify as trans- may not be illegal to discriminate given the political climate in Texas at gender. As there grows awareness of against a transgender individual, this time. Kentucky’s bill is similar the needs of transgender individuals depending on the state in which you to Texas’ bill, and the Virginia bill in terms of health care, and legal pro- reside, many organizations have poli- has a unique stipulation that would tections, states and government have cies that prohibit discrimination based require school officials to “out” any students who came out as transgender moved to institute policies – some on gender identity, and violations of 5 protective and some discriminatory. policy could result in termination at school to their parents. Given all the recent changes, this arti- from one’s job. cle will summarize the up to date Treatment Options and Payment for information. Bathroom Access Gender Transition The three primary topics that legis- In 2016, North Carolina’s governor The process of transitioning can be latures and government entities are signed House Bill 2, commonly expensive. Treatment, as recommend- addressing are 1) general discrimina- known as the “bathroom bill.” The ed by organizations such as the World tion statutes, 2) bathroom access, and bill specified, among other things, Professional Association for Trans- 3) treatment options/payment for that people must use public accom- gender Health, includes hormone medication and surgery for transition modations based on the biological sex medication, living in one’s gender to the identified gender. that is identified on their birth certifi- role, and mental health counseling. cate, meaning that transgender people While coverage for hormonal and General Discrimination Statutes cannot use the bathroom of the sex mental health treatment has been The Civil Rights Act of 1964 and with which they identify, even if they more prevalent, recently gender tran- Title IX substantiate the federal laws no longer physically resemble the sex sition surgery is getting the green regarding discrimination in the work- on their birth certificate. Not only light from government and private place and education, respectively. The was the signing of this bill controver- entities as a covered and medically Civil Rights Act of 1964 dictates that sial among residents of North Caroli- necessary treatment. For example, the it is illegal for an employer to “fail or na, but it led to more consequential US military began to provide this for refuse to hire or to discharge any action. The Department of Justice its active duty members as of October individual, or otherwise to discrimi- advised Governor Pat McCrory that 2016. The Pentagon spokesperson, nate against any individual with HB2 likely violated the Civil Rights Ben Sakrisson, was quoted in Sep- respect to his compensation, terms, Act of 1964. President Obama said tember as stating, "The Secretary of conditions or privileges or employ- HB2 violates Title IX and issued Defense has made clear that service ment, because of such individual’s guidance that students in public members with a diagnosis from a mil- race, color, religion, sex, or national schools should be allowed to use the itary medical provider indicating that origin.”1 Title VII of the Act created bathroom corresponding to the gender gender transition is medically neces- the Equal Employment Opportunity with which they identify. The federal sary will be provided medical care and treatment for the diagnosed med- Commission (EEOC) to implement government sued North Carolina, and 6 the law. North Carolina then sued the federal ical condition.” Title IX of the Education Amend- government.3 The NBA All-Star Similarly, earlier this month, a ments Act of 1972 states that “no per- Game was set to be held in Charlotte California prison inmate was the first son in the United States shall, on the but was moved to New Orleans in to undergo gender reassignment basis of sex, be excluded from partic- protest of HB2. Several large compa- surgery, paid for by the state. This ipation in, be denied the benefits of, nies, including PayPal, halted plans to came about after a settlement or be subjected to discrimination expand in North Carolina after the between a transgender inmate, Shiloh under any education program or bill was signed, Bruce Springsteen Quinne, and the Department of Cor- activity receiving Federal financial canceled a major concert, and the rections. The terms of the agreement, assistance.”2 state lost other NCAA and ACC col- which occurred in 2015, included the Although these laws clearly state lege sports events. Economists pre- fact that prisoners seeking gender that discrimination based on sex is dict that HB2 has cost North Carolina reassignment surgery would be evalu- illegal, there are no federal laws that upwards of $400 million in lost rev- ated by medical and mental health extend this protection from sex to enue and legal fees.4 experts and present their cases to a gender identity. However, 22 states Other states have followed North committee, who would vote on (continued on page 21)

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ALLABOUT AAPL COMMITTEES

Transgendered that the questioner only raised the fact continued from page 20 that he found the material grueling. I have used this as a springboard to dis- whether the surgery was warranted. cuss more serious manifestations of Individuals would also have to live workplace stress, with vicarious for a year in their preferred gender PTSD the extreme version of the 7 roles and undergo hormone therapy. spectrum. For private citizens, certain com- panies (Google, for example) and pri- Take Home Points: vate insurance companies are begin- Early intervention is vital so we ning to offer this option. A number of must give credit to the insightful col- foundations have funds set up to help league who raised this issue, prompt- individuals pay for this treatment. ing this article. We would encourage Some states have begun making all of our colleagues to be so honest changes as well to their Medicaid References: and open, so that early recognition, programs, following a ruling in 2016 acknowledgement, and help seeking by President Obama and the Depart- 1. https://www.archives.gov/education/ lessons/civil-rights-act will avoid more serious mental health ment of Health and Human Services 2. https://www.dol.gov/oasam/regs/ issues. that pressures insurance companies statutes/titleix.htm and federal programs like Medicare 3. http://www.theatlantic.com/politics/ Horror Films and Medicaid to cover gender reas- archive/2016/05/hb2-is-a-constitutional- signment surgery. monstrosity/482106/ continued from page 11 A spokesperson for the Department 4. https://www.wired.com/2016/09/ of HHS stated that "The final rule guess-much-anti-lgbtq-law-costing-north- identity, and The Jack of All Trades does not require covered entities to carolina/ shooting his own patient. As well, cover any particular procedure or 5. https://www.theatlantic.com/politics/ forensic psychiatrists can be seen to treatment for transition-related care, archive/2017/01/states-see-a-new-wave-of- have lessons of their own to learn, including gender reassignment transgender-bathroom-bills/512453/ and to be causing danger to society surgery. However, it does bar a cov- 6. http://www.military.com/daily- by being ignorant of dangers in their ered entity from categorically exclud- news/2016/09/21/pentagon-pay-for-some- own home. Concerns have been ing from coverage or limiting cover- sex-change-operations-transgender- raised about horror films increasing age for all gender transition-related troops.html stigma towards people with mental services."8 7. http://www.reuters.com/article/us-califor- illnesses, [3] but these films also neg- For example, in November, a Min- nia-transgender-idUSKBN14R01Q atively portray forensic psychiatrists. nesota district judge ruled that a pro- 8. http://www.newsmax.com/Politics/oba- On the bright side, the Jack of All hibition on the use of public funds for macare-Traansgender-surgery-sex- Trades can save the day, unlike those sexual reassignment surgery is uncon- changes/2016/05/14/id/728819/ of us real-world forensic psychia- stitutional. Because Medicaid is trists… administered by states, the regulations are as different as there are different Ask the Experts REFERENCES: states. Yet for many transgendered continued from page 9 1. Friedman SH, Cerny CA, Soliman S, individuals, gender reassignment West SG. Reel forensic experts: forensic surgery remains an expensive and sion, or a team approach, where one psychiatrists as portrayed on screen. J Am often out of reach medical treatment can voice and share these concerns Acad Psychiatry Law. 2011;39:412-417. and it is unclear how these provisions and symptoms. It is also important to 2. Friedman SH, Forcen FE, Shand JP. Hor- and regulations will change moving attempt to diversify one’s practice to ror films and psychiatry. Australas Psychia- forward with the new administration. decrease the dosage of exposure. try. 2014;22(5):447-449. Additionally, the usual modes of self- 3. Shand JP, Friedman SH, Forcen FE. The Concluding Thoughts care, involving avoidance or reliance horror, the horror: stigma on screen. Lancet Psychiatry. Overall, it appears that there is on alcohol or drugs, healthy eating 2014;1(6):423-425. 4. Forcen, FE, Monsters, Demons and Psy- mixed progress with respect to legal and sleeping, and living a balanced chopaths: Psychiatry and Horror Film. protections and health care access for lifestyle are a sine qua non for main- CRC Press. New York: 2016 transgendered individuals in this taining one’s equilibrium. It is also country. It will be important to main- important to use resources, possibly tain awareness and see the direction in the form of mindfulness and medi- this moves in the new administration. tation, or possibly psychotherapy, and even pharmacotherapy if necessary. In the particular case above, I realize

