E-mail and psychiatry: some psychotherapeutic and psychoanalytic perspectives.

In this paper, we consider the use of e-mail in psychotherapy and its impact on the experience of therapy for both patient and clinician. We discuss in detail the potential for boundary compromise by e-mail use and consider how e-mail may undermine the therapeutic alliance and the cultivation of empathy. Case studies illustrate the possible positive aspects of e-mail and elucidate several fundamental problems with any use of e-mail in psychodynamic treatment.

The treating psychiatrist thrust into the role of expert witness.

Treating psychiatrists may precipitously and unwittingly be thrust into the role of expert witness because of certain actions they may take on behalf of their patients and may suffer adverse consequences as a result of lack of training and experience. The authors review this problem and suggest means of avoiding the pitfalls involved. Recommendations include warning patients of the uses that will be made of communications between their treaters and third parties, recording the sources of clinical data for use in communications with the legal system, separating the roles of treating psychiatrist and expert witness, and consulting with attorneys or experienced forensic practitioners.

The phantom expert: unconsented use of an expert's name and/or testimony, as a legal strategy.

The authors explore the forensic, legal, and ethical issues involved in a spectrum of attorney practices involving designating experts without notifying them. Recommendations are offered for dealing with this unethical practice, including exposure of the practice, reportage to bar association ethics committees, and continued open discussion and research.

Moral justification for Tarasoff-type warnings and breach of confidentiality: a clinician's perspective.

After brief review of the background and context of the Tarasoff case and its impact on clinicians, the author examines the "Tarasoff warning," proposed in the 1974 Tarasoff opinion, from a moral position, with brief discussion of its clinical and risk management dimensions. Moral issues considered include confidentiality itself, agency, fiduciary duty, a shift in the victim paradigm, the emergency context, a novel risk, and a proposed approach. The dilemma presented by the original Tarasoff fact situation is re-examined. The author stresses the need for individualized responses to the risks posed by patients.

"Don't write me down": legal, clinical, and risk-management aspects of patients' requests that therapists not keep notes or records.

UNLABELLED: Although many clinicians have reported anecdotally that patients occasionally ask that treatment or evaluation notes or records not be kept, the issue has not been addressed in the literature. This article deals with the problems arising from patients' requests that their therapists refrain from record keeping, first from a legal and regulatory perspective, and then from a clinical perspective. METHOD: The authors' consultative experience provides examples of variations on the theme of patients' requests not to take notes. RESULTS: While records must usually be kept, there exist narrow exceptions to this rule. Risk-management suggestions are offered as well. CONCLUSIONS: All such requests should be met first with exploration, but limits may have to be set in granting the request.

Expert witness billing practices revisited: a pilot study of further data.

This pilot study follows up an earlier study of the strategies and rationales by which psychiatric expert witnesses bill for their time on a case. Questionnaires were answered by participants at a workshop at the Annual Meeting of the American Academy of Psychiatry and Law (AAPL). In this follow-up, additional novel billing issues were addressed, some subtler than in the original study. In addition, responses to one question supported the previous finding that experts billed more reasonably when a case was simple. Additional issues included use of fee agreements and returning an unpaid-for case. The implications of these findings are discussed.

Adventures in the twilight zone: empirical studies of the attorney-expert relationship.

A series of empirical pilot studies, performed during workshops at meetings of the American Academy of Psychiatry and Law (AAPL), and examining various aspects of the attorney-expert witness relationship are presented and their implications are discussed. The author calls for further investigation of a topic that--although constantly a feature of discussion among both experts and attorneys--lacks extensive empirical investigation.

Informed consent in psychotherapy.

OBJECTIVE: The authors sought a rational approach to implementing informed consent within the practice of psychotherapy. METHOD: The history of informed consent in psychotherapy was reviewed to define a common synthesis that maximizes the potential benefits and minimizes the potential hazards. RESULTS: The benefits of informed consent in psychotherapy include fostering a positive treatment outcome through enhancing patient autonomy, responsibility, and self-therapeutic activity; lessening the risks of regressive effects and therapist liability; and helping the practice of psychotherapy extend beyond particular parochialisms by providing checks and balances on therapist judgments. The hazards include the unpredictability of interactional outcomes and the possibilities of replacing positive expectancy with negative suggestion, replacing a therapeutic alliance with a legalistic stance, and misimplying that patients are passive recipients. CONCLUSIONS: Practical implementation of informed consent in psychotherapy must balance such tensions in service of optimal treatment. As a guiding principle, the authors recommend that psychotherapists convey to a prospective patient information that is material to the particular patient's decision. The level of detail needed in informed consent discussions varies directly with the cost and risks of the proposed treatment, the presence of viable alternatives and their relative grounding in scientific data and professional acceptance, and the presence of significant controversy. Unresolved is the question of how to address problematic or controversial psychotherapeutic trends that temporarily enjoy wide professional support.

