Psychiatric Disability in Law Enforcement Officers.

Law enforcement officers all across the world are exposed to violence, confrontation, and traumatic incidents. They regularly witness death and suffering and are at risk of personal injury. Psychiatric sequelae include an increased risk for trauma-related symptoms, depression, alcohol-use disorders, and stress-related medical conditions. Law enforcement officers have been applying for early disability retirement pensions at an increased rate for stress-related psychiatric and medical conditions. As a result, law enforcement agencies are prematurely losing valuable resources, officers with training and experience. Departments have become proactive in trying to address mental health issues to prevent psychiatric disability by implementing employee wellness plans and stress reduction interventions. Programs have been developed to mitigate the effects of stress on law enforcement personnel. Many law enforcement agencies have developed strategies to encourage early confidential referral for psychiatric treatment. They utilize peer support groups and employee assistance programs and develop alliances with mental health professionals. When these approaches fail, a fitness for duty process can be used to identify impairment in work functioning due to psychiatric factors with the prospect of later returning the officer to full duty. Copyright © 2017 John Wiley & Sons, Ltd.

Gender bias and judicial decisions of undue influence in testamentary challenges.

Allegations of undue influence constitute a common basis for contests of wills. Legal research from the 1990s suggests that gender bias factors significantly into judicial decision-making regarding alleged undue influence and testamentary intent. In this study, we sought to assess whether this bias is present today and to identify any factors that may be associated with it. Probate judges from several jurisdictions in the United States were asked to consider two hypothetical case vignettes drawn from actual published decisions. In our study, the gender of the testator played only a minor role in how judges weighed factors in the decision-making process and, overall, did not significantly influence opinions regarding the presence of undue influence. The specifics of the case and the gender of the judge emerged as the most consistent and robust potential influences on decision-making. Our results suggest that probate rulings involving undue influence are likely to represent a complex interaction of factors involving the testator's and judge's genders and the specifics of individual cases. The implications of these findings are discussed.

Peer review and psychiatric physician fitness for duty evaluations: analyzing the past and forecasting the future.

In the United States, oversight of health care practitioners is delegated to a matrix of health care entities including but not limited to the state medical board which licenses physicians in the relevant jurisdiction. Typically, these organizations have their own codes of professional conduct. When a physician joins one of these health care organizations, legally the physician has entered into a contract with the organization and agreed to be bound by its regulations and procedures. The organization's peer review of a member physician for reasons of investigating questions of health care quality may require a psychiatric fitness for duty evaluation. That assessment is a forensic psychiatric examination to assist the peer review body much as an expert witness would assist the trier of fact in a criminal or civil law adjudication. Experts can better perform these functions if they are familiar with the legal differences that define these agencies' service under administrative as compared to civil or criminal law and procedures.

Peer review committees and state licensing boards: responding to allegations of physician misconduct.

Although physicians tend to be more concerned about malpractice actions, adjudication of complaints of alleged physician misconduct by peer review organizations and state licensing authorities can have equally serious consequences. Unlike medical malpractice, no patient injury is necessary to support the claim of alleged misconduct. Unlike malpractice, in which a plaintiff must be the injured party, in administrative peer review, colleagues, family members, and patients may all qualify as potential complainants. Unlike malpractice, where the standard of care is what the average prudent practitioner would be expected to do in similar circumstances, in peer review, the standard of care is the code that the organization has endorsed and to which the individual practitioner has agreed by choosing to join the organization. Forensic psychiatrists who may serve either as experts for a peer review or state board investigation or as peer review committee members must understand the legal foundation of the process and the attendant psychological and sociopolitical forces affecting the different parties.

Restraint and seclusion in psychiatric treatment settings: regulation, case law, and risk management.

Changing federal regulations, civil rights and malpractice cases, and new treatment methods have influenced the use of restraint and seclusion (R&S) in inpatient psychiatric treatment settings, such that restraint and seclusion today are among the most highly regulated practices in psychiatry. Despite increased pressure from regulatory bodies and litigation, the use of R&S remains controversial and risky. These procedures can compromise safety if performed incorrectly or monitored inadequately, but intervention by restraint or seclusion may be necessary to maintain safety on the treatment unit, especially during emergencies. Case law and medical research have demonstrated the importance of a patient-focused, treatment-oriented approach toward risk management. Analysis of specific clinical scenarios can help to develop risk mitigation strategies that are therapeutically conceptualized rather than driven by regulation. Insights drawn from clinical cases that have resulted in litigation can offer an opportunity to develop an approach oriented to patient care from a clinical or risk management perspective. In this article, we seek to provide a foundation for evaluation of current protocols, an analysis of adverse R&S events, and strategies to minimize risk.

Firearm laws: a primer for psychiatrists.