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ALLABOUT AAPL COMMITTEES What’s in a name? Deciphering the alcohol.7 These distinctions play an important role, as an offenders dispo- meaning of the word “addiction” sition or a plaintiff’s case can hinge, at least in part, on a finding of an Elie Aoun, MD, Adam Fusick, MD, Ryan Wagoner, MD, Addiction Committee addiction. Today, people all over the world heading.2 This set of diagnoses were The legal distinction between addicts non-addict drug users search for the definition of words in defined by their undesirable conse- and different ways, from the classic paper quences to the functioning of society often assumes a model of varying dictionary to electronic search and the individual’s inability to con- degrees of substance use severity, engines. However, in the field of form with cultural norms. The term which was previously paralleled in substance abuse substance depen- forensic psychiatry, words can often was dropped from DSM-III and fur- the / dence have different meanings based on the ther revised in DSM-III-R, presenting dichotomy. Several states pre- addiction context, particularly if a legal defini- a different model of addictive disor- viously conflated the term substance dependence, tion is required. This can become ders that did not include the term with which was a well-defined clinically recog- even more challenging when a clear addiction, by introducing a distinc- 8 legal definition is difficult to find, as tion between substance abuse and nized diagnosis. in the case of the word “addiction.” substance dependence diagnoses.3,4 The previous scheme used by The multitude of descriptive terms The DSM-5, released in 2013, some states is now hampered by the referring to individuals with maladap- eliminated this distinction in favor of changes in the DSM-5. When sub- tive patterns of alcohol or drug use a single substance use disorder diag- stance dependence is no longer a include: addiction, substance use, nosis, with the severity determined by diagnosis, what clinical definition do substance dependence, and substance the number of symptoms present that you use and how does it is interact addiction use disorders. These terms are often meet criteria.5 The DSM-5 comments with the term ? One pro- used inconsistently in legal settings, that the term addiction, while not a posed model has been to relate sub- stance dependence and certain levels which further complicates an already diagnosis, is commonly used to 8 murky issue. describe severe problems related to of substance use disorder. This idea The term “addiction” comes from compulsive and habitual use of sub- is based on epidemiological research the Latin verb addico, meaning “giv- stances. showing greatest concordance between the old and new classifica- ing over.” In Roman law, the related Although the clinical definition of 9 term addictus was used to refer to addiction has evolved over the years, tion. One method would include set- severe substance use disorder individuals who failed to pay their the legal definition has moved at a ting as debts and were given over as bond more varied and inconsistent pace. the equivalent to the previous diagno- substance dependence, slaves. Its application to illicit sub- One major problem with diagnosing sis of as this stances and substances of abuse dates an individual with an addiction is that would likely result in higher interrater reliability and validity for expert back to the 1800’s, in the midst of it is not a clinical term defined in the 10 increasing anti-opium rhetoric.1 DSM-5. Furthermore, the courts and opinions. Another consideration moderate severe Today, it comes up in multiple areas legislatures have been reluctant to would be to use and of the legal system, including both provide a clear definition of addiction when equating the new definitions to dependence. criminal and civil cases. For exam- and have instead relied upon varied However, roughly one ple, in criminal cases, a person with methods for clarifying the meaning. fifth of individuals who used to meet an addiction can sometimes be divert- These different methods result in cri- substance dependence criteria would not meet the moderate to severe sub- ed to specific services available for teria that often vary from state to 11 treatment. In civil cases, this term state and can be based on a multitude stance use disorder diagnosis and can be a factor in litigation, running of factors, including severity and/or would not benefit from certain legal the gamut from personal injury to duration of symptoms, presentation or protections in some states. The child custody to product liability. behavior and even the type of sub- National Institute of Drug Abuse The psychosocial and scientific stances used. Illinois, for example, (NIDA) and other agencies use a nar- progress in understanding the phe- specifically excludes alcohol use rower definition of addiction repre- sented by severe substance use disor- nomenological and neurobiological when the state defines the term addict 12 aspects of addictions may provide and instead lists separate criteria that ders only, which would exclude some insight on the perceived incon- must be met for an individual to suf- even more individuals previously sistencies in definitions. Addiction is fer from alcoholism.6 New Jersey, on diagnosed with substance depen- listed as Alcoholism (addiction) and the other hand, uses the term depen- dence. With either model, the previ- addiction Drug addiction in the first edition of dence instead of addiction, but ous practice of equating substance dependence the DSM and included in the person- employs uniform criteria for all sub- and is no ality disorders section under the stances an offender could use and longer as easy as it once was. Sociopathic Personality Disturbance does not specifically exclude (continued on page 31)

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ALLABOUT AAPL COMMITTEES Legalizing It: New Marijuana Laws tion, memory, and executive func- tion.5, 8, 9 Many of these decrements and Adolescent Mental Health in performance were correlated posi- tively with the lifetime amount of Marc Heiser MD, MPH cannabis use and were more pro- In the November 2016 elections, case. In Colorado, pooled data com- nounced in those persons who began voters in California, Maine, Massa- paring use among 12-17-year-olds in use earlier in life. chusetts, Nevada, and the District of 2012-13 (pre-legalization) to 2014-15 There is mounting evidence that Columbia passed ballot measures that (post-legalization) demonstrated a adolescent cannabis use is associated legalized the production and use of small decrease in past-year use with the development of psychiatric recreational marijuana. This followed (20.81% to 18.35%, p=0.092) and a disorders and worse socioeconomic similar legislation enacted in Col- small but not statistically significant outcomes in adulthood. Meta-analy- orado, Washington, Oregon, and decrease in past-month use (12.56% ses of longitudinal studies have con- Alaska. As a result, a total of 26 to 11.13%, p=0.265). However, these firmed that there is an increased risk states and the District of Columbia rates were among the highest in the of psychosis in people who have used now allow for marijuana use in some country (1). Rates of use among tran- cannabis, with a “dose-response” effect apparent and an earlier age of form, either recreationally or medici- sitional age youth (18-25) were 10-12 nally. Despite this, the federal Con- unchanged during this period (~31%) onset of illness. A number of lon- trolled Substances Act classifies while adults’ rates of use increased gitudinal studies also suggest that tetrahydrocannabinol (THC), the (12.45% to 14.65%). It should be adolescents who use or have used main psychoactive ingredient in mari- stressed that this data is very prelimi- cannabis are more prone to develop depression and anxiety than adoles- juana, as a Schedule I substance, nary and the true impact of these laws 13-15 meaning marijuana is illegal to pro- on marijuana use in adolescents cents who do/have not. Although duce and possess. Under President remains to be seen. these studies indicate that cannabis Obama’s administration, the federal One major concern is that these use during adolescence is associated government generally did not enforce laws essentially create a for-profit with an increased likelihood of mood, these regulations and override state industry that will benefit from heavy anxiety, and psychotic disorders, it is marijuana laws, and it seems unlikely use that begins at an early age and not currently known whether that the new administration will that will therefore market marijuana cannabis use causes the disorders or attempt to eliminate a now $6.8 bil- to youth and encourage the social whether the disorders (or early mani- lion industry that has the support of normalization of regular use (a strate- festations thereof) predispose children most Americans (60% of Americans gy utilized by the tobacco industry).3 to use cannabis. Adolescents are also more susceptible to becoming depen- support legalization, according to a It is easy to imagine the appeal of 16 2016 Gallup Poll). Although these various edible marijuana products dent on marijuana than adults. laws prohibit cannabis use by minors (such as lollipops) to youth, and there Finally, multiple longitudinal studies (most prohibit use by those under 21 has already been a significant indicate that more frequent use of years of age), the impact of the legal- increase in emergency department cannabis during adolescence is corre- ization of recreational marijuana for visits by children in Colorado for lated with an increased likelihood of adults on use by children and adoles- ingestion of THC-containing edibles.4 leaving school without a degree, a cents remains unknown. Adolescence is a critical period of lower income, greater dependence on Marijuana is already the most structural brain development, and welfare and unemployment, and lower life satisfaction as an adult.5, widely used illicit drug in the United environmental exposures, such as 17-19 States with 44% of people age 12 or cannabis use, may alter the course of Together, these data demonstrate older reporting lifetime use.1 Accord- this process and ultimately have the importance of limiting the expo- ing to the 2015 National Survey on behavioral and psychiatric implica- sure of adolescents to marijuana and Drug Use and Health, 7% of 12-17- tions. Acute psychiatric symptoms of of monitoring the effects of recent year-olds and 19.8% of 18-25-year- use can include anxiety, panic attacks, marijuana laws on adolescent use. olds report use in the past month. and psychosis.5 Studies have demon- Along with the risks associated Most teens also view marijuana as strated that heavy cannabis use during with changes in marijuana laws come safe and easy to obtain.2 Although adolescence and early-adulthood is opportunities. More attention is being there is much concern that legaliza- associated with significant alterations paid to research on potentially benefi- tion of cannabis for adults will lead to of brain anatomy and physiology.6,7 cial components of marijuana. Of increased use in teenagers because of These alterations, in turn, have been great recent interest for clinical increased availability and perceived associated with poorer performance researchers is cannabidiol (CBD) a safety, very preliminary data from on cognitive tasks, including long non-intoxicating component of mari- states that legalized recreational use lasting effects such as lower IQ, and juana. Studies suggest that CBD may in 2012 suggest this may not be the poor performance on tests of atten- be useful for the treatment of psy- (continued on page 25)

