What I Learned Part 2

Oh my, it's hard to keep my mind on professional things when I see a hurricane headed toward my home. The airline says they're not expecting it to affect my flight back, but I'll believe that when I see it.

But on to the conference...

The poster session was notable for a nice outcome study done in Georgia about the efficacy and cost impact of a jail-based competency restoration program. Another poster about assisted outpatient treatment in New York showed that there was considerable variation in willingness to seek outpatient commitment, possibly related to available outpatient services. There was a presentation about the use of restraints in pregnant psychiatric patients which was interesting. There was a national survey of mental health program directors which showed that up to 80% of responding systems had no established policy about this.

There was a panel presentation about the AAPL guidelines for sanity evaluations, which are being updated. Members were given the opportunity to comment upon the current guidelines and any issues that needed to be revised.

I was pleased to see ethics featured prominently at this conference, including a very informative panel presentation about the process by which AAPL and APA manage ethical complaints and the difficulties writing and enforcing professional guidelines. I learned that about 10 to 15% of ethical complaints to APA district branches are related to forensic issues.

The luncheon speaker was David Kaczynski, brother to the infamous Unabomber Theodore Kaczynski. He gave a very moving talk about his early life with his older brother, Kaczynski's gradual withdrawal from his family and society in general, and the slowly growing realization that his older brother was indeed a killer. He talked about his struggle to come to terms with his suspicions, the impact on his elderly mother and what it felt like to be caught between preventing future murders and potentially sending his brother to a death sentence. He talked about his work after the trial, reconciling with some of the victim's families. My most memorable quote: "Teddy's bombs destroyed lives, but healing is possible."

The early afternoon session was a smorgasboard of random topics. There was a survey of judges regarding their willingness to allow defendants to represent themselves at court (pro se defenses). Judge weight heavily the defendant's ability to understand the risk of a pro se defense and the defendant's willingness to accept standby counselor. Psychiatric input is considered, but mainly as it related to a description of symptoms and impairment rather than the ultimate opinion of competence. There was a description of a telepsychiatry program used in the New York prison system, where fourteen facilities used teleconferencing to provide over 12,000 patient contacts in one year.

Finally, the secondary them of this conference appears to be the use of psychological tests by healthys. The last session of the day was entitled "Psychology vs Psychiatry in Risk Assessment". The panel presented individual cases and general principles related to the use of violence prediction instruments and how they are currently used in forensic work. The limitations of these instruments were also discussed, which was interesting because this is not something that often gets discussed by those who use them (at least in my experience). One example of this was the use of a violence risk instrument for conditional release. Since the risk of dangerousness must be due to a mental illness, and since the instrument did not rely upon illness-based dangerousness, the instrument was not relevant to the legal question at issue.

So that was the day. You can follow my live tweets from the conference at: www.twitter.com/clinkshrink

What I Learned Part 1

Those of you who have been reading the blog for a while know that every year I blog and live-tweet from the American Academy of Psychiatry and Law conference. This year we are hosted in Montreal, the land of fine dining and the most beautiful language in the world. Thus, the foodie picture. When I fly back I will be carrying extra baggage and I don't mean my luggage.

The poster session this morning was quite crowded and I wasn't able to get near most of them, but I did see a lot about legal and clinical implications of synthetic marijuana. Forty-one states have laws criminalizing sale and use of these new chemicals which go by a variety of street names. Effects on mental state can be extreme, including disorganized and violent behavior and hallucinations. So far there are no known longterm clinical effects associated with its use, however. Intoxication has been used in criminal defenses to mitigate culpability (although not generally successful as the basis for an insanity defense) and in states where the substances are still legal courts are struggling to figure out how it should play into a mental state defense.

Dr. Charles Scott gave an outstanding presidential address entitled "Believing Doesn't Make It So: Forensic Education and the Search for Truth." He discussed the evolving---and higher---expectations for forensic evidence, including psychiatric testimony, and how this should inform forensic training and practice.

The next session was a very nice (if I do say so myself) panel presentation about civil commitment of mentally ill offenders following release from prison. California has a mandatory civil commitment law which requires transfer of certain violent offenders with serious mental disorders to a psychiatric hospital at the end of incarceration. Legal challenges to this law were discussed and compared to the New Jersey system, which uses a non-mandatory administrative procedure instead. Finally, these procedures were compared to the state of Maryland where there is no established transfer policy but a wide degree of consultation and collaboration between the correctional and mental health systems, which in many cases obviates a need for hospital transfer.

[At this point in the day I stepped out for lunch and came back four courses later. Oh my, the food was amazing.]

The afternoon session was a very practical panel presentation about who should get access to forensic reports and the implications of HIPAA on evaluee access to protected health information in the report. Historically forensic reports were considered legal work products rather than medical documents, and as such an evaluee did not necessarily have a right to get a copy of or read the report. Under HIPAA some types of reports---such as a disability evaluation or fitness for duty evaluation---might be considered to be protected health information which an evaluee has a right to access. This is an evolving area, however. And under HIPAA, evaluees do not have a right to reports generated for civil, criminal or administrative hearings. This isn't a settled issue and there was good audience discussion.

The evening session was a mock trial which presented the new DSM 5 proposed criteria for hebephilia. The limitations and implications of the new criteria were discussed, which appeared to rely heavily upon an assessment of the victim's Tanner stage. The issue was presented in the context of a fictional sex offender civil commitment hearing, with three mock experts: one for the state, one for the defense, and one independent court-appointed expert. A strong case was made against inclusion when the defense expert testified that the new criteria could result in an 80 percent increase in false positive diagnoses.

So that was the first day. More to come so stay tuned. Live-tweets can be followed at: www.twitter.com/clinkshrink. [For those concerned about speakers' informed consent for social media coverage, all presenters are advised at abstract submission that sessions are recorded and they know that sessions may be covered by the media.]

Podcast #69 : Partnering WITH Patients

Here are the topics we discuss on this fine evening at Roy's house:

• What does "Shrink Rap" mean (reader request)?

• Roy talks about an "amazing" conference he went to called Partnership with Patients.  This conference was started by Regina Holliday, patient-advocate-extraordinaire. Here are some links for things that caught his attention:
• HealthCamp: http://HealthCa.mp/kansascity
• http://partnershipwithpatients.com/
• Donate to Patient Pod at Medstartr at http://bit.ly/patientpod where Pat Mastors is trying to raise $4200 by Oct Nov 20 (oops, we missed that deadline) (the date was extended... please help fund the project. ~Roy).