Forensic psychiatrists' fee agreements: a preliminary empirical survey and discussion.

The author performed a preliminary empirical study of forensic fee agreements. A survey of forensic psychiatrists produced samples of fee agreements used for expert witness work. The samples were analyzed to determine patterns of usage, critical elements, styles of agreement design, and other observations. Despite uncertainties of payment in this field, a surprising number of experts do not use formal fee agreements. This and other results are discussed.

The presentation of forensic psychiatric evidence in court.

After defining the role of expert witness, the article reviews the basics of courtroom testimony under the rubrics of (a) truth (presenting under oath only that testimony that one can "swear to," to a reasonable degree of medical certainty); (b) testing (including both psychological testing and tests to assess admissibility standards); and (c) theater (including elements of drama, solemnity, and ritual as well as persuasiveness to the "audience"). Pathways to effectiveness are discussed, including use of visual materials, adjustment of language level for the jury's comprehension and attention to the narrative dimension of the case. Areas of excluded testimony are identified, such as the "ultimate issue" in the case, comments on credibility of other witnesses and comments on the legal process itself. Pitfalls that lie on the path to effectiveness are described, including narcissistic arrogance, anger, and using testimony in a personal crusade; means of avoiding these pitfalls are noted. The author concludes that effective courtroom testimony fulfills expert witness functions necessary to the legal system.

"Telling tales out of court": a pilot study of experts' disclosures about opposing experts.

A pilot questionnaire surveyed forensic psychiatrists and psychologists about information they would feel it appropriate to disclose to their retaining attorneys about an opposing expert witness. A spectrum of hypothetical disclosures was offered, varying in their relevance to the case at hand and in their degree of "public" versus "personal" information. Respondents agreed significantly that "public" information could be disclosed to one's attorney, but responses about disclosing "personal" information varied widely. The findings and their implications are briefly discussed.

Dementia as a risk factor for homicide.

We report a patient with dementia due to B-12 deficiency and syphilis who presented to a forensic hospital after killing his ex-wife with a gun. Despite current awareness on the occurrence of aggression and violence in patients with dementia, there has been no report discussing dementia secondary to an infectious or nutritional origin causing homicide or severe violent behavior. We discuss possible mechanisms and several predisposing factors for violent behavior in the elderly. We also discuss use and access of a gun in demented patients and its complications. We recommend availability of neuropsychiatric assessments in the elderly, limitation of gun access to demented patients and inquiry about weapon possession in the elderly.

A confusion of tongues: competence, insanity, psychiatry, and the law.

Psychiatrists share with the public some confusion and uncertainty about two highly visible forensic psychiatric examinations: competence to stand trial and criminal responsibility (insanity). The author reviews the content and context of these examinations, examines legal issues that define and underlie them, and clarifies commonly encountered areas of ambiguity and misunderstanding. The competence examination, which assesses a defendant's ability to participate in the trial process, focuses on the present state of the defendant's mental capacities. Two standards generally used are whether the defendant has a rational and factual understanding of the charges and penalties and has the ability to cooperate with the defense attorney. The examination for insanity is one of the most challenging and comprehensive in forensic psychiatry. The criteria in general address the defendant's awareness of the fact that the act was illegal, wrong, or a crime. Additional criteria address the defendant's ability to control behavior.

Attorneys' pressures on the expert witness: early warning signs of endangered honesty, objectivity, and fair compensation.

While most attorneys practice ethically and treat their retained experts fairly, there are a few that do otherwise. The authors describe "early warning signs" of the likelihood that the attorneys attempting to retain the psychiatric expert witness may compromise the expert's honesty and striving for objectivity. Experts themselves may have certain vulnerabilities that interfere with their ability to detect those early warning signs. Recommendations for the expert are offered.