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ALLABOUT AAPL COMMITTEES A Primer on Kratom and death.1,2,6 A withdrawal syn- drome resembling opiate withdrawal, Joseph C. Cheng, MD, PhD, Ryan C. W. Hall MD (agitation, anxiety, tactile hallucina- tions, restlessness, insomnia, confu- A substance of abuse that has ally advertise by potency, vein color sion), has been reported.6 Effects of recently been gaining national atten- and country of origin. However, kratom can be seen within 10 minutes tion is the plant kratom (Mitragyna claims of potency based on these of ingestion, with full effects occur- speciosa; aka Thang, Kakuam, Thom, parameters have not been substantiat- 1 7 ring at 30 to 60 minutes after admin- Ketum, and Biak). The plant is ed. stration.1 Effects can last for about indigenous to Southeastern Asia and One of the authors of this newslet- five to seven hours. The terminal Africa, but is consumed throughout ter article has seen one patient who, half-life of kratom is approximately the world for its psychoactive proper- through recreational use of kratom, 6 1-4 24 hours. ties. At low doses, kratom has had a severe manic episode, which The complex effects of kratom use stimulant effects causing users to feel resulted in legal difficulties. Howev- have led many to promote its study more alert, energetic, and talkative; er, given that the individual had and use for medicinal purposes, such and at higher doses, kratom has anal- bought the substance legally at a as treating opiate addiction.2,3 Opioid gesic effects and may cause sedation smoke shop, it did not occur to them 5 abusers report using kratom to man- or euphora. In fact, its history paral- to initially disclose that they were age opioid withdrawal because pro- lels that of cocaine in that kratom was using kratom when they started seek- curement is easy and legal, and it is originally chewed or brewed by ing medical treatment since it was an less expensive than other opioid laborers in Asia for enhance work “herbal tea.” When it was finally rec- 6,7 replacement therapies, such as productivity. It has also been ognized that the person had been buprenorphine.6 Although many reported as a folk remedy for malaria, using kratom few treaters counseled claim kratom has medicinal proper- cough, hypertension, diarrhea, him on stopping its use because they ties, it is currently banned or regulat- depression, fever reduction, and opi- did not know what kratom was. 7 ed in multiple countries: Banned in oid withdrawal. The leaves of this There are 25 alkaloid substrates Australia, Malaysia, Myanmar; regu- plant are typically brewed into a tea, that can be isolated from the kratom lated in Australia, New Zealand, Swe- chewed, smoked, or ingested in cap- leaf, but the primary agents of psy- 1 den, Denmark, Finland, Germany, sules. choactive effects are mitragynine Romania, Thailand.7 The first leg- Although the National Institute of (stimulant) and 7-hydroxymitragynine 2,7 islative attempts to limit its consump- Drug Abuse has identified kratom as (7-HMG; narcotic). These agents tion occurred in Thailand with the an emerging drug of abuse, the gener- are thought to act on mu- and delta- Kratom Act of 1943.4 Although com- al medical community is not familiar opioid receptors as well as alpha-2 prehensive assessment has not been with this substance.1 Kratom use in adrenergic and 5-HT2A receptors.6 6 conducted, the FDA has banned use the U.S. emerged in the early 2000s Like many substances, the amount of kratom as a dietary supplement.6 and its increasing popularity in the absorbed can change the pharmaco- This has resulted in a seizure of U.S. is evidenced by a ten-fold logic effects one experiences from kratom products in California by fed- increase of kratom-related calls to kratom. Taking a dose of approxi- eral marshals from a company adver- poison control centers from 2010 to mately one to five grams of raw 1 tising kratom as a cure or treatment 2015. In December 2016, a PubMed leaves will yield mild stimulant for various diseases without FDA search for the term “kratom” yielded effects, such as alertness, sociability, indication.5 only 86 articles. However, subsets of and increased sexual desire. Howev- The DEA currently has kratom on the general public seem much more er, some report this dose range also the list of Drugs and Chemicals of aware of the substance and its uses. A produces negative effects such as Concern, which contains substances YouTube search also done in Decem- anxiety or agitation. At 5 to 15 that are not currently regulated by the ber 2016 yielded 36,000 videos, most grams, opioid effects will be noticed, Controlled Substances Act, but pose featuring laypeople or alternative sub- such as analgesia and euphoria. risks to persons who abuse them.1,4 stance “experts” discussing how to Above 15 grams of ingestion, kratom Currently, there is no national law use kratom and the positive or is generally very sedating and risk of regarding kratom, but Alabama, Flori- euphoric effects one can expect from experiencing stupor and potential 2,6 da, Indiana, Louisiana, Tennessee, it. In addition, there are many non- dysphoria increase. A panoply of Wisconsin, and Vermont have passed medical-based websites, such as side effects has been reported, includ- legislation banning or regulating its Erowid, Sage Wisdom, and Reddit, ing nausea/vomiting, fatigue, weight sale; other jurisdictions are also con- that publish similar information on loss, constipation, insomnia, dry sidering laws regarding the use and achieving a “legal high” with kratom. mouth, frequent urination, myalgias, sale of kratom.1,4,7 In August 2016, Kratom is available through the Inter- chills, hypertension, hyperpigmenta- the DEA announced plans to make net, in convenience stores, gas sta- tion in cheeks, tremor, anxiety, irri- kratom a Schedule I drug.4 However, tions, and head shops.7 Vendors usu- tability, agitation, psychosis, seizures, (continued on page 32)

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Legalizing It Public Health Policy.” Retrieved chiatry 2007;46:408-17. 01/30/2017 from https://www.drugabuse. 16. Hall, W. Degenhardt, L. Adverse health continued from page 23 gov/about-nida/noras-blog/ effects of non-medical cannabis use. Lancet 4. Wang GS, Le Lait M, Deakyne SJ, et al. chosis,20 anxiety disorders,21 and 374:1383–1391, 2009. Unintentional Pediatric Exposures to Marijua- 17. Brook JS, Stimmel MA, Zhang C, et al. epilepsy.22 Though CBD remains a na in Colorado, 2009-2015. JAMA Pediatr. The association between earlier marijuana schedule I substance because of its 2016;170(9):e160971. doi:10.1001/jamapedi- use and subsequent academic achievement containing small amounts of THC, atrics.2016.0971 and health problems: a longitudinal study. the DEA recently eased requirements 5. World Health Organization. The Health Am J Addict 2008;17:155-60 on CBD research. Furthermore, sev- and Social Effects of Nonmedical Cannabis 18. Fergusson DM, Horwood LJ, Beautrais eral states have proposed using taxes Use. http://www.who.int/substance_ AL. Cannabis and educational achievement. collected from marijuana sales and abuse/publications/cannabis_report/en/. Addiction 2003;98:1681-92. production to fund research on medic- Retrieved 01/30/2017 19. Fergusson DM, Boden JM. Cannabis inal uses of marijuana. California, for 6. Wilson W, Mathew R, Turkington T, et use and later life outcomes. Addiction example, will use marijuana tax rev- al. Morphological changes and early mari- 2008;103:969-76; discussion 77-8. enue to create the Center for Medical juana use: a magnetic resonance and 20. Rohleder C, Müller JK, Lange B, et al. Cannabis Research at the University positron emission tomography study. J Cannabidiol as a Potential New Type of an of California, San Diego. Similarly, Addict Dis 2000;19:1-22. Antipsychotic. A Critical Review of the Evi- states also are using revenue collected 7. Mata I, Perez-Iglesias R, Roiz-Santianez dence. Frontiers in Pharmacology. from marijuana taxes to fund mental R, et al. Gyrification brain abnormalities 2016;7:422. health services. Thus, these laws may associated with adolescence and early-adult- 21. Blessing EM, Steenkamp MM, Man- indirectly facilitate the discovery of hood cannabis use. Brain Res zanares J, et al. Cannabidiol as a Potential important new treatments for neu- 2010;1317:297-304. Treatment for Anxiety Disorders. Neu- ropsychiatric disorders and improve 8. Auer R, Vittinghoff E, Yaffe K, et al. rotherapeutics. 2015;12(4):825-836. mental health care overall. (2016) Association between Lifetime Mari- 22. Detyniecki K, Hirsch LJ. Cannabidiol The recent changes in marijuana juana Use and Cognitive Function in Mid- for epilepsy: trying to see through the haze, dle Age: The Coronary Artery Risk Devel- laws likely will have far-reaching The Lancet Neurology, 15, 2016, 235-237. opment in Young Adults (Cardia) Study. impacts on adolescent marijuana use JAMA Intern Med 176: 352–361. doi: JOIN US IN DENVER! and therefore, adolescent mental 10.1001/jamainternmed.2015.7841. health. The careful regulation of pro- 9. Jacobus J, Tapert SF. Effects of Cannabis Forensic Psychiatry duction and marketing of marijuana, on the Adolescent Brain. Current pharma- Review Course along with monitoring of use preva- ceutical design. 2014;20(13):2186-2193. October 23-25, 2017 This intensive three-day course in lence by the public will be critical in 10. Moore TH, Zammit S, Lingford-Hugh- detecting any potential increases in es A, et al. Cannabis use and risk of psy- forensic psychiatry will provide an rates of regular use by adolescents chotic or affective mental health outcomes: in- depth review of selected topics and associated poor outcomes. Clear- a systematic review. Lancet 2007;370:319- and relevant landmark cases. Basic ly, more time and careful research on 28. concepts will be reviewed along the effects of marijuana use and its 11. Compton MT, Kelley ME, Ramsay CE, with the latest case law. legalization on the mental health of et al. Association of pre-onset cannabis, youth are required for the public to alcohol, and tobacco use with age at onset 48th Annual Meeting of prodrome and age at onset of psychosis October 26- 29, 2017 draw meaningful conclusions about This meeting will inform atten- this complicated issue. in first-episode patients. Am J Psychiatry 2009;166:1251-7. dees about current major issues in Citations: 12. Large M, Sharma S, Compton MT, et forensic psychiatry and afford 1. 2015 National Survey on Drug Use and al. Cannabis use and earlier onset of psy- them opportunities to refresh skills Health: Methodological summary and defin- chosis: a systematic meta-analysis. Arch in the fundamentals of the disci- itions. Rockville, MD: Substance Abuse and Gen Psychiatry 2011;68:555-61. pline, engage in discussion with Mental Health Services Administration.) 13. Fergusson DM, Horwood LJ, Swain- peers, and update their present 2. Johnston, L. D., Miech, R. A., O’Malley, Campbell N. Cannabis use and psychosocial knowledge. For the first time ever, P. M., Bachman, J. G., & Schulenberg, J. E. adjustment in adolescence and young adult- we will have a dedicated “correc- (December 13, 2016). “Teen use of any hood. Addiction 2002;97:1123-35. tional track” of presentations on 14. Patton GC, Coffey C, Carlin JB, et al. illicit drug other than marijuana at new low, Saturday, October 28. Other pre- Cannabis use and mental health in young same true for alcohol.” University of Michi- sentations of interest to correction- gan News Service: Ann Arbor, MI. people: cohort study. BMJ 2002;325:1195- al psychiatrists will be scattered Retrieved 01/30/2017 from 8. http://www.monitoringthefuture.org 15. Hayatbakhsh MR, Najman JM, Jam- throughout the meeting—not only 3. Volkow N. (December 8, 2016). Nora’s rozik K, et al. Cannabis and anxiety and about our interconnectedness, but Blog. “As Some States Implement New depression in young adults: a large prospec- also about the unique challenges Marijuana Laws, Science Should Guide tive study. J Am Acad Child Adolesc Psy- faced by correctional psychiatrists.

