As exemplified by the career of Robert L. Sadoff, M.D., the teaching roles of the forensic psychiatrist are enacted in medical settings (with medical students, psychiatric residents, forensic psychiatry fellows, and other fellows) and in legal settings as well (via expert witness testimony, amicus briefs, law school teaching, and legislative advocacy). New technologies and new audiences will continue to extend the educational influence of forensic psychiatrists, transforming as well as reflecting the profession's public and scientific profiles.
Psychosomatic medicine, also known as C-L (consultation and liaison) psychiatry, is a subspecialty of psychiatry that deals with the interface of psychological, ethical, social, and legal issues arising in clinical medicine. This article addresses ethical and legal aspects of practice in this area utilizing a case-review perspective.
Narrative is a fundamental means of making sense of experience. As child forensic psychiatrists attempt to convey evidence and opinions via report writing and testimony, they need to bear in mind an obligation to ensure that their efforts are as well received as feasible under the circumstances. This article discusses how narrative can serve functions that include humanizing individuals in the courtroom, giving voice to a young child, explaining interpersonal situations, and gathering and evaluating existing data.
Noncompliance with medication therapy and mental health care is prevalent among the mentally ill. Its multifactorial dynamics can include aspects of the illness itself, such as anosognosia. Noncompliance with medication can increase risk of violent or other criminal behavior, but the law currently does not recognize it as a factor in determining culpability. The legal test of insanity that focuses on a “defect of reason from disease of the mind” presumes that the disease was not self-induced. Noncompliance with medication and voluntary intoxication can both be seen as self-induced incapacities, but their adjudication is often quite different. A psychotic condition may be the basis of an excuse, whereas simple intoxication is not. The distinction is not only the obvious one of acts of omission (medication noncompliance) and acts of commission (voluntary intoxication). There are other complicating factors, such as the knowledge of the effects of noncompliance, the mental state prior to the noncompliance, and the presence of any conditions that would excuse or justify it. These and other considerations render the assignment of criminal responsibility for the noncompliant psychiatric offender complex. A possible solution to this would be the application of therapeutic jurisprudence to the noncompliant mentally ill offender.
The history of the hospitalization of persons with mental disorders has progressed in distinct stages over the course of the past two centuries. From Philippe Pinel's introduction of moral treatment principles, through the advent of professional psychiatry as a result of Sigmund Freud's innovations, through the move toward deinstitutionalization enabled by the discovery of new psychiatric medications, the groundwork was laid for the fourth and most recent of what can be seen as “revolutions” in institutional mental health care: the focus of both law and medicine on the parameters of the state's commitment power. This article addresses the function of the criminal procedure model in the context of civil commitment, its practical effects, and opportunities for continued reform.
Dr. Robert Sadoff's teaching of honesty and integrity in forensic psychiatric work resonates both with current ethical principles and the ancient proscription against bearing false witness against one's fellow citizen. This article explores the misuse of psychiatric testimony in a 1928–1929 murder prosecution in Innsbruck, Austria. Amid clear undercurrents of Nazism, a Jewish youth found himself on trial for the murder of his father. Though there was no evidence that he was guilty, the expert testimony included distorted presentations of psychology and Freud's theory of the Oedipus complex. Freud and others protested the misuse of his work to convict the defendant, noting the difficulty in adapting psychoanalytic theory to legal settings. After 2 years in prison, the young man was set free, later becoming a world-renowned portrait photographer. Forensic professionals must continue to be vigilant in self-regulating the use of scientific information in legal settings.
Therapeutic jurisprudence (TJ) provides a framework for psycholegal analysis that has had no difficulty in attracting adherents within the law and a broad range of health-oriented disciplines. Although psychiatry has proven perhaps predictably less willing to embrace TJ, the work of Robert L. Sadoff, M.D. provides a heartening exception. Dr. Sadoff's career stands for many enlightening principles—not least of which is the redemptive promise of TJ.
Forensic mental health nurses are independent professionals who have individual professional responsibilities, but also share responsibility with medicine, hospitals, incarceration staff, and community teams. These nurses can be found in a variety of practice settings and are important members on a variety of mental health teams. Much has changed—for the better—in the evolution of the forensic mental health nurse in recent decades.
This brief essay provides a snapshot of forensic psychiatrist Robert L. Sadoff and how his life has reflected the exemplification of honesty and integrity in the field of forensic science.
Dr. Bernard L. Diamond (1973) published the first article in the first issue of the Journal of Psychiatry & Law. Entitled “The Psychiatrist as Advocate,” it was a follow-up to his famous editorial, “The Fallacy of the Impartial Expert” (Diamond, 1959). Given the impossibility of total impartiality, the expert witness can still be ethical, but then undertake a form of activism. After nearly 40 years, we continue to reassess our boundaries as expert witnesses. In this article, the author has asked Dr. Robert L. Sadoff to comment on Dr. Diamond's ideas in the context of contemporary ethics.
