191581 AAPL April 2019 Newsletter_rev8.qxp_April 2019 5/3/19 3:50 PM Page 1 AAPL Newsletter American Academy of Psychiatry and the Law

April 2019 • Vol. 44, No. 2 ter Reports and The Truth About True 2019 Annual Meeting - AAPL at 50: Crime. Her current work seeks to Teaching and Advocating for expose issues of wrongful conviction and public shaming, and to promote Forensic Psychiatry empathy and truth seeking. She has published in USA Today, The Los Susan Hatters Friedman, MD Angeles Times, The Seattle Times, Program Chair Seattle Magazine, and The West Seat- tle Herald. Attendees of the AAPL Annual Meeting may benefit from watching the Netflix documentary entitled Amanda Knox which was released in 2016, prior to the meeting. Professor Adam Benforado is Pro- fessor of Law at Drexel University. His work applies insights from cogni- tive psychology to legal theory and law. Professor Benforado was award- ed a National Science Foundation grant for his work investigating human intuition about punishment. His op-eds and essays have appeared in The Washington Post and The New York Times. His book, Unfair: The New Science of Criminal Injustice, has been a New York Times bestseller, in addition to winning the 2017 American Psychology Law Society As President, Richard Frierson’s time, Raffaele Sollecito, who was Book Award. Professor Benforado theme for the 50th Anniversary of the also incarcerated, spoke at a recent has been interviewed by Larry King American Academy of Psychiatry and International Academy of Law and as well as on National Public Radio. the Law is teaching and advocacy, Mental Health meeting.) Ms. Knox In his book, Professor Benforado uses and this year’s Annual Meeting will published her memoir in 2013 enti- historical examples, court cases, and highlight the last 50 years of that tled Waiting To Be Heard. After mul- scientific studies to demonstrate how theme. We are excited to announce tiple trials, in 2015, Knox was acquit- judicial processes do not protect the the distinguished speaker series for ted definitively by the Italian weakest members of society. Further, 2019. The lunch speakers will include Supreme Court of Cassation, and ear- he describes the scope of this dys- Ms. Amanda Knox, Professor Adam lier this year Italy was ordered to pay function and proposes practical Benforado, and Dr. Stephen Young. damages to Ms. Knox after a finding reforms to help achieve fairness in Amanda Knox was an American of rights violations by the European the law. college student studying abroad in Court of Human Rights, because she Dr. Stephen Young, US State Perugia, Italy in 2007. Ms. Knox’s wasn’t allowed access to an appropri- Department Psychiatrist covering roommate Meredith Kercher, a fellow ate interpreter or a lawyer during her Europe, is our third lunch speaker. He exchange student, was murdered in interrogation. is the Regional Medical Officer for their apartment. Ms. Knox was incar- Upon return to America as an Psychiatry and is currently stationed cerated in an Italian prison for exoneree, Ms. Knox became an at the US Embassy in London. He is approximately four years following author and an activist, and has been also the former Director of Mental her conviction for the murder. Ms. sharing her story of wrongful incar- Health Services, United States Knox was in international headlines ceration overseas as a university stu- Department of State. Dr. Young will for approximately a decade, and in dent. Waiting To Be Heard was a New talk about forensic psychiatry in the these stories she was both shamed York Times bestselling memoir. She is State Department. This would focus and vilified. (Her boyfriend at the currently the host of The Scarlet Let-

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American COVER STORY Academy of 2019 Annual Meeting Psychiatry and the Law continued from page 1 on, for example, medical clearance, fitness for duty, suicide, and criminal Editor issues that arise in the State Depart- Joseph Simpson, MD, PhD ment. Issues of confidentiality and The AAPL Awards Committee Associate Editors dual agency must be considered in would like your help. We would Philip Candilis, MD this role. Mental health services com- be interested in receiving nomina- Ryan Hall, MD bine local resources, Washington D.C. tions by June 1 for the following Stephen Herman, MD resources, and the Regional Medical awards: Neil S. Kaye, MD Officer. Dr. Young will share with us Renée Sorrentino, MD Red AAPL - For AAPL members Joel Watts, MD what he has clearance to share. Additionally, the Thursday evening who have provided outstanding AAPL Photographer program will be a debate regarding service to AAPL, e.g., through Eugene Lee, MD the most influential Landmark Case committee membership. since the founding of AAPL 50 years Former Editors Golden AAPL – For AAPL mem- Susan Hatters Friedman, MD (2016-2018) ago. Led by past AAPL President Dr. Charles Dike, MD, MPH (2008-2016) Peter Ash, five forensic psychiatrists bers over the age of 60 who have Victoria Harris, MD, MPH (2003-2008) will present arguments as to which made significant contributions to Michael A. Norko, MD (1996-2003) case is the most influential case in the field of forensic psychiatry. Robert Miller, MD PhD (1994-1996) forensic psychiatry in the past half- Alan R. Felthous, MD (1988-1993) century in America. These cases Seymour Pollack Award – For Robert M. Wettstein, MD (1983-1988) include Wyatt v. Stickney, Roy v. Har- APA members (who may not be Phillip J. Resnick, MD (1979-1983) AAPL members), who have made Loren H. Roth, MD, MPH (1976-1979) togs, Tarasoff v. Regents of University of California, United States v. John distinguished contributions to the Officers Hinckley, and Cruzan v. Director, teaching and educational functions President Missouri Department of Health. We of forensic psychiatry. Richard Frierson, MD expect a lively audience discussion, President-elect as well as the opportunity to provide Amicus Award – For non-AAPL William Newman, MD feedback using the audience response members who have contributed to Vice President system, and finally a vote regarding AAPL. Richard Martinez, MD which is the most influential case Best Teacher in Forensic Vice President since the founding of AAPL. James Knoll, MD – For out- The 50th anniversary is the perfect Fellowship Award Secretary standing faculty member in fel- Michael Champion, MD opportunity to return to Baltimore, Maryland, where AAPL was born. lowship program. Treasurer Stuart Anfang, MD This year is a great time to come to Please send your nominations to Immediate Past President the annual meeting, even if you Jeffrey Metzner, MD, Chair of the Christopher R. Thompson, MD haven’t been to AAPL in years, to Awards committee at help AAPL celebrate. Looking for- [email protected]. The AAPL Newsletter is published by ward to seeing everyone and celebrat- AAPL, One Regency Drive, PO Box 30, ing with AAPL! Bloomfield, CT 06002. Opinions expressed in bylined articles and columns in the Newsletter are solely JOIN US IN BALTIMORE! those of the authors and do not neces- Forensic Psychiatry sarily represent the official position Review Course of AAPL or Newsletter editors. October 21-23, 2019 Manuscripts are invited for publication in This intensive three-day course in forensic psychiatry will provide an in-depth the Newsletter. They should be sub- review of selected topics and relevant landmark cases. mitted to the editor via email to Basic concepts will be reviewed along with the latest case law. [email protected] The Newsletter is published in 50th Annual Meeting January (deadline for submission is October 24-27, 2019 November 15), April (deadline Febru- This meeting will inform attendees about current major issues in forensic psychiatry ary 1), and September (deadline July 1). and afford them opportunities to refresh skills in the fundamentals of the discipline, engage in discussion with peers, and update their present knowledge. www.aapl.org A block of hotel rooms will be reserved at the Marriott Waterfront in Baltimore, Maryland. © 2019 AAPL. ALL RIGHTS RESERVED.

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EDITOR’S COLUMN fiction. This is the very broad and Looking to the Future somewhat vaguely defined field of “neurolaw.” Over the past several Joseph Simpson, MD, PhD years, grant-funded academic centers In this, AAPL’s It seems likely that there will be a and even a combined PhD/ JD degree 50th year, there growing demand for experts to opine (at Vanderbilt University) have been will be many on what the standard of care should established, focusing on potential reflections on the be for novel treatments such as these. applications of neuroscience to organization’s his- (Time will tell if the recently- medico-legal questions of all types. tory, its accom- approved esketamine nasal spray These run the gamut from measuring plishments, and reduces or even ends the proliferation pain to lie detection to the ethics of how much it has of “ketamine clinics.”) Another cognitive enhancement technologies, evolved, grown and changed over promising area is the use of genetic among many others. these past five decades. There is testing to aid in the selection of psy- Will consultants one day subject much to be learned in looking back chopharmacological treatments. Will potential jurors to neuroimaging to over AAPL’s illustrious record and such testing ultimately be done rou- identify bias? Can neuroimaging seeing how far the field has come. tinely prior to starting medications? accurately predict future dangerous- This milestone anniversary is also an At what point will prescribers who ness? excellent time to think about new are not obtaining such tests expose In the pages of law reviews and areas of forensic psychiatric practice themselves to liability for adverse bioethics journals, scholars have that are little-known or even purely effects of the medication they choose been examining the possibilities and theoretical now, but which may see a – or simply for a delay in identifying pitfalls contained in advances in our great expansion in the next couple of an effective treatment? neuroscientific understanding of decades. Looking further into the future, we brain and behavior since around the Although forensic psychiatry can imagine a time when forensic turn of the century. The sci-fi flavor might be considered a “small” sub- psychiatrists are called upon to opine this endeavor can take on is indicated specialty, in terms of the number of on the mental health implications of by the titles of some of that output, fellowship training programs, gene editing via techniques such as such as, “The Government Can Read trainees in those fellowships, and CRISPR, a technology that at some Your Mind: Can the Constitution board-certified practitioners, it point may offer the possibility of cre- Stop It?” (1) and one of my personal encompasses a wide variety of dis- ating so-called “designer babies,” favorite titles, “Fundamental Protec- parate areas of specialized knowl- among many other potential applica- tions for Non-Biological Intelli- edge. Attending an AAPL Annual tions. gences or: How We Learn to Stop Meeting, or just reading the organi- Of course, changes in the field’s Worrying and Love Our Robot zation’s Journal or Newsletter, one is approach to forensic challenges will Brethren.” (2) bound to be struck by the sheer not be limited to the harnessing of All practicing forensic psychia- diversity of topics addressed. With advances in neuroscience. Two grow- trists stand to benefit by keeping cur- the pace of advances in the bio- ing areas of forensic psychiatry that rent on the state of the art in various sciences today, it is inevitable that are not as directly related to brain aspects of the field. Attending AAPL psychiatry and forensic psychiatry research include the movement Annual Meetings exposes us to will experience a great deal of toward delivery of community-based newly emerging ideas, as does being change in the years ahead. As foren- forensic services – which has an active in AAPL Committees. Both sic practitioners, we should strive to AAPL Committee dedicated to it, but will also facilitate networking with keep informed about some of the is still not as widely known and colleagues. Taken together, they areas likely to see an expansion in implemented as it seems certain to be increase your prospects for staying the need for forensic expertise in the in the future – and the broad topic of up to date. After all, the future will future. No one can keep current in all threat assessment and management, be here before you know it. areas, so focusing on those areas one which until recently was not a com- finds most interesting will make this mon theme of AAPL Annual Meeting References: challenge more manageable. presentations, but which has become (1) Boundy M. The Government Can Read For example, new treatment increasingly visible over the past Your Mind: Can the Constitution Stop It? modalities for depression, such as couple of years. Hastings LJ 63:1627-1644, 2012. repetitive Transcranial Magnetic The final area I will mention is (2) Dowell R. Fundamental Protections for Stimulation and ketamine infusions, one that in its more speculative incar- Non-Biological Intelligences or: How We are being offered by an increasing nations tends to quickly provoke Learn to Stop Worrying and Love Our number of clinical practitioners. In skepticism in some, along with an Robot Brethren, 19 Minn J L Sci & Tech 305-336, 2018. the case of ketamine, many of these impression that the discussion is physicians are not even psychiatrists. drifting into the realm of science

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PRESIDENT’S REPORT must include experience evaluating Taking our Heads out of the Sand: patients’ potential to harm themselves Manpower Needs in Correctional or others, appropriateness for commit- ment, decisional capacity, disability, Psychiatry and competency”. (7) The require- ments are silent on the need for gener- Richard L. Frierson, MD al psychiatry residencies to include an In his Presi- oped in collaboration with county and educational experience that involves dent’s address at state governments. (4) Among the provision of treatment in a correction- AAPL’s 49th facets of this approach is the develop- al or forensic facility. Annual Meeting ment of diversion programs (e.g., Should general psychiatry residents last year, “A Seat mental health courts and drug courts) be required to have a correctional or at the Table,” designed to divert persons with mental forensic hospital experience? Certain- Christopher illness into treatment programs in lieu ly, any well-trained psychiatrist could (“Kip”) Thomp- of incarceration. However, most diver- work in such a setting without specific son, MD called sion programs are not available to per- training. However, correctional sys- for AAPL to begin working towards sons with felony-level charges; fur- tems provide unique treatment chal- governmental advocacy and public thermore, these programs are typically lenges including, but not limited to, engagement. This includes educating not available in more rural areas. In the following: policymakers and the public on cur- fact, some states lack mental health • establishing a working relation- rent and future topics related to foren- courts altogether. ship with correctional officers sic mental health. (1) Sometimes, The APA Board of Trustees who have no medical training however, advocacy regarding forensic approved an updated Position State- • understanding custody levels issues needs to begin at home – that ment on Psychiatric Services in Adult • managing boundaries is, with AAPL’s role in the framework Correctional Facilities in July of 2018 • balancing patient confidentiality of organized psychiatry and AAPL’s (currently available by request), and with the facility’s security needs interaction, or lack thereof, with the has previously issued a position state- • providing quality psychiatric care various organizations that oversee ment on Segregation of Prisoners with with a limited formulary education and training in psychiatry Mental Illness. (5) However, all of • understanding prison culture and forensic psychiatry. these initiatives and position state- • dealing with medication diversion AAPL members are undoubtedly ments fail to address one crucial issue: (including medications that are aware of the crisis involving the large the training and development of future abused in correctional settings but numbers of persons with mental ill- psychiatrists to meet the growing not outside correctional settings) ness in US jails and prisons. Although demands for treatment of incarcerated • advocating for needs of the seri- epidemiological methods differ, the persons. In regard to this issue, it is ously mental ill in a system that is prevalence of mental illness among time for AAPL and APA to take our inherently not designed as a thera- incarcerated individuals is unquestion- heads out of the sand and advocate for peutic milieu. ably high. At least 15-30% of prison this growing manpower need. and jail inmates have psychiatric dis- The curriculum for forensic psychi- Exposure to these challenges while orders that result in significant func- atry fellowships and general psychia- in psychiatric training can lay the tional disabilities, and another 15-20% try residency training programs is foundation for a rewarding career in will require some form of psychiatric developed on a program-by-program correctional psychiatry, whether prac- intervention during their incarceration, basis, but there are core requirements ticed full- or part-time. with higher rates noted among female dictated by the Accreditation Council Many psychiatrists have inaccurate prisoners. (2) Perhaps most shocking, for Graduate Medical Education impressions of what it is like to work there are now more mentally ill per- (ACGME). The ACGME Program in corrections (partially because of a sons in jails and prisons in the United Requirements for Graduate Medical fear of the unknown), and therefore States than in hospitals. (3) Clearly, Education in Forensic Psychiatry state do not consider practicing in a correc- jails and prisons have become the new that “fellows must have at least six tional setting. Common obstacles mental hospitals. months of longitudinal experience in include concerns over personal safety The response of organized psychia- the management of patients in correc- and a negative impression of inmate- try (i.e., the American Psychiatric tional systems.” (6) Currently, the patients. However, the presence of Association) to this crisis has primari- ACGME Program Requirements for correctional officers, physical restric- ly been aimed at reducing the number Graduate Medical Education in Psy- tions on inmate movement, and other of incarcerated persons with mental chiatry have very minimal require- institutional safety policies can create illness, as reflected in programs such ments for forensic psychiatry: “Resi- a personal feeling of safety that is as the Stepping Up Initiative, devel- dent experience in forensic psychiatry greater than that found in general