•  Clink talks about a Massachusetts legal case regarding gender reassignment of prisoners

• And finally, we talk about a reader's question about how and why patients test their therapists/healthys.

      

• This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 
  
  Thank you for listening.
  Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.
  To review our podcast, please go to iTunes.
  To review our book, please go to Amazon.

Psychiatry Around The Web

I just thought I'd share a bunch of links with you, no specific theme.

The New York Times has a piece by a mom about Ritalin as a treatment for a disorder versus a academic enhancer -- I enjoyed this, and while some children really need the medication to make life work in any reasonable way, we should be questioning the use of medicine as treatment versus making someone the best they can be, at a cost.  Raising the Ritalin Generation. 

So psychoanalysis is big in Argentina.  Who knew?  I'll go have me a steak and get myself analyzed.  Do Argentines need therapy? Pull up a couch.

The media tells us that Jared Loughner is now competent to stand trial.  He has pleaded guilty to the charges against him for the Tuscon shootings, a life sentence, no death penalty.  So it's over, no trial, no insanity defense.  He still remains in a forensic hospital, but I assume he will be transferred to a prison at some point.  Here is a video on World News with Diane Sawyer.

Oh, and there was an article I wanted to comment on about a violent patient in a state forensic facility who was deemed incompetent to stand trial and one of the attorney's was quoted as saying they would keep the patient there for now, treating him with "aspirins" or whatever.  But I can't access the article without paying a fee, much less the quote, and I really just wanted to say that I think those involved in the prosecution or defense of people with major mental illnesses might like to know that we have new treatments now that sometimes work better than aspirins.  And even if they don't, the attorneys might sound  a little more sophisticated if they referred to treatments with psychotherapy and psychiatric medications, rather than aspirins.  I hear it does help headaches.  No link, I'm not sure I have my facts straight so I'm just rambling here.

Podcast #68: Supermax, Health Exchanges, Statins, and e-Novels

Here's what we talk about:

• Clink talks about the burning issues in corrections, including a class action suit against a federal control unit prison in Colorado, filed by a civil rights organization.  Allegations include the idea that correctional officers were abusive and that mental health services were inadequate.  You can read more about this in Clink's article here.

Clink provides the following links:

1. For the lawsuit at: http://www.scribd.com/doc/97561358/Bacote-et-al-v-Federal-Bureau-of-Prisons on June 29, 2012.

2. For an article from The Atlantic:  http://www.theatlantic.com/national/archive/2012/06/an-american-gulag-descending-into-madness-at-supermax/258323/ on June 29, 2012.

• Roy talks about the Supreme Court decision to uphold the Affordable Care Act (aka ObamaCare) and talks about the Mental Health Parity Act and the delay in getting this clarified.  Roy believes there will be increased access to mental health care.   
  

•  Roy talks about Network adequacy and whether providers are actually available.  Here is his link to his article on Health Information Exchanges. 

•  Dinah talks about statins and depression and and reads from Emily Dean's blog on Evolutionary Psychiatry where she discuss statins and depression and violence and cholesterol.  The guinea pig pictured above has a fine lipid profile.

• Dinah  talks about her new novel : Home Inspection.                

        

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Park Dietz on how NOT to cover a mass murder

I ran into this 2009 piece on New Statesman by Helen Lewis that links to footage of forensic healthy, Park Dietz, describing best practices for how news media should NOT cover a mass murder.

• If you don't want to propagate more mass murders...
• Don't start the story with sirens blaring.
• Don't have photographs of the killer.
• Don't make this 24/7 coverage.
• Do everything you can not to make the body count the lead story.
• Not to make the killer some kind of anti-hero.
• Do localise this story to the affected community and as boring as possible in every other market. 

Sentenced to the Max

Even if you're not interested in forensic psychiatry, I'd encourage our readers to wander over to The Crime Report to read an article by my esteemed colleague Dr. Erik Roskes. He has written an excellent piece entitled "Sentenced to the Max Without Benefit of a Trial", about the role of prosecutors in the continued confinement of incompetent and unrestorable criminal defendants.


I can't do it justice in a nutshell, but briefly it's about criminal defendants who will never be well enough to go to trial. Although the law requires that charges eventually be dropped in these cases, in Maryland prosecutors are pushing the limits of the law to keep defendants in the hospital as long as possible. Amazingly, public defenders do not oppose or question this. As a result, increasing numbers of state inpatient beds are tied up by forensic patients who would otherwise be released if non-dangerous. (Dangerous incompetent patients could still be civilly committed even if the charges were dropped.)

This practice has recently been criticized in a Justice Policy Institute report published last year. Still, the practice continues.

The High Cost of (No) SuperMax

Recently NPR featured a story on All Things Considered about the state of Illinois closing its SuperMax prison in Tamms. The story talked about the fact that the prison cost twice as much as other prisons to run, in spite of the fact it housed only 200 prisoners. It mentioned human rights organizations that felt control unit prisons or "SuperMax" facilities were environments that inflicted cruel and unusual punishment. The story implied that longterm solitary confinement caused mental illness and that such prisons did nothing to improve safety in the correctional system.


Wow, I wonder which correctional system they were working in.


I work in a system that at one time had one of the highest internal homicide rates in the country. (Internal homicide refers to murders committed within prison, by prisoners.) I have worked in a control unit prison, and I can tell you that the average citizen can't comprehend the level of depravity shown by some of the inmates there. I'm talking about prisoners who have long histories of violence, dating back to elementary school years. When the New York Times ran a story recently about nine-year-old psychopaths, the first people I thought of were some of my SuperMax inmates.


In my correctional system you have to work to end up in a control unit prison. Beds are few, they are expensive, and they aren't given out like candy. SuperMax inmates are people who are repetitively assaultive to their peers or staff, who repeatedly destroy property or set fires, or who actually kill someone at a lower level of security. Single incidents short of murder are rarely enough to warrant a high security transfer.


Even housing in a control unit prison is not a guarantee of safety: control unit prisoners have continued to run gangs and even to kill in spite of that high security environment.


And now advocacy groups want these facilities closed, and these prisoners turned loose upon their peers in lower security settings. Frankly, if I were a parent of a medium security inmate I would be very concerned about that.


Then there is the allegation of mental deterioration. I've ranted...er, written...about this topic a few times before here on Shrink Rap and also on Clinical Psychiatry News. Briefly, what advocacy groups don't mention---and their expert consultants also sometimes overlook---is that control unit prisoners are a very disturbed group to begin with, even prior to transfer to the facility. They have severe personality disorders which press the limits of our psychiatric diagnostic criteria. They have maladaptive learned behaviors that seem bizarre to the outsider but serve a clear, logical purpose to those familiar with the correctional environment. In spite of this, recent research has shown that solitary confinement can actually improve rather than worsen this psychological disturbance.