Persons with mental illness or substance abuse have been perceived by the public to pose an increased risk of violence to themselves and others. As a result, federal and state laws have restricted the right of certain categories of persons with mental illness or substance abuse to possess, register, license, retain, or carry a firearm. Clinicians should be familiar with the specific firearm statutes of their own states, which describe the disqualifying mental health/substance abuse history and the role and responsibility of the psychiatrist in the process. State statutes vary widely in terms of the definitions of, and reporting requirements relating to, prohibited persons with mental illness or substance abuse. States also vary in the duration of the prohibition and in the timing of the appeals process. Some of the statutes have specific provisions for the removal of a firearm when a prohibited person is identified. States may maintain a mental health database that is used to determine firearm eligibility and may forward information to the National Instant Criminal Background Check System. The National Instant Criminal Background Check System Improvement Amendments Act of 2007 will likely increase the number of persons identified as belonging to the prohibited class.

White-collar crime: corporate and securities and commodities fraud.

In this era of increased interest in white-collar crime, forensic psychiatrists are in a key position to study the individual characteristics of offenders. While a comprehensive theory of high-level white-collar crime should consider societal and organizational contributions, there is value in understanding the personal traits that place an individual at high risk for offending. As the impact of the criminal acts of this group has been increasingly felt by larger groups from all socioeconomic strata, there is less willingness by the public to view these crimes as victimless and harmless.

National Instant Criminal Background Check Improvement Act: implications for persons with mental illness.

The National Instant Criminal Background Check Improvement Act has serious implications for persons with mental illness with regard to the ability to purchase firearms. Federally prohibited persons include those who have been adjudicated as mentally defective, or have been committed to a mental institution, or are unlawful users of or are addicted to a controlled substance. The legislation was intended to expand the reporting practices of states by providing significant financial incentives and disincentives for releasing all relevant records, including those contained within mental health databases, to the National Instant Criminal Background Check System (NICS). As of April 2007, only 22 states were voluntarily submitting records from mental health databases to the NICS. The legislation was introduced following the Virginia Tech tragedy, when public opinion favored tightening control over access to firearms of persons with mental illness.

Firearm laws, patients, and the roles of psychiatrists.

OBJECTIVE: Persons with mental illness and/or substance abuse are frequently perceived by the public to be dangerous. This has resulted in an increase in state legislation restricting their ability to purchase, possess, register, obtain licensure, retain, and/or carry a firearm of any sort. The purpose of this article is to educate clinicians about the impact of firearms statutes and restrictions for their patients. Many state statutes mandate that treating psychiatrists report such gun possession to state justice or police departments. Psychiatrists may also have a statutory role in an appeals process. METHOD: The firearms statutes of the 50 states, the District of Columbia, and Puerto Rico and the Federal National Firearms Act were surveyed, with particular attention paid to the ability of persons with mental illness and/or alcohol or substance abuse to obtain firearms. The results were tabulated. RESULTS: These statutes are not uniform. They vary in their definition of mental illness, the type and duration of gun restriction, reporting practices, the confidentiality of medical information, and the immunity of clinician reporters and appeals processes. CONCLUSION: Clinicians would be wise to familiarize themselves with the provisions of the relevant statutes in their particular states. This will allow them to identify the consequences to their firearm-possessing patients, understand their own roles and obligations -- if any -- and better consider potential clinical and ethical issues for particular patients.

Forensic psychiatric assessments of behaviorally disruptive physicians.

Forensic psychiatrists may be requested by a wide range of agencies and committees to assess physicians alleged to be behaviorally disruptive. Many of the adjudicatory procedures and questions of these agencies differ substantially from the familiar ones in civil litigation. Proximate cause and patient harm are not essential elements of the forensic questions raised by these health care agencies. In addition to assessing past professional conduct, the examiner is asked to opine about the examinee's present and future professional health and fitness for duty and what treatment or professional supervision, if any, may be needed to ensure the continuance of those professional capacities.

Self-disclosure in psychotherapy supervisors: gender differences.

OBJECTIVE: This article will explore the possible reasons for gender differences found in self-disclosure in psychotherapy supervisors. METHOD: Trainees and supervisors in the Brown University Department of Psychiatry and Human Behavior completed a questionnaire that asked about the appropriateness of the actions of a psychotherapy supervisor. RESULTS: On three items, male and female supervisors differed significantly in their perceptions of appropriate boundaries. These items were: interacting with the resident alone outside of supervision e.g. playing tennis (p = .0005), publishing identifiable content of supervision discussions with resident's consent (p = .0006), and disclosing the supervisor's prior struggles with substance abuse (p = .0008). Female supervisors answered "never" to these items in greater numbers than the male supervisors, who, for the most part answered "occasionally". CONCLUSION: Traditional gender role behaviors and differential gender socialization patterns are possible reasons for the gender difference in perception of boundaries by supervisors.