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MEDICAL DIRECTOR’S REPORT Robert Trestman and others, the brief Charles v. Orange County: provided data to support the follow- The Importance of Discharge ing principles: 1) Discharge planning is essential to Planning on Release from Custody minimally adequate mental health care for incarcerated persons; Jeffrey S. Janofsky, MD 2) For individuals with serious men- AAPL, along The District Court dismissed the tal illness, continuity of care is essen- with the American complaint. The court agreed that the tial to effective treatment; Psychiatric Asso- defendants may have owed a limited 3) Discharge planning reduces the ciation, the Ameri- duty of protection beyond their peri- risk that needed care will be inter- can Medical Asso- ods of incarceration to the defendants. rupted following release and is criti- ciation, the Ameri- However, the District Court noted cal in ensuring continuity of mental can Psychological that while the most recent guidance health care for inmates with severe Association and from ICE itself requires discharge mental illness; three other amici curiae, participated planning, the claims asserted were 4) Discharge planning must include, in a brief in Charles v. Orange Coun- more akin to negligence or malprac- at a minimum, a discharge plan for an ty, New York. (1) The brief, primarily tice claims than constitutional viola- inmate with serious mental illness authored by APA, explained the tions. The District Court found that that accounts for the inmate’s medical importance of discharge planning for any alleged failure to provide dis- needs; detainees with severe mental illness charge planning did not “shock the 5) Failure to provide discharge plan- in the correctional setting. contemporary conscience,” the ning can place individuals with seri- Plaintiffs Charles and Ross were required threshold for a substantive ous mental illness at risk of grave both confined in an Immigration due process claim under the Four- harm; Detention Facility in Orange County, teenth Amendment. (2) 6) Standards for discharge planning New York. Mr. Charles had been Plaintiffs appealed to the Second for person discharged from correc- diagnosed with bipolar disorder and Circuit. Plaintiffs argued that while tional facilities exist and are promul- schizoaffective disorder prior to his under DeShaney v. Winnebago Cty. gated by professional and standard- incarceration and had received psy- Dep’t of Soc. Servs. (3) there is gener- setting organizations; and chiatric care and psychotropic med- ally no affirmative right to govern- 7) Discharge planning enhances post- ications while incarcerated. Ms. Ross mental aid including health care, release outcomes for individuals with had no pre-incarceration psychiatric under special circumstances like civil serious mental illness. history, but developed psychotic immigration detention, a constitution- As is usual practice, the AAPL symptoms while detained. Ross was al right to health care for detainees Council reviewed draft versions of newly diagnosed with schizophrenia does exist. Plaintiffs argued that this the brief and approved the brief in and received medications and psychi- special relationship includes dis- principle. AAPL members, including atric care while detained. Both were charge planning, in part because dis- members of the AAPL Corrections allegedly discharged from custody charge planning must begin while the Committee, were asked to review the without medications, a discharge plan detainee is still detained and because brief and to provide additional data or follow-up care. Charles was psy- the detainee has no immediate access and citations. Our members’ com- chiatrically hospitalized two weeks to medication or treatment once ments were forwarded to APA amicus after discharge. Ross went to an released. counsel, and substantially improved emergency room which she found on Our amicus brief attempted to edu- the brief. Some AAPL members who her own, and received psychiatric cate the Circuit Court that, “profes- reviewed the brief expressed the con- care. sionals with expertise in correctional cern that AAPL should not sign on to Charles and Ross sued Orange mental health care are in uniform an amicus brief in a case that could County (which had operated the agreement that discharge planning is expand the potential risk of correc- detention center on contract with US an essential component of mental tional psychiatrists being sued for Immigration and Customs Enforce- health care for incarcerated individu- deliberate indifference. Others felt ment (ICE) and others) in US District als with serious mental illness,” (4) that it was important to educate the Court alleging their substantive due and that continuity of care after court regarding existing data, and if process rights were violated under the release from incarceration is critical the courts found a constitutional right Fourteenth Amendment to the US to prevent relapse or re-incarceration. to discharge planning, that would Constitution. They argued that the Citing the work of AAPL members lead to improved funding and allow failure to provide discharge planning Alec Buchanan, Ken Hoge, Beatrice correctional psychiatrists to provide during detention rose to the level of Kovasznay, Jeffrey Metzner, Debra better services. After re-review the deliberate indifference. Pinals, Erik Roskes, Charles Scott, AAPL Executive Committee con-

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EXECUTIVE DIRECTOR’S REPORT I don’t know how many of you As the 50th Anniversary Comes Close use EHRs, but I can tell you that Jacquelyn T. Coleman, CAE most doctors I see have complaints about the system they are expected to some really sophisticated require- As the 50th use. ments and an online Journal. Anniversary As for generational shifts, I don’t Life was no longer good when it comes close, I am need to tell you that there are many came to database management. We shocked to realize approaches to technology. We still had to search for programs that that I have been have many members who only access would do exactly what we wanted, or involved for over email through their home system that could be modified to do what we half of the AAPL when they get home from work. wanted. Anyone who purchases soft- lifespan. Then on the other side, there are ware programs will know what we Still, I hesitate many who are very innovative. Our experienced. When you ask a sales to comment. My sense of AAPL’s systems of communication have to person can your system do “X” they history is so much different from account for all levels. say yes, but yes means I’m pretty what a member’s would be. So, these days, new technology is sure we can build it if we don’t have When I started working for AAPL not greeted by us with the same it. And let’s not even have the discus- in 1992, the Internet and email were enthusiasm it once was. We are no sion if the product will work on a novel. AAPL’s first email address was longer in control, and we want to be network, and if so, is there a charge [email protected], and we had to in control so we can deliver for you. for EACH station in the network? remember to go check email at the We want to meet your expectations. Nothing is free anymore. The one computer that had internet ser- Technology has made radical companies have gotten smart; month- vice. Our fax machine was relatively improvements in all aspects of soci- ly maintenance fee plus extra fees for new then also. ety. In AAPL’s case, the efforts of development are now the norm, and The advent of the ABDick your staff are multiplied dramatically, they decide what is “extra.” machine that would actually print and members benefit, but everything My father said that if you ask a labels for mailings was a blessing. comes with a price. machine to do two things, it will only From the ABDick, we graduated to I hope to still be alive when all do one well. In the age of comput- actual computers with WordPerfect as that needs to be done is to THINK it ers, it’s a struggle to make sure that the software. Then came Access, a and it happens. And meanwhile, put everything is done well. We hate relational database program, which that chip under my skin! along with other Microsoft products patches and quick fixes. Allowing handled rudimentary organizational for increases in scale, you were so necessities. right, Dad. Medical Director As time went on, however, the task The most essential element to became too complicated for Access, AAPL’s management is our relational continued from page 5 and we purchased an association database. It has huge amounts of firmed that AAPL should sign on to management system. We had easy data, and we have to carefully man- the final brief. access to the developer and updates age it so that when one function is Oral arguments were held on Sep- were free. A talented person, which changed, we don’t accidentally cause tember 25th, 2018. They were record- we were lucky to have in Marie another one to fail. We also have to ed and can be heard at: www.courtlis- Westlake, could discover new ways assure that our ancillary programs, tener.com/audio/58403/charles-v- to manipulate data. We were able to such as the abstract database and the orange-county-new/ . At the time I do so many things and people were MOC test don’t accidentally mess write this article the Circuit Court has impressed. something else up. Another example: not issued a decision in the appeal. Life was good. we have four different entities Much to our horror however, the involved in delivering the online References: system started showing signs of age. Journal to you. (1) Charles v. Orange County, New York. A surprising number of software Court of Appeals for the Second Circuit. Running old software on new hard- Docket No. 17-3506. ware is tricky and eventually the two programs have glitches. I hate that (2) Charles v. Orange County, New York. systems stop communicating with word because “glitch” doesn’t begin United States District Court for the South- each other. In less than a year our to describe the magnitude of some of ern District of New York (White Plains), software would be – those dreaded these failures. We all spend a lot of No. 16-cv-5527-NSR words – “no longer supported.” time these days speaking to “cus- casetext.com/case/charles-v-cnty-of-orange Along with database management, tomer support.” And we’re so (3) DeShaney v. Winnebago Cty. Dep’t of other needs arose. Members wanted relieved to find a person who is flu- Soc. Servs. 489 U.S. 189, 195 (1989) online abstract submissions, and a ent in translating computer speak to (4) Amicus Curiae Brief of the APA, AAPL, Maintenance of Certification test with person speak. et al., p. 17. Available at www.psychiatry.org/

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CHILD COLUMN tion could not support the child’s The Voice(s) of the Children wishes. On the contrary, he said, she Stephen P. Herman, MD had been programmed by her mother. In this state, however, that child could Leo Szilard, a they were capable of imitating human have her own counsel. Who would well-known physi- speech and that the intelligence of the prevail? How much “weight” ought cist and inventor, dolphins might be equal to that of the court grant this child’s wishes? who was born in humans…Subsequent attempts to Another state codified the hoary Budapest and edu- learn the language of the dolphins, to “Age of Reason” doctrine through cated in Berlin, communicate with them and to teach case law. Any child seven or older achieved fame in them, appeared to be discouraging, could hire counsel and compel the the United States. however, and it was generally court to consider her desire or explain He invented the linear accelerator, assumed that Dr. Lilly had overrated through findings why the child’s wish cyclotron and electron microscope. In their intelligence…” did not prevail. What about “weigh- 1939, he wrote a historic letter to Pres- That short story inaugurated my ing” the child’s preference? ident Franklin D. Roosevelt which lifelong commitment to working with A 13-year-old boy, whose single was signed by the pacifist, Albert Ein- children: to learn how to communicate father lost his parental rights, was stein. That correspondence led to the with them, respect them and recognize ordered to live with relatives in anoth- Manhattan Project, whose team built that they possessed an abundance of er state. He demanded to be returned the first atom bomb. Einstein wrote gifts for those who listened. to his home state, because his friends FDR: Today, everyone takes this for lived there. His lawyer was ardent; the “…It may become possible to set granted. Clinicians and researchers law guardian informed the court that up a nuclear chain reaction in a large appreciate that developmental stages, the child wanted to return because the mass of uranium, by which vast genetics, environment, resilience and house rules were lax, and his friends amounts of power and large quantities many other factors – some yet to be were experimenting with drugs and of new radium-like elements would be discovered – lead to the complexity of alcohol. The seasoned judge took the generated…This new phenomenon the term “child.” And this intricacy is child in chambers and with empathy would also lead to the construction of ineluctably experienced in forensic explained his reasoning and told the bombs, and it is conceivable – though psychiatry. teenager he was staying where he was. much less certain – that extremely Legal definitions vary; case law A 16-year-old girl was caught up in powerful bombs of a new type may may be confusing; rules are some- the vortex of a custody battle. She thus be constructed…” times arbitrary and contradictory; refused to have any communication Szilard was one of the founders of judges may possess or lack the experi- with her father. He insisted their the Salk Institute for Biological Stud- ence, training and ability to speak with daughter had been alienated by his ex- ies. He died in 1964, at age 66. In children in the mystifying in camera wife. The mother charged that the 1961, his book of short stories, The interview. Questions confront us: How father had been violent toward her and Voice of the Dolphins, was published. do you define a law guardian? What their daughter. The court followed the The book was one way of demonstrat- are the responsibilities of the lawyer teen’s wishes. Another judge might ing his moral outrage about the Cold for the child? Do Court-appointed have ordered a therapeutic process War and the dangers of nuclear Special Advocates help with or obfus- with the hopes of helping father and weapons. The fictional story by the cate issues? What about custody dis- daughter reconnect. A domestic vio- same name called for the establish- putes, severance actions, foster care lence finding in most states requires a ment of a European consortium to decisions, Miranda rights, delinquen- detailed explanation by the trier of study molecular biology. When this cy dispositions? How much weight fact if he deviates from the presump- became a reality, the association was should judges give to children of what tion that DV is not in the child’s best named after him. Its stamp depicts age? What does “weight” mean, any- interest. dolphins. way? About 20 years ago, I was part of a I read this book when I was 15 A five-year-old girl ensnared in a multidisciplinary team in the New years old. I am now 72, but that story custody battle offered, unsolicited, that York State First Appellate Division has remained close to my heart. In his she wanted to live with her mother, a convened to provide firm definitions futuristic tale, Szilard wrote of a mar- veterinarian. Her mother promised, the of the clear boundaries between vel: child told me, all the while drawing a guardian ad litem and a lawyer for the “…The organization of the brain of picture of a kitten, that she and her child. What if the child is three and the dolphin has a complexity compa- mother would live in the country and the family has the money to pay for a rable to that of man had been known have dogs and cats and maybe even a law guardian and an attorney for the for a long time. In 1960, Dr. John C. horse. The law guardian, sometimes child? Do these professionals have Lilly reported that the dolphins might called the Best Interests Attorney, different responsibilities? Does the have a language of their own, that related to the court that his investiga- (continued on page 8)