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ALLABOUT AAPL - Committees Fostering Interest and Mentorship Our committee has learned these facts, and we want to promote addi- in Research tional avenues to help bright talent develop into successful researchers. Andrew R. Kaufman, MD, Jennifer Piel,MD, JD, Douglas Mossman, MD, One way to do this is to turn to the Research Committee AAPL Institute for Education and Research (AIER). The AIER offers Young people have ideas… integrating research effort, be it ten research grants specifically for pro- research ideas… good research ideas. percent, one-hundred percent, or any- jects that will advance our field. The This has been a recurrent theme dis- thing in between, into their career tra- Research Committee encourages all cussed among members of AAPL’s jectories. To aid this effort, the members – particularly those in train- Research Committee. The question Research Committee has promoted ing and early career – to take advan- has always been: How can we capi- two avenues to increase research par- tage of these funds. It is your time to talize on the youthful enthusiasm of ticipation, particularly among early shine and inspire the next generation our early career members and facili- career members. First is the Research to join our profession. The AIER tate their development in research? Poster Contest based on poster sub- selected several projects to fund for The answer to this question is vital to missions to the annual meeting. The this coming year. the future of our profession, which second is the Young Investigator Another way to inspire and foster will increasingly demand research Award for the best scientific paper research is through training and men- evidence to support forensic opinions submitted for presentation at the torship related to research skills. The and treatment in the forensic context. annual meeting. Each year it is a Research Committee sponsored at the Our profession is relatively young. pleasure to review the submissions annual meeting in Portland a course It is only since 1992 that we have for these contests. Each year the qual- focused on research design and devel- been sanctioned by the ABMS and ity seems to improve and the science opment. The panel included some of now have endless MOC requirements seems to be more grounded. Yet there AAPL’s most experienced and suc- to stay credentialed. We are relatively is something missing: too many cessful researchers: Drs. Nathan few and, at present, in great demand. trainees abandon their research pro- Kolla, Philip Candilis, Douglas Moss- Our origins are rooted in legal schol- jects once their fellowship is com- man, Robert Trestman, and Alexander arship and high ethical standards of plete. Westphal. The session included a professionalism. We have become course component focused on core excellent at maintaining a neutral research concepts and strategies, such stance in our legal expert opinions. “How can we capital- as research design and methods; sta- We have learned to navigate the ize on the youthful tistical analysis; application and world of courtrooms, penal institu- approval by institutional review tions, administrative entities, licens- enthusiasm of our early boards; and funding. The course ing authorities, insurers, and others. included practical how-to instruction However, too few forensic psychi- career members and on finding sources of funding and atrists are actively involved in applying for grants. research. Our opinions are strength- facilitate their develop- In addition, the course included ened by support of sound research ment in research?” onsite research consultation for each and evidenced-based practices. Our participant in the course. At the founding father, Jonas Rappaport beginning of the course, each partici- wrote, “There will be changes In some cases, residents, fellows, pant shared their research interests because of developments in the ‘brain and early career members have and what they hoped to gain from the sciences,’ as molecular biology, brain inspiring research ideas but lack course. All participants were invited imaging, and psychopharmacology available mentors or time to carry out to pitch their research ideas and dis- furnish a sounder scientific basis for their research pursuits. At academic 1 cuss any current works in progress psychiatric opinions.” We must be institutions, fellowships are generally for direct feedback and consultation prepared to be experts about these small and many lack faculty members of the expert presenters, as well as findings and we should be a key with research expertise. Further, the other course participants. Participants source of designing experiments to inspired budding researcher needs were encouraged to discuss all phases contribute to this knowledge base. protected time to conduct the research of research, from initial topics of It makes perfect sense that early or the ability to pay an assistant to interest, to design, to mentoring, and career forensic psychiatrists are in the collect the data. For those who have efforts to maximize chances of suc- best position to pursue these goals. never written a grant application, the cess for peer-reviewed grants. What AAPL’s Research Committee has process can be overwhelming. It is is more, the panelists offered to con- begun the process of helping develop practically impossible without appro- tinue mentoring course participants this talent and promoting a model of priate guidance and mentoring. (continued on page 32)

