The forum: case vignette: a model proposal--psychotherapists with knowledge of danger.
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Beneficence↗
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Ethical and legal issues in e-mail therapy.
Psychologists and psychiatrists recently started using electronic mail (e-mail) to conduct therapy. This article explores relevant ethical and legal issues including, among others, the nature of the professional relationship, boundaries of competence, informed consent, treating minors, confidentiality, and the duty to warn and protect. To illustrate these complex issues, two services currently operating are discussed. To address potential hazards to clients and the profession, a new ethical standard for e-mail therapists is offered.
Adolescent↗
Ethical dilemmas in the treatment of adolescent gang members.
Therapists treating adolescent gang members face unique ethical dilemmas. These dilemmas arise from clinical issues that inevitably emerge in the treatment of this population. Clinical issues related to the adolescent gang member having great difficulty trusting, having experienced and observed much violence, and usually having participated in criminal activities are central to the treatment process. In this article I discuss the ethical problems that subsequently emerge: maintaining confidentiality, discharging one's duty to warn or protect, and imposing one's personal values. Suggestions for future research are offered.
Adolescent↗
Mental health professionals and assisted death: perceived ethical obligations and proposed guidelines for practice.
I have three purposes in this article: (a) to briefly review the legal obligations a mental health professional has when working with a client who is talking about taking some action that could lead to his or her death, (b) to clarify the positions of the 4 major national mental health organizations regarding the acceptable roles of their members with clients who are discussing the possibility of receiving assisted death, and (c) to propose a set of guidelines for practice for mental health professionals working with clients who are considering assisted death that comport with the various laws and codes of ethics.
Attitude↗
The struggle to maintain neutrality in the treatment of patient with pedophilia.
This article explores the ethical concept of neutrality through use of a psychiatric clinical vignette. In this case a psychiatry resident is faced with the treatment of a patient who was found by the FBI to be in possession of child pornography. Although not accused of any other crimes, the patient was a fugitive from the law and requesting treatment for pedophilia. Faced with the pressures of limited resources and anxiety about the patient's dangerousness to others, the resident and his supervisor tried to strike a balance between the ethical principles of neutrality and beneficence. Through this vignette, the importance of neutrality, as well as how it can be compromised by other pressures such as expediency and anxiety, is explored.
Beneficence↗
Early memories and the criminally dangerous.
We demonstrated the efficacy of using early memory (EM) data to distinguish postdictively criminally dangerous from nondangerous psychiatric patients. Dangerous patients (n = 30) had been adjudicated not criminally responsible (NCR) for felonies, whereas nondangerous psychiatric patients (n = 30) had no convictions for aggressive offenses. Groups were comparable in age, IQ, socioeconomic status (SES), marital status, and diagnoses. Group racial compositions, however, were significantly different. Statistical analyses were thus performed to clarify the potential effect of this racial confound. Overall, 73% of the dangerous and nondangerous patients were accurately classified via a newly developed EM scoring system, the Early Memory Aggressiveness Potential Score System (EMAPSS). Of those classified as dangerous, 15 of 16 (94%) were actually dangerous. The false-positive rate was an impressively low 6%, suggesting EM aggression is highly predictive of dangerousness postdictively.
Adult↗
Predicting dangerousness with two Millon Adolescent Clinical Inventory psychopathy scales: the importance of egocentric and callous traits.
Psychopathy in youth has received increased recognition as a critical clinical construct for the evaluation and management of adolescents who have come into contact with the law (e.g., Forth, Hare, & Hart, 1990; Frick, 1998; Lynam, 1996, 1998). Although considerable attention has been devoted to the adult construct of psychopathy and its relation to recidivism, psychopathy in adolescents has been less thoroughly researched. Recently, a psychopathy scale (Murrie and Cornell Psychopathy Scale; Murrie & Cornell, 2000) was developed from items of the Millon Adolescent Clinical Inventory (MACI; Millon, 1993). This scale was found to be highly related to the Psychopathy Checklist-Revised (Hare, 1991) and was judged to have demonstrated good criterion validity. A necessary step in the validation process of any psychopathy scale is establishing its predictive validity. With this in mind, we investigated the ability of the MACI Psychopathy Scale to predict recidivism with 55 adolescent offenders 2 years after they had been evaluated at a juvenile court evaluation unit. In addition, we devised a psychopathy scale from MACI items that aligned more closely with Cooke and Michie (2001) and Frick, Bodin, and Barry's (2001) recommendations for the refinement of psychopathy and tested its predictive validity. Results indicate that both scales had predictive utility. Interpersonal and affective components of the revised scale were particularly important in the prediction of both general and violent reoffending.