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NEWS FROM THE APA nearing a first draft from the Practice Report From the APA Assembly Guidelines Committee. Danielle B. Kushner, MD Assembly members were also encouraged to tour the new APA head- AAPL Representative to APA Assembly quarters, which officially moved back The American Psychiatric Associa- settlement. To become more involved to Washington, DC as of January 2nd, tion (APA) Assembly met November in such issues, APA members are 2018 in order to be closer to the US 2-4, 2018 in Washington, DC. The encouraged to become involved with Capitol and other political organiza- meeting opened with a moment of the APA Political Action Committee tions to more effectively advocate for silence recognizing the recent loss of (APAPAC) and the APA Congression- people with mental illness and to sup- life at the Tree of Life Synagogue in al Advocacy Network (CAN). port the professional needs of its mem- Pittsburgh, Pennsylvania. In the In addition to hearing reports, the bers. All APA members have been Report of the APA President, Altha APA Assembly voted on approximate- encouraged to take advantage of the Stewart, MD, spoke of the responsibil- ly thirty motions. One of the more Members’ Lounge along with viewing ity of psychiatrists to speak up regard- important items on the agenda was the panels that recount APA and psychia- ing the growing public trauma in our passing of a new Position Statement try history. Another highlight is visit- communities caused by violent acts of on Safe Prescribing after a lively dis- ing the Rare Book Room where some terror. Together with Dr. Stewart, APA cussion. The statement reads: “1) The of APA’s treasures are on display. Speaker James Batterson, MD and treatment with medication of patients The APA will be celebrating its APA Medical Director/CEO Saul with mental illness requires a founda- 175th Anniversary at the Annual Levin, MD, MPA additionally reflect- tion of medical education, training, Meeting in San Francisco from May ed on the experience of the wreath- supervision, and care of patients with 18-22, 2019. This year’s theme will be laying ceremony at the Vietnam War a broad range and severity of medical Revitalize Psychiatry: Disrupt, Memorial the previous day. This event problems. 2) The safety of patients Include, Engage, & Innovate, which is was inspired by an Action Paper and the public must be the primary dedicated to the work of addressing passed by the Assembly to commemo- consideration of each state’s licensing the most challenging issues facing rate the 50th anniversary of the Viet- agencies and legislature.” The goal of psychiatry today. nam War. the statement is to provide a founda- In his report, Dr. Levin discussed tion for the ongoing fight regarding the organization’s recent political and scope-of-practice issues. In response Child Column legislative updates. The APA was one to recent events, the Assembly also continued from page 7 passed a Position Statement on Police of three awardees of a CMS Quality law guardian in this Division have to Brutality and Black Males and a Measure Development Grant for man- be an attorney? (Rules varied across motion to develop and distribute a tool aging substance use disorders. The the state.) After a year, we thought we kit addressing racial discrimination to grant will forge a partnership between had cleared up the confusion. But department chairs and training direc- the APA and the National Committee some judges still made up their own tors. Other forensic issues of note for Quality Assurance (NCQA). APA minds about which professionals did included approving action papers legislative priorities continue to be what. designed to improve psychiatric treat- Telehealth, CURES state-targeted opi- In some areas, Court-appointed ment in child welfare and juvenile jus- oid grants, ChiP parity, Medicaid for Special Advocates have wide latitude tice programs, promoting access to jail and prison inmates with substance in their responsibilities. They might quality mental health services to use disorders, NIH opioid pain man- opine that a nine-year-old’s wishes forcibly separated immigrant children agement research, establishing best should be followed. Or, they may be and families, and advocating for keep- practices for opioid prescribing and limited to steering the family through ing families intact while applying for pain management, and defense of the the maze of the court system. There asylum status in the United States. Affordable Care Act. Of note, the APA might be no statute or case law that Highlights from the Assembly has joined a lawsuit against short-term sets the boundaries. Committees included a discussion limited insurance (www.stopjunkinsur- There are no easy answers to these regarding a new thinking process for ance.com). conundrums. We know that cetaceans, upcoming revisions of the DSM and a The APA was one of the first orga- e.g. dolphins, porpoises and whales, possible forensic dilemma as to nizations to oppose the Trump admin- are intelligent, play, communicate and whether the online or print version of istration’s immigrant family separation even pass on what they have learned the DSM should be regarded as the and detention policies. They signed on to their offspring. By 2021, Swedish authoritative version. The Mainte- to a letter to Congress opposing poli- researchers expect to have compiled a nance of Certification committee con- cies of separating refugee children complete dictionary of cetacean lan- tinued to explore alternative options from their parents. The organization guage. One hopes these scientists will for board certification. In addition, a also submitted comments opposing listen as well. proposed modifications to the Flores practice guideline on schizophrenia is

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ASK THE EXPERTS mit me to travel and see the sights. I Ask the Experts used to try to look at this as an oppor- tunity to see the country. I quickly real- Neil S. Kaye, MD, DFAPA ized that is not the case. Generally Graham Glancy, MB, ChB, FRC Psych, FRCP (C) speaking, because of time constraints, I Drs. Kaye and Glancy will answer consider an hourly billing day to be 8- fly in the night before, get up early, questions from members related to 12 hours long. It is not appropriate to spend the next day assessing the client, practical issues in the real world of charge for alcohol or entertainment. If I rush to the airport for an early evening forensic psychiatry. Please send ques- am able to work on another case or flight, and often get home late at night. tions to [email protected]. income-producing endeavor, I don’t Things are even worse when I have to This information is advisory only, charge for those hours. testify. This often involves arriving the for educational purposes. The authors I do feel I can afford to reduce the evening before feeling tense and wor- claim no legal expertise and should not charges if I am traveling on a Sunday, ried, perhaps meeting with the lawyer be held responsible for any action testify on Monday, and can get home for an hour or more, and then returning taken in response to this educational late Monday night or early Tuesday to my hotel room to ruminate over advice. Readers should always consult morning and still see some patients. I what is in store over the next day or their attorneys for legal advice. know some AAPL members charge for two. This might involve the meager only half a day if the flight is after 3 luxury of ordering room service eaten Q: How should I charge for out-of- PM or the return flight gets home by while I continue preparation. Far from state work and travel time? noon. That decision is made on a case- seeing the city sights, any recreation is by-case basis. confined to a solo late-night walk A. Kaye: I always require payment of any around the block to try and clear my Psychiatrists outstanding charges and for the expect- mind. Inevitably, the next morning is and forensic psy- ed travel expenses in advance of direct examination and a lonely sand- chiatrists have departing my house. If I am driving, I wich for lunch. The afternoon is usual- always billed for bill mileage at the IRS approved rate ly spent being cross-examined by a our time. If I have [2018: $0.545/mile (www.irs.gov/tax- lawyer who seems to be a disciple of to testify across professionals/standard-mileage-rates)]. the Marquis de Sade. I keep one eye on the country, it I keep the receipts and send them the clock, wondering whether I’ll make takes me a day to with a final bill and a thank-you note. my 6:00 PM flight, in order to get get there, a day to be there, and a day If I have been overpaid due to an over- home at a reasonable time. to return. It costs me three full billing estimate of expenses, I send a refund Suffice it to say, as peripatetic days out of my office to appear for the promptly and that always builds good forensic psychiatrists, we earn our hiring lawyer, and so I charge for three will. money! You should not feel guilty full days. I use a flat day rate but it about charging reasonable rates for could just as well be an hourly rate. A. Glancy: your valuable time. Often most of us In advance of taking a case, I tell I agree that it is put in time for which we never bill the lawyer via my written fee agree- essential to estab- such as brief phone calls with the ment that: “fees for expert testimony lish a fee schedule, lawyer or time spent reading around and days away from office (traveling usually by way of the subject of the case, doing on weekdays) are billed for a full cal- the written fee “research” just because we’re all so endar day and not for any increments agreement, prior to obsessive by nature that we need to of time thereof. All expenses incurred taking on a case. make sure we know the latest. will be billed after computation, but You should also be fair when sending Life would be a lot easier just to go fees for testimony time will be paid at an invoice. For example, it is often to my office or my home hospital and least three days in advance.” possible, and even expedient, to travel do a routine day’s work. There is no Incurred expenses include: coach in the evening for a case the next day. reason why we should not be well- airfare for me (I know AAPL members In this case, usually after discussion compensated for all of our time. The who charge the lesser of first-class air with the lawyer, I may feel I only have lawyer who retains you for a case out- travel or car+ground expenses+the to bill for the actual hours spent travel- side your geographic locale is picking time difference), parking, tolls, car ing. In addition, I can often spend you because of your special knowl- rental if required, hotel, and a reason- some of my traveling hours reading edge, experience, and reputation. Be able stipend for meals. I make it clear material for the case. Be careful not to comfortable and professional about that I’m not expected to fly after hours double-bill for this time. your charges and don’t devalue your- just to save the lawyer money. I’m too self! old for red-eye flights and I’m not When I first started in forensic psy- I do realize that the above descrip- expected to start a trip after a full chiatry, I had no idea that if I took on tion, which is partly in jest, may paint a workday. Most AAPL members I know cases in different places it would com- (continued on page 11)

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FACES OFAAPL Court Psychiatrist for Baltimore Jonas R. Rappeport, MD: Founding County. Father of the American Academy of After Dr. Guttmacher’s death, Dr. Rappeport left Baltimore County and Psychiatry and the Law was invited to succeed Dr. Guttmach- er as Chief Medical Officer for the Jeffrey S. Janofsky, MD and Christiane Tellefsen, MD Supreme Bench in Baltimore City in Originally appeared in J Am Acad Psychiatry Law 35:290–3, 2007 1967. Dr. Shah had obtained funding Dr. Jonas Medicine in 1952. He first became for teaching fellowships in forensic Rappeport, first interested in forensic psychiatry when psychiatry through the NIMH for President and first he conducted research on inpatient eight university forensic psychiatry Medical Director psychiatric patient violence, after a teaching programs across the United of the American patient assaulted a staff member. He States. (3) Dr. Rappeport applied for Academy of Psy- interned at the Michael Reese Hospi- and obtained funding for his first chiatry and the tal in Chicago and then returned to forensic fellow at the University of Law (AAPL), Maryland for his residency in psychia- Maryland in 1968. retired from forensic practice in 1999. try at the University of Maryland He remained interested in teaching Even during his retirement, he Medical School and the Sheppard and advancing knowledge of forensic remains active in AAPL and teaches Pratt Hospital. He remained an extra psychiatry and began correspondence forensic psychiatry at the University year at Sheppard Pratt as assistant to locate other training program direc- of Maryland Fellowship in Forensic chief of service (chief resident) in tors. This resulted in an initial meet- Psychiatry. Dr. Rappeport continues as 1956. While a resident at Sheppard, ing during the APA Annual Meeting in a resource and mentor for us, two of he was asked to testify at civil com- Boston in May 1968, and a subse- his former fellows, as well as for his mitment hearings and worked with quent meeting of forensic psychiatry colleagues throughout the United psychoanalyst Dr. Samuel Novey, program directors at the Miami APA States. Recently, we sat down with evaluating juveniles for the Baltimore in May 1969, which he chaired. At him over the course of several days County Circuit Court. that meeting, a new organization was and asked him to review his life’s After completing his residency, Dr. formed to: story. He was happy to oblige us. Rappeport joined the staff at Mary- Jonas Rappeport grew up in Balti- land’s Spring Grove State Hospital. . . . advance the body of knowl- more. As a teenager he babysat for Spring Grove housed Maryland’s only edge in the area of psychiatry and Manfred Guttmacher, a noted forensic forensic psychiatry unit at the time. law, to act as an agency of psychiatrist and chief medical officer He recalled that the forensic unit was exchange of information, knowl- at the Court Clinic for Baltimore a primitive place by today’s standards, edge and ideas between members City’s Supreme Bench. (1) He re- with literally a hole in the floor in and at the interface between psy- called leafing through Dr. Guttmach- which violent patients were housed. chiatry and the law, and to indi- er’s medical library while babysitting, Spring Grove Hospital Superintendent cate and study where contribution including a copy of Krafft-Ebbings’ Isadore Tuerk, who was interested in to the legal and penal system Psychopathia Sexualis. Much later, forensic psychiatry, supervised Dr. could be made by the behavioral Dr. Guttmacher invited him, then a Rappeport’s evaluation and treatment sciences [Ref. 4, p 1]. newly minted psychiatrist, to sit in on of forensic patients. Dr. Rappeport discussions at the legal psychiatry sec- also began psychiatric consulting at The organization, which became tion of the annual meeting of the the Hagerstown Maryland Reformato- AAPL, had its first meeting in Balti- American Psychiatric Association ry. While at Spring Grove, he worked more in November 1969. Dr. Rappe- (APA). Dr. Rappeport recalled being and socialized with Dr. Saleem Shah, port became the first President that with Colonel Albert Glass, Henry then a psychology intern, who later year and the first executive director in Davidson, Manfred Guttmacher, Karl became branch chief for the Center 1980. He recalled that AAPL was Menninger, Herbert Modlin, John for Studies of Crime and Delinquency originally a “mom and pop organiza- Ordway, John Torrens, and several at the National Institute of Mental tion.” Administrative support was ini- others at those meetings. As he Health (NIMH). (2) tially provided by staff at the Balti- recalled the experience, “They’d ask In 1959, Dr. Rappeport opened a more City Court Medical office, then what I thought and I shot my mouth private practice in clinical psychiatry through the Baltimore City Medical off.” After President Kennedy’s assas- in Baltimore. He continued his outpa- Society and the Maryland Medical sination, Dr. Guttmacher evaluated tient clinical practice until his retire- Society (MedChi). During its early Jack Ruby, who had killed the assas- ment. He consulted Dr. Novey for years, members’ wives provided all sin Lee Harvey Oswald. Dr. Rappe- supervision in his practice. Dr. Novey administrative support at meetings (all port recalled Dr. Guttmacher’s discus- recommended him for the new part- of the original members were men). sion of Ruby at those meetings. time position as court psychiatrist for Along with Herbert Thomas, Winn Dr. Rappeport graduated from the the Baltimore County Circuit Court. Perr, and Robert Sadoff, Dr. Rappe- University of Maryland School of Dr. Rappeport established the office of port wrote AAPL’s first ethics code. (continued on page 21)