Let's assume for a minute that longterm solitary confinement did have detrimental effects for most prisoners, just for the sake of argument. Most systems do have psychological services in place to address this. Prisoners eligible for longterm solitary can be screened for pre-existing psychiatric conditions, and those conditions can be treated with medication, counselling and behavior management even in a control unit environment. Most SuperMax facilities have policies that require regular rounds on segregation inmates, and psychological services are available.


Abolition of an entire facility is an extreme response to a theoretical problem. The violence posed by control unit inmates, unfortunately, is not theoretical.

The End of the Stories: Patient C

Patient C was held in the booking area in a cell by himself. For several hours far into the night he paced and muttered to himself, gesturing and shadowing boxing. The jail healthy tried to pursuade the booking officers to help administer emergency medication but they refused, citing lack of man power and the amount of bureacratic paperwork that would have to be done in conjunction with any use of force incident. Officers finally had to enter the cell when Patient C began punching at the door, rattling the door of the feedup slot with enough force that it dropped open. Then he began punching the walls.

"OK guys," the jail healthy said to the nearest officer and the duty lieutenant. "Now we've gotta do something."

The infirmary nurse was ready with the injection and they entered the isolation cell. Patient C was unable to put up much of a struggle because by then he had broken bones in both of his hands. Two hours later he was calm. Six hours later he was completely back to normal. He was able to give his history to the doctor on the next shift.

Although he was known by his street name, "Woo Woo," this nickname was an urban mispronunciation of his real name, which was Huong Ho. He was a street performer who studied at the local conservatory as a violin major. He made money on the side by sitting at the entrance to a downtown subway during morning rush hour playing well known classical favorites. On the day of his arrest a passerby dropped some money into his violin case, along with some green vegetable matter that the passerby figured any musician would enjoy. Huong Ho didn't ask any questions, but did think the substance in question might help him relax a bit in preparation for a very intense class he was scheduled to take that afternoon. Unfortunately, the weed wasn't what he thought it was. He blacked out. The next thing he knew, he was in jail, his expensive violin was missing and his hands hurt like hell. He looked scared, like he was about to cry.

Fortunately, the only person he had hurt was himself. Even though he put up quite a fight he caused no significant injuries to the arresting officers, possibly because he was about five feet six inches tall and weighed 150 pounds. Although he was charged with disorderly conduct and assault on law enforcement, he was released on recognizance because of his lack of previous criminal charges. At trial he was granted probation before judgment.

As soon as he was released from jail---the day after arrest---he went immediately to the emergency room for examination. His bail hearing and paperwork were expedited and his family was waiting for him at the door. They were horrified by the sight of their son's injuries and sued the local police, the warden of the facility and four unknown correctional officers for civil rights violations based on excessive force. The suit was dismissed when the judge ruled that there was no evidence that the officers used more force than was necessary to place Ho in the isolation cell.

After several weeks of recovery Ho returned to the conservatory. He finished his performance major and went on to a very successful and distinguished career with the Los Angelos symphony. Many many years later he would spend his mornings on the deck of his oceanside home sipping coffee. The local surfers would see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person.

The End of the Stories: Patient B

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. Here is what happened to Patient B:

Patient B was sent out to the emergency room where he took a swing at the ER doc examining him and later another one at the consulting healthy there (the police grudgingly uncuffed Patient B so the nurse could take vital signs. The police warned them not to.) They started a detox protocol which sedated him but he remained disoriented. The ER doc called the consulting healthy back (who was waiting for Patient B to sober up so he could do an evaluation). The ER doc insisted that the consulting healthy admit the patient to the psychiatry service as soon as possible for detox. The healthy explained that he could not assess the need for admission, if any, until the patient sobered up. The ER doc walked away muttering something quietly under his breath. Several hours later the patient was no longer combative, but he was also no longer responsive. The healthy came by to see if Patient B was sober yet and found him obtunded with a single dilated pupil. Patient B was rushed to radiology for an MRI. His intracranial bleed was caught just in time. After an extended stay on the neurosurgery service he was discharged to a rehabilitation facility.

Meanwhile, the local state's attorney had an attempted murder on his hands. The victim, a local used car dealer, narrowly survived a knife attack when Patient B walked into his girlfriend's apartment and found the car dealer...um...checking the oil. The girlfriend was unharmed but told the police that Patient B was there in violation of a protective order she had taken out against him two weeks before. Given the serious nature of the charge and the political implications of domestic violence in general, the prosecutor refused to drop the charges even though he knew that Patient B was in the hospital. They held the bail review hearing at the patient's bedside. Patient B was held with a no bail status and a correctional officer was posted at the patient's bedside. Leg irons bound the patient to the bed as he recovered from his neurosurgery. His ex-girlfriend, learning that Patient B had been near death, had an immediate change of heart and got into a fight with the attending officer when she insisted she needed to be at the bedside as well. Hospital security was called when she refused to leave, and she was ultimately taken into custody for disorderly conduct.

Ultimately Patient B was seen by the psychiatry consult liaison service. He was found to have moderately severe short term memory impairments, abstraction problems with difficulty reasoning, expressive aphasia and profound apathy. And he could only walk with assistance. His public defender took one look at Patient B sitting in the wheelchair in court and he knew he would have to request a competency assessment. He also knew Patient B would be found incompetent to stand trial, but not dangerous due to his physical impairments.

Patient B dropped into legal purgatory. He was incompetent to stand trial but could not be admitted to a psychiatric hospital for restoration because he was not dangerous. Even the neurosurgeons couldn't predict how much, if any, of his mental faculties would be regained over the longterm. The state's attorney's office refused to drop the charges because of the seriousness of the offense. When the statutory limit of incompetence was reached, the judge threw out the charges but the state's attorney immediately reindicted the defendant, thus restarting the clock. The case was appealed to the highest court in the state and a final opinion is pending.

Meanwhile, many many years later Patient B spends a few minutes every morning sipping coffee on the front porch of the assisted living facility the nursing home released him to. He hasn't heard from his girlfriend in many years although he has vague fond memories of motorcycle road trips with her hugging him from behind. His housemates---a demented elderly professor of economics and a frail former teacher---see him on the porch and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person.

The End of the Stories: Patient A

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. I thought it was interesting that people with different professional backgrounds and levels of experience pretty much agreed on what to do, who to keep and who to send out.