Adolescent↗
Investigating family-based alternatives to institution-based mental health services for youth: lessons learned from the pilot study of a randomized field trial.
The development and validation of family-based alternatives to out-of-home placements for children is an important goal in the mental health services field. The rigorous evaluation of such alternatives, however, can be difficult to accomplish. The purpose of this article is to describe initial barriers experienced during the pilot study of a randomized trial, funded by the National Institute of Mental Health, conducted in a field setting, and the strategies that were used to overcome these barriers. The randomized trial is examining home-based multisystemic therapy as an alternative to the psychiatric hospitalization of youths presenting psychiatric emergencies. The pilot study illuminated the interface of treatment and services research issues, prompting significant changes in the project's clinical procedures, organization, and supervisory processes, as well as in the project's interface with existing community resources for serving youths with serious emotional disturbances.
Adolescent↗
"Apraxia" of eyelid opening: an involuntary levator inhibition.
Apraxia of lid opening was described by Goldstein and Cogan as "a non paralytic motor abnormality characterized by the patient's difficulty in initiating the act of lid elevation." We studied six such patients with this finding accompanied by vigorous frontalis contraction and no evidence of ongoing orbicularis oculi contraction, dysfunction of the oculomotor nerve, or loss of ocular sympathetic innervation. Four patients had Parkinson's disease or atypical parkinsonism, one had progressive supranuclear palsy, and one had Shy-Drager syndrome. At onset of ocular symptoms, mean age was 64 years, and the mean duration of extrapyramidal symptoms was 9.7 years. By definition, the motor system must be intact in any apraxia. Therefore, this disorder of lid opening in patients with extrapyramidal motor dysfunction is not an apraxia, but rather involuntary levator palpebrae inhibition of supranuclear origin.
Aged↗
Suicide and civil commitment.
The contemporary approach to suicide prevention relies primarily on involuntary commitment of the suicidal individual. While there is generally widespread acceptance of the principle of society's right, even its moral obligation, to intervene to prevent a suicide, there is much less agreement concerning the conditions under which such an action should proceed. Most of the debate centers on the widely applied commitment criteria of mental illness and dangerousness to self and others. Questions have also been raised regarding the efficacy of commitment as a preventive measure. In this paper, these controversies are placed in a broader historical context. We examine empirical evidence concerning prevailing commitment criteria and the prophylactic value of involuntary hospitalization, and discuss the appropriateness of our current approach to civil commitment in light of existing data.
Commitment of Persons with Psychiatric Disorders↗
Alcohol, freedom, and responsibility.
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Alcoholism↗
The right to refuse treatment and the movement for mental health reform.
The right to refuse treatment is the most controversial of the rights of mental patients, and usually polarizes the movement for mental health reform between providers of care and external activist reformers. A broad alliance supported earlier struggles for recognition of patients' rights, but most professionals oppose recognizing this most extreme right of treatment refusal. Professional opposition to treatment refusal is not based on a wide extent of actual refusal; rather it derives from a defense against challenges to professional and institutional autonomy, an opposition to legal interference, and a belief that the community as well as the patient must be protected. These three reasons for opposition are examined by reviewing studies of attitudes toward patients' rights, knowledge about patients' rights, and implementation of patients' rights. Finally, the implications of these studies for future directions in the movement for patients' rights are examined.
Dangerous Behavior↗
Going underground and going after women: trends in sexual risk behaviour among gold miners in South Africa.
This paper examines trends in risk behaviour among South African gold miners, a population with an estimated HIV prevalence of 10-20%. The study is based on a 1995 and 1997 survey of a random sample gold miners in the town of Welkom, South Africa. The results show that the percentage of miners who perceived they were likely to contract HIV increased from 33% in 1995 to 35% in 1997 (P<0.01). The percentage who had 4 or more partners in the past year decreased from 25% to 13% (P < 0.01), and the percentage whose last sexual partner was their spouse increased from 56% to 70% (P<0.01). Condom use in last intercourse with a spouse increased from 18% to 26% (P < 0.05). Condom use with other partners was considerably higher (67%), but did not increase significantly from 1995. The most likely contributors to this behaviour change were the AIDS awareness programmes implemented by the mining industry and the behaviour change communications of a condom social marketing campaign targeted at miners and commercial sex workers in the mining community.