Supervisor-trainee relationship boundaries in medical education.

Despite concerns about the prevalence and ramifications of medical student mistreatment, the boundaries of faculty-student relationships have not been studied systematically in medical training programs. This study aimed to identify behaviours that occur with some frequency and potentially raise issues related to boundaries in the supervisor-trainee relationship. An anonymous questionnaire was distributed to the mailboxes of 154 residents in the departments of psychiatry, internal medicine, and obstetrics and gynaecology at four hospitals affiliated with Brown University Medical School. Residents were asked to report whether they had encountered specific behaviours from supervisors during medical training, the frequency of these experiences, and the professional status of the supervisor involved in each episode. There was a significant reported incidence of behaviours related to academic/professional boundaries, personal boundaries, and dating boundaries. Some of these behaviours raise issues related to exploitation. The major sources of these reported boundary behaviours were hospital-based clinical faculty, university-based academic faculty, and senior house staff. The potentially adverse effects of boundary behaviours on the individual student, the teacher-student relationship, and the doctor-patient relationship are discussed. Future research is recommended to clarify the limits of appropriate behaviour between supervisors and trainees in the medical learning environment

Gender differences in the practice patterns of forensic psychiatry experts.

In the past 25 years, the number of female forensic psychiatrists has increased dramatically. To assess whether there are gender differences in the practice patterns of forensic psychiatry experts, members of the American Academy of Psychiatry and the Law were surveyed during an annual business meeting. Women in the sample were shown to perform fewer categories of evaluation than men. Women were less likely than men to do criminal work, civil commitment/involuntary medication evaluations, and testamentary capacity evaluations, but there was no significant difference in the percentage of those performing some personal injury/disability/fitness for duty, custody, sexual harassment, or malpractice evaluations. Gender was not a significant factor in determining hourly rate. When subjects were asked to comment on whether they thought that gender was a factor in the selection of a forensic expert, 80 percent of the women, but only 41 percent of the men, believed that gender was a consideration.

Sexual harassment in medical education: liability and protection.

The prevalence and frequency of sexual harassment in medical education is well documented. On the graduation questionnaire administered by the Association of American Medical Colleges in 2003, 15% of medical students reported experiences of mistreatment during medical school. On items that specifically address sexual mistreatment, over 2% of students reported experiencing gender-based exclusion from training opportunities, and unwanted sexual advances and offensive sexist comments from school personnel. Sexual harassment of medical trainees by faculty supervisors is obviously unethical and may also be illegal under education discrimination laws. In two cases in 1998 and 1999, the U.S. Supreme Court clarified that schools may be held liable under Title IX of the Education Amendments of 1972 for the sexual harassment of their students. In 2001, the Office of Civil Rights of the Department of Education released revised policy guidelines on sexual harassment that reflect the Supreme Court rulings. Medical school administrators should undertake formal assessments of the educational environment in their training programs as a first step toward addressing the problem of sexual harassment. The authors recommend that medical schools implement measures to both prevent and remedy sexual harassment in their training programs. These constructive approaches include applying faculty and student education, establishing a system for notification and response, and creating an institutional structure to provide continuous evaluation of the educational environment.

Boundaries in psychotherapy supervision.

OBJECTIVE: This study examines the perceptions of trainees and supervisors on the boundaries of the supervisory relationship. METHOD: A 19-item questionnaire about the appropriateness of the actions of a psychotherapy supervisor was completed by 43 supervisors and 52 trainees. It was distributed at Grand Rounds and mailed out to psychotherapy supervisors in the community. RESULTS: Generally, trainees and supervisors agreed about the boundaries of supervision. Only one item indicated a significant difference between trainees and supervisors. Trainees considered the discussion of sexual fantasies as less appropriate than did supervisors. Using factor analysis, two scales accounted for 66% of the common variance. Supervisors scored higher than trainees on scale 1 (F = 5.14, df = 1.92, p = .03) and women scored lower than men on scale 2 (F = 9.88, df = 1.92, p = .002). CONCLUSION: Scale 1, a set of items related to sexual topics, revealed a significant difference in supervisor/trainee response with supervisors considering discussion of sexual items as appropriate compared to trainees. Scale 2, a set of items related to self-disclosure, revealed a significant difference with male respondents favoring looser boundaries and more self-disclosure than female respondents. The boundaries of the supervisory relationship are important concerns for our profession. This is the first study to provide an empirical evaluation of perceptions of trainees and supervisors on aspects of boundaries in the supervisory relationship. If the findings are replicated, they could contribute to future analysis of trainee/supervisor relationships. The maintenance of good boundaries between trainees and supervisors is crucial to the integrity of the supervisory relationship.