Since people seemed to enjoy speculating on the back stories, I thought I'd supply the endings.

Patient A was kept in the jail and admitted to the infirmary. After a few days of medication he quickly got better and was able to tell you what happened since his last release. His mother tried to get him an appointment at the local mental health clinic shortly after he got home, but she was told there was a three month wait until the first available appointment and that she should call the police or take him to an emergency room if it was an emergency. After he ran out of his thirty day supply of release medication he went to the emergency room to get it renewed, but when he ran out of meds a second time he was told he could no longer get his meds renewed through the emergency room. It didn't really matter though since his benefits were cut off while he was in jail and he couldn't afford them anymore anyway.

His mental state went downhill quickly after that. His mother, the much-beloved Cookie Lady (as she was known in the neighborhood), didn't stand much of a chance. I'll spare you the details. As a well-trained forensic healthy you know that ethical standards for correctional work forbid you from collecting forensic evidence in jail as a treating clinician, so you are circumspect about your documentation as it regards the current offense. Eventually, an outside forensic evaluation is done and Patient A becomes an insanity acquittee. He is transferred to a forensic hospital.

Immediately after the verdict, there is public uproar. The local newspaper publishes an opinion piece calling for reform of the public mental health system and looser standards for civil commitment and involuntary treatment. A state delegate proposes legislation for outpatient civil commitment. The governor organizes a task force to study the issue and the entire police force is required to undergo crisis intervention and mental health training. Mental health advocates decry Patient A's incarceration, loudly insist that jail couldn't help anybody, and accuse the jail (not you in particular, but the jail) of giving lousy, horrible, inadequate or nonexistent care. (Meanwhile, the somatic jail doc has diagnosed Patient A's new-onset diabetes and Patient A is getting a diagnostic workup for the lump that was discovered on his admission physical---it turned out to be benign. Because of patient confidentiality, none of this can be revealed to the public but you know it.) Meanwhile, on the newspaper internet discussion board some people express outrage that "that dangerous nut case" should have been sent to prison forever, given the electric chair, or made to undergo the same horrible acts he did to his mother. Patient A reads all about this in the newspaper delivered to his ward, and hears about it on the ward television news reports.

Years later, many years later, Patient A is quietly granted conditional release by a sympathetic judge, with the support of the local state's attorney. He goes to live back in his old neighborhood---now gentrified beyond recognition, where he spends a few minutes every morning sipping coffee at the corner Starbucks. His neighbors---a young attorney fresh out of law school, a music student at the local conservatory, and a young couple who work for the local newspaper, see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person. They enjoy having him as a neighbor.

Send Them Away

I saw this story on my twitter feed, about a jail sheriff in Ohio who has instituted a policy to refuse to accept any detainees who are violent due to a mental illness. Some people are saying this is a great policy because it will keep people with psychiatric disorders from getting locked up. The sheriff was quick to add though that diverting people out to an emergency room was not an alternative to incarceration. Rather, it was a means of providing immediate care and stabilization to people who might need it.

What lead to this new policy? The article mentioned that budget cutbacks at the jail lead to a decrease in psychiatric coverage, from full time to less than part time. There was also an incident at the jail in which an inmate on the psychiatric infirmary died while struggling with correctional officers. (No details were mentioned about this incident, although some officers were criminally charged.)

I read this story with mixed emotions. On the one hand, I appreciated the need for emergency medical care for some newly arrested prisoners. On the other hand, I had a visceral response to the sheriff's statement: "We're not going to be a dumping ground for these people," said the sheriff. Apparently, he equates seriously mentally ill people with trash. That's the issue I have with this policy. It's not really about getting people the help they need, it's about NIMBY-ism (Not In My Back Yard), a way to turf the treatment of the seriously ill off on someone else. So the jail doesn't want to accept violent mentally ill people, and hospitals don't want to admit psychiatric patients with histories of violence. It seems that the most ill folks are destined to sift down through the institutional bureaucracies until they pool into some environmental equivalent of a Thunderdome.

While the sheriff may be reacting to a budget cut, remember that legislatures don't dictate line-item cost cutting. That's up to the facility administration. So when the sheriff sat down with his new reduced budget, what made him cut the psychiatric hours? Do you think there may be some problem with priorities here?

In my experience people spend too much time arguing over who belongs where. People with mental illness require the right treatment, at the right time, regardless of their physical location. The real solution is to have adequate mental health staff in place and to have custody staff trained to work with them. The facility needs to have policies in place to give emergency medication, adequate safe and humane housing and staff skilled in verbal de-escalation, not to mention adequate mental health coverage.  This particular jail has hired an outside consultant who will undoubtedly consider and review all these things. The main point of my post being: The solution to a health care problem should never be to get rid of the patient.

But let's assume for the moment he's acting with good intentions and walk this policy through it's logical outcomes. The biggest challenge---and this is not a small barrier---is that custody will not know when violence is due to mental illness. Even clinicians can have trouble telling if someone is drunk or high on crack or psychotic or just really really pissed.

I'd like to invite our readers to participate in a little practical exercise. Read these scenarios and tell me what you think. Although these are clinical questions you don't have to be a clinician to answer. I'd like to give the general public a chance to think like a forensic doctor.


Clinical Scenario:

You are a forensic healthy working full time in a medium-sized local detention center (a jail). Each of the following patients are brought to you on the same day, and you have to make the call to send the patient out to an emergency room for further evaluation and treatment or keep them in the facility. Remember that none of them have been booked or formally charged yet (they are so 'out of it' that they are brought directly to you rather than getting charged first). If you send them to an emergency room you will get a basic set of lab work done but no further workup is guaranteed. There is also the chance that the arresting officer may decide not to press charges after all, so that he can drop the patient off in the emergency room and get back to the streets. On the other hand, if you keep the patient in the detention center you run the risk of missing a serious physical condition that could leave the patient dead in his cell overnight. Here we go:

Hypothetical Patients:

Patient A: Patient A is brought to the jail by the police covered in blood. He is thought disordered, incoherent and talking about angels and demons. He believes he is in heaven and thinks that satellites have been tracking his movements throughout the city. He is homeless and has no known family or friends. This is his tenth incarceration in five years and his presentation today is consistent with all the other times that he has been locked up. From previous jail treatment records you know that he responds quickly to low doses of medication and will require only a week or ten days of admission to the jail infirmary. When well he has a good relationship with you and always reminds staff when his medication order is about to expire. Even now, he knows who you are and appears significantly relieved to know you are there to start his treatment promptly. The arresting officers, who don't know any of this, warn you as you escort him into your office (in a waist chain and handcuffs), "Careful doc, you don't want to know what he just did to his mother." All of Patient A's previous incarcerations were for non-violent offenses like drug possession and minor thefts.

