Forensic Psychiatry
Psychiatric practice is influenced by four major factors: (1) the psychiatrist’s professional, ethical, and legal duties to provide competent care to patients; (2) the patients’ rights of self-determination to receive or refuse treatment; (3) court decisions, legislative directives, governmental regulatory agencies, and licensure boards; and (4) the ethical codes and practice guidelines of professional organizations. All of these issues fall within the realm of forensic psychiatry. The word forensic means “belonging to the courts of law,” and at various times, psychiatry and the law converge.
Traditionally, psychiatrists’ efforts help explain the causes and, through prevention and treatment, reduce the self-destructive elements of harmful behavior. Lawyers, as the agent of society, are concerned that social deviants are potential threats to the safety and security of other persons. Both psychiatry and the law seek to implement their respective goals through the application of pragmatic techniques based on empirical observations.
Psychiatrists can act as either witnesses of fact or expert witnesses. As a witness of fact, a psychiatrist is acting as an ordinary witness, someone who has observed something and is being called to describe it in open court. This can include simply reading portions of a medical record into the legal record but does not include expressing opinions or reporting others’ statements. An expert witness is one who is accepted by the court and by advocates of both sides of the case as qualified to perform expert functions and whose qualifications may include education, publications, and board certifications. Expert witnesses may render opinions, for example, that a patient meets the legal criteria for a guardian appointment. Psychiatrists often act as expert witnesses and may be hired by the defense or prosecution to provide opinions. This may lead to the common situation in which two psychiatrists representing two different sides provide diametrically opposed opinions about the case under dispute. The result can be confusion both on the parts of juries and the public about the value of psychiatric testimony, as well as cynicism and disillusionment. Many experts in forensic psychiatry believe that this problem could be minimized if the testifying psychiatrists were appointed by and reported only to the court.
Students should study the questions and answers below for a useful review of all of these topics.
Helpful Hints
Students should be able to define each of these terms and know each of these cases.
abandonment
actus reus
alliance threat
antisocial behavior
battery
Judge David Bazelon
civil commitment
classical tort
competence to inform
competency
confidentiality
consent form
conservator
court-mandated evaluation
credibility of witnesses
culpability
custody
disclose to safeguard
discriminate disclosure
documentation
Durham rule
duty to warn
emancipated minor
emergency exception
forced confinement
the four Ds
Gault decision
going the extra mile
habeas corpus
hearsay
informal admission
informed consent
insanity defense
involuntary admission
irresistible impulse
judgment
leading questions
malpractice
mature minor rule
medical expert
mens rea
mental health information service
M’Naghten rule
model penal code
O’Connor v Donaldson
parens patriae
peonage
plea bargaining
pretrial conference
probationary status
right to treatment
right-wrong test
rules of evidence
seclusion and restraint
state training school standards
Thomas Szasz
Tarasoff v Regents of University of California (I and II)
task-specific competence
temporary admission
testamentary capacity
testator
testimonial privilege
voluntary admission
Wyatt v Stickney
Questions
Directions
Each of the questions or incomplete statements below is followed by five suggested responses or completions. Select the one that is best in each case.
57.1 Of the following, which is the least common cause of malpractice claims against psychiatrists by patients?
A. Suicide attempts
B. Improper use of restraints
C. Failure to treat psychosis
D. Sexual involvement
E. Substance dependence
View Answer
57.1 The answer is D
Sexual involvement with patients accounts for 6 percent of malpractice claims against psychiatrists and is the least common cause of malpractice litigation. This fact does not, however, minimize its importance as a problem. (It should be noted that the short statute of limitations for this particular offense may well discourage patients from pursuing litigation because they have not had sufficient time to reach a point of emotional readiness.) Sexual intimacy with a patient is both illegal and unethical. There are also serious legal and ethical questions about a psychotherapist’s dating or marrying a patient even after discharging the patient from therapy. Most psychiatrists believe in the adage “Once a patient, always a patient.”
For other malpractice claims, the following figures are given: failure to manage suicide attempts, 21 percent; failure to treat psychosis, 14 percent; and improper use of restraints, 7 percent. Substance dependence accounts for about 10 percent of claims and refers to the patient’s having developed a substance-related disorder as a result of a psychiatrist’s not carefully monitoring the prescribing of potentially addicting drugs.
