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PubMed1989

Clinical flexibility and confidentiality: effects of reporting laws.

Legal constraints upon therapeutic flexibility, resulting in breaches of confidentiality, can promote counterproductive effects upon patients and society. Conflicts can be created for mental health professionals who sometimes must choose between maximum self-protection and doing what they believe is ethical. A survey of forensic psychiatrists indicated that most believe they face ethical problems created by some ambiguities in current reporting statutes if they are interpreted to mandate reporting and warning. Emphasis is given: (1) to the ethical choice faced by therapists as to whether rigidly to report and warn to limit liability in all Tarasoff-type situations and in some ambiguous child abuse situations, or to take an alternative action when it is clinically indicated for the benefit of a patient and/or society; (2) to the importance of understanding the distinction between potential criminal liability for failure to report under many child abuse laws, and the risk only of civil liability in Tarasoff-type cases; and (3) to appreciate the flexibility permitted by current "Tarasoff" laws. Our case histories demonstrate that mandated erosion of therapeutic confidentiality can present serious problems for patients and others. Suggestions are included for modifications in the current reporting statutes, focusing on the perspective that clinical flexibility is an essential adjunct to community protection as well as to effective therapy.

Adult↗
PubMed1990

Judicial discharge of involuntary patients.

Involuntarily hospitalized patients oftentimes request judicial review of their commitments. Many psychiatrists believe that such judicial review results in the discharge of too many of these patients. We attempted to assess this hypothesis as well as identify which patients receive judicial discharge.

Adult↗
PubMed1988

Ethical considerations of clinical use of Miranda-like warnings.

Psychiatrists and other psychotherapists are not generally required to provide Miranda-like warnings to their patients. Even so, many psychotherapists issue such warnings before encountering clinical situations that frequently arise in general clinical practice and have potential involvement with the legal system. Ethical considerations of whether to utilize Miranda-like warnings in common clinical situations such as involuntary hospitalization, the duty to warn and protect, and suspected child abuse reporting, are explored.

Adult↗
PubMed1989

Monitoring and managing the suicidal prisoner.

In this paper, we have examined a number of measures that can be used by correctional and health personnel to protect the suicidal inmate. Not every measure is suited for every jail. Correctional and health services personnel must design a suicide prevention program based on the particular requirements of their facility. One person should be given the responsibility for overseeing the development and implementation of the program. This would include preparing policies and procedures for the supervision of the suicidal inmate, creating a safe environment for the prisoner at risk, and coordinating the work of correctional and health services personnel. Even in the best run jails, prisoner suicides can and do occur. The measures outlined in this paper can be used to minimize the risk of these occurrences. Although these measures may require significant fiscal expenditures, we believe that the longterm cost savings will more than offset the short-term costs and contribute immeasurably to the efficient management of the correctional facility in which they are employed.

Dangerous Behavior↗
PubMed1984

Dangerousness and violence in hospitalized mentally ill offenders.

Clinical judgments of dangerousness depend not only on patient characteristics, but are greatly influenced by the perspective of the rater and the context for which the assessments are made. Similarly, institutional violence is determined not only by patient characteristics, but is also a function of contextual variables such as physical milieu, important clinical events not under the control of the patient, etc. To increase the predictive validity of assessments of dangerousness it is essential to specify the vulnerabilities and strengths of the patient, the current life stressors, and the contextual triggers to which the patient is likely to react violently. The momentary contextual triggers may be useful to predict the type and severity of violence and perhaps the most likely victims as well. Analyses of previous violent incidents may provide markers for contextual triggers, e.g., type of weapon, victim, severity of violence, etc.

Antisocial Personality Disorder↗
PubMed1984

Ethics in psychiatry: a view from the clinic.

Decisions and interventions made in the course of psychiatric practice often have important ethical dimensions. Issues such as confidentiality, freedom of information, the duty to warn, double agentry, the patient's rights to treatment, and to refuse treatment are often identified in the context of inpatient psychiatry. In the practice of ambulatory psychiatry these issues are more easily ignored and therefore less frequently considered. The authors present six cases seen in an outpatient clinic of a community mental health program which illustrate ethical dilemmas in the six areas listed above. Questions raised by the cases and the clinic's interventions are discussed. Consequences for the patients and the clinic of the ethical decisions made in these are explored.

Adult↗
PubMed1985

Problem solving with families in psychiatric emergencies.

The first phase of the interview with families in psychiatric emergencies assesses the emergency and the family system. This is in preparation for the second phase, problem solving. Problem solving can consist of crisis intervention, social systems brokering, and/or therapy consultation. The authors describe a way of thinking about and intervening in family emergencies that maximizes therapist leverage and effectiveness with highly stressed and difficult families. Case examples are used to illustrate both the utility of the approach and the mistakes the authors made when certain tasks were ignored. The effective practice of emergency psychiatry is enhanced by the flexible use of systems and strategic principles.

Adult↗
PubMed1985

Trends in New York State secure care patients: 1980-1982.

Demographic and clinical characteristics of patients in special security units in New York State psychiatric centers are examined over time. The percentage of recently dangerous patients increased dramatically over the first three years of "official" operation. In addition there were increases in the percentages of patients with physical problems, alcohol/drug problems, and mental retardation diagnoses.

Adult↗
PubMed1985

Some necessary assumptions in private psychiatric treatment centers: the functions and dysfunctions of myths.

The functions and dysfunctions of myths in private psychiatric inpatient treatment are examined. Myths are here defined as beliefs given uncritical analysis by members of a group in support of traditional practices and institutions. Myths give inspiration to the ongoing work of the psychiatric center, and without them the work could not successfully proceed. The following myths are examined: the Myth of the Higher Order, the Myth of Uniqueness and Superiority, the Myth of Omnipotence, the Myth of the Psychotic Patient and the Healthy Staff, and the Myth of the Family. Myths provide the comforting language of absolutes, but may become anachronistic and proven false by reality. They will then no longer drive away chaos, and individuals will feel betrayed.

Adolescent↗
PubMed1992

The insanity verdict, the psychopath, and post-acquittal confinement.

Automatic post-acquittal confinement, an almost inevitable concomitant of a verdict of not guilty or not responsible by reason of insanity has for many acquittees been nothing more than punishment in disguise. Replacement of the insanity defense by statutes that provide for expert witness testimony to show that the defendant lacked the state of mind required as an element of the offense charged, has been found by two state supreme courts to be in accord with constitutional requirements. Procedures can be implemented, with due regard for public safety, so that all offenders, mentally disordered or otherwise, may be dealt with in an ethical, effective and humane manner. The 1992 decision of the Supreme Court of the United States in the case of Foucha v. Louisiana, holding that the Constitution does not permit the continued confinement of a still dangerous, but no longer mentally ill, insanity acquittee, makes it all the more necessary that the insanity defense be abolished and that an offender's mental illness be considered primarily in the context of mitigation, disposition and sentencing, rather than exculpation.

Adult↗