Patient B: Patient B is brought to the jail by the police covered in blood. He smells of alcohol and has an open bleeding gash on the back of his head. The arresting officer tells you that this is the third time in two months he has arrested Patient B for public intoxication and misdemeanor assault. You have never met Patient B before and have no old records. Patient B is disoriented, hallucinating and talking about angels and demons. As the arresting officer escorts him into your office (in a waist chain and handcuffs), he warns you, "Careful doc, you don't want to know what he just did to the other guy."

Patient C: Patient C is brought to the jail by the police covered in blood. He is angry, swearing and wrestling with both the police and the correctional officers in the booking area. You are unable to get close enough to him to ask questions and when asked questions by the booking officer he responds only with profanity. He has no obvious open wounds or signs of trauma. The arresting officers don't need to warn you about anything. You know enough to stand waaaay back. The only thing you know about him is his reported name, which may or may not be an alias. The officers know him only by his street name, "Woo Woo." He isn't cooperative enough to verify his identity through fingerprints so you can find no old records.

Question:

Which of these patients would you send out to an emergency room from the jail, and which would you keep and treat in house? Why? Discuss.

(This topic is a classic problem in forensic work. It was the subject of one of my earliest blog posts entitled Hot Potatoes.)

This Week In The News

There are a lot of stories in the news lately that have a forensic connection: the disgruntled noncustodial father who blew up his house (and kids), Madonna's stalker who eloped from a psychiatric hospital, a recent legal decision out of Georgia about assisted suicide, and an inmate with gender identity disorder who may be the first to get a state-sponsored sex change operation.


Where to begin, where to begin?


The Georgia decision has personal relevance since it means one of our retired local doctors won't face murder charges for offering advice and encouragement from a distance to someone who died of suicide there. The Georgia Supreme Court decided that the law banning suicide in that state was unconstitutional since it barred mere conversation about the issue separate from any act of aiding a suicide. As such, it was an unlawful infringement on free speech. It's hard to believe that it's been five years already since the first time I've blogged about this topic and fifteen years since the US Supreme Court said it was OK to ban it. Over half the country has laws against it now, but I don't know how many, if any, could be at risk because of the issue with the Georgia statute.


The story about the inmate with gender identity disorder (found thanks to my friend Lorry Schoenly's twitter feed---thanks Lorry! please follow her) also interests me because it's an emerging issue in the treatment rights of prisoners. Specifically, prisoners with gender identity disorder. We've talked about gender identity disorder before on podcasts number 20 and 21 (which included an interview with Dr. Chris Kraft about evaluation and treatment), respectively. I blogged about the history of right to treatment for prisoners here, but there's been one significant change since that 2006 blog post: courts have decided that gender identity disorder does constitute a serious mental disorder which requires treatment. What the courts are arguing about now is whether that right to treatment includes sex change operations. The state of Wisconsin passed a law to ban use of health care funds for this, but that law was overturned as unconstitutional. Prisons are required to continue hormone therapy if it was being prescribed prior to incarceration, though.


Separate from the issue of treatment, GID prisoners don't have a right to dress in opposite sex clothing or to have access to makeup. They don't have a right to be housed in a facility consistent with their gender identity. (Female prisoners sued, and won, cases alleging invasion of privacy when male-to-female GID inmates were housed in a female correctional facility.)


So that's where we are on the GID inmate front. Regarding the Madonna stalker, well, I have some personal experiences with psychotic stalkers but since I don't blog about specific patients that story will go untold.


That leaves the child murder story. Ugh. No thanks. I've seen these cases, they're awful, I'd rather not dwell on them. I'm taking a personal pass.

More Forensic Stuff

I'm going to apologize to regular readers for missing your usual Shrink Rap fare. This blog isn't usually this heavy into forensic topics but since Dinah is on hiatus, I'm commandeering the blog to talk about my own interests.

I wanted to address some ideas Sunny brought up in my last post. Her comment was: "...I can't figure out why it is that when a psychotic person commits a crime, that "they" send the person to jail to take psych drugs so that they can become "normal" to stand trial. Weren't they mentally impaired at the time of the incident? Why would we, as a society, not consider the state that person was in at the time of the crime? I wonder how those people feel, when they "wake up" from a psychosis to find that they killed people. It must be awful."

There's a lot to talk about here. The first issue is why people have to become 'normal' to stand trial. This is something that is required by the American constitution. The Sixth Amendment gives every defendant the right to call and confront accusers. While defendants can voluntarily give up their right to be present at trial, they can't otherwise be tried in absentia. If someone is too mentally ill to understand what's going on in the courtroom, that's considered an absence (physically present, but mentally 'in absentia'.) This is the origin of the requirement for competency to stand trial.

The state---or more properly, the defense---does consider the mental state of the person at the time of the offense. This is done through a category of defenses known as 'mens rea' defenses---criminal defenses based upon some aberration of mental functioning. There are a lot of them: extreme emotional disturbance, heat of passion, intoxication and insanity. Mens rea defenses don't generally lead to an acquittal---the person doesn't 'walk'---it just reduces the level of guilt. So, for example, instead of being guilty of first degree murder a defendant may only be guilty of involuntary manslaughter. Exactly what you have to prove to make your case about the mental state will be determined by the law. Each state will have statutory or case law that defines insanity or other various mens rea situations.

The states takes mental state into account at sentencing, too. The defense can introduce all kinds of mitigating information for the judge (or jury, in a death penalty case) to consider.

Regarding how insanity acquittees feel when they 'wake up' and realize what they've done: oh yeah, awful---really awful. Particularly since many insanity acquittees commit offenses against their own families. (See the New York Times article I linked to in my last comment on yesterday's post.) Sometimes you wonder which is worse for them: the symptoms of active psychosis or an awful reality.

You're A Whore

On my post "The Violent Patient", Anonymous Clinician wrote this comment:

"Frankly, I have little respect for Forensic Psychiatry these days. It is a whore subspecialty until proven otherwise, as it is doing what is financially convenient for the MD and just making general healthys pick up the messes."