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SPECIALARTICLE careers early in life, others are late Criminal Behavior & Developmental starters. Some are frequent offenders, Theories while others travel a more moderate path. Experiences in young adulthood Kavita Khajuria, MD and beyond can redirect criminal tra- Are people truly different or are we Early entry into adult roles with jectories or paths. In some cases people essentially the same but shaped by dif- precocious sexuality, motherhood, can be turned in a positive direction, ferent experiences? Crime is a baffling independent living and romantic rela- while in others, negative life conse- phenomenon. Criminal careers can be tionships can all pave the path into a quences can be harmful and injurious. difficult to explain, partly because substance-abusing lifestyle. By adult- How are crime causation theories there are many paths to crime. hood, vocational achievement and relevant to correctional and forensic In the 1940s and 1950s, research by marital relations may be the most criti- psychiatrists? The same question could the Gluecks on the biopsychosocial cal influences. Love (not sex) is cited be asked as to why we consider stres- approach formed the basis of the as a key to success: it strengthens sors, medical history, family history or developmental theory. This was social bonds and reduces the likelihood a social history during an intake evalu- sharply criticized at first. The eventual of offending. McCarthy and Casey ation. They all have potential influence question posed was: When faced with found juveniles involved in sexual on mental health treatment and rehabil- the same life circumstances, what activity without the promise of love to itation decisions, and could also have prompts one person to engage in per- actually increase their involvement in implications for wrongfulness and sistent criminal activity, while another criminality. criminal responsibility. steers clear? Why do some escalate According to Sampson and Laub’s Reference: while others don’t? age-graded life course theory (1993), Siegel, L PhD: Developmental Theories: Life Developmental theories look at the the course of a criminal career can be Course, Propensity, and Trajectory. In: Crimi- evolution of a criminal career. The life affected by events and turning points, nology, The Core. 6th ed., Boston, Massachu- course theory suggests criminal behav- which can alter the course and trajecto- setts: Cengage Learning: 2016; 264-300. ior to be a dynamic process influenced ry. Acquiring social capital helps some by individual characteristics and social at-risk people disengage from a crimi- experiences stimulated by shifts in nal career. The propensity theory holds Ask The Experts experience and life events. People the view that a stable unchanging fea- continued from page 9 begin relationships and engage in ture, characteristic or condition, such grim picture of our work. On the other behaviors that will determine their as defective intelligence or impulsive hand, it is what we do, what we live entire life course. These transitions are personality, makes some people crime- for, and let’s face it, we cannot resist expected to take place in an orderly prone. doing it. fashion, disruptions of which could be In a general theory of crime, destructive and ultimately promote Gottfredson and Hirschi argue the Take Home Points: criminality. propensity to commit antisocial acts to Written fee agreements and advance Suspected causes of childhood be tied directly to a person’s level of payment/retainers and the standard for offending include inadequate emotion- self-control. By integrating socializa- forensic psychiatry. Make sure the al support, distant peer relationships tion and criminality, they help explain lawyer signs the agreement and returns and poor parental discipline and moni- why some people who lack self-con- it with a check. Always get paid in toring. While most adolescents age out trol can escape criminality, and con- advance when doing work for private of crime, the ability to change declines versely, why some people with self- lawyers. You will never regret standing with age as one becomes engrossed in control might live conventional lives. by your fee schedule; having it avail- the criminal lifestyle. Those who join In contrast, the concept of the popula- able will make it easier for you and for gangs are more likely to get involved tion heterogeneity assumes that the the lawyers with whom you work. in antisocial behavior after they leave, propensity of an individual to partici- There are some cases (e.g.: Federal rather than before they join. One life pate in antisocial and/ or criminal Public Defender, State Medical Board) course view is that criminality is one behaviors is a relatively stable trait, where you will not be able to be paid of many problems faced by people unchanging over the life course. in advance. Further, some of these who live a risky lifestyle. Referred to The trajectory theory suggests mul- agencies have predetermined fee collectively as problem behavior syn- tiple trajectories or paths into a crimi- schedules and when you agree to work drome, this cluster of antisocial behav- nal career with distinctively different for them you are agreeing to their iors includes family dysfunction, sub- routes, both towards and away from a terms and rates, so make sure you read stance abuse, smoking, precocious sex- criminal career. Some may specialize and understand the fine print. But, as uality, early pregnancy, educational in violence, some in fraud, while oth- long as you have a signed contract with underachievement, suicide attempts, ers may engage in a variety of criminal the public/government entity you will sensation-seeking, unemployment and acts. Some offenders begin their be paid, although this will not necessar- criminality. ily be timely.

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ALLABOUT AAPL COMMITTEES the expert toward quick, slipshod Financial Arrangements in Forensic work. Don’t discount your fees to Work lawyers or firms on their promise to send you more, better cases. Those William H. Reid, MD, MPH; Brian Crowley, MD; cases never materialize. These Ana Natasha Cervantes, MD and James Reynolds, MD arrangements may mark you as doing cheap, low-quality work. Private Practice Committee Many forensic practitioners, especial- To avoid one’s work being under- Get a retainer or, if not possible ly early career psychiatrists, experi- valued by agencies, consider a non- (e.g., in most government matters), a ence difficulty collecting fees. The discrimination clause. This provides specific contract. Your retainer, as authors, in the field for decades, hav- that the evaluator is not being paid less your fee agreement details, applies ing had such experiences ourselves, than any other evaluator doing similar against future billings. If the case, or now collect almost all our fees. work, and that should another evalua- your role in it, ends before the retain- Below are practical steps that should tor be given a better rate, the expert’s er is exhausted, promptly refund; lead to financially thriving practices, rate will be increased to match. however, your agreement should allowing concentration on service We strongly discourage accepting allow you to keep the retainer if you without worry about payment. payment directly from litigants. If a have submitted a report or your name check signed by a litigant arrives, has been used in legal proceedings. Be scrupulously honest. Forensic send it, uncashed, to the attorney. Ask professionals should be honest about that payment be processed though the Require deposits for significant their abilities, intentions, value, and firm. This reinforces that the law firm future work (e.g., travel and deposi- charges. Understand your worth to a is the responsible party, not the liti- tion or trial testimony). Once you client, but don’t overestimate it. gant. release a report or are deposed, your Never pad bills. Document all time value to the retaining entity decreas- and expenses transparently. Never bill What and how much to bill for. es; it becomes zero after testimony. your rate for an assistant’s work. Forensic psychiatrists set rates at their Unless you are extremely comfort- When a refund is due, pay it prompt- discretion. Professional services are able relying on the retaining entity ly. typically billed hourly. Testimony may for payment, do not release reports or be billed hourly, on a half-day, or full- testify until the bill is current. Expert Be clear, in writing, from the begin- day rate. Experts may bill for research witnesses may usually decline testi- ning. Have a written, detailed fee or literature review and include a mony if they haven’t been paid. We agreement in place before work retainer provision to bill for these often tell clients, “Juries doubt the begins. That agreement should speci- tasks. Some charge a fixed hourly rate credibility of experts who testify fy fees charged, exactly who is regardless of the type of work; some while owed a lot of money. It’s much responsible for payment, how and charge different rates depending on better to say, ‘The bill’s been paid.’” when expenses are billed, conse- the task (e.g. travel might be billed at Send a deposit letter to the lawyer quences of arrears or nonpayment, a lower rate than depositions or testi- several weeks before deposition or retainer and deposit requirements, mony). There are regional differences trial. Waiting until later may suggest and cancellation and refund proce- in expert charges. Fees may depend on that you’re extorting rather than con- dures, and should state that compen- expert supply and demand, expertise, ducting a routine office procedure. sation will not be contingency-based. experience, and specific skills (e.g. Many government agencies cannot Be sure the person signing the agree- foreign language fluency). issue deposits, but may provide travel ment is authorized to sign by the Experts should initially establish advances. retaining entity. Keep a signed copy current and anticipated record quanti- Explain in the letter that you can- on file. ties, whether records are handwritten not schedule travel, testimony, etc., Some retaining entities, e.g., many or electronic, and any unique situa- without a deposit covering time and government agencies, cannot accept tions, e.g., interpreter use. One might expenses. Estimate preparation, trav- private fee agreements. In those track the time it takes to review “x” el, attorney conference, testimony, cases, a clear contract is usually suffi- pages or inches of records, to accu- expenses, etc., noting that you will cient, provided it addresses key sub- rately estimate for future cases. commit the date(s) once the deposit jects in your fee agreement. However, arrives. Clarify that the amounts are some, particularly small local agen- Avoid package deals & flat rates. estimates only. cies and rural counties and courts, Local agencies, e.g., jails, often pay Remember that these payments are may not pay reliably. Satisfy yourself flat rates for evaluations, and (usually deposits; send refunds promptly in advance that you will be paid new) forensic psychiatrists may when appropriate. You may keep promptly. Don’t rely on “Don’t accept them. Such arrangements are some of the deposit if your testimony worry; you’ll get paid.” notoriously exploitative, and tempt (continued on page 13)

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ALLABOUT AAPL COMMITTEES Financial insurer or government payments to threats of lawsuit are sometimes ille- Arrangements flow through the retaining lawyer, but gal. settle this before starting work. Pay- continued from page 12 ment is often faster, especially with We don’t recommend charging is canceled at the last minute, provid- government payers, when you accept interest on overdue bills. It entails ed your fee agreement allows it. direct deposit or electronic funds lots of recordkeeping and irritates transfer. people without real return. Your fee Be alert for early signs of trouble, agreement should say that costs of especially with new clients, plain- Decline pro se cases. Always go collecting overdue bills may be tiff’s lawyers, criminal defense through a lawyer, court or contracting charged to the client. lawyers, family law attorneys, and agency that understands your forensic Finally, don’t be cowed by lawyers small government agencies. Discuss role and guarantees your fees and threatening to spread bad reviews if your fees in the first conversation and expenses. Don’t accept cases that you insist on full payment. Dissatis- be cautious if the potential client have a court or lawyer overseeing the fied clients are entitled to spread balks or invokes litigants of limited pro se litigant. Decline people accurate complaints, not to slander or means. If you wish to work pro bono requesting fitness-for-duty or other libel. Such threats are usually empty or at a discount, it’s best to decide evaluations on themselves. Pro se bullying. Other lawyers probably this at the outset, not when the bill clients (often criminal defendants, won’t pay attention. Believe in your- has mounted. Note also that a civil plaintiffs, or parents in child self, not the blowhard. lawyer’s working pro bono doesn’t custody disputes) rarely understand suggest that the expert work for noth- our need for honesty, objectivity and ing, any more than it suggests the completeness. This creates conflicts FUTURE AAPL lawyer need not pay their phone bill. of interest and payment issues. Be cautious about contracting with MEETING DATES lawyers who are being paid by third Be careful when subcontracting, parties. Make clear from the outset, e.g., for psychological testing. It’s Forensic Psychiatry in writing, that the contracting entity usually better for the professional to Review Course be separately retained. If you subcon- is responsible for your bill regardless October 19-21, 2020 of third-party payment. tract with additional professionals, “Court-appointed” does not usual- ethics require that you compensate 51st Annual Meeting ly mean court-paid. If you expect them promptly even if you don’t get October 22-25, 2020 payment from a court, be certain that paid. Also, note that you likely must Marriott Downtown, Chicago, IL the court is actually the contracting file W-9/1099 forms. entity. Forensic Psychiatry Don’t nickel & dime your clients. Review Course Bill early and often. Do not wait Treat them as valued customers. October 25-27, 2021 Never charge for an initial inquiry or until the bill is substantial or the case 52nd Annual Meeting has progressed or resolved. Any a brief update. Reasonable copying October 28-31, 2021 lawyer who wants you to wait until and administrative charges are part of the case is resolved is suggesting a your overhead; don’t bill for them. If Vancouver, BC, Canada contingency process. Don’t do it. a case settles just before deposition Billing should start within weeks or on the courthouse steps, congratu- Forensic Psychiatry of your initial work and be regular late the lawyer and consider refund- Review Course thereafter. Your first bill starts the ing most or all of the deposit. October 23-26, 2022 compensation process and the expec- Lawyers love to get refunds from 53rd Annual Meeting experts and remember them fondly! tation of payment, and its payment October 27-30, 2022 denotes acceptance of your fee agree- ment. Problems with the first pay- Overdue bills & collections. It’s New Orleans, LA ment are harbingers of future prob- business. Be reasonable, but not shy, lems. Deal with them early. Don’t be about collections. Don’t sue unless For more information afraid to suspend work or resign for the amount is truly worth it (unpaid regarding these meetings nonpayment (which should be cov- bills shouldn’t get big in the first please visit our website at ered in your fee agreement). place). The authors have successfully www.aapl.org or contact Be certain your bills are submitted sued lawyers, choosing our cases us at 800-331-1389. to the appropriate person or depart- carefully. The experiences were ment and know whom to call to fol- unpleasant. Don’t threaten suit unless low up. You may choose to wait for you plan to follow through. Empty

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ALLABOUT AAPL COMMITTEES nation with opioids. (2, 3, 5) Brief review of Gabapentin Mersfelder and Nichols in their Abuse Potential review focusing on abuse, depen- dence and withdrawal of gabapentin Ryan Hall, MD found examples of it being abused as Psychopharmacology Committee a single agent and in conjunction with other compounds such as opioids or Gabapentin has traditionally been mate. Gabapentin does not bind to the sedatives (e.g., benzodiazepines). (4) thought to be a relatively safe med- GABAA, GABAB, or glycine/NMDA It appeared that gabapentin often ication with no addictive potential. receptors at relevant clinical concen- worked as a potentiator, increasing (1-3) It was considered a good treat- trations. (1, 3) In addition, there is no the effects of the primary intoxicant. ment option for many neurologic and indication that gabapentin binds to Individuals abusing gabapentin were psychiatric conditions, both for FDA- benzodiazepine, opioid or cannabi- on average taking more than 3000 mg approved indications (seizure disor- noid receptors. (1, 3) To date there a day (range, 600-8000mg). (4) With- ders, certain forms of neuropathies) have not been any studies showing drawal was noted to occur within 12 and for off-label indications (e.g., that gabapentin by itself actually hours to seven days of last use, with alcohol withdrawal/dependence, anxi- increases the extracellular dopamine common symptoms being agitation ety, mood instability, insomnia, activity in the mesolimbic reward and confusion. (4) Other symptoms of somatoform disorders, and withdraw- system. (5) It has been hypothesized gabapentin withdrawal included al symptoms from recreational that since dopamine release is not diaphoresis, gastrointestinal symp- drugs). (1-6) Given its perceived inhibited and other control pathways toms, tremor, tachycardia, hyperten- safety, gabapentin has historically not are, that gabapentin may indirectly sion and insomnia. (4) When been listed as a controlled substance, affect traditional reward pathways gabapentin was restarted the suspect- unlike its pharmacologically-related and potentiate the effects of other ed withdrawal symptoms resolved. cousin pregabalin, which is a Sched- drugs of abuse. (1, 5) One of the case reports reviewed ule V drug in the US. Although Over the last 10 years concerns even noted that the subject experi- gabapentin has a similar mechanism regarding the abuse potential of enced cravings for gabapentin upon of action to pregabalin, it does gabapentin have begun to arise. (2, 4, discontinuing the drug. behave differently, pharmacologically 6) Gabapentin abuse has been report- In a review of both gabapentin and speaking. Gabapentin is absorbed ed in the United Kingdom, Scandi- pregabalin (i.e. gabapentinoid) abuse more slowly (3-4 hours to peak navia, and Germany. (1, 5) Four hun- Bonnet and Sherbaum noted much absorption with a 6-hour half-life, dred and ten cases of suspected stronger literature support for prega- compared to one hour for pregabalin gabapentin abuse were reported to the balin addiction (e.g. greater magni- with a similar 6.3-hour half-life), has European Medicine Agency by means tude of behavioral dependence symp- a lower bioavailability, especially at of the EudraVigilance database (peak toms, more frequent transitions from higher doses (60% bioavailability for reporting in 2014). (5) The estimate prescription to self-administration, low doses, dropping to 30% for high- of lifetime prevalence of gabapentin and greater length of time of self- er doses, compared to 90% bioavail- abuse in the general population was administration). (5) In addition, there ability for pregabalin, unaffected by 1.1% in a British study. (3) were four cases of pregabalin behav- dose), and has roughly six times less In the US, a 2013 study found that ioral dependence symptoms by ICD- binding affinity for its target (voltage- 15% of individuals in the Appalachi- 10 criteria in individuals who did not dependent calcium channels) than an region in Kentucky being treated already abuse other substances (apart pregabalin. (1, 5) However some arti- for opioid abuse reported using from nicotine) either currently or his- cles and case studies report that gabapentin “to get high.” (6) With torically, but none for gabapentin. (5) gabapentin abuse results in feelings studies such as this it is not surprising The review did not find any cases of of euphoria, improved sociability and that Kentucky in 2017 was the first patients seeking substance abuse a “marijuana-like high.” (1) state to list gabapentin as a Schedule treatment for just gabapentinoid Gabapentin is a derivative of the V controlled substance. (7) In addi- abuse and rarely found reports of neurotransmitter GABA which tion, Bastiaens et al. found 26% of an relapse on gabapentinoids. The inhibits 2 -subunit-containing volt- incarcerated population with an opi- review also reported a 15-22% six- age-depeαndδent calcium channels. (1- oid abuse disorder reported abuse of month prevalence rate for individuals 5) This action reduces exocytosis of gabapentin, compared to only 4% of in opioid substance abuse treatment synaptic vesicles, affecting primarily those who did not abuse opioids. (2) (either abstinence or opioid mainte- glutamate, norepinephrine, and sub- Although gabapentin has been report- nance programs) taking gabapentin stance P, but not dopamine. (1, 3, 5) ed to be helpful in treating some sub- without a prescription. (5) Primary Its antiseizure effects are thought to stance abuse populations (e.g. alco- means of ingestion was oral, but there be related to the inhibition of excita- hol, cannabis) it appears to have some were reports of ingestion by nasal, tory neurotransmitters such as gluta- risk of being abused, often in combi- (continued on page 23)