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ALLABOUT AAPL - Committees Neurolaw 101: Intro to Neurolaw conditioning and thus ability to learn from punishment is impaired. Finally, for Forensic Psychiatrists Dr. Fozdar discussed that at the brain level, moral thinking (knowing that) Vivek Datta, MD, Neuropsychiatry Committee and moral emotion (feeling that) are Neurolaw – the field exploring the the University of Minnesota; Stephen distinct, and it is the latter that is use of neuroscience in general, and Morse, JD, PhD, Professor of Psy- impaired in psychopaths. Our evolv- neuroimaging in particular, to answer chology and Law in Psychiatry at the ing understanding of the neuroanato- complex legal questions – has estab- University of Pennsylvania; Manish my of moral reasoning and its dys- lished itself as a legitimate field of Fozdar, MD, a past Chair of the functions may have significant impli- scholarly inquiry. Scientific meetings Forensic Neuropsychiatry Committee; cations for our understanding of crim- devote themselves to neurolaw, and me. inal responsibility. learned societies have penned reports on it, journals have dedicated special Neural Correlates of Moral Violence Neuroprediction issues to it, a small library of books Reasoning Next, I discussed neuroprediction on the topic is amassing, and the Dr. Fozdar presented a survey of of violence recidivism. Neuropredic- MacArthur Foundation funds a pro- the neuroanatomy of moral reasoning. tion refers to the use of neuroimaging ject on it. At the same time, between He noted that recent structural and to make future predictions. Violence 2005 and 2012, over 1585 judicial functioning neuroimaging studies risk assessment is fundamental to the opinions have been penned that dis- exploring morality gone awry did not practice of clinical and forensic psy- cuss neurobiological evidence used focus on specific diagnostic groups, chiatry. Determinations of violence by criminal defendants, and the num- but tend to conflate psychopathy, risk and dangerousness assume rele- ber of judicial opinions discussing antisocial behavior, and aggression. vance to important decisions includ- neuroscience in criminal cases more Nevertheless, current research ing civil commitment, bail, parole, than doubled between 2007 and appears to highlight that dysregula- capital sentencing, sex offender regis- 1 tration, and sexually violent predator 2012. This is not to mention the tion of neural circuits involved in 2 increasing popularity of neuroimag- moral thinking and feeling, may give status. I noted that violence risk ing to bolster expert opinion in civil rise to antisocial behavior. In particu- assessment has certainly advanced cases. Despite the rapid ascendance lar, reduced activity and grey matter since 1983, when the American Psy- of neurolaw as a field of inquiry and volume of certain prefrontal brain chiatric Association noted in their the increasing presence of neuro- structures including the orbitofrontal amicus brief in the case of Barefoot v. science in the courts, neurolaw has cortex, ventromedial prefrontal cor- Estelle that “the unreliability of psy- been relatively neglected by AAPL. tex, and dorsolateral prefrontal cortex chiatric predictions of long-term dan- gerousness is by now an established Only 3 non-book review articles pub- have been associated with antisocial 3 lished in the Journal of the American behavior in numerous studies. fact within the profession.” Despite Academy of Psychiatry and the Law Dr. Fozdar further discussed simi- advances, including the development have ever used the term “neurolaw.” larities between developmental and of a number of structured risk assess- Though the Forensic Neuropsychiatry “acquired” sociopathy. Acquired ment instruments, a recent meta- Committee regularly presents neu- sociopathy refers to antisocial behav- analysis of structured violence risk ropsychiatric topics at the Annual ior that arises in later life, predomi- assessment instruments concluded, Meeting, the term “neurolaw” nantly due to traumatic brain or “assigning predetermined probabili- appears only 3 times in the programs behavioral variant frontotemporal ties to future violence risk on the of the AAPL Annual Meetings dementia. Studies of antisocial behav- basis of structured risk assessment is not supported by the current evidence between 2006 and 2015 (twice in ior of the different etiologies 4 2011, and once in 2012). To remedy described above all appear to point to base.” Because of that, the field has this deficiency, the Forensic Neu- the orbitofrontostriatopallidal neural turned towards neuroscience in the ropsychiatry Committee presented a circuits as underlying morality. He hope that neuroimaging can improve course at the 2016 Annual Meeting then discussed the role of temporal the reliability of determinations of titled “Neurolaw 101: Intro to Neuro- structures, chiefly the amygdala and future dangerousness. law for Forensic Psychiatrists”. hippocampus, dysfunction of which I reviewed the neurobiology of Organized by Octavio Choi, MD, have been identified in children with aggression as it pertains to mental Chair of the Forensic Neuropsychia- conduct disorder and adults with psy- disorder, noting that there are differ- try Committee and Assistant Profes- chopathy. These brain structures if ences in the neurobiology of instru- sor of Psychiatry at Oregon Health hypoactive or poorly developed lead mental aggression (as seen in psy- Sciences University, other speakers to impaired fear conditioning, which chopathy) and reactive aggression featured included Francis Shen, JD, is probably why psychopaths have (e.g. as seen in borderline personality PhD, Associate Professor of Law at high rates of recidivism: their fear disorder). Mental disorder can lead to (continued on page 28)

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Neurolaw 101 ies have small sample sizes and thus analysis (MVPA), to “train” the continued from page 27 lack statistical power to answer the machine to distinguish lying from questions they purportedly aim to. truth-telling. There are many different violence through impairments in top- Finally we discussed two competing types of lies, and he suggested that down processing; that is, the regula- ideas on law, brain and behavior. The different kinds of lying would likely tion or suppression of impulses, first is that if violence is yoked to our be associated with different brain pat- which involve the orbitofrontal cortex neural circuitry, can we be held terns. Currently however fMRI lie and anterior cingulate gyrus; or responsible for our behavior at all? detection is not ready for the court- through impairments in bottom-up The second is that of “brain over- room because of lack of ecological 9 processing, through impairments in claim” , coined by Stephen Morse, validity, standards and error rates. emotion regulation involving struc- which argues that neuroscience has Interest in fMRI for lie detection has tures such as the amygdala and insu- been (ab)used to provide moral excul- fallen off since the Sixth Circuit la.5 While a number of psychiatric pation for behavior when it is not Court of Appeals affirmed a lower disorders are associated with violent warranted. court decision to exclude fMRI lie behavior, the neuroimaging literature detection in a Medicare fraud case has focused on schizophrenia and Reading the Mind with Machines where Lorne Semrau, a clinical psy- psychopathy. I also discussed that Dr. Choi then discussed whether chologist, claimed that fMRI evi- dysfunction of the anterior limb of the machines can read the mind. The dence would prove the veracity of his 11 internal capsule and the striatum short answer is yes, it is possible, but denials of wrongdoing. appear to be involved in psychopathy. we’re not there yet. The longer The striatum has been implicated in answer is that the notion of mind Neurolaw and the Aging Brain prediction error signaling, which is reading is predicated on the idea that Dr. Shen discussed the aging brain the mismatch between expected and mental states map onto brain states as the next frontier of neurolaw. Neu- actual reward or punishment, and and decoding these brain states will rolaw may potentially be most useful important in stimulus-reinforcement allow us to read the mind. In the in answering legal questions involv- learning (modulated by the amyg- forensic context, this may have impli- ing the aging brain. There has been dala)6. Impaired prediction-error sig- cations for lie detection, memory increasing attention paid to brain naling explains why psychopaths fail detection, mental state at the time of health, with many companies claim- to learn from punishment and why the offense, measuring pain, and ing their brain training products can psychopathy is a risk factor for vio- brain-based detection of implicit bias- stave off dementia, and these claims lence recidivism. Of particular inter- es. We can visualize brain activity have already been challenged in the est, one study found that reduced grey using positron emission tomography courts. At the same time, many ques- matter volumes in the prefrontal cor- (PET) and functional magnetic reso- tions are unanswered, but Dr. Shen tex and increased grey matter vol- nance imaging (fMRI). fMRI using suggested that neurolaw may enhance umes in the caudate and cerebellum blood oxygenation levels in the brain legal determinations of criminal and was associated with psychopathy as a proxy of brain activity – bloody civil competencies involving the scores on the Hare Psychopathy oxygenation level dependent (BOLD) aging brain, as well issues involving Checklist-Revised and violence signals. The limitations of fMRI dis- contested wills, guardianship, undue recidivism risk as predicted by the cussed include the fact that fMRI influence, elder fraud and abuse. Neu- Violence Risk Appraisal Guidelines.7 measures vascular response to brain roimaging may allow the early detec- I briefly discussed some of the eth- activity, rather than brain activity tion of dementia and cognitive ical issues of violence neuropredic- itself; not all brain activity triggers a decline, and has implications for the tion, including the fact that neurobio- neurovascular response; lack of stan- aging inmate brain, and the ethics of logical data can be contemporaneous- dardization of statistical methods; and early detection of dementia. This area ly mitigating and aggravating evi- that statistical packages for fMRI coalesces as the interface of elder law dence, problems with knowing analysis result in a 70% false-positive issues and the growing use of neuro- whether imaging findings are simply rate thus potentially invalidating over scientific evidence in the courtroom. 8 correlates or causal, and whether a 40,000 fMRI studies. In particular, Dr. Shen suggested that neurobiological basis for psychopathy Dr. Choi then discussed the cate- there might be significant implica- means psychopaths are less criminal- gory of specific visual areas that have tions for brain changes identifying the ly responsible for their behavior. I been identified suggesting that we can beginning of neurodegenerative dis- also discussed some of the challenges create maps of the representation of ease before the frank symptoms with functional neuroimaging object and action categories across appear. 10 research, such as the recent finding the human brain. He suggested that that software glitches may invalidate fMRI could be a powerful lie detector Indispensable forensic psychiatry more than 40,000 fMRI studies8, and if we scanned a large number of peo- Finally, Dr. Morse gave a more the fact that most neuroimaging stud- ple and essentially used a machine guarded forecast for the future of neu- learning approach, multivoxel pattern (continued on page 29)