The accusation that forensic healthy are 'hired guns' is not a new one. When I was a medical student I did a neurosurgery rotation. Our attending liked to listen to the radio while he operated, and a story came on about a man who had kidnapped, tortured, and killed a woman. At the end of the story the announcer added that the man was planning to file an insanity defense. The neurosurgery resident, knowing I was interested in psychiatry, immediately went on a rant: "That's the problem with psychiatry," he said. "Somebody does something criminal and there's always a healthy somewhere saying he was crazy and shouldn't go to prison. This guy should be locked up for the rest of his life. They should do the same thing to him that he did to that woman."

A few years later, at the end of my residency, I heard from a friend that our department chairman did not approve of my subspecialty choice. "It's too bad she's going into forensics," he had told my friend. Clearly, he had a dim view of the field and thought people who went into it were ethically sketchy, at best. (Ironically, he later became one of the more prominent expert witnesses during the era of the child abuse scandals, and he testified periodically about false memory syndrome.)

Shortly after I began my fellowship, Dr. Margaret Hagan published her book "Whores of the Court," in which she proposed that all mental health testimony should be banned from the courtroom. (Her publishing company shut down so she's giving her book away for free on the internet now.)

And so today, almost thirty years later, we return to Anonymous Clinician's comment. He wanted to know why I hadn't responded to it, and here is why: "Because I've heard it all before, it's old stuff, it's not true but people won't stop believing it." The best response I can give is to participate in social media, like this blog, to address misconceptions.

Here are the common misconceptions about forensic psychiatry:

1. Forensic healthys 'get people off' from their crimes.

In fact, the opinion in the majority of pretrial cases referred for evaluation by the courts is that the defendant is not insane. Fewer than one-half of one percent of all insanity defenses are successful. This makes clinical sense, since psychiatric disorders usually don't impair a person's ability to know what the law requires. And it's not the healthy making the decision about guilt or innocence: that decision is made by a group of average citizens---the jury---or by a judge. Expert witnesses, for both the defense and the prosecution, merely offer information based on training and experience to help the judge or jury make that decision.

2. Forensic healthy will say what they're paid to say.

A good attorney will not hire a 'hired gun.' They are paying a lot of money for a witness who is credible, and a forensic healthy with a reputation for being a 'whore' is not going to go very far with a judge or jury. Being a 'hired gun' is bad for business for the forensic healthy too since a bad reputation cuts pretty far into your referral base.

Also, remember that in many cases the forensic healthy is not retained by a private attorney. Many forensic healthys are employed by state health departments. They are salaried employees, not private practitioners. As such, their income is independent of the opinions they form.

3. Forensic healthys aren't doing 'real' psychiatry.

In other words, they're not clinicians. Ah, so untrue. Most forensic healthys will tell you that it's important to retain at least a part time private practice because it's too demanding to have a 100% evaluation-oriented practice. Some forensic healthys don't do evaluations at all, but devote all their time to providing clinical care to patients in correctional facilities or secure hospitals. Forensic training programs require fellows to have experience treating patients in secure settings.

The post is getting a bit long so I'll stop now. Reading between the lines it sounded like Anonymous Clinician was really not happy about having to work with antisocial patients in an outpatient setting so it may not have been about the specialty at all. But there's my response.

(Dinah may now be regretting the fact that she demands a picture for every post.)

The Violent Patient

On the New York Time's Well blog recently, nurse Theresa Brown wrote a piece entitled "Feeling Strain When Violent Patients Need Care," in which she talked about caring for a very threatening, potentially dangerous patient suffering from cancer. This patient, a large 300 pound man, had a reputation for causing havoc in the hospital. He had been banned from one ward for tearing a light fixture off the wall and fighting with hospital security. He had "slugged" a family member at the nursing station and threatened to kill a nurse. In spite of all this, he apparently was not in custody at the time that Ms. Brown was caring for him, which meant that he was not a prisoner in shackles and there was no dedicated law enforcement professional watching over the situation. Understandably, Ms. Brown was afraid.

What some people might not appreciate or been aware of, was that she was also embarrassed about being afraid. Working in the health care field, and in nursing in particular, meant that one could be exposed to volatile situations at any time. Being a professional meant being able to stay calm and poised enough to manage these situations, and this is where the author of this piece felt lacking. She felt she should have been tougher, more unflappable, or somehow invincible to this very concerning patient's intimidating demeanor. Ultimately she was replaced on the case by a male nurse. We never find out what happened to the patient, whether he actually did commit acts of violence during that admission, or whether he calmed down with the male nurse and cooperated with the care he needed. We also don't come to any resolution about what a health care professional should do in a situation like this. This is not a question the narrative was meant to answer, apparently.

As always in story like this, the most interesting part to me were the comments that followed. Over the next two days nearly one hundred people wrote in, mostly nurses and doctors and other health care professionals, to talk about the multiple incidents in which they were bitten, scratched, spat upon, cursed, hit and kicked in the emergency room, on the psychiatric unit, and in the intensive care unit. Half way through the comments I found myself wondering what the incidence of post-traumatic stress disorder must be among health care professionals after a few years of routine work. (I don't know the answer to that question.)

I was also impressed by the range of thoughtfulness that some commenters brought to the situation. Some quickly speculated that the patient might have been a veteran or someone equally traumatized, who would naturally have responded with aggression when startled awake in the middle of the night by a stranger. Others speculated that he might have been having an unexpected reaction to a medication, or been in the midst of a delirium. Some suggested that a CT scan should have been done to make sure his impulsivity and temper weren't due to a malignant brain metastasis. Clearly, these health care professional readers were setting aside their own personal experiences to consider the cause of the patient's emotional reaction and behavior. This was heartening to me.

Other comments were less sympathetic, implying that hospitals should be more liberal in their use of physical and chemical restraints and that assaultive and threatening patients should be prosecuted consistently.

I felt rather fortunate after reading this piece. I've worked with patients known for this kind of violence, but I've been comfortable doing so knowing that safety and security were a necessary and essential condition to providing treatment. I've always felt safer in most correctional facilities I've worked in than in some more traditional clinical settings. Even so, I rarely have had to deal with patients who were so angry or potentially dangerous that I wasn't sure I could treat them even in the correctional setting. That's not good because in most cases there is no one else to turn the patient's care over to when you're the only shrink in the building. This is how I've managed to handle it:

If the patient starts the appointment calmly but escalates during the interview, the first thing I do is slow down. I want time to listen, to think, to make sure the patient knows that I'm hearing him and am concerned about what he's saying. This also helps me listen better. I set my pen down and stop taking notes. I look at the patient. I make sure he knows he has my full attention. If he allows me, I will ask questions to get more information or to clarify something he has said. I repeat what he's told me, and ask him if I am understanding him. If and when he says 'yes', things chill out immediately and we negotiate a treatment plan.