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ALLABOUT AAPL COMMITTEES trists and other mental health profes- Prenatal Alcohol Exposure in Forensic sionals are unaware of the implica- Patients – Why Does It Matter? tions of ND-PAE. (7) The important question is: will a forensic psychiatrist Mansfield Mela, MBBS encounter individuals with these Developmental Disability Committee deficits during assessments (e.g., for competency to stand trial or insanity) Forensic psychiatrists frequently presumption of competence and crim- and treatment (sorting out comorbid encounter cognitive and adaptive inal responsibility). (3, 4) mental disorders, correctional place- deficits in perpetrators, victims and Diagnosis of those affected by the ment and psychotherapy)? witnesses in the criminal justice sys- neurocognitive and behavioral conse- ND-PAE, unlike other neurodevel- tem (CJS). These deficits are respon- quences of PAE has become more opmental disorders, has minimal or no sible for poor decision making, con- straightforward since the introduction physical distinguishing features tinued victimization and increased of the DSM-5, which includes criteria (invisible disability). Complexity is risk of recidivism. (1) Deficits in for Neurodevelopmental Disorder the norm, with comorbid diagnoses in executive function, impulse control, Associated with Prenatal Alcohol over 90%. (3, 8) High rates of misdi- attention and memory abound in Exposure, (under Other Specified agnosis have caused many offenders offender populations and are the Neurodevelopmental Disorder, 315.8 and witnesses to fall through the essential brain domains affected in (F88)), as well as Neurobehavioral cracks of the CJS. Given this level of individuals with prenatal alcohol Disorder Associated with Prenatal unrecognized psychopathology, foren- exposure (PAE) or diagnosed with Alcohol Exposure (ND-PAE) (in Sec- sic mental health systems bear the fetal alcohol spectrum disorder tion III, Conditions for Further brunt of the disproportionate overrep- (FASD). (2) Those same deficits chal- Study). (5) Offenders are 5-25 times resentation of ND-PAE among lenge the basic assumptions of the tra- more likely to have PAE or an FASD offenders. Studies estimate that in ditional CJS (e.g., punishment for diagnosis than the general population. psychiatric units, 8% of adults and individuals who fail to make the link (6) Despite the overrepresentation of over 20% of youths were diagnosed between actions and consequences, ND-PAE in the CJS, many psychia- with ND-PAE. (6, 7) Between 10-36 TABLE 1 Author & Year PopulaƟon (age range) Method Rate of ND- Comments PAE/FASD (%) Rojas & GreƩŽn 230 youths (12-18) RetrospecƟve Įle 10.9 sexual oīender 2007 (13) review community program

Murphy & 137 youths (14-19) Adolescent health 11.7 in custody and only ChiƩenden 2007 (14) quesƟonnaire survey 14% females

Fast et. al 1999 (15) 287 youths (12-18) AcƟǀĞ case 22.3 in forensic psychiatric ascertainment facility (DiagnosƟc) McPherson & Grant 91 adults (19-30) AcƟǀĞ case 10-18 Only those <30 years 2008 (16) ascertainment old (DiagnosƟc)

SƟnson & Robbins secure forensic DiagnosƟc survey 8 Only Fetal Alcohol 2014 (7) psychiatric hospital, Syndrome not FASD n=235 McLachlan et. al 90 adults in prison AcƟǀĞ case 17 <50 years old, PAE 2017 (17) ascertainment conĮrmed in 50% (DiagnosƟc) Bower et al. 2018 (9) DiagnosƟc in youth AcƟǀĞ case 36 Predominantly male prison, n=99 ascertainment and aboriginal (DiagnosƟc) Australian; majority not previously diagnosed

(continued on page 22)

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SPECIALARTICLE the Student Right-to-Know and Cam- Evolving Policy Topics of Interest for pus Security Act (1990) and Clergy Institutions of Higher Learning Act (1998), which require all Title IX- eligible institutions of higher educa- Ryan Hall, MD; Susan Hatters Friedman, MD; and Renée Sorrentino, MD tion to publically disclose crime statis- tics, crime prevention and security Due to changing societal and politi- was not a legal justification to prevent policies and procedures. (11, 12) cal pressures, colleges and universities medicinal use. Traditionally, courts Unfortunately many institutions have are facing some unique policy chal- have allowed colleges to prohibit not successfully responded to the lenges, many of which directly or medical marijuana on campus or in mandates outlined in these Acts. As a indirectly implicate forensic psychia- the dorms as part of school policy (6), result many of the reporting proce- try themes. These challenges range however whether the new K-12 school dures, on-campus procedures for from marijuana on campus to firearms rulings will carry over to the college investigating, adjudicating, and disci- on campus, to policies on investiga- level is yet to be seen. In the K-12 plining perpetrators of sexual assault tions of sexual assault. Although school rulings usually a guardian or vary greatly across institutions of some aspects of these issues arise in healthcare professional is in charge of higher education. the primary and secondary school sys- the medication, not a student, which In an attempt to clarify and stan- tems as well, on college campuses the would be harder to enforce in college dardize the process, new polices on majority of students are legally adults, and dorm environments. college sexual misconduct were pro- and there is less parental and school- It needs to be remembered that col- mulgated by first the Obama adminis- based oversight. leges and universities often have poli- tration and more recently the Trump Medical and recreational marijuana cies which restrict what would be oth- Administration. In April 2011 the is one area where universities are hav- erwise legal behavior. An example Obama administration issued what’s ing to make significant policy deci- would be firearms on campus and in known as the “Dear Colleague” letter, sions while trying to navigate conflict- dorms. One large study found that which was a directive that required ing state and federal laws. Historical- 4.3% of American university students Title IX schools to investigate sexual ly, institutions of higher learning have had a working firearm at college. (7) assault allegations and adjudicate not allowed marijuana on campus in When lawmakers focus on whether them under a “preponderance of the order to comply with the Drug-Free concealed firearms should be allowed evidence” standard. (13) The pro- Schools and Campuses Act, as well as on campuses across the US, what stu- posed Trump administration’s the Drug-Free Workplace Act. (1, 2) dents and faculty think about safety approach (public comment closed on However, Congress passed the 2014 related to guns on campus should be January 30th, 2019, with rule finaliza- Hinchey-Rohrabacher Amendment considered. Cavanaugh et al., study- tion pending at time of writing) (a.k.a. Rohrabacher–Farr or ing undergraduates at public universi- addresses CSA with a higher legal Rohrabacher–Blumenauer), which ini- ties in Texas and Washington state, standard (“clear and convincing”) as tially had a time-limited restriction on found that approximately one-quarter well as a change in scope of responsi- the US Department of Justice spend- of students were not comfortable at all bility for institutions. (14) Under this ing federal dollars to enforce federal with guns on campus. (8) Opponents proposal, institutions would be exempt prohibition laws in states with medical to guns on campus may cite research from investigating any assaults that marijuana laws. (3) Although this law finding that college students who occurred outside the school’s own has been repeatedly renewed, as of carry guns are more likely to be male, program or activity, as well as from 2018, nine states allow recreational engage in binge drinking and drug investigating any assaults that were marijuana and 21 states allow medici- use, drive under the influence, perpe- not reported to school school officials nal marijuana. Although campuses trate physical and sexual violence, be with authority to take corrective action may still forbid recreational use, the in trouble with the law, attend college (such as a Title IX Coordinator). number of legal challenges to the pro- in southern and mountain states, and Although this is just a brief synop- hibition of medical marijuana is ris- live off-campus. (7, 8) Proponents for sis of some evolving issues facing uni- ing. In 2018 there were two court rul- increased access to weapons on cam- versities, it is easy to see how forensic ings, one in Illinois (4) and the other pus list concern for the need for self- psychiatrists could become involved, in California (5) which prevent K-12 protection in the wake of rare large- and thus need to be aware of the back- school districts from imposing a blan- scale events such as shootings or knife ground and current legal standards. It ket denial of students’ access to medi- attacks, or the more frequent small- should also be noted that any govern- cinal marijuana on school grounds. scale acts of violence such as sexual ment or college/university policy deci- The California ruling noted that since assault, estimated to occur at an inci- sions that are made in one of these the federal government was not dence of 20-25%. (9-11) areas could potentially have ramifica- actively enforcing the Drug-free In an effort to address campus vio- tions for the others as well. Schools and Campus Act in regard to lence and college sexual assault medical marijuana, citing such laws (CSA), Congress passed such Acts as (continued on page 25)

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ALLABOUT AAPL COMMITTEES and criminal courts. Even the most Shrinking Access to State Hospital stable psychiatric patient bears a stig- Beds: A Growing Problem ma when there is a history of criminal charges, and community providers Joy Stankowski, MD juggling limited resources may be Forensic Hospital Services Committee reluctant to assume this perceived risk. The forensic patient population in year. (7, 8) At minimum, therefore, a Forensic patients themselves often state psychiatric hospitals has been forensic patient is likely to occupy a have circumstances that are impedi- steadily rising over the past 20 years, bed for many months. For patients ments to discharge. Since most largely due to increased admissions who do not get restored stays are admissions for competency restoration for restoration to competency to stand often much longer. Charges may be are restored, those not restored tend to trial. (1) Since forensic patients, typi- dismissed, but not competent and not be more resistant to treatment. Over- cally defined as those with a history restorable (NCNR) patients are likely all, non-restorability has been shown of criminal charges, have longer aver- to be found eligible for hospitalization to be related to older age, treatment- age lengths of stay than their non- via civil commitment. (2, 9, 10) In resistant psychotic disorders, sub- forensic counterparts (2), many hospi- fact, such persons are more likely to stance use disorders, and intellectual tals are experiencing a “funnel effect:” be civilly committed, and to stay disability (7, 16), all of which present the pace and ease of bringing in a longer than persons without forensic unique challenges to discharge plan- forensic referral far exceeds the steps status. (2) Someone found NCNR ning. Furthermore, extended lengths needed to plan and execute a forensic never stands trial, yet sometimes has a of stay may promote dependence on discharge. As demand for forensic history suggesting dangerousness, the institutional setting. As noted by admissions to state hospital beds making community placement diffi- Talbot in his review of deinstitutional- grows, courts have shown little cult. As suggested by Fisher and ization, expecting people with chronic patience for hospital administrators Grisso, the result is a population com- mental illness “without families and unable to prevent an admission bottle- posed of a “class of individuals who social networks, to suddenly be able neck and the resulting waitlist. (3) seem to not fit anywhere else” (Ref. to obtain for themselves the profes- Furthermore, federal courts have ruled 11, p. 367). When this population is sional and custodial services they for- that lengthy jail stays waiting for state combined with patients adjudicated merly took for granted in a total insti- hospital beds are unconstitutional. (4) not guilty by reason of insanity, the tution seems the stuff of sheer fanta- There are two possible approaches plight of keeping state hospital beds sy” (17). Although forensic patients to improving bed access: decrease open becomes even more problematic. typically are not left to fend for them- admissions or increase discharges. What are the barriers to discharge? selves, especially in the case of condi- Regarding the former, some states Theoretically, case law supports the tional release, few community plans have sought to reduce hospital refer- discharge of those who are no longer match the breadth and convenience of rals for restoration to competency mentally ill and dangerous (Jones v. institutional services. The long through community- or jail-based pro- United States; Foucha v. Louisiana) lengths of stay most forensic patients grams. (5) These programs, however, (12, 13), do not have a substantial experience can contribute to depen- present their own challenges. (4-6) probability of being restored to com- dence on such services. (18) Competency restoration in jail offers a petency (Jackson v. Indiana) (14), or So, what to do? With state hospital secure environment for those with can be safely cared for in a less beds at a premium, research on opti- high-level charges or histories of dan- restrictive environment (Olmstead v. mal management is critical. As sug- gerousness, yet there are limitations to LC and EW). (15) In practice, how- gested by Bloom and Novosad, a tar- what can be provided in terms of ever, the perception of dangerousness geted census of the different popula- treatment or a therapeutic milieu. (4, based on history of criminal charges is tions in state hospitals would help 5) Community-based programs offer a significant hurdle. As Fisher and define categories of forensic patients a more recovery-focused environ- Grisso note, there is a belief that “per- and pinpoint needs. (19) Management ment, but may not be appropriate for sons who have committed a crime, of each type of patient could then be persons where there are serious issues cannot simply be allowed to walk guided by data predicting outcomes. of dangerousness (7) or a high risk of away because of their psychiatric ill- For example, there is evidence that alcohol or illicit substance abuse. As ness” (Ref. 11, p. 367). Discharge of persons found either NCNR or not a result, most competency restoration a forensic patient therefore requires guilty by reason of insanity may be is still done in state facilities. demonstration of symptom stability, successfully transitioned to the com- Increasing the rate of forensic dis- lack of dangerousness, and frequently munity via step-down programs lead- charges presents many challenges. consent from proposed community ing to conditional release, or court- The majority (75-80%) of patients partners. These may include treat- monitored discharge, and both clinical admitted for competency restoration ment providers, case managers, hous- and actuarial data such as the HCR-20 are successfully restored within one ing supervisors, forensic monitors, (continued on page 20)