Clinical traumatologists who treat children constantly work with multiple systems and agencies that have tremendous influence on children's developmental trajectory and may either support or impede recovery by the actions that they take. While the circumstances with which these children contend are not uncommon, they are always extremely intricate and complex. The child and adolescent psychiatrist who is an expert in childhood trauma and adversity has the formidable task of providing expert opinions and recommendations to multiple systems that typically are not knowledgeable about how to support, treat, and promote the development of traumatized children.
Capacity to consent to informed treatment decisions is an often overlooked, yet tremendously critical, aspect of modern medical practice. Despite its importance, research has shown that clinicians often fail to identify patients who lack capacity. Currently, other than a clinical psychiatric consultation and evaluation, there is no standardized method for determining whether a patient has capacity to make treatment decisions. Cognitive scales, such as the MMSE, may inform capacity evaluations but are neither sensitive nor specific. Accordingly, various clinical instruments have been developed to aid in the determination of capacity to consent to treatment. This is a review of several of these instruments. While there is no convincing evidence for the use of a particular scale, the CQ and ACE are easy to administer and can be efficiently utilized by clinicians to inform capacity assessment. While more time consuming to administer and score, the MacCAT-T also provides a comprehensive evaluation of key capacity domains.
Borderline personality disorder (BPD) is a complex mental disorder that straddles the line between psychosis and neurosis. As such, questions about the moral and legal responsibility of persons with BPD are especially vexing. Persons suffering with borderline personality disorder typically are impulsive and suffer from impaired volition. They also lack a stable sense of self. Nonetheless, persons with borderline personality disorder often hold long-term, stable preferences—often related to discontinuing particular problematic behaviors—and have a degree of capacity that we argue creates prima facie conditions for holding them ethically and legally responsible. However, this limited capacity often falls short in smoothly accommodating day-to-day relationships. We argue that while a certain degree of accommodation is appropriate for persons with BPD, the diagnosis of BPD does not by itself provide sufficient grounds for voiding responsibility for criminal acts. Using a hierarchical theory of autonomy recognizing first- and second-order volition, we propose a sliding scale be used to ascertain the degree to which a person with BPD should be exculpated weighing the graveness of the act against an estimation of the congruence of second- and first-order volitions.
Accredited fellowship training programs in geriatric psychiatry are required to address ethical and legal issues pertaining to mental health in older adults, and to provide clinical experiences that enable trainees to develop competencies in long-term care consultation. The growing number of criminal offenders with mental illness and other disabling conditions that require long-term care, along with comprehensive federal regulations that affect mental health care in nursing homes, is creating a more urgent public health need to train psychiatrists with specific competencies in patient care, interpersonal skills and communication, and systems-based practice as they apply to medicolegal aspects of psychiatric consultation in the nursing home setting. This article reviews legal and regulatory information that is pertinent to training fellows in the care of elderly nursing home residents with mental illness or behavioral problems. It describes several aspects of the Geriatric Psychiatry Fellowship Training Program at the University of Pennsylvania that promote development of skills in geriatric psychiatry consultation in nursing homes.
Mental health funding cuts and associated reductions in training have exercised a starkly negative effect upon psychiatric patient care in recent years, as reflected in research conducted in the United States and abroad. This article conveys and discusses an illustrative case example with additional reference to appellate and institutional advocacy approaches to the problem.
The Program in Psychiatry and the Law (the Program) resides in the Department of Psychiatry, Beth Israel Deaconess Medical Center—a teaching hospital of Harvard Medical School. Over the course of three decades of collaborative work, the Program has evolved from its origins in several ways. To understand this evolution, it may be valuable to place members’ contributions into perspective by offering a conceptual biography, as it were, of the Program’s ideas and activities. Such a review will also convey some sense of the functioning of the Program itself, in addition to providing a context for the articles that comprise this first of two special issues of the Journal of Psychiatry & Law.
Legislators, jurists, and advocates often turn to science to solve complicated normative problems addressed by the law. This article addresses what motivates these parties, surveys the psychology of law and its concepts of the person and responsibility, and describes the general relation of neuroscience to law in terms of the issue of “translation.” Numerous distractions have clouded our understanding of the relationship between scientific, causal accounts of behavior and responsibility. The notion of “NeuroLaw” is examined here in detail, with the conclusion that a cautious optimism regarding the contributions of neuroscience to the law is warranted.
Several states have recently considered legislation that effectively prohibits physicians from asking patients about firearm ownership. In 2011, Florida passed the Privacy of Firearm Owners Act, which prevented the state's medical personnel from asking patients about gun ownership, documenting information concerning firearms in a patient's medical record, and denying care for patients who refuse to answer questions about gun ownership. This article considers the legislation's constitutionality and its implications for public health, clinical standards of care, and medical ethics.
