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Managed care and organized systems of care are restructuring the delivery of care in the United States. As care is reorganized, physician practice styles, autonomy, and compensation are undergoing profound changes. To successfully integrate physicians into the new managed systems of care, their organizational relationship to and their compensation within these systems must be carefully considered. This paper first explores physician motivation as it is related to compensation. The paper then describes a variety of emerging organizational designs aimed at aligning the interests of physicians and hospitals. The author considers fully integrated, physician-hospital organizations with target income compensation arrangements to be most suitable to the collective success of professionals and organized systems of care. The paper concludes with a discussion of the many dilemmas and challenges posed by the intertwining of managed care, organized networks of care, and professional compensation. [ABSTRACT FROM AUTHOR]

The elder population continues to grow rapidly in many countries. Florida's elder population is growing faster than most states', with over one-quarter of the Florida population projected to be aged 65 and over by 2025. Involuntary examination (i.e. emergency commitment) under a state's civil commitment law is one means by which older adults experience assessment for acute mental health care. In Florida, the civil commitment law permits the involuntary examination of an individual for up to 72 hours to determine whether the person meets standards for involuntary treatment. From calendar year 2001 through 2005, there were 531,091 involuntary examinations in Florida for 301,886 people of all ages. Thirteen percent were 60 years and older at the time of their examination. The purpose of this paper is to describe the characteristics of older adults subject to involuntary examination and the nature of their examinations. While these data permit a number of inferences, there is an expansive area of research and policy analysis that remains untapped and would permit better understanding of how older adults experience such examinations. These research and policy issues will also be discussed. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Much attention has begun to focus on the quality of care for persons near the end of life. Palliative care, especially through hospice, has generated much discussion as possibly the most holistic care available. Consideration of how chronically ill older adults receive such care as a result of public policy can benefit from adopting a multidimensional perspective. This paper adopts Bronfenbrenner's ecological model to understand current end-of-life care for nursing home residents, followed by consideration of how each of these dimensions or levels of influence can be used to foster both research agendas and policy reforms to improve end-of-life care of nursing home residents. Specifically, the benefits of considering the influence of such policy initiatives as the Medicare hospice benefit and the Patient Self-Determination Act (PSDA) on end-of-life care in nursing homes and the means through which policy can be informed by clinical research is emphasized. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Psychology as a profession has entered the arena of palliative and hospice care later in the process than other health care professions. Through the use of Familial Advance Planning Evaluations (FAPEs), however, psychologists can assist individuals and families in facing end-of-life transitions in important ways. Hospice and palliative care philosophy treats the patient and family as the unit of care. End-of-life decision-making is therefore a family matter as well as a normative developmental transition. Yet, little is known about the decision-making process. This paper reviews the literature regarding informed consent, advance care planning, and proxy decision-making and outlines a theoretical model for familial decision-making. Previous models of end-of-life capacity evaluations and family assessments are presented and serve as the basis for a comprehensive assessment of familial decision-making at the end of life. Functional capacity evaluations of individuals at the end of life regarding decisions about life-sustaining medical treatments enable both the individual patient and one identified proxy from his or her family to discuss important issues families may face during medical crises at the end of life. The information gleaned from such evaluations has the potential to assist psychologists and other professionals in designing family-specific interventions to reduce caregiving distress, improve quality of life for dying patients, and ease the transition to bereavement for caregivers. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Treatment of antisocial personality disorder (APD) and ";core" psychopathy is usually considered a pessimistic clinical exercise. This paper reviews the importance of accurate diagnosis (including differences between APD and other antisocial syndromes), limited techniques for predicting and preventing adult antisocial syndromes, several kinds of treatment that have been attempted with varying success, management of specific antisocial behaviors, and the frustrations-even dangers-of working with severely antisocial patients. [ABSTRACT FROM AUTHOR]

This paper offers a discussion of some of the nuances of mental disease or defect as required for the insanity defense in criminal law. It also compares and contrasts the mental disease or defect definitions of criminal law with those definitions used in clinical practice. It points out a general pattern of vagueness and dispute regarding the proper interpretation of the mental disability requirement in the insanity defense and in other legal provisions. It reports a variety of interpretations by courts and commentators regarding the meaning of these phrases, and it reports attempts by state legislatures to narrow the range of applicable conditions by excluding various mental or emotional states. [ABSTRACT FROM AUTHOR]

This paper reviews published tort cases that arose after a patient impulsively hurt or killed someone. Plaintiffs alleged breach of the duty to protect (Tarasoff) or negligent release from hospital. There are sixteen cases involving a variety of facts and diagnoses. As a matter of law courts typically hold that impulsive violence is not foreseeable. One jury found a defendant negligent but that verdict was ultimately overturned. Statutes on duty to protect do not imply a duty to act on the fact patterns of impulsive violence in this sample. The author concludes that the ethical duty to do careful clinical work is essentially identical to the legal duty to use due care in these cases. The law imposes no additional burden on the clinician in these cases. [ABSTRACT FROM AUTHOR]