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ALLABOUT AAPL COMMITTEES resentation and assist with many dif- Female Incarceration – What is ferent needs including housing, immi- Happening in Oklahoma? gration when applicable, and social support. Similarly, the Women’s Jus- Reagan Gill, DO; Susan Hatters Friedman, MD; Jennifer Piel, JD, MD; tice Team focuses on keeping first- time, nonviolent female offenders out and Jason Beaman, DO, MS, MPH of prison. (14) They work with Gender Issues Committee women without means of assistance to Oklahoma incarcerates more laws. In 2004 Tondalao Hall was a 19- navigate the legal system. They devel- women per capita than anywhere else year-old mother of three young chil- op individualized treatment plans in the world. Thailand ranks highest dren with no criminal record. While including mental health services, sub- when comparing countries at 66.4 she was at work, the father of her two stance abuse treatment, housing pro- women per 100,000. The US is second youngest children fractured a femur in grams, employment, and educational at 64.6. (1) When comparing states, each child, as well as 12 ribs of their services. Rhode Island has the lowest rate of one-year-old son and seven ribs of Women who are incarcerated often female incarceration at 12 per their three-month-old daughter. He have complex mental health needs. A 100,000, while Oklahoma is highest at pled guilty and was sentenced to 10 history of trauma has been reported in 142. (2) Even more concerning is the years in prison. After serving two approximately three-quarters of fact that while male incarceration has years he was released in 2006. Hall, female prisoners. (15) The rate of increased nationwide by approximate- however, was charged with failure to PTSD among female prisoners is ly 6% since 1980, female incarcera- protect her children and was sentenced higher than for male prisoners, and tion has increased by closer to 10%. to 30 years in prison, where she much higher than the rate in the gener- (3) remains today. (8) Laws like “Failure al population. “Complex PTSD” from Over half of Oklahoma’s incarcer- to Protect” are almost exclusively a series of events or prolonged trauma ated women are in prison for drug charged against mothers. also occurs. Both women and men in offenses, and 20% are sentenced for One approach to combat the multi- prison average about 4% prevalence technical violations of probation or faceted problem of astronomical of psychosis across studies. (16) How- parole. (4) A majority are first-time female incarceration rates is legislative ever, women in prison, like women in offenders. Oklahoma incarcerates peo- change. Oklahomans for Criminal Jus- the community, have higher rates of ple 80% longer than the national aver- tice Reform led the “Yes on 780 and mood disorders than men in prison. age for drug and property crimes. 781” campaign. (9) State Question Substance use disorders are commonly Incarcerating non-violent offenders 780 reclassified drug possession from comorbid with mental health concerns. increases recidivism rates. (5) Unlike a felony to a misdemeanor. (10) Since Oklahoma’s Women in Recovery is men, for whom longer sentences show its passage felony charges have an intensive outpatient alternative to a negative correlation with violent dropped 28%. (11) State Question incarceration for women with drug- recidivism, women with longer sen- 781 distributed the funds saved by the related offenses. (17) Its goal is to tences for both violent and non-violent reclassification into privately-run reha- reduce recidivism, reunite families, crimes actually have a greater risk for bilitative organizations providing drug and break the cycle of intergenera- violent recidivism. (6) and mental health treatment, job train- tional incarceration. Since 2009 over Only recently has research started ing, and education programs. (10) 700 women have participated. to focus on differences between male Another law, State Question 788, Approximately 75% are mothers. By and female offenders. Women, collec- legalized medical marijuana. (10) the end of the program, 92% reestab- tively, are less likely to commit vio- Prior to this legislation, a second mari- lished contact with their children, lent crimes against others as compared juana possession charge was a felony which is an important factor in suc- to men. When they do, it is often in requiring between two and 10 years in cessful community reintegration. (18) the context of a relationship: they are prison. In 2016 arrests for marijuana The program has a recidivism rate of more likely than men to have commit- possession made up almost half of 6.7%, less than one-third the overall ted their offense against someone drug-related arrests in the state. (12) rate for Oklahoma in 2014. (19) close to them. (7) Drug offenses Question 788 should drastically Unfortunately, Oklahoma’s female account for much of the rise in the reduce the number of women being incarceration rate continues to rise. number of women incarcerated nation- sent to prison. Most women in the state are incarcer- ally. In the 1980s, public concern about Another type of solution is bolster- ated for non-violent offenses, held in crime led to a crackdown on drug ing a woman’s legal defense team. prison for longer periods than men, crimes. Many jurisdictions imposed Still She Rises Tulsa was established and suffer from antiquated laws. How- mandatory minimums and longer sen- in February 2017 to reduce incarcera- ever, there are solutions giving hope tences for drug-related crimes. tion for women, reunite them with including legislative reform, defense Women in Oklahoma are receiving their children, and stabilize families. teams, and alternatives to incarcera- harsher sentences from gender-biased (13) They provide individualized rep- tion. (continued on page 20)

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ALLABOUT AAPL COMMITTEES be “in the reasonably foreseeable Physician-Assisted Suicide and future,” as opposed to the US notion Euthanasia for Individuals with of “terminal illness”. The Canadian term was not statutorily Non-terminal or Mental Illness – is defined, but is generally believed to imply that patients are somewhere Canada Sliding Down the Slippery near the end of their lives due to their illness. While this suggests that peo- Slope? ple with psychiatric disorders would Patricia Westmoreland, MD and Mark Komrad, MD not be eligible, they are not explicitly excluded. In Carter v. Canada (2015), Suicidology Committee the Canadian Supreme Court ruled Physician-assisted suicide (PAS) is ing, between 10 and 15% of cases in that PAS could not be prohibited for a legal in several European countries, the Netherlands involved diagnoses of competent adult who 1) consents to Canada and eight states/jurisdictions anxiety and PTSD. (4) Approximately the termination of life and 2) has a in the US. Other jurisdictions will 70% were female and under 70 years grievous and irremediable medical likely follow. However, it appears that old. Personality disorders, as well as a condition that causes enduring suffer- the more experience a country has propensity for social isolation and ing that is intolerable to that individ- with PAS, the more the horizon of eli- loneliness, were pervasive in that ual. In addition, in demonstrating that gibility has expanded beyond terminal sample. (4) These demographics could a condition is irremediable, an indi- cases. The “Benelux” countries (Bel- indicate that female gender, difficulty vidual is not required to accept a treat- gium, the Netherlands and Luxem- getting along with others and social ment that he or she finds unacceptable bourg) have expanded criteria for PAS isolation could be considered potential (7), preserving the status quo in med- (by self-administered prescription) indicators of a life not worth living. ical ethics allowing patients to refuse and euthanasia (by physician-adminis- Moreover, these are endemic issues in treatments. For individuals with psy- tered injection) to include patients those with chronic mental illness. As chiatric illness, this opens a veritable whose psychiatric conditions cause to the point that applicants for PAS Pandora’s Box. Those who eschew intense distress and are unresponsive need not try any form of treatment psychiatric medications and life-sav- to treatment. (1) Also, they have fol- they deem unacceptable, up to 28% of ing procedures such as ECT might lowed the spirit of parity and removed those with personality problems may more easily be assisted in ending their any distinctions between “physical” not have received psychotherapy prior lives than provided treatment that and “mental” suffering. Therefore, to receiving PAS. (5) could assist in improving if not saving individuals who suffer from psychi- In all US jurisdictions with PAS, it their lives. atric illness can request PAS and is limited to terminal medical condi- In the first reported Canadian case euthanasia. tions (individuals who are expected to of MAID in the context of psychiatric In the Benelux countries, where survive less than six months and for illness, in 2016, EF, an individual these practices have evolved over 18 whom there is no known cure for their with conversion disorder, was granted years, 4.6% of all deaths are by physi- condition) and excludes psychiatric MAID on the basis of her mental dis- cians’ injections (2). They have slid a conditions. In addition to standing order which caused intractable muscle significant distance down the slippery with the American Medical Associa- spasms resulting in severe pain. She slope, to include eligibility for people tion (AMA) against all PAS and also suffered from digestive dysfunc- with non-terminal illnesses. In some euthanasia, the American Psychiatric tion, resulting in being unable to eat. cases, advanced directives and proxy Association (APA), concerned about She had lost significant weight and consent for euthanasia of the incom- practices in Europe, has adopted a muscle mass and could not ambulate. petent are honored. Two retrospective position statement opposing PAS for EF’s quality of life was described as studies, one from The Netherlands any non-terminal disorder, noting that “non-existent.” (8) Although the gov- and one from Belgium, uncovered a a psychiatrist should not prescribe or ernment argued that she did not meet troubling pattern with regard to the administer medication to a person criteria for MAID, the court granted demographics of individuals request- who is not terminally ill for the pur- her request. When Parliament later ing physician-assisted death. In both pose of causing death. (6) passed C-14, it specified that the studies, roughly half the individuals In Canada, a federal law (C-14 patient be in “an advanced state of requesting death for psychiatric con- Medical Aid in Dying - MAID) has irreversible decline” and that death be cerns had a personality disorder diag- permitted PAS and euthanasia since reasonably foreseeable. (9) nosis. (3, 4) In addition, although 2016. As in the Benelux countries, the Since the passage of C-14, more than treatment-resistant depression was vast majority of the practice is 3,700 Canadians have received PAS, responsible for the majority of death euthanasia. The Canadian terminolo- predominantly via euthanasia. (10). requests by individuals requesting gy for eligibility, not shared by any Under Canadian law, patients must be relief from intractable mental suffer- other country, states that death must (continued on page 23)

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ALLABOUT AAPL COMMITTEES Forensic Hospital (11) Fisher WH and Grisso T. Commentary: step on criminal justice reform. Civil Commitment Statutes—40 Years of (5) Mears DP, Cochran JC & Bales WD. continued from page 17 Circumvention. J Am Acad Psychiatry Law (2012). Gender differences in the effects of (Historical-Clinical-Risk Management 38:365–8, 2010. prison on recidivism. J Crim Justice 40: (12) Jones v. United States (1983). 463 U.S. 370-378. 20) can help predict readiness. (20, 454. (6) Collins RE. (2010). The effect of gender 21) Defining the nature and scope of (13) Foucha v. Louisiana (1992). 504 U.S. on violent and nonviolent recidivism: A forensic patients in state hospitals may 71. meta-analysis. J Crim Justice 38: 675-684. help guide clinicians towards (14) Jackson v. Indiana. (1972). 406 U.S. (7) Women in the Criminal Justice System improved management and discharge 715. Briefing Sheets. The Sentencing Project strategies, thereby helping fulfill (15) Olmstead v. LC and EW. (1999). 119 2007. Available at: obligations to both patients and the SCt 2176. www.sentencingproject.org/wp- community. (16) Uggerby R, Nielsen E et al. Character- content/uploads/2016/01/Women-in-the- istics and predictors of long-term institution- Criminal-Justice-System-Briefing- References: alization in patients with schizophrenia. Sheets.pdf (1) NRI, Inc. Forensic Patients in State Psy- Schiz Res 131:120-6, 2011. (8) Kaplan S. (2015, September 24). A bat- chiatric Hospitals: 1999-2016. Available at (17) Talbott, JA. Institutionalization: tered woman will stay in prison for failing www.nri-inc.org/our-work/nri-reports/foren- Avoiding the Disasters of the Past. Psych to protect her kids from her abuser. He was sic-patients-in-state-psychiatric-hospitals- Services, 55:1112-5, 2004. (Originally pub- released 9 years ago. Washington Post. 1999-2016/ lished in Hospital and Community Psychia- (9) Oklahoma needs criminal justice reform. (2) Levitt GA, Vora I, et al. Civil Commit- try, 1979, pp. 621-624.) (2018). Retrieved from okjusticereform.org ment Outcomes of Incompetent Defendants (18) Chovil I. Reflections on Schizophrenia, (10) Oklahoma Secretary of State. J Am Acad Psychiatry Law 38:349–58, Learned Helplessness/Dependence, and www.sos.ok.gov/gov/questions.aspx. 2010. Recovery. Psychiatric Rehab J, 29(1):69- (11) Gentzler R. SQ 780 is already reshap- (3) Dresser M. Maryland official held in 71, 2005 ing Oklahoma’s justice system. (2018, Feb- contempt by judge is out at Health Depart- (19) Bloom JD and Novosad D. The Foren- ruary 19). Retrieved from okpolicy.org/sq- ment. Baltimore Sun Octoer 31st, 2017. sic Mental Health Services Census of Foren- 780-already-reshaping-oklahomas-justice- www.baltimoresun.com/health/bs-md-health- sic Populations in State Facilities. J Am system/ official-20171026-story.html; O;Sullivan J. Acad Psychiatry Law 45:447-51, 2017. (12) Eastes L. (2016, April 20). 420: Data Court Orders New Western State Hospital (20) Manguno-Mire GM, Coffman KL, et al. shows marijuana isn’t Oklahoma’s problem CEO to Jail over Failure to Admit Patient. What Factors Are Related to Success on drug. Retrieved from Seattle Times, June 10th, 2016. www.seat- Conditional Release/Discharge? Findings www.okgazette.com/oklahoma/420-data- tletimes.com/seattle-news/health/court- from the New Orleans Aftercare Clinic: shows-marijuana-isnt-oklahomas-problem- orders-new-western-state-hospital-ceo-to- 2002-2013. Behav. Sci. Law 32: 641-658, drug/Content?oid=2962948 jail-over-failure-to-admit-patient/ 2014. (13) Still She Rises, a holistic defense pro- (4) Felthous AR and Bloom JD. Jail-Based (21) Cabeldue M, Green D, et al. Using the ject of The Bronx Defenders based in Tulsa, Competency Restoration. J Am Acad Psy- HCR-20 v3 to Differentiate Insanity OK. (2016). Retrieved from www.stillsh- chiatry Law 46:364-72, 2018. Acquitees Based on Opinions of Readiness erises.org/ (5) Wik, A. Alternatives to Inpatient Compe- for Transfer. J Am Acad Psychiatry Law (14) Schaefer R. (2016, April 20). Trio leads tency Restoration Programs: Jail-Based 46:339-50, 2018. Women’s Defense Team. Tulsa World. Competency Restoration Programs. Avail- Retrieved from able at www.nri- Female Incarceration www.tulsaworld.com/archive/trio-leads- inc.org/media/1508/ocr_website- women-s-defense-team/article_50260d02- format_oct2018.pdf. continued from page 18 409e-51e5-afad-a9302aea22cc.html (15) Gunter TD et al. (2012). Relative con- (6) Kapoor, R. Commentary: Jail-Based References: Competency Restoration. J Am Acad Psy- tributions of gender and traumatic life expe- (1) Walmsley R. World Female Imprison- chiatry Law 39:311-15, 2011. rience to the prediction of mental disorders ment List, 3rd Edition. World Prison Brief. (7) Mikolajewski AJ, Manguno-Mire GM, et in a sample of incarcerated offenders. Behav Accessed at al. Patient Characteristics and Outcomes Sci Law 30: 615-630. www.prisonstudies.org/sites/default/files/res Related to Successful Outpatient Competen- (16) Fazel S, & Danesh J. (2002). Serious ources/downloads/world_female_imprison- cy Restoration. Behav Sci Law 35:225-238, mental disorder in 23000 prisoners: a sys- ment_list_third_edition_0.pdf on October 2017. tematic review of 62 surveys. Lancet 359: 16, 2018. (8) Zapf PA and Roesch R. Future Direc- 545-550. (2) The Sentencing Project. (2015). Fact tions in the Restoration of Competency to (17) Tarrasch M. (2018, August). [Interview sheet: Incarcerated women and girls. Wash- Stand Trial. Curr Dir Psychol Sci, 20: 43- by the first author]. ington, DC. 47, 2011. (18) Sharp SF, Jones MS & McLeod DA. (3) Sawyer W. (2018, January 9). The gen- (9) Simpson JR. When Restoration Fails: (2014). Oklahoma study of incarcerated der divide: Tracking women’s state prison One State’s Answer to the Dilemma of Per- mothers and their children - 2014. The U. of growth. Retrieved from manent Incompetence. J Am Acad Psychia- Oklahoma, Dept. of Sociology. www.prisonpolicy.org/reports/women_over- try Law 44:171–9, 2016. (19) Gentzler R. (2016, February 9). What’s time.html (10) Parker GF. The Quandary of Unrestor- driving Oklahoma’s prison population (4) Oklahomans for Criminal Justice ability. J Am Acad Psychiatry Law 40:171- growth? Retrieved from okpolicy.org/whats- Reform, & FWD. (2018). Oklahoma out of 6, 2012. driving-prison-population-growth/