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Neurolaw 101 high-risk violent offenders and their associ- https://www.nytimes.com/2016/08/16/health ation with psychopathic traits and criminal /analyzing-donald-trump-psychology.html continued from page 28 recidivism. Neuroscience 2015; 208:194- Friedman, R.A. (2008). Role of physi- 201 rolaw. He suggested that whatever cians and mental health professionals in dis- 8. Eklund A, Nichols TE, Knutsson H. cussions of public figures. Journal of the advances happen in the neuro- Cluster failure: why fMRI inferences for American Medical Association, 300, 1348- sciences, forensic psychiatry as it spatial extent have inflated false-positive 1350. stands will remain indispensable to 12 rates. Proc Nat Acad Sci 2016; 113:7900- Ghaemi, N. (2016, August 15). Is Psy- criminal and civil law. With passion 7905 choanalyzing Our Politicians Fair Game? and vigor, he communicated that 9. Morse SJ. Brain Overclaim Syndrome Medscape Psychiatry. Retrieved from criminal law relies on folk psycholog- and criminal responsibility: a diagnostic http://www.medscape.com/viewarticle/8673 ical models of the person, and the cri- note. Ohio St J Crim L 2006; 3:397-412 20_4 teria for responsibility and competen- 10. Huth AG, Nishmoto S, Vu AT, Gallant Klitzman, R. (2016, March 7). Should cy are acts and mental states. He JL. A continuous semantic space describes Therapists Analyze Presidential Candidates? noted that free will, though often the representation of thousands of object The New York Times. Retrieved from mentioned in discussions of neurolaw and action categories across the human https://www.nytimes.com/2016/03/07/opin- and responsibility, is not relevant to brain. Neuron 2012; 76:1210-1224 ion/campaign-stops/should-therapists-ana- legal determinations and not a criteri- 11. United States v. Semrau, No. 11-5396 lyze-presidential-candidates.html on for any legal doctrine.13 He argued (6th Cir. 2012) Kroll, J., Pouncey, C. (2016). The Ethics that the “causal theory of excuse”, 12. Morse SJ. Indispensable forensic psy- of APA’s Goldwater Rule. Journal of the that is behavior is excused if outside chiatry and psychology: the (non) challenge American Academy of Psychiatry and the of one’s control, is “the fundamental from neuroscience. In: Sadoff R. (Ed.) The Law Online, 44. psycholegal or psychomoral error.” Evolution of Forensic Psychiatry: History, Levin, A. (2016, August 25). Goldwater Dr. Morse further argued that nothing Current Developments, Future Directions. Rule’s Origins Based on Long-Ago Contro- can replace careful clinical evaluation Oxford: Oxford University Press, 2015 versy. Psychiatric News. Retrieved from of acts and mental states and that neu- pp.339-359 http://psychnews.psychiatryonline.org/doi/fu 13. Morse SJ. The non-problem of free will roimaging is of no help in mens rea, ll/10.1176/appi.pn.2016.9a19?trendmd- in Forensic Psychiatry and Psychology. shared=0& provocation, diminished capacity, or Behav Sci Law 2007; 25:203-220 Martin-Joy, J. (2015). Goldwater v. insanity defenses. He ended with Ginzburg. American Journal of Psychiatry, some cautious optimism, suggesting The Goldwater Rule 172. that neuroscience may be helpful in Milligan, S. (2007, January 27). The individual case adjudication, evalua- continued from page 14 Temperament Tantrum: Some say President tion of pain and memory accuracy, Donald Trump’s personality isn’t just evaluating folk wisdom and evaluat- leagues Jerome Kroll and Claire flawed, it’s dangerous. US News & World ing and shaping policy and legal doc- Pouncey suggest in the June 2016 Report. Retrieved from trines. issue of JAAPL? Or should we con- http://www.usnews.com/news/the- sider reformulating and refining it for report/articles/2017-01-27/does-donald- References modern times, such as in the manner trumps-personality-make-him- 1. Farahany N. Neuroscience and Behav- suggested by Ronald Pies in the Octo- dangerous?src=usn_tw ioral Genetics in US Criminal Law: An ber 7th, 2016 Psychiatric Times? Moffic, H. S. (2016, September 12). The Empirical Analysis. J Law Biosci 2016; Despite the closure of the election Results of a Psychiatric Poll on Presidential : 2 485-509 cycle, there continues to be much dis- Candidates. Psychiatric Times. Retrieved 2. Nadelhoffer T, Sinnott-Armstrong W. cussion of public figures and mental from Neurolaw and Neuroprediction: Potential http://www.psychiatrictimes.com/blogs/couc Promises and Perils. Philosophy Compass health concerns. Although the Gold- water Rule stands, many continue to h-crisis/results-psychiatric-poll-presidential- 2012; 7:631-642 candidates disregard it. Perhaps the time is ripe 3. Barefoot v. Estelle, 463 U.S. 880 (1983) M Oquendo. (2016, August 3). The 4. Singh JP, Fazel S, Gueorguieva R, that we embark on a reconsideration Goldwater Rule: Why breaking it is Unethi- Buchanan A. Rates of violence in patients of the merits of the current rule. As a cal and Irresponsible. Retrieved from classified as high risk by structured risk field, we should together determine https://www.psychiatry.org/news-room/apa- assessment instruments. Br J Psychiatry whether refinement or revocation best blogs/apa-blog/2016/08/the-goldwater-rule 2014; 204:180-187 respects the dignity of our patients, Watts, A. L., Lilienfeld, S. O., Smith, S. 5. Siever LJ. Neurobiology of Aggression our society, and our profession. F., Miller, Campbell, W. K., Waldman, I. D., and Violence. Am J Psychiatry 2008; Faschingbauer, T. J. (2013). The Double- 165:429-442 References: Edged Sword of Grandiose Narcissism: 6. Blair, RJR.The Neurobiology of psycho- Carey, B. (2016, August 15). The Psy- Implications for Successful and Unsuccess- pathic traits in youth. Nature Rev Neurosci chiatric Question: Is it Fair to Analyze Don- ful Leadership Among U.S. Presidents. Psy- 2013; 14:786-799 ald Trump from Afar? The New York Times. chological Science, 24, 2379-2389. 7. Leutgeb, V. et al. Brain abnormalities in Retrieved from

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NEWS FROM THE APA Pre-Meeting Update promises the integrity of the psychia- trist and the profession and may stig- Cheryl D. Wills, MD, matize individuals who have mental AAPL Representative to APA Assembly disorders. The APA is providing resources The American Psychiatric Associa- assist district branches and other part- and assistance to help members tion has grown to represent 37,106 ners in addressing policy develop- understand and benefit from the members, an increase of 1.6% in the ment and interested parties should Merit-Based Incentive Payment Pro- past year. The Annual Meeting will contact Ariel Gonzalez gram (MIPS) and to earn incentives take place in San Diego, California ([email protected]). for participating in the Alternative from May 20-24, 2017. The theme, Discussions about national politics Payment Models (APMs) that are part “Prevention through Partnerships,” remain a salient topic for APA mem- of Medicare’s new “Quality Payment underscores the importance of psychi- bers and leadership. The organization Program.” There is an APA Payment atrists collaborating with other health- has always worked across the aisle Reform Toolkit available at care professionals, as well as profes- with both major political parties to www.psychiatry.org/PaymentReform sionals in community development promulgate a better understanding of that contains fact sheets and other and education, to implement early the needs of APA members and indi- information. There also is a webinar, identification of and interventions for viduals with mental disorders. In titled “Quality Reporting 101,” that is individuals with mental disorders. February 2017 the APA led a group of available in the APA learning Center The Meeting will offer a diverse allied stakeholders in holding several at no charge to members. Additional selection of programs and discipline- CEO-level meetings with Congres- resources are being developed to aid specific tracks so attendees may craft sional and committee leadership. The members. individualized programs in substance coalition included: the American There is a new APA mobile health use disorders, child psychiatry, geri- Foundation for Suicide Prevention, (mhealth) webpage that includes a atric psychiatry, psychosomatic medi- American Psychological Association, Mobile Apps Evaluation Tool which cine, forensic psychiatry etc. Eating Disorders Coalition, Mental is designed to help mental health pro- Attendees may sign up to tour of Health America (MHA) and National fessionals review the efficacy and the U.S. Naval Medical Center of San Alliance on Mental Illness (NAMI), risks associated with mobile and Diego learn how medical care is National Council for Behavioral online apps. The APA Apps Work delivered at sea. The guest speaker at Health, and Sandy Hook Promise. Group is considering increasing the the Convocation of Distinguished The coalition educated our political tool’s functionality and expanding its Fellows will be Elizabeth Vargas, leaders about how changes in health- content. The tool is a resource for who anchors “20/20” on ABC. She care policy might affect mental health mental health professionals who rec- has spoken and written about her own practice and the well-being of indi- ommend apps to patients as part of a struggles with anxiety and alcohol viduals with mental disorders. These comprehensive treatment plan. use and wrote the memoir Between efforts will continue regardless of The World Health Organization Breaths: A Memoir of Panic and how the government chooses to pro- (WHO) is proposing to transfer all Addiction. ceed with healthcare reform. diagnoses for dementia - in the beta APA members are encouraged to The ability of mental health pro- version of International Classification visit the Innovation Zone that will be fessionals to comment about the men- of Diseases, 11th edition (ICD-11) - located in the exhibit area. The Zone tal health of public figures has been a from the Mental Health or Behavioral provides a forum for contemplating matter of much debate in the past Disorder Chapter to the chapter of the future of mental health technolo- year. Several psychiatrists, psycholo- Diseases of the Nervous System. The gy and advancing psychiatric prac- gists and social workers have prof- recommended change may prevent tice. Attendees can engage in discus- fered opinions about the fitness of mental health health professionals sions with technology professionals political leaders to govern.1 Many from delivering services to individu- and executives. There will be a com- APA members have questioned the als with dementia in the U.S. and petition for psychiatrists to present appropriateness of this action. In other countries; health insurance innovative ideas to their colleagues response, the APA’s Ethics Commit- companies may refuse to reimburse and a panel of technology experts. tee revisited the Goldwater Rule mental health professionals for diag- In 2012 the APA drafted a Position which was included in the Code of nosing, conducting medical and psy- Statement on Discrimination against Ethics in 1973. The Committee chological testing, and psychosocial Transgender and Gender Variant Indi- affirmed the Rule, which states psy- treatment and pharmacological inter- viduals. The Federal Government chiatrists should not offer profession- vention for individuals with demen- recently delegated policy develop- al opinions about the mental state of tia. ment regarding transgender restrooms individuals whom they have not per- APA President Maria Oquendo and to the states. The APA is ready to sonally evaluated. The practice com- Medical Director Saul Levin submit- (continued on page 31)