57.2 Which of the following is not one of the basic elements of the insanity defense?
A. Presence of a mental disorder
B. Presence of a defect of reason
C. Finding of incompetence to stand trial
D. Lack of knowledge of the nature of the act
E. Incapacity to refrain from the act
View Answer
57.2 The answer is C
No precise, generally accepted definition of legal insanity exists. Tests of insanity have always been controversial and have undergone much modification and refinement over the years. The insanity defense standard has four basic elements:
Presence of a mental disorder
Presence of a defect of reason
A lack of knowledge of the nature or wrongfulness of the act
An incapacity to refrain from the act
The insanity defense is one of the most controversial issues in American jurisprudence. The presence of a mental disorder has remained the consistent core of the insanity defense; the other elements have varied in importance over time. The finding of incompetence to stand trial is unrelated to this defense. Defendants with mental impairments who are found competent to stand trial may still seek acquittal on the claim of insanity, alleging that they were not criminally responsible for their actions at the time the offense was committed. The term insanity is a legal construct, not a psychiatric diagnosis.
57.3 A 43-year-old prisoner is found to have major depressive disorder. The correctional psychiatrist wants to start him on antidepressant therapy because of the severity of his disease. He was very often in solitary confinement for violent behavior with correctional staff. The prisoner refuses to take any medications, stating he does not want to complicate his life any more by having to take drugs every day. Correctional officers tell you it would be a security risk to have this prisoner out of his cell every day for treatment anyway.
What is the most appropriate next step in his management?
A. Do not give the prisoner antidepressants because he has the right to refuse.
B. Do not give the prisoner antidepressants because it is a security risk.
C. Do not give the prisoner antidepressants because it is not a medical emergency.
D. Give the prisoner antidepressants because he does not have the right to refuse.
E. Do nothing and observe the prisoner for worsening symptoms.
View Answer
57.3 The answer is D
The law and ethical analysis of informed consent and refusal inside corrections are complicated. The legal rule is that inmates have the right to consent to care but do not necessarily have equally extensive rights to refuse care. Complicating this issue is the reality that distinguishing between a refusal of care and a possible denial of care is often difficult. An additional complication is the fact that other correctional staff may not want to offer appropriate psychiatric treatment for a variety of reasons (e.g., security risks, cost, deservedness). Simultaneously, inmates can be insistent and manipulative and sometimes seek care for inappropriate reasons. Despite these pressures from opposite poles, correctional psychiatric personnel must ensure that patients get appropriate care. Medical autonomy means that nonmedical personnel cannot overrule the professional judgment of correctional psychiatrists regarding their patients’ needs. Medical autonomy means that only legitimate clinical decisions direct patient care, not patient wishes. Correctional psychiatrists should be neutral in nonmedical matters. Aligning with security staff costs them their rapport with their patients. Alternatively, being inmate advocates for non-health-related issues would cost them their rapport with their correctional coworkers.
57.4 Which of the following statements regarding juvenile detention centers is true?
A. Youth suicide in juvenile detention centers occur four times as often as youth suicide in the general population.
B. Suicide prevention guidelines are strictly enforced in juvenile detention centers.
C. Prevalence of mental illness in detention centers is extensively researched.
D. Juvenile detention centers are long-term facilities for juveniles convicted of crimes.
E. More than 80 percent of incarcerated boys meet the criteria for posttraumatic stress disorder.
View Answer
57.4 The answer is A
Youth suicide in juvenile detention and correctional facilities have been shown to occur four times more often than youth suicide in the general population. Yet 75 percent of the nation’s confined juveniles are in facilities that fail to conform to even the most basic suicide prevention guidelines. Several studies note that 25 percent (not 80 percent) of incarcerated boys and 50 percent of incarcerated girls meet criteria for posttraumatic stress disorder (PTSD). Juvenile detention centers are short-term facilities that confine juveniles who are awaiting trial; juvenile confinement facilities are long-term facilities (e.g., residential treatment centers and training schools) for the confinement of juveniles convicted of crimes. Mental illness in detention centers has not been extensively researched.
57.5 A 30-year-old white woman was admitted to a local hospital because of cocaine abuse and major depression with suicidal ideation. She had been referred to the hospital after being arrested for cocaine use.
Which of the following is the most appropriate discharge plan for this patient?
A. Discharge to the local jail
B. Discharge to home
C. Discharge to care of her family
D. Discharge to a psychiatric ward within a correctional facility
E. Discharge to a substance abuse detoxification center
View Answer
57.5 The answer is D
The most appropriate placement for this patient is in a psychiatric facility within a correctional facility. Because she was arrested for cocaine use before her hospital referral, she still has charges pending against her and cannot be released to her home or the care of her family. Although a substance abuse detoxification center may be helpful in the future, she first must have her legal situation dealt with. Discharge to a local jail is inappropriate in this case as well because the local jail will not be able to adequately address her mental illness (major depression).