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FACES OFAAPL Jonas R. Rappeport form of the verdict. The Task Force assassination of President Reagan), specifically rejected any proposal to and John DuPont (murder of wrestler continued from page 10 restrict expert testimony by mental David Schultz) cases. The writers concentrated on forensic health professionals in cases involv- Dr. Rappeport met his wife Joan psychiatrists’ relationships with the ing the insanity defense based on “the during his internship at Michael people they examined and how much general excellence the task force Reese Hospital, where she served as information should be shared when found in Maryland’s forensic psychi- head nurse on the psychiatric unit. writing a report or testifying. Dr. Sad- atric examination and evaluation Recalling her professionalism, he off recalled that the initial draft was which in turn influences the thor- stated, “She wouldn’t date me while I written by a group seated at his oughness and quality of independent was working on her service.” They kitchen table in Philadelphia during psychiatric evaluation and testimony quickly fell in love and married when 1980 or 1981 (Sadoff R, personal in criminal cases” (Ref. 8, p 37). In both were 29 years of age. In Balti- communication, April 2007). That 1984, the Maryland legislature passed more, Mrs. Rappeport taught psychi- draft became the basis for AAPL’s parallel bills that retained the ALI atric nursing and worked as a psychi- “Ethics Guidelines for the Practice of Insanity Test based on the recommen- atric nurse, an outpatient therapist, Forensic Psychiatry.” (5) dations of the Task Force. Dr. Rappe- and then a visiting nurse until 1985 Dr. Rappeport became very active port advocated for the same position when she retired. She staffed the reg- in the Maryland Psychiatric Society when he testified before the U.S. istration booth at almost every AAPL (MPS), Maryland’s APA district Congress in hearings after the Hinck- meeting through October 2006, only branch. He recalled, “I’d go to meet- ley verdict. (9) a few months before her death in ings, and I’d sound off in committees. In the early 1980s, along with June 2007. The Rappeports have If you sound off enough they either Nicholas Conti, LCSW-C, his long- three children and four grandchildren. kick you out or make you President.” time colleague and the administrator By the time he retired, Jonas Indeed, Dr. Rappeport served as MPS of the Supreme Bench of Baltimore Rappeport had trained 39 fellows. President from 1965 to 1966. Before Medical Office (the name of the court Twenty of those fellows, along with his presidency, he wrote and advocat- was changed in 1983 to the Circuit 130 AAPL members, celebrated Dr. ed the passage of a psychiatrist- Court for Baltimore City), Dr. Rappe- Rappeport’s contributions to Ameri- patient privileged-communications port developed Maryland’s pretrial can forensic psychiatry during a din- statute in Maryland. (6) An initial screening program for all defendants ner at AAPL’s 30th Annual Meeting attempt to pass the statute failed. The who raised questions about their com- in Baltimore in 1999. (11) AAPL cre- legislature then passed a privileged- petency to stand trial or about their ated the Rappeport Fellowship in communications statute for psychia- criminal responsibility. (10) Before 1985 to offer outstanding residents trists in 1965, only to have it vetoed the initiation of the program, such with interests in forensic psychiatry by the governor after lobbying by the defendants were always sent to the the opportunity to attend AAPL’s state bar association and the state hospital. The pretrial screening pro- Annual Meeting to develop their psychological association (who gram reduced unnecessary hospital- knowledge and skills in forensic psy- claimed they were discriminated izations, saved money, and resulted in chiatry. Dr. Rappeport received the against). Thus began the “territorial more rapid submission of reports to APA’s Isaac Ray Award in 1984 and rift” between psychologists and psy- the court. In addition, the program led the MPS Lifetime of Service Award chiatrists. During Dr. Rappeport’s to quicker hospitalization for those in 2002. MPS presidency, a new bill was who were found to be acutely mental- Phillip Resnick, MD, another Past signed into law only when psychia- ly ill. Mr. Conti recalled, “Jonas has a President of AAPL, views Dr. Rappe- trists and psychologists joined to good understanding of people. He port as his “primary mentor.” When obtain the privilege for both profes- looked for people who thought out- Dr. Resnick began running the court sions. (7) He said, “I can still see side the box.” Dr. Rappeport and Mr. clinic in Cleveland, there were no myself on the telephone getting peo- Conti received strong support from local forensic psychiatrists to turn to ple to call their legislators [to gain Maryland’s chief judge and then visit- for guidance. He said Dr. Rappeport support for the bill].” ed all 23 Maryland counties to was “warm, open, and supportive.” Dr. Rappeport remained active in explain the program and to obtain the Over the years, he found that Dr. advocacy and public policy matters, support of county judges and sheriffs. Rappeport’s “most remarkable quali- both in Maryland and nationally. As Baltimore City’s Chief Medical ties were his inclusiveness and gra- After the Hinckley verdict, he was Officer, Dr. Rappeport consulted on ciousness to young people.” In sum- appointed in 1983 to the Maryland virtually all major forensic psychiatry ming up Dr. Rappeport’s contribu- Governor’s Task Force to Review the cases in Baltimore City during his tions to AAPL, Dr. Resnick recalled a Insanity Defense. He strongly advo- career. Nationally, he consulted on famous quote of Ralph Waldo Emer- cated retaining Maryland’s American the Arthur Bremer (attempted assassi- son that “every institution is the Law Institute (ALI) insanity test. The nation of presidential candidate lengthened shadow of one man.” Task Force subsequently recommend- George Wallace), Sarah Jane Moore Dr. Rappeport has cast a long ed retaining the ALI Test, but (attempted assassination of President shadow indeed. changed the burden of proof and the Ford), John Hinckley (attempted Reprinted with Permission by JAAPL (continued on page 24)

American Academy of Psychiatry and the Law Newsletter April 2019 • 21 191581 AAPL April 2019 Newsletter_rev8.qxp_April 2019 5/3/19 3:50 PM Page 22

ALLABOUT AAPL COMMITTEES Prenatal Alcohol versial. For nonviolent offenses, functional impairment, multiple com- diversion programs may allow for plex traumas, and parental substance continued from page 15 assessment and treatment instead of abuse. Supportive interventions that % of incarcerated offenders were incarceration. are informed and targeted are benefi- diagnosed with ND-PAE in surveys After sentencing, the ingredients cial to those with ND-PAE. Strategies, and active case ascertainment studies. necessary to perpetuate high rates of approaches, and adaptations specific (6, 9) Therefore, forensic systems institutional offending align with ND- to FASD follow the Risk-Need- should accommodate these manifesta- PAE features such as impulsivity, sug- Responsivity (RNR) model. tions of mental or cognitive disorder. gestibility, gullibility, dysregulation Continuing to ignore ND-PAE (Table I lists rates of ND-PAE and and disinhibition. High rates of leads to missed opportunities for pre- FASD found in published studies over increased sensitivity to physical vention, early identification and inter- the past two decades.) touch, risk unawareness and self-harm ventions to reduce recidivism. The Cognitive deficits and disorders behaviors characterize ND-PAE and path of an ND-PAE offender through affect medico-legal tasks such as feature prominently in institutional the CJS contributes to the dispropor- competence to stand trial and criminal perpetrators. (8) Therefore, institu- tionate cost arising from arrest, responsibility. The expert/clinician tional psychiatrists have a role in administration of justice offenses and should be sensitive to these deficits understanding these behavioral serious and violent offenses. The cost because those with ND-PAE are fre- deficits in ND-PAE in order to reduce of being victimized as an individual quently unrecognized by the police, psychological consequences, as well living with ND-PAE is high. show higher suggestibility and may as reducing the impact on staff morale Only through understanding the falsely confess to crimes. (8, 10) They when approaches that work with other behaviors viewed through a develop- also receive their first criminal charge offenders fail to have the desired mental lens can customized and tar- earlier in life, display substantial effect. geted interventions be effective and impairments in their ability to appre- Misdiagnosis and under-recogni- negative consequences reduced. Inno- ciate and understand their rights relat- tion of ND-PAE call for targeted vative, comprehensive treatment inter- ed to arrest, interrogation, and court training. Knowledge of maternal alco- ventions coupled with diversionary procedures, and have significantly hol history, multiple childhood place- measures signify an FASD-informed poorer ability to adequately communi- ments, academic underachievement approach and are pivotal tools in the cate with counsel. Interestingly, their and cognitive deficits should prompt hands of the forensic psychiatrist. (3, self-rated assessments of their abilities comprehensive assessments. Execu- 6) Details of interventions will be the do not correspond to these objective tive dysfunction contributes to a dis- subject of a future article. impairments. (10) proportionately higher number of Inconsistent application in insanity administration of justice offenses References: proceedings and criminal sentencing (breaches and failures). Obstacles to (1) Tuominen T, Korhonen T, Hämäläinen was apparent in a systematic review diagnosis (lack of training, preference H, et al. (2014). Neurocognitive disorders in of ND-PAE cases raised in US courts. for extra specialization using a multi- sentenced male offenders: Implications for (11) Not surprisingly, deficits due to disciplinary team approach) can be rehabilitation. Crim Behav Mental overcome by adopting a “red flag- Health, 24(1), 36-48). ND-PAE typically fail to meet the (2) Wyper K & Pei J. (2016). Neurocogni- high threshold for an insanity defense. ging” system combining confirmed tive Difficulties Underlying High Risk and ND-PAE was mentioned in the maternal alcohol use and evidence of Criminal Behaviour in FASD: Clinical defense of diminished capacity and neurocognitive deficits. Implications. In: Fetal Alcohol Spectrum noted as the number one reason in Forensic psychiatrists’ expertise Disorders in Adults: Ethical and Legal Per- 133 Canadian cases in which neuro- and comfort with uncertainty and spectives (pp. 101-120). Springer. scientific evidence was presented in ambiguity are advantageous in sepa- (3) Mela M & Luther G. (2013). Fetal alco- court. (12) Alternative legal approach- rating the effects of PAE in the con- hol spectrum disorder: Can diminished es should be considered when opining text of multiple psychiatric diagnoses. responsibility diminish criminal on criminal responsibility in ND-PAE. PAE’s contribution is clarified behaviour? Int J Law Psychiatry, 36(1), (3) Linking deficits with capacity for through reconceptualization of behav- 46-54. ior in a hierarchical list of causes. For (4) Roach K & Bailey A. (2009). The rele- a medico-legal duty (legal nexus) is vance of fetal alcohol spectrum disorder in paramount in comprehensive forensic instance, criminal activities associated Canadian criminal law from investigation to assessments. Such thorough evalua- with lifelong neurodevelopmental sentencing. UBCL Rev., 42, 1. tion may allow recommendation of deficits may support ND-PAE as (5) American Psychiatric Association, Diag- individualized supports or interven- opposed to mental disorders of later nostic and statistical manual of mental dis- tions. Recognition is the first step to onset such as schizophrenia. Com- orders: DSM-V (5th ed.). Washington, DC: identification, responsivity and appro- pared to other offenders, those with American Psychiatric Publishing Inc. 2013. priate intervention. ND-PAE’s impor- ND-PAE experience an earlier onset (6) Flannigan K, Pei J, Stewart M, et al. tance as a mitigator remains contro- of problem behaviors, higher rates of (2018). Fetal Alcohol Spectrum Disorder and the criminal justice system: A systemat- (continued on page 23)

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ALLABOUT AAPL COMMITTEES Prenatal Alcohol Gabapentin Slippery Slope continued from page 22 continued from page 14 continued from page 19 ic literature review. Int J Law Psychia- intravenous and rectal routes. There lucid enough to give informed consent try, 57, 42-52. was no indication from this review twice: at the time the request is made (7) Stinson JD & Robbins SB (2014). Char- that gabapentin was a gateway agent and immediately before they are acteristics of people with intellectual disabil- for use of opioids or other drugs; it administered life-ending drugs. For ities in a secure US forensic hospital. J Men- was usually taken/abused after opioid this reason, unlike in Benelux coun- tal Health Res Intellectual Disabilities, 7(4), 337-358. use had already been occurring. tries, advance directives for euthana- (8) Greenspan S & Driscoll JH (2016). Why It will be interesting to see if other sia are not permitted. Critics say this people with FASD fall for manipulative states or the federal government will forces patients to make a cruel choice: ploys: Ethical limits of interrogators’ use of follow Kentucky’s lead in making forgoing the death they want and pro- lies. In: Fetal Alcohol Spectrum Disorders in gabapentin a controlled substance. longing their suffering, or ending their Adults: Ethical and Legal Perspectives (pp. There is definitely literature that sup- lives before they want to. Neither sce- 101-120). Springer. ports that gabapentin abuse occurs, nario provides the autonomy to end (9) Bower C, Watkins RE, Mutch RC, et al. especially in certain populations, such their lives on their own terms. (2018). Fetal alcohol spectrum disorder and as the incarcerated and opioid While the question of MAID for indi- youth justice: a prevalence study among abusers. However, the risk of abuse viduals with psychiatric illness in young people sentenced to detention in Western Australia. BMJ open, 8(2), in patients without a pre-existing sub- Canada has been in limbo, the overall e019605. stance use disorder using low to mod- rate of MAID increased 30% in the (10) McLachlan K, Roesch R, Viljoen JL, et erate doses appears to be relatively last half of 2017. (11) One province al. (2014). Evaluating the psycholegal abili- low. declared that it is neither ethical nor ties of young offenders with fetal alcohol legal for a conscientiously objecting spectrum disorder. Law Hum Behav, 38(1), References: physician to refuse to refer a patient to (11) Douds AS, Stevens HR, & Sumner WE. (1) Schifano F. Misuse and Abuse of Prega- a colleague who is more open to PAS. (2013). Sword or shield? A systematic balin and Gabapentin: Cause for Concern? (12, 13) Apropos psychiatric illness is review of the roles FASD evidence plays in CNS Drugs 2014; 28:491–496 a case involving two plaintiffs, one judicial proceedings. Crim Justice Policy (2) Bastiaens L, Galus J, Mazuri C. Abuse with cerebral palsy and the other with Rev, 24(4), 492–509 of Gabapentin is Associated with Opioid post-polio syndrome, before the Que- (12) Chandler JA (2015). The use of neuro- Addiction. Psychiatr Q 2016; 87:763–767 scientific evidence in Canadian criminal (3) Smith R, Havens J, Walsh S. Gabapentin bec courts. These individuals are ask- proceedings. J Law Biosci, 2(3), 550–579. misuse, abuse and diversion: a systematic ing that they not be discriminated (13) Fast DK, Conry J, & Loock CA (1999). review. Addiction, 2016; 111: 1160–1174, against and prevented from accessing Identifying fetal alcohol syndrome among 2016 euthanasia for their “unbearable” and youth in the criminal justice system. J Dev (4) Mersfelder T, Nichols W. Gabapentin: “untreatable” conditions because their Behav Ped, 20(5), 370–372. Abuse, Dependence, and Withdrawal. Ann deaths are clearly not going to occur (14) Murphy A, Chittenden M, & The Pharmacother 2016; 50: 229–233 in the “reasonably foreseeable future.” McCreary Centre Society (2005). Time Out (5) Bonnet U. Scherbaum N. How addictive There is a similar challenge in British II: A Profile of BC Youth in Custody. Van- are gabapentin and pregabalin? A systematic Columbia. If these cases are success- couver, BC. The McCreary Centre Society review. Eur Neuropsychopharm 2017; 27: ful, the door will open far wider to (15) Rojas EY & Gretton HM. (2007). 1185–1215 Background, offence characteristics, and (6) Smith R, Lofwall M, Havens J, Abuse people with indisputably non-terminal criminal outcomes of Aboriginal youth who and Diversion of Gabapentin Among Non- illnesses. This raises concerns about sexually offend: A closer look at Aboriginal medical Prescription Opioid Users in all chronically disabled people; there youth intervention needs. Sexual Abuse, Appalachian Kentucky. Am J Psychiatry is special concern about allowing peo- 19(3), 257–283 2015; 172:487–488 ple with psychiatric illness to have (16) MacPherson PH, Chudley AE, & Grant (7) Important Notice: Gabapentin Becomes doctors provide assistance in suicide BA (2014). Fetal alcohol spectrum disorder a Schedule V Controlled Substance in Ken- instead of preventing it, as has hap- (FASD) in a correctional population: Preva- tucky. Amendments to 902 KAR 55:035 pened in the Benelux countries. lence, screening and diagnosis (Research finalized and adopted on March 3, 2017. An argument against euthanasia in Report R-247). Ottawa: ON: Correctional The regulation may be accessed on the Ken- such cases is made by Catherine Fer- Service of Canada. tucky Legislative Research Commission rier, President of Collectif des Medi- (17) McLachlan K. (2017). Fetal Alcohol website at: Spectrum Disorder in Yukon corrections: www.lrc.ky.gov/kar/902/055/035reg.htm cines Contre L’Euthanasia (Physi- Final report to Yukon Justice: Estimating the (accessed 2/17/2019) cians’ Alliance Against Euthanasia). prevalence of FASD, mental health, and Dr. Ferrier raises the concern that if substance use problems in the justice sys- these cases modify the current para- tem. Retrieved from meters for euthanasia, all individuals www.justice.gov.yk.ca/pdf/Corrected_McLa with disabilities could be stripped of chlan_Final_Report_to_Yukon_August_201 the protections to which they are enti- 7.pdf (continued on page 24)