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AAPL Representative At this time, Blankenship remains American Psychiatric Association, 1952 3. American Psychiatric Association: Diag- continued from page 30 on the sex offender registry in Ohio, along with many individuals who are nostic and Statistical Manual of Mental Dis- ted a letter to the WHO to formally consumers of mental health services. orders, Third Edition. Washington, DC: American Psychiatric Association, 1980 object to the proposed changes, The When I see patients who have been 4. American Psychiatric Association: Diag- letter has been shared with nearly 20 designated as sex offenders, I acknowledge the stigma that they nostic and Statistical Manual of Mental Dis- national and international health orga- orders, Fourth Edition, Text Revision. nizations and many have or plan to feel. I make sure that my patients understand what their legal require- Washington, DC: American Psychiatric formally oppose the changes. Association, 2000 ments are, and encourage them to 5. American Psychiatric Association: Diag- References: meet their registry requirements to nostic and Statistical Manual of Mental Dis- 1. Dodes L, Schacter J. Mental health pro- avoid legal peril. The registry will orders, Fifth Edition. Washington, DC: fessionals warn about Trump. NY Times, continue to be a legal issue with American Psychiatric Association, 2013 Feb. 13, 2017 Available at implications for community reintegra- 6. IL Con. Substance Act § 527/102 (2010) https://www.nytimes.com/2017/02/13/opin- tion in Ohio, as well as other states, 7. NJ Rev Stat § 2C:35-2 (2013) ion/mental-health-professionals-warn-about- unless more cases challenging its con- 8. Norko MA, Fitch WL: DSM-5 and Sub- trump.html?_r=0 Accessed 3/11/17 stitutionality arise. stance Use Disorders: Clinicolegal Implica- tions. J Am Acad Psychiatry Law 42:443– State v. Blankenship, 145 Ohio 52, 2014 Sex Offender Registry St.3d 221, 2015-Ohio-4624 9. Compton WM, Dawson DA, Goldstein RB, et al: Crosswalk between DSM-IV continued from page 17 dependence and DSM-5 substance use dis- What’s In A Name orders for opioids, cannabis, cocaine and means to protect society. Justice alcohol. Drug Alcohol Depend 132:387–90, O’Donnell’s opinion concurred in continued from page 22 2013 judgment only, and he wrote a sepa- 10. Beckson M, Tucker D: Commentary: rate opinion in order to state that he So what does a forensic psychia- Craving Diagnostic Validity in DSM-5 Sub- believed Blankenship did not have an trist do if asked for a definition of stance Use Disorders. J Am Acad Psychiatry Eighth Amendment claim at all addiction? Unfortunately, there is not Law 42:453–8, 2014 because the sex offender registry was a uniformly accepted answer at this 11. Dawson DA, Goldstein RB, Grant BF: a civil requirement. Justice Kennedy time. As with most legal issues, if a Differences in the Profiles of DSM-IV and concurred. legal definition happens to be avail- DSM-5 alcohol use disorders: implications Justice Pfeifer wrote the dissenting able in the state or jurisdiction where for clinicians. Alcohol Clin Exp Res opinion, and was joined by Justice the question is posed, then that defini- 37:E305–E313, 2013 O’Neill, who concurred but also tion may be used. However, in most 12. National Institute on Drug Abuse wrote his own dissenting opinion. areas, a legal definition of addiction (NIDA): Drugs, Brain and Behavior: The Justice Pfeifer stated that Blanken- is not readily available. In those cir- Science of Addiction. Retrieved February 10, 2017, from https://www.drugabuse.gov/ ship’s case exemplified one in which cumstances, the forensic psychiatrist the punishment imposed was dispro- publications/drugs-brains-behavior-science- may consider the factors detailed addiction portionate to the crime and “shocking above and reach their own conclusion to any reasonable person.” Justice about how the current substance use O’Neill expressed, through his dis- disorder diagnosis interacts with the Terrorism sent, frustration with the “one-size- legal term addiction. Until a more continued from page 13 fits-all mentality that increasingly uniform statement regarding the defi- dictates criminal sentencing in Ohio.” nition is available, it will continue to References: He stated that a 21-year-old offender part of the individual opinion of the 1. Post J: The Mind of the Terrorist. New who was opined by a respected men- expert, based on their own interpreta- York: Palgrave Macmillan; 2007.4. Folio: tal health professional to present a tion of the available literature and Terrorism. The Globe and Mail News. low risk of reoffending should not be their personal knowledge, experience, Canada. July 6, 2016, A6- A7. subject to a punishment which would and training. 2. Siegal, L PhD: Political Crime and Ter- “guarantee an unnecessarily long rorism. In: Criminology, The Core. 6th Edi- period of public humiliation only.” References: tion. Boston, Massachusetts: Cengage He stated that the Tier II registry 1. Alexander BK, Schweighofer ARF: Learning: 2016: p 352-371. requirements, which would restrict Defining “Addiction.” Canadian Psychology 3. Borum, R: Psychology of Terrorism. Blankenship’s job and relationship 29(2):151-62, 1988 Mental Health Law & Policy Faculty Publi- opportunities, and “lay shame at the 2. American Psychiatric Association: Diag- cations. Paper 571. 2004. Accessed at http://scholarcommons.usf.edu/mhlp_facpub feet of others,” clearly represented nostic and Statistical Manual of Mental Dis- /571. cruel and unusual punishment. orders, First Edition. Washington, DC:

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A Primer on Kratom es-and-countries-where-kratom-is-banned/ Bibliography: (accessed 2017/01/25. 1. Global Trends Forced Displacement In continued from page 24 5. Voelker R. Kratom Products Seized. 2015, June 20, 2016. United Nations High Commissioner for Refugees. due to opposition from those who felt Jama 2016; 316(11): 1142. 6. Chang-Chien GC, Odonkor CA, Amora- 2. Executive Order 13767 Border Security kratom may have medicinal purposes, panth P. Is Kratom the New ‘Legal High’ on and Immigration Enforcement Improve- as well as concern from politicians the Block?: The Case of an Emerging Opi- ments, January 25, 2017 about whether or not procedure was oid Receptor Agonist with Substance Abuse 3. Sieckelinck S, Kaulingfreks F, De Winter appropriately followed, the Schedule M. 2015. Neither Villains Nor Victims: 3 Potential. Pain physician 2017; 20(1): I change did not occur. The DEA is E195-E8. Towards an Educational Perspective on currently engaging in a more trans- 7. Griffin OH, 3rd, Daniels JA, Gardner Radicalisation, British Journal of Education- parent approach to address these con- EA. Do You Get What You Paid For? An al Studies, 63 (3): 329-343. cerns such as having an official pub- Examination of Products Advertised as 4. Ellis B, et al. 2015. Trauma and openness lic comment period before again con- Kratom. Journal of psychoactive drugs to legal and illegal activism among Somali sidering action. 2016; 48(5): 330-5. Refugees. Terrorism and Political Violence, Use may be higher than previously 8. Le D, Goggin MM, Janis GC. Analysis 27 (5): 857-83. suspected since many standard drug of mitragynine and metabolites in human 5. Meffert SM, Musalo K, McNiel DE, screens do not detect kratom.2 urine for detecting the use of the psychoac- Binder RL. 2010. The Role of Mental Although kratom can have opioid-like tive plant kratom. Journal of analytical toxi- Health Professionals in Political Asylum Processing. Journal American Academy of effects, it is structurally unrelated to cology 2012; 36(9): 616-25. Psychiatry and Law, 38: 479-89. opium and, therefore, many standard 6. Rogers R. 1990. Models of feigned men- urine toxicology screens do not detect Asylum Evaluations tal Illness. Professional Psychology 21: it. Sophisticated screening such as 182-8. liquid chromatography or mass spec- continued from page 2 7. Brwin CR. 2007. Autobiographical mem- trometry needs to be used to detect by professionals to measure features ory for trauma: update on four controver- 2 kratom. There have been some possi- of radicalization, include the Violent sies. Memory. 15: 227. ble urine tests studied, but they are Extremist Risk Assessment (VERA- 8. Scarcella A, Page R, Furtado V (2016) not readily available in most clinical 2), Identifying Vulnerable People Terrorism, Radicalisation, Extremism, 8 settings. (IVP), Extremism Risk Screen (ERS), Authoritarianism and Fundamentalism: A Given recent DEA and legislative and the controversial, unpublished Systematic Review of the Quality and Psy- actions involving kratom, difficulty in Extremist Risk Guidance 22+ (ERG chometric Properties of Assessments. PLoS detecting kratom use either from his- 22+). The VERA-2, ERS, and IVP, ONE 11(12): e0166947. tory or objective screening, and however, are designed to be used with 9. Nowrasteh A., 2016. Terrorism and increasing use of kratom as a recre- persons with histories of extremist Immigration: A Risk Analysis. Cato Insti- ational substance in the United States, violence or terrorist offenses. Other tute, 798, https://object.cato.org/sites/ it is important for forensic psychia- tools have been developed for cato.org/files/pubs/pdf/pa798_1_1.pdf trists to be aware of its existence and research measures, but have not been properties. spread to general use at this time.8 Fostering Interest According to a new Cato paper, References from 1975 to 2015, the United States continued from page 26 1. Anwar M, Law R, Schier J. Notes from accepted approximately 700,000 asy- the Field: Kratom (Mitragyna speciosa) lum seekers and 3.25 million after the meeting in cases where this Exposures Reported to Poison Centers - refugees. Excluding foreign attacks, would be helpful. United States, 2010-2015. MMWR Morbidi- four of those asylum-seekers became So, if you are now saying to your- ty and mortality weekly report 2016; 65(29): terrorists and killed four people in self, “I can’t believe it. I’ve been hop- 748-9. ing to find ways to get involved in 2. Warner ML, Kaufman NC, Grundmann attacks in the United States. Twenty of the 3.25 million refugees became research,” this is your chance. There O. The pharmacology and toxicology of are several avenues to support entry kratom: from traditional herb to drug of terrorists and killed three Americans on U.S. soil.9 Thus, the forensic eval- into forensic research, including those abuse. International journal of legal medi- discussed here. Please help our pro- cine 2016; 130(1): 127-38. uator should be aware of the height- ened political climate for asylum fession move forward and give your- 3. Silverman L. Kratom gets reprieve from self the satisfaction of testing your DEA’s Schedule I drug list. 2016/10/17. seekers and refugees, but should con- idea, using scientific methods. http://www.cnn.com/2016/10/17/health/krat tinue to focus on a valid and compre- om-dea-schedule-i-comments/ (accessed hensive assessment. Remember, the References: 2017/01/25. final determination of credibility is 1. Rappeport JR, The Present and Future of 4. States and countries where kratom is the responsibility of the trier of fact: Forensic Psychiatry. J Am Acad Psychiatry banned. 2015/07/25. the judge. Law 33:2:263-264 (June 2005) http://kratomcrazy.com/blog/2015/07/25/stat