If this doesn't help, or if I start to feel I can't listen safely, I tell the patient I feel uncomfortable or worried. It's not waving a red flag in front of a bull to admit that you're scared. You'd be surprised how many temperamental men (I only treat male prisoners) have no awareness whatsoever that they are talking way too loud or gesturing too broadly or behaving in a way that attracts attention. The nearest correctional officer usually notices first. If I see an officer glancing in to check on me that gives me a nice opportunity to point out to the patient that his behavior is arousing the concern of custody. That always works.

I'm surprised how often an angry inmate will suddenly pull himself together and calm down once you tell him you're scared. Some of them are quick to apologize, or emphasize that---in spite of what they might have done in the past---they have never laid hands on a woman.

Lastly, I know when to recognize when I need to take a break. If I find myself wanting to cut the patient off or getting annoyed---too annoyed to listen---I know it's time to call it a day and try again another time. These are the times when mistakes get made. I can ask the patient if we can take a break and come back to the discussion later in the clinic session, or on another day. I explain that things have gotten heated and I really want to make sure I'm taking the time to think about his care.

If none of this works, I still keep trying. I will make sure I have any necessary security in place, and explain to the patient why it's needed. If someone is available, I may ask another health care professional to sit in the room with me. And make sure an officer is outside the door. In extreme cases, it might be necessary to put the person in handcuffs and a waist chain for the appointment.

Hospitals aren't used to doing any of this, or can't. But when 15% of all US nonfatal on the job injuries take place in health care settings, through patient assaults on staff, it's time to take de-escalation training seriously.

The Privileged Patient

I'm still dwelling on these discussions we've had about the inpatient experience. A number of readers commented that they weren't like other patients on the ward who weren't educated, who used drugs and were in and out of jail. I took that a little personally since those "other" inpatients are my correctional patients. I like working with them and I don't like it when people dismiss them as being "just criminals." I also found it a bit ironic that the people who are quick to claim peer kinship with staff are also quick to disclaim equality with forensic patients. You really can't have it both ways. My offender patients deserve to be taken seriously, treated with respect and given humane care whether you want them in your community or not.

I don't like the idea of framing treatment in terms of who is more 'deserving' of care. I don't think you can put a rating scale on suffering or prioritize trauma. Nevertheless, when it comes to the spectrum and amount of services that are needed my forensic patients are right up there. They may not be very literate, they've got poor social supports as well as mental health and addiction problems. Oh, and chronic medical problems that go untreated because they have no insurance. They're facing an uphill battle just to reach a "normal" place in society. For my patients, success means having a place to live, a job, people who care about them, maybe even a car and a girlfriend. That's a lot to have when you're starting at zero. Yet when it comes to apportioning services and access to treatment these are the first folks to get cut.

Some inpatient units do have patients of privilege---people who aren't starting at zero---and these patients really do seem rich (figuratively and literally) in comparison. But forensic patients are increasingly part of our mental health care system. When we talk about making the system better they have to be part of that discussion.

What We Need

OK, I've gone back through the comments on my last post as well as on Dinah's forced treatment post. I think I've come up with a list of what people have identified as things that need to be added, improved or changed. I'm going to talk to myself in this post, thinking out loud a bit about what each item means to me and how to implement them. Feel free to follow along, add, edit or just ignore me. Like I said, I'm thinking out loud in public.

1. An emergency ear
     Even people on an inpatient unit need a crisis contact. A friend to call, an outside volunteer, better access to visitors like family, or a hospital ombudsmen. Patients may not want to or can't access staff, which is a problem. Purposely or unconsciously, inpatient staff discourage patients from approaching them about problems. Patients feel they have no recourse when they are treated poorly or unprofessionally. Some hospitals use after-the-fact patient satisfaction surveys, but personally I'm reluctant to solve a problem by using a form. There needs to be a neutral mediator or ombudsman who is easily accessible to an inpatient. Perhaps allowing an outpatient therapist to hold sessions during a hospitalization would be helpful. (I know there may be financial and bureaucratic issues related to all the items I'm discussing---for the time being let's ignore that. This phase is just outlining the problems and needed solutions.)

2. Professionalism
    This item is closely related to item #1. If this item were fixed then item #1 might not exist. What most people may not know is that medical schools recognize this is an issue and now incorporate assessment of professionalism into every medical student and resident evaluation. National professional organizations are also thinking about ways of building this into ongoing licensure processes by requiring physicians to solicit evalutations from their patients. There are also now loads of online 'rate-your-doctor' sites. This is just for physicians, though. I'm not sure how to go about evaluating professionalism for hospital security staff who put someone into seclusion. The psych aides or techs would likely fall into the nursing department realm, and there's no reason there couldn't be a patient feedback loop for that profession as well.

3. Regret
    Ah, this is the tricky one. Some commenters said they wished their doctor would have told them that the doctor felt horribly about having to commit someone. Well, when a patient is in crisis it's really not the time to focus on the doctor's feelings. The point is well taken though that mental health providers should be able to talk to the patient afterward about the experience of involuntary treatment, what it was like (for both parties) and ways to avoid it in the future. See item #4.

4. Outpatient crisis plan
    I've seen some nursing admission forms that routinely ask patients on admission what they do when they are feeling angry or upset, and what helps them feel better in times of crisis. This almost never involves social connections though, which commenters here say they want more of. This is related to #11, the ongoing discharge plan. Who is in your social support system? Are they helpful are hurtful? Who can you reach most easily? Have you actually used this support system in the past or are you b.s.-ing to get out of the hospital (honesty is going to have to cut both ways, now!)? Hospital lengths of stay are so short now there is almost no purpose to a trial pass or day pass. The general thinking is that if you're well enough for a day pass you must be well enough for discharge. The generic 'return to emergency room' is far from an ideal crisis plan. Perhaps some temporary ongoing outpatient relationship, similar to what internal medicine does: discharge from hospital, to be seen in inpatient doc's own outpatient clinic within X days, until more permanent or preferred outpatient care is arranged.

5. Decent food
    Oy, I am the Shrink Rapper with zero food skills. Either of my co-bloggers will confirm that. Nevertheless, it seems evident that medically appropriate, religious or personal preference diets should be available. This one just doesn't seem that complicated, but I don't question that it's a problem.

6. Clean, comfortable environment
    Ditto #5. This is one item where patient satisfaction surveys actually could be useful. If month-by-month discharge surveys are all saying you've got bugs in your bathroom, you've got a problem.