This article examines the social perception of disease. Understanding medical perceptions provides an opportunity to gain insight into factors that influence health care seeking behavior patterns, treatment compliance and social policy. This paper views addictive disease models as metaphorical substitutes for moral turpitude models. This conclusion suggests that it is important for health care providers to carefully and instrumentally apply their language to facilitate patient compliance with treatment protocols, in general, and psychotherapy in particular. [ABSTRACT FROM AUTHOR]

This paper explores the development of the informed consent doctrine as it relates to psychiatric practice. The contribution of the issues of civil commitment and the right to refuse treatment to current developments in the informed consent doctrine is also addressed. Special informed consent issues are related to specific categories of psychiatric treatments. Basic informed consent requirements in psychiatry are seen as still in the formative stages but he constitutional law and common-law foundations for further developments are outlined. The complicated clinical, ethical, and legal issues involved in modern psychiatric treatment are stimulating new interest and concern about the informed consent doctrine throughout medical practice. [ABSTRACT FROM AUTHOR]

Senile dementia in the early is a prevalent condition which require ongoing medical treatment. This disease causes a deterioration of cognitive processes and, consequently, it is likely to impair the capacities required to give informed consent to needed medical care. However, a diagnosis of senile dementia does not necessarily indicate that the afflicted individual is incompetent. The means of assessing competency id dementia patients and their likely impairments according to five standards is described in this paper. Recommendations for obtaining consent from the competent dementia patient are made and mechanisms for providing special protection to the incompetent patient in the consent process are discussed. [ABSTRACT FROM AUTHOR]

Over the past 25 years, obtaining informed consent for the performance of many medical procedures has become part of the practice of medicine. As opposed to the ‘duty to warn’ that is enforced by the law, informed consent should be a cornerstone of a fully collaborative decision-making process, the elements of which are presented in this paper. The responsibility for this process rests upon health care institutions and financing arrangements, as well as upon physicians and courts. In response to emergencies, patient preferences, and public interest, the consent process is justifiably abbreviated. However, as presently articulated, the consent process treats communication too simplistically, is distorted by the way it is enforced in litigation, is inattentive to social justice issues, and is not integrated into the moral commitment of physicians. [ABSTRACT FROM AUTHOR]

The rise in the mental health movement coincides with a decline in prestige and importance of criminal law. While this may, in part, reflect the greater effectiveness of mental health treatment in dealing with overlapping problems, it also reflects certain problems that criminal law has with the individualistic values of modern society and the value-attractiveness of the mental health professions' commitment to helping the individual. However, many of the same value problems inherent in criminal punishment also apply to some aspects of mental health treatment, especially the paternalism of the doctor-patient relationship and involuntary treatment. Informed consent can be seen as a response to these value conflicts as well as part of the general extension of citizenship rights to the less privileged members of the society. This paper analyzes some of the conflicts inherent in the application of informed consent to mental health treatment from the above perspective. [ABSTRACT FROM AUTHOR]

People commonly use the Internet to search for health information and tend to use the information they find without regard to source or credibility. Although regulation plays some role in minimizing false claims made by manufacturers of self-help products, effective communication with health professionals likely offers greater protection to the patient or consumer accessing self-help materials. In order to best serve patients (or healthcare consumers), providers should educate them about their healthcare needs, inquire about self-help product use, understand appropriate use, discuss the risks and benefits of use, monitor the patients' condition during use, and document these conversations. Although some people fear that patient use of brain-themed self-help will undermine the doctor-patient relationship, it is more likely to open another avenue of communication if providers are knowledgeable about self-help products. Given the rise in importance of the Internet as a source of information for people, opting out of these discussions is realistically not an option. [ABSTRACT FROM AUTHOR]

Between January 1, 2012 and December 31, 2014, there was a large population (N = 200) of insanity acquittees placed on conditional release (CR) in the state of Oregon. This article looks at the demographic and system characteristics of this large group of individuals. The authors then focus on the initial housing placement and what happens to individuals after their release in relation to their housing placement. In Oregon, insanity acquittees are either conditionally released directly by the court or placed in the hospital prior to potential CR by a supervising board. In general, once CR occurs, individuals tend to stay in their initial placement without moving to less structured levels of care, raising concerns about transinstitutionalization. This is especially true for individuals released to the most structured living arrangement (secure residential treatment facility). Those individuals who are conditionally released to less structured settings have a higher rate of revocation back to the hospital. Those individuals who do move to less structured levels of care usually have longer hospital stays and start off in more structured levels of care to start their CR. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Little is known about service delivery for those in the correctional system with co-occurring mental health and substance abuse disorders (COD). Using data from the National Criminal Justice Treatment Practices survey (NCJTP) on community corrections and jail agencies, this study found that correctional organizations that offer COD services differ from agencies that do not. Organizations that respond to the needs of COD offenders tend to be more “service friendly,” rank higher on measures of various dimensions of organizational climate that embrace learning and goal achievement, and tend to adopt more innovations, particularly those classified as evidence-based practices. These survey findings indicate that correctional agencies who serve COD offenders are in a better position to be responsive to the changing service needs of the populations, and are more likely to be able to balance public safety and treatment goals. Future steps to develop support environments for COD assessment and treatment services are discussed in light of these findings. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