57.6 In the case above, the patient cut her wrists 4 days later. The most appropriate next step is
A. dismiss this act as it is manipulative
B. treat her as she has documented mental illness
C. continue to withhold psychiatric medications
D. continue one-on-one suicidal watch
E. complete examination by a mental health professional
View Answer
57.6 The answer is E
Because self-mutilation is hard to control, it is a serious challenge for correctional officials and psychiatric staff. When self-mutilation is not the product of a mental disorder, mental health professionals often deny admission to the mental health unit. This confuses correctional authorities who view such behavior as a sign of mental instability. It is essential to have clear protocols for self-mutilation when it is (1) a psychiatric symptom, (2) a manipulative gesture to escape a dangerous situation, and (3) an effort to manipulate the system for personal gain. This woman’s documented history of major depressive disorder should alert correctional staff to the likelihood that cutting her wrists is a true suicide attempt. She should have a complete evaluation by a psychiatrist to determine the extent of her current symptoms. If this woman is indeed having an exacerbation of her symptoms of major depression, continuing to withhold medications and simply putting her on a one-on-one suicidal watch may not be enough and is neglectful. However, a thorough evaluation should precede any treatment.
57.7 In the case above, 2 days later, her family succeeded in obtaining a court order for the patient to get medication for her psychiatric illness. Which medication should this patient be given at this time?
A. Haloperidol
B. Imipramine
C. Lorazepam
D. Carbamazepine
E. Lithium
View Answer
57.7 The answer is A
Haloperidol (Haldol) is an appropriate treatment for this psychotic patient. Acute psychosis, with significant risk for impulsive behavior such as suicide attempts, is effectively treated with Haldol. Imipramine, a tricyclic antidepressant, is lethal in overdose and should be prescribed carefully and not at all in high doses to actively suicidal patients. In a patient with a history of substance abuse, benzodiazepines such as lorazepam should be carefully prescribed. Benzodiazepines also work only by sedating without addressing this patient’s psychosis. Carbamazepine and lithium are mood stabilizers indicated for patients with bipolar disorder.
57.8 A 42-year-old single male patient committed suicide while on a 4-hour therapeutic pass from the hospital before anticipated discharge. The patient was hospitalized with a diagnosis of major depression, single episode, and suicidal ideation. The patient steadfastly denied suicidal thoughts or impulses after admission. He experienced moderate to severe depression, anhedonia, global insomnia, hopelessness, agitation, and loss of appetite. The patient signed a suicide prevention contract, promising to inform the psychiatrist immediately of any suicidal ideation or impulses. After antidepressant treatment was started, the patient’s energy level improved. The man’s family sued the psychiatrist for wrongful death. The expert found no evidence in the psychiatric record that a formal suicide risk assessment was conducted before the pass was issued. During the trial, the psychiatrist testified that he did a formal suicide risk assessment but that it was an oversight that he did not record it.
Which of the following is the most likely outcome of a trial under these circumstances?
A. The psychiatrist is not liable because a formal assessment of suicide risk was done.
B. The psychiatrist is not liable because adequate medical treatment was started.
C. The psychiatrist is not liable because the patient contracted for safety.
D. The psychiatrist is liable because a formal assessment of suicide risk was not documented.
E. The psychiatrist is liable because antidepressant therapy is known to increase the risk for suicide.
View Answer
57.8 The answer is D
The failure to adequately document events in the written clinical record is a major reason for lack of credibility to legal testimony. The psychiatrist in this case testified that he completed a formal assessment of suicide risk, but there is no way to prove this is true with no documentation. Although the patient was at a greater risk of suicide after administration of an antidepressant drug, the psychiatrist cannot be held liable for starting treatment with an antidepressant, which is the standard of care. It is also arguable that the psychiatrist had not placed total reliance on the suicide prevention contract but had used it appropriately to assess the working alliance with the patient, that is, the patient’s willingness to work toward getting better. There is an adage in legal circles that if it is not documented, it was not done.
57.9 A 45-year-old man has a documented history of paranoid schizophrenia. Upon returning home from work one day, he finds his wife in bed with another man. He immediately grabs a butcher knife and kills both his wife and her lover. He then systematically attempts to dispose of the bodies but is caught in the act.
What is the most likely outcome of a trial using the M’Naghten rules under these circumstances?
A. Guilty charge
B. Not guilty by reason of insanity
C. Guilty by mens rea
D. Guilty by actus reus
E. Not guilty by reason of diminished capacity
View Answer
57.9 The answer is A
To be found not guilty by reason of insanity, the defendant, as a result of a severe mental disease or defect, must be unable to appreciate the nature and quality or the wrongfulness of his acts. In making an insanity determination, the threshold issue is not the existence of a mental disease or defect per se but the lack of substantial capacity caused by it. In this case, the fact that the man tried to dispose of the bodies shows he was aware of the criminal act, negating any insanity plea. For conviction of any crime, a criminal state of mind (mens rea) must be accompanied by the commission of a prohibited act (actus reus
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