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ADS MUSE & VIEWS SAVE THE DATES FOR FUTURE AAPL MEETINGS ------“Once a man indulges him- October 22-24, 2018 – Forensic Review Course self in murder, very soon he Austin, TX – JW Marriott comes to think little of rob- October 25-28, 2018 – 49th Annual Meeting bing and from robbing he Austin, TX – JW Marriott comes next to drinking and May 5-9, 2018 – APA Annual Meeting sabbath-breaking, and from New York NY that to incivility and procras------tination.” October 21-23, 2019 – Forensic Review Course - Thamas De Quincey Baltimore, MD – Marriott Waterfront October 24-27, 2019 – 50th Annual Meeting “It is hard to believe that a Baltimore, MD – Marriott Waterfront man is telling the truth when May 18-22, 2019 – APA Annual Meeting you know that you would lie San Francisco, CA if you were in his place.” ------H. L. Mencken (1880 - 1956) October 19-21, 2020 – Forensic Review Course Chicago, IL – Marriott Downtown “I have the heart of a child. I October 22-25, 2020 – 51st Annual Meeting keep it in a jar on my shelf.” Chicago, IL – Marriott Downtown - Robert Bloch April 25- 29, 2020 – APA Annual Meeting Philadelphia, PA “If it weren't for my lawyer, I'd still be in prison. It went a lot faster with two people digging. ” - Joe Martin, Mister Boff ONE POLICY. “A criminal is a person with predatory instincts who has not sufficient capital to form ONE DECISION. a corporation.” - Howard Scott, Economist WE PROTECT YOU “America believes in educa- Select a psychiatric professional liability insurance tion: the average professor policy from PRMS, and you will be protected earns more money in a year throughout your career by a team of experts than a professional athlete who truly understand psychiatric risk. earns in a whole week. ” - Evan Esar (1899 - 1995)

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ADS

The State of Connecticut Department of Mental Health and Addiction Services (DMHAS) offers rewarding opportunities for Board Eligible and/or Board Certified Psychiatrists Diversity interested in working in the Public Sector. DMHAS is the behavioral health authority for the State of Connecticut. We strive to improve the quality of life, economic opportunity Committee and community integration for people who have mental health and addiction disorders. The Psychiatrist role within DMHAS functions as part of a multi disciplinary team, pro- In keeping with the plan viding a variety of behavioral health care services for adults ages 18 and above. Opportunities are available in both inpatient and outpatient settings throughout the entire of Dr. Emily Keram, State of Connecticut. immediate past president We are currently seeking professionals for our: of AAPL, I hereby invite Forensic Services: Focusing on competency restoration, social learning, specialized treat- ment and assessment, and community restoration AAPL members to the General Psychiatry: Emphasis on psychosocial rehabilitation, vocational rehabilitation, inaugural meeting of the neurobehavioral services and community transition Addiction Services: Provide a variety of treatment services to persons with substance use Diversity Committee of disorders, including ambulatory care, residential detoxification, long-term care, long-term AAPL in October 2017. rehabilitation, intensive and intermediate residential services, methadone or chemical maintenance, outpatient, partial hospitalization, and aftercare. Dr. Keram’s vision is to J1 and HB-1 Visa candidates encouraged to apply establish a forum where The State of Connecticut offers a competitive salary and benefits package. We have issues of diversity in all immediate openings in Middletown Connecticut which is conveniently located between Boston and NYC. The campus is close to Wesleyan University, the scenic Connecticut areas of AAPL are River Valley, and centrally located between New Haven and Hartford. explored and discussed, Interested applicants should contact: and ultimately presented Jaime Sanz, DMHAS Clinical Recruiter [email protected] to the AAPL council. 860.262.6745 AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER The State of Connecticut is an equal oppor- Questions to be addressed tunity/affirmative action employer and strongly encourages the applications of women, minorities, and persons include, but not limited to: with disabilities. do all groups represented in AAPL see AAPL as their professional home? Forensic Psychiatrist Are there factors that Physician needed to provide therapeutic leadership and medical interfere with members supervision for 24/7 community-based inpatient and outreach level developing a sense of of care for PACT (Program of Assertive Community Treatment) belonging at AAPL? Do program. Must have strong collaborative leadership skills and work people believe issues well with a multidisciplinary team consisting of the Senior Vice regarding their specific President of Adult Services, the Program Director and the nursing, group(s) are addressed by residential, and counseling staff. This position requires approxi- AAPL? Do minority mately four hours a day of on-site time with on-call availability for groups feel empowered to consultation. Knowledge of medication assisted treatment options be all they could be at for substance abuse preferred. Must be familiar with electronic AAPL? And so on. health records and word processing. Medical license in Massachu- setts required. Controlled substance registration application and a For questions or to federal DEA certificate needed. become a member of the committee, please contact Please send CV to: Charles Dike at Susan West at [email protected] [email protected] Behavioral Health Network

34 • April 2017 American Academy of Psychiatry and the Law Newsletter 171526 AAPL April 2017 Newsletter_rev4.qxp_April 2017 5/3/17 9:46 AM Page 35

ADS

The Midwest Chapter of AAPL held its annual meet- ing in Kansas City, MO, March 31-April 1. The Pro- gram Committee for the excel- lent program was Jim Reynolds, Larry Jeckel, Melissa Spanggaard, and Phil Pan.

Outgoing President Larry Jeckel turning the gavel over to Incoming President Delaney Smith.

MUSE & VIEWS

"Documentation is like sex: when it is good, it is very, very good; COOKK COUNTY HHEALLTHTH and when it is bad, it is better than nothing." & HOOSPITTALSALS SYSTEM - Dick Brandon We are hiringg Psychiatrists for Cermak Photo Gallery Health Servicces at Cook County Jail. Several correctional continued from page 19 psychiatric openings

Pleasease send your resume with Corrrectional Psychiatrist in thehe subject line to: [email protected]

Visit http://///wwww.cookcountyhhs.org//carcareeers to apply today.

Charles Dike asks a question at the Annual Meeting

American Academy of Psychiatry and the Law Newsletter April 2017 • 35 171526 AAPL April 2017 Newsletter_rev4.qxp_April 2017 5/3/17 9:46 AM Page 36

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