Condoms↗
Secondary HIV transmission rates in a mixed-gender sample.
Information about the sexual behaviour of HIV-infected individuals is needed to predict the course of the sexually transmitted HIV epidemic in the US. The present study provides model-based estimates of the secondary transmission rate (i.e. the number of infections expected among the sex partners of already infected individuals) for a sample of HIV-positive persons in Atlanta. A mathematical model was used to estimate the secondary transmission rate of HIV infection for a sample of HIV-positive men and women in Atlanta, based on their self-reported sexual behaviour, extrapolated over a 15-year horizon. Separate rates were calculated for different transmission routes, including: from women to men-who-have-sex-with women (MSW) and from men-who-have-sex-with-men (MSM) to other MSM. Sensitivity analyses were conducted to assess the impact of different parametric and modelling assumptions. Restricted to the sub-sample that reported transmission risk behaviours, the mean number of secondary infections was 0.14 for transmission from women to MSW; 0.31 for transmission from MSW to women; and 0.84 for MSM to MSM transmission. Bisexual men were at especially high transmission risk, with 1.59 and 0.54 secondary infections expected among their male and female partners, respectively. The main analysis indicates that, in this sample, each current infection will lead to fewer than one future infection for all groups other than bisexual men, which suggests that the epidemic is contracting in this community, although this analysis cannot rule out the possibility of a growing epidemic among MSM. This method can be used to identify groups at high risk for HIV transmission and thereby to better target HIV prevention resources.
Dangerous Behavior↗
An update on managing dangerous people with severe personality disorder--"the human time bombs.".
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Commitment of Persons with Psychiatric Disorders↗
Tightropes and tragedies: 25 years of Tarasoff.
In 1976 the California Supreme Court decided the case of Thrasoff v Regents of the University of California. That case has had very significant effects on psychiatric practice on both sides of the Atlantic, and its very name is instantly recognizable to most psychiatrists. Yet the details of the case are often misunderstood or misquoted; as a legal precedent it was rapidly superceded, and is now largely redundant. Twenty-five years on it seems appropriate to revisit the case itself, and its impact on contemporary psychiatric practice. English law has yet to impose a similar duty, but two leading cases raising similar issues are also described.
Adult↗
The Mental Health Act 1983 section 5(2): clinical application and predictors of outcome.
This study examined trends and influences of variables in the 100 most recent applications of Section 5(2) of the Mental Health Act 1983 in a major teaching hospital in England. Case notes, section-forms, log-books and computerised records were scrutinised. Sixty-four per cent of the cases were converted to Section 2(28%) or Section 3(36%), the remainder we rescinded or lapsed. No demographic, illness characteristic or grade of doctor significantly effected conversion or lapse rate of Section 5(2). The clinical implications of a high rate of non-conversion of Section (2) is clear. Non-psychotic patients may be less likely to be regarded for further Sections when detained under Section 5(4) before detention under Section 5(2), yet no ingle factor determines the outcome of emergency.
Commitment of Persons with Psychiatric Disorders↗
Detecting the dangerous, violent or criminal patient: an analysis of referrals to maximum security psychiatric care.
Britain's high security hospitals provide care for mentally disordered patients who have dangerous, violent or criminal propensities. The State Hospital, Carstairs, takes referrals from the population of Scotland and Northern Ireland. This retrospective case-control study describes the sociodemographic and clinical characteristics of referrals (n=149) to the State Hospital during a 12-month period, and delineates differences between admitted (n=57) and rejected (n=92) patients. The referrals had an average age of 31.1 years, and were mostly male (86.6%), single (64.4%) and unemployed (90.6%). Admitted patients were more likely to have a criminal history, to be psychotic, to have a family history of mental disorder and to be viewed by the assessor as having psychotic beliefs which contributed to the behaviour or alleged offence leading to the referral. Rejected patients were more likely to have been remanded to prison or assessed by specialist registrars. Patients admitted to high security psychiatric care are more likely to show dangerous behaviour secondary to psychosis. These findings are in keeping with the requirements of mental health legislation and the admissions policy.
Adult↗