7. More autonomy over medications
    Pharmacotherapy is always a balancing act between the level of symptoms a patient can live with versus the burden of side effects that they have to carry. I would throw in this thought as well: the people in your support system have to live with your symptoms, too, so they should also be considered. Can we engage family and friends in this balance? If so, how?

8. Meaningful activities
    I get this, totally. It's tough when you have an inpatient unit that contains both patients who are so ill they need help bathing and dressing as well as multiply-graduate degreed professionals. William Styron once called occupational therapy 'organized infantilism.' These individualized treatment plans that every team has to fill out should be made useful in some way, and this is where this item should be addressed. What meaningful activities would an educated, high-functioning professional want to do (or feel up to) doing? Most of the units I've worked on have not served many of this kind of patient so I'm open to suggestions here. You also have to address the question: if you're well enough to do (high functioning activity X), do you really need to be in the hospital? That's the question insurance companies will be asking your doctor.

10. Alternative and complimentary treatments
     People want things to do besides (or in addition to) taking medication. I'm guessing this means things like emphasizing regular activity or exercise, proper diet, decent sleep but also activities like yoga or tai chi, bibliotherapy (journal keeping, poetry or other writing), music therapy, and so forth.

11. Ongoing discharge planning
     I've already covered this a bit, but this would refer to the feeling that people are just dropped outside the door of the unit after discharge with no further contact with the inpatient team. There are already some programs available like day hospitals or partial hospitalization programs, but I don't think this is what people are asking for. I'm thinking more along the lines of returning to the inpatient unit for an "outpatient" visit, if that makes sense, while making the transition to a traditional outpatient practice.

12. Humanize (or de-traumatize) the observation process
     This is the last and toughest point. How do you humanely take someone's clothes away while putting them in physical restraints on continuous observation? I know, some people will say this should never be done but that's just not the world I live in. Some people are dangerous when they get sick. healthys have to make sure everyone in the unit is safe, in addition to protecting the patient. Making sure everyone is trained to recognize and intervene early is important, to prevent seclusion and restraint. Working with the patient early on to identify coping skills and practice those skills, and make sure people on the unit are trained in verbal de-escalation techniques. This won't obviate the need for seclusion in all situations, but it should help minimize its use.

OK, I've spent a fair amount of time thinking about this post, reading old comments, writing and speculating and I'm running out of steam. More later. The last three or four items are going to be the longest, I think. Dinah and Roy, feel free to jump in with your thoughts. This is the stuff of inpatient interviews.

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Recent posts on forced treatment:
Jan 9: Forced Treatment: Does it Help? ("make psychiatric care something patients want to get")
Jan 13: I'm Sorry ("I'm sorry that... the mental health system has failed [those who have died due to hiding from 'treatment']")
Jan 14: What We Need (list of 12 things readers are saying they need from the MH system)
Jan 14: Poll: Involuntary Commitment: Would you do it again? (a survey for those who have been committed in the past)

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I'm Sorry

Rob wanted to know if I was reading the comments on Dinah's post about involuntary treatment. He thinks that healthys may read these comments, shrug and say, "Well, sometimes it's necessary."

I did read the post, and the comments. I can tell you that the decision to involuntarily admit or treat someone is never a "shrugging" issue. This is something healthys hate to do. I mean, literally hate. We know it's something that can destroy a therapeutic relationship and undermine someone's willingness to seek care in the future. We know that psychiatric units can be horrible places to be and that admission is expensive, humiliating and sometimes traumatic. The decision to seek involuntary treatment is not done lightly or easily. You and some others may feel it should never be done, but I think that's an issue that may never get resolved between us. Maybe someday medicine may develop better ways to diagnose and treat mental illness, or society may evolve and decide that psychiatric patients are worthy of the time and money spent on other suffering people but we're not there yet. We deal with the present, as it stands, with what we've got.

Remember that there are comments that you don't read here. The missing comments. The comments that can't be posted because the suffering people are dead. On behalf of those folks, and the people who care about them, I'm sorry. I'm sorry that psychiatry as a profession and the mental health system failed you. I'm sorry that you had to hide your suffering from your friends and family, or maybe from your doctor, because you thought you had no choice. Clearly, something needs to change.

This is why Dinah posted about the issue and why I'm following up. As a group, we need to figure out better ways of doing things. The Shrink Rappers don't have the answer. We need to hear concrete ideas and suggests. General comments like, "Stop treating me like a child" or "Don't be a jerk" honestly aren't helpful. The commenter who suggested that patients should be allowed to have cell phones on the unit, to call friends or family when in crisis on the unit, now that's the kind of idea we healthys need to hear. The discussion about post-discharge aftercare and the continuity gap is crucial. Please tell us more about that and about what kind of services or support would have been useful and what we need more of. I like the idea that this could also help catch people in early relapse. We need to answer the questions about these services: what, when, where, who and how.

Now let's get started.

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Recent posts on forced treatment:
Jan 9: Forced Treatment: Does it Help? ("make psychiatric care something patients want to get")
Jan 13: I'm Sorry ("I'm sorry that... the mental health system has failed [those who have died due to hiding from 'treatment']")
Jan 14: What We Need (list of 12 things readers are saying they need from the MH system)
Jan 14: Poll: Involuntary Commitment: Would you do it again? (a survey for those who have been committed in the past)

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What I Learned Part III

• More on social media and medicine today. One survey of a surgery department showed half of residents and faculty had public Facebook accounts and a third posted professional information.
• People are using "mindfulness" therapy to treat sex offenders. No studies on efficacy.
• Offenders with bipolar and psychotic disorders are twice as likely to have more than two additional arrests than non- SMI offenders.
• Some criminal defendants try to claim that the government is a corporation, and that they should be tried under contract law rather than criminal law. This is sometimes called a "straw man defense" and may prompt judges to request a competency assessment.
• Defendants who graduate from mental health courts demonstrate improved life circumstnaces with regard to housing, quality of life, symptoms and compliance. Some studies have shown mental health courts to result in improvement for as many as 78% of defendants.
• Court ordered custody evaluators are more likely to recommend paternal custody if the mother is poor or has a history of psychiatric admissions. They are more likely to recommend maternal custody if the father has a history of arrests.
• No suicide prediction tool has a predictive validity greater than 3%.
• Forty percent of patients given opioids for non-cancer pain misuse their meds, 5% become addicted.
• In the UK people with ASPD may be subject to multiagency public protection agreements, sharing information between government agencies.

Coming up tomorrow:
      Correctional risk management and the forensic sciences sampler. Good luck to everyone without power in the snow!