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FACES OFAAPL Jonas R. Rappeport continued from page 21 CALL FOR AWARD NOMINATIONS

References: (1) Guttmacher MS: Adult court psychiatric Isaac Ray Award clinics. Am J Psychiatry 106:881– 8, 1950 (2) Roth LH: Saleem Shah: his national and The Isaac Ray Award, established in 1951, recognizes a person who has made international contributions to forensic mental outstanding contributions to forensic psychiatry or to the psychiatric aspects health systems. Law Hum Behav 19:15– of jurisprudence. It is a joint award of the APA and the American Academy of 23, 1995 Psychiatry and the Law that honors Isaac Ray, M.D., one of the original founders (3) Sadoff R: Education and training in and the fourth president of the American Psychiatric Association. forensic psychiatry in the United States. J Deadline for Nominations: June 1 Forensic Psychiatry 12:263–7, 2001 (4) Meeting minutes compiled by Ames Robey, Temporary Secretary. AAPL Manfred S. Guttmacher Award Newsletter 24:I-III, 1999. Available at The Manfred S. Guttmacher Award, established in 1975, recognizes an www.emory.edu/AAPL/newsletter/N243time outstanding contribution to the literature of forensic psychiatry in the form of a line.htm. Accessed May 2, 2007 book, monograph, paper, or other work published or presented at a professional (5) American Academy of Psychiatry and the Law: Ethics Guidelines for the Practice meeting between May 1 and April 30 of the award year cycle. of Forensic Psychiatry. Bloomfield, CT. Deadline for Nominations: June 1 Adopted May 2005 (6) Rappeport JR: Psychiatrist-patient privi- lege. Md Law Rev 23:39–49, 1963 (7) Schroeter G: Protection of confidentiality Learn more about how to make in the courts: the professions. Soc Probl a nomination at: 16:376–85, 1969 psychiatry.org/awards (8) Curran JJ (chairman): Report of the Gov- ernor’s Task Force to Review the Insanity Defense. Annapolis, MD: Office of the Attorney General, November 1983, p 37 (2) Chambaere K, Vander Stichele R, Morti- Act to Amend the Criminal Code and to (9) Taylor S Jr: Insanity law seen as hurting er F et al. Recent trends in euthanasia and Make Related Amendments to Other Acts society. New York Times. July 1, 1992. other end-of-life practices in Belgium. N (Medical Assistance in Dying) Available at: query.nytimes.com/gst/full- Engl J Med 2015; 372:1179-1181, rDOI: (10) Coletta A. “The right time to die.” page.html?res=9F04E2D8123BF932A35754 10.1056/NEJMc1414527 Canada’s law allowing physician-assisted C0A964948260&sec=health&spon=&page- (3) Thienpont L, Verhofstadt M, Van Loon T suicide faces criticism over restrictions. wanted=all. Accessed May 2, 2007 et al. 2015. Euthanasia requests, procedures Washington Post, November 15th, 2018. (10) Rappeport JR, Conti NP, Rudnick B: A and outcomes for 100 Belgian patients suf- www.washingtonpost.com/world/2018/11/15 new pretrial screening program. Bull Am fering from psychiatric disorders: a retro- /right-time-die-canadas-law-allowing-physi- Acad Psychiatry Law 11:239–48, 1983 spective, descriptive study. BMJ open cian-assisted-suicide-faces-criticism-over- (11) Janofsky JS: Dr. Jonas R. Rappeport 5:e007454 restrictions/?tid=ss_mail&utm_term=.23589 honored at AAPL. Maryland Psychiatrist (4) Kim SYH, De Vries RG, Peteet JR: 3a79c28 26:5, 1999 Euthanasia and assisted suicide of patients (11) Third interim report on medical assis- with psychiatric disorders in the Nether- tance in dying. bit.ly/2tnrl4X Slippery Slope lands, 2011 to 2014. JAMA Psychiatry (12) Fine S. Ontario court rules doctors who 73:362–368, 2016 oppose assisted death must refer patients. continued from page 23 (5) Nicolini ME, Peteet JR, Donovan GK et The Globe and Mail Canada, Jan-March al. H. Euthanasia and assisted suicide of per- 2018. tgam.ca/2EJ00OX tled. (14) For psychiatric patients, sons with psychiatric disorders: the chal- (13) Murphy S. Legalization of Assisted Sui- PAS flies in the face of all we have lenge of personality disorders. Psychol Med, cide and Euthanasia: Foundational Issues been taught as psychiatric physicians, 1-8. doi:10.1017/S0033291719000333, 2019 and Implications, 31 BYU J Pub L 333-394 in evaluating and caring for those (6) American Psychiatric Association (APA): (2017). whose lives are fraught with struggle Position Statement on Medical Euthanasia. (14) Ferrier C. Truchon, Gladu and euthana- so that they may have the opportunity Approved by the Board of Trustees, Dec sia of individuals who are not terminally ill. to live meaningful lives despite adver- 2016. psychiatry.org/psychiatrists/search- Collectif des Medicines Contre L’Euthanasia th sity. directories-databases/policy-finder blog, February 7 , 2019. collec- (7) Carter v Canada (Attorney General), 1 tifmedecins.org/en/truchon-gladu-and-the- References: SCR 331, 2015 euthanasia-of-people-who-are-not-terminal- (8) Canada (Attorney General) v EF, 2016 ly-ill/ (1) Appelbaum P. 2017. Should mental dis- ABCA 155 orders be a basis for physician-assisted (9) Statutes of Canada: 2016, Chapter 3, An death? Psychiatric Serv 68(4)315-317

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PRESIDENT’S REPORT President’s Report _jails_v_hospitals_study.pdf Accessed Feb- Board Of Education For Schaumburg School ruary 16, 2019 District #54 Case: 1:18-cv-00181 continued from page 4 (4) American Psychiatric Association: APA (5) Parents on behalf of student v. Rincon inpatient settings. Therefore, because Foundation Supports New National Effort to Valley Union School District 2018 OAH Reduce the Number of People with Mental Case No. 2018050651 the future need for correctional mental Illnesses in U.S. Jails, June 15, 2015. (6) State v. Maestas, 394 P. 3d 21 - Ariz: health services can only be expected www.psychiatry.org/newsroom/news-releas- Court of Appeals, 1st Div. 2017 to increase, the requirement of a cor- es/apa-foundation-supports-new-national- (7) Bouffard JA, Nobles MR, Wells W, et al: rectional training experience during effort-to-reduce-the-number-of-people-with- How Many More Guns?: Estimating the residency training could alleviate such mental-illnesses-in-u-s-jails Accessed Febru- Effect of Allowing Licensed Concealed fears and help create a mental health ary 16, 2019 Handguns on a College Campus. J Interper- workforce that is motivated to work in (5) American Psychiatric Association: Posi- sonal Violence 27(2):316-43, 2012 such systems. (8) tion statement on segregation of prisoners (8) Cavanaugh MR, Bouffard JA, Wells W, Finally, there are also tremendous with mental illness. December 2017, et al: Student Attitudes Toward Concealed benefits for correctional systems to www.psychiatry.org/psychiatrists/practice/he Handguns on Campus at 2 Universities. Am have an affiliation with an academic lping-patients-access-care/position-state- J Pub Health 102(12):2245-7, 2012. ments. Accessed February 16, 2019 (9) Fisher BS, Cullen FT, Turner MG: The institution. These include an improve- (6) Accreditation Council for Graduate Med- Sexual Victimization of College Women. ment in the overall standard of care, ical Education (ACGME): Program Require- Research Report. 2000. Available help for overburdened correctional ments for Graduate Medical Education in at: eric.ed.gov/?id=ED449712 medical staff, the possibility of acade- Forensic Psychiatry. 2017, (10) Kilpatrick D, Resnick H, Ruggiero KJ, mic appointments for correctional www.acgme.org/Portals/0/PFAssets/Pro- Conoscenti LM, McCauley J: Drug-facilitat- psychiatrists, and opportunities for gramRequirements/406_forensic_psych_201 ed, Incapacitated, and Forcible Rape: A research collaboration and publica- 7-07-01.pdf?ver=2017-05-03-161027-783; National Study [Internet].2007. Report No.: tion. Most importantly, having an aca- pp.12-13. Accessed February 18, 2019 219181. www.antoniocasella.eu/archila/Kil- demic affiliation provides the opportu- (7) Accreditation Council for Graduate Med- patrick_drug_forcible_rape_2007.pdf nity for correctional systems to recruit ical Education (ACGME): Program Require- (11) Krebs CP, Lindquist CH, Warner TD: ments for Graduate Medical Education in The Campus Sexual Assault Study (CSA) residents to work after they graduate, Psychiatry. 2016, Final Report. 2007 thus helping the system meet the www.acgme.org/Portals/0/PFAssets/Pro- (12) Jackson V, Goldberg S, Morningo J: increasing demand for correctional gramRequirements/400_psychiatry_2017- Student Sexual Misconduct: Introductory psychiatrists. 07-01.pdf?ver=2017-05-25-083803-023; Note. The American Law Institute. 2018. The development of correctional p.20. Accessed February 16, 2019 www.thealiadviser.org/campus-sexual-mis- experiences for psychiatry residency (8) Holoyda BJ and Scott CL: Psychiatric conduct/student-sexual-misconduct-introduc- programs is a win-win proposition, education in the correctional setting: chal- tory-note/ and the training of future psychiatrists lenges and opportunities. Int Rev Psychiatry (13) US Dept. of Education “Dear Col- should take into account the needs of 29:11-20, 2017 league” Letter, April 4th, 2011. this population of psychiatric patients. www2.ed.gov/about/offices/list/ocr/letters/co Given the fact that persons with seri- lleague-201104.pdf. Accessed 2-20-2019 Policy Topics (14) US Dept. of Education Background & ous mental illness are increasingly Summary of the Education Department’s found in correctional and forensic set- continued from page 16 Proposed Title IX Regulation. tings, the need for a mandated training References: www2.ed.gov/about/offices/list/ocr/docs/bac experience has never been greater. For (1) Education Department General Adminis- kground-summary-proposed-ttle-ix-regula- that reason, in regard to an ACGME- trative Regulations, CFR Title 34, Subpart A tion.pdf. Accessed 2-20-2019 mandated correctional experience in Chapter 1 Part 86. www.ecfr.gov/cgi- psychiatry residency, the time has bin/text- come. idx?SID=393301a7cdccca1ea71f18aae51824 JANUARY e7&node=34:1.1.1.1.30&rgn=div5- NEWSLETTER References: se34.1.86_17 (2) Higher Education Center for Alcohol and CORRECTION: (1) Thompson CR: President’s address: a Other Drug Abuse and Violence Prevention. seat at the table. J Am Acad Psychiatry Law “Complying with the Drug-Free Schools and 47: 12-21, 2019 Campuses Regulations,” www.higheredcom- In the January 2019 (2) Gottfried ED, Christopher SC: Mental pliance.org/resources/resources/dfscr-hec- newsletter on page 2, disorders among criminal offenders: a 2006-manual.pdf review of the literature. J Corr Health Care the winner of the Award (3) Williams T. Congress gives medical 23:336-346, 2017 marijuana users a good reason to be para- for Outstanding Teaching (3) Torrey EF, Kennard AD, Eslinger D, et noid. Marketwatch.com. Available at: al.: More mentally ill persons are in jails and in a Forensic Fellowship www.marketwatch.com/story/house-blocks- prisons than hospitals: A survey of the states. Program should be listed as medical-marijuana-budget-amendment-that- Treatment Advocacy Center and National would-protect-patients-2017-09-07 Kaustubh G. Joshi, MD. Sheriffs’ Association, 2010 www.treatmen- (4) J. S. And M. S. As Parents Of A.S., Vs. tadvocacycenter.org/storage/documents/final

American Academy of Psychiatry and the Law Newsletter April 2019 • 25 191581 AAPL April 2019 Newsletter_rev8.qxp_April 2019 5/3/19 3:50 PM Page 26

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26 • April 2019 American Academy of Psychiatry and the Law Newsletter 191581 AAPL April 2019 Newsletter_rev8.qxp_April 2019 5/3/19 3:50 PM Page 27

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