A growing body of literature now suggests that use of telepsychiatry to provide mental health services has the potential to solve the workforce shortage problem that directly affects access to care, especially in remote and underserved areas. Live interactive two-way audio–video communication—videoconferencing—is the modality most applicable to psychiatry and has become synonymous with telepsychiatry involving patient care, distance education, and administration. This article reviews empirical evidence on the use and effectiveness of videoconferencing in providing diagnostic and treatment services in mental health settings that serve child, adolescent, and adult populations. Descriptive reports, case studies, research articles, and randomized controlled trials related to clinical outcomes were identified and reviewed independently by two authors. Articles related to cost-effectiveness, technological issues, or legal or ethical aspects of telepsychiatry were excluded. The review of the evidence broadly covers mental health service provision in all settings, including forensic settings. Given the sparse literature on telepsychiatry in forensic settings, we discuss implications for mental health care across settings and populations and comment on future directions and potential uses in forensic or correctional psychiatry. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

India, with its huge population and limited mental health resources, must find alternative ways of delivering its mental healthcare services. Telepsychiatry seems to be a promising option even with no regulatory authority in place or specific laws in India that deal with telemedicine practice, there has been a mushrooming of telemedicine services in India. Healthy cooperation between government organizations such as the Indian Space Research Organization (ISRO) and institutions in the non-government and private sectors is another key feature in India. The experience of the Schizophrenia Research Foundation (SCARF), at Chennai, in South India, in running and establishing a telepsychiatry network is presented in this article. We identified the following tasks as essential to ensure an efficient intervention using telemedicine: identifying a suitable technology, a suitable location, and a local collaborator; providing training and creating awareness; establishing peripheral telepsychiatry centers and ensuring case documentation; and accountability. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Researchers and scholars assert that feigning should not be equated with malingering. Some practicing clinicians doing the everyday work of forensic assessment may view this as merely an academic distinction. This case study illustrates that a high level of certainty about feigning must not be considered indicative of malingering. The case also contrasts two models for assessing malingering and highlights the need for forensic examiners to present assessment-of-malingering data clearly and cautiously. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Far more people in relationships are subjected to violent acts than those who receive injuries. The degree of damage sustained may not reflect the perpetrator's intent to deliberately harm a partner. Data documenting aggressive acts determines the population at risk and their prevention and early treatment requirements; whereas data focusing on harm and injury helps determine emergency medical and refuge services. Data from national crime surveys, police records, or clinical populations should not be generalized to the population at large. Even if men perpetrate the majority of serious partner attacks, addressing the issue of female violence will significantly reduce the overall level of domestic violence. Judicial, medical, and social services should take note that while male violence may be more problematic, violence is a relationship issue, not a male issue. [ABSTRACT FROM AUTHOR]

Provides an author's overview of articles discussed in the issue "Behavioral Sciences and the Law. Problem presented by managed mental health care for clinicians; Examination of various strategies for organizing and compensating health care providers under managed care; Implications of verbal expressions for informed consent to health care.

The scientist-practitioner model is presented as a format for conducting child sexual abuse evaluations. This model bases conclusions on empirically established relationships between data and the behavior of interest, rather than on subjective opinions. Using empirically derived evidence, the scientist-practitioner defines child sexual abuse as a life event rather than a clinical syndrome, relies on base rates of behavior for distinguishing and understanding differences between nonsexually abused and sexually abused children, and considers issues of instrument sensitivity and specificity when utilizing assessment tools in child sexual abuse evaluations. This model enlists safeguards to keep the evaluator from inappropriately forming cause and effect associations between a child's single response (e.g., behavioral and emotional symptoms, interactions with anatomically detailed dolls, drawing genitalia) and the occurrence of an event (e.g., sexual abuse). [ABSTRACT FROM AUTHOR]

Bayes' theorem has been successfully applied to clinical decision making in circumstances where the prevalence rate is both stable and well established. An attempt by Mossman and Hart (1996) to apply Bayes' theorem to malingering is critically examined. When marked fluctuations in the base rates of malingering (both within and across settings) are considered, this model appears to have little clinical utility. For the sake of illustration, Mossman and Hart data were reanalyzed, taking into account the pronounced variation in base rates. Within a 90% confidence level, the estimates of malingering for many scores extended the full range from 0% to 100%. © 1998 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The efficacy of reforms in the civil system, including professional liability in the health care arena, depends upon the accuracy with which problems are defined. A growing empirical literature argues that the description of the civil justice system underlying the movement for tort reform in the health care arena is not an accurate one. Regardless, that description continues to be used successfully as the basis for a variety of enacted reforms. The interesting question now posed by some researchers is why that description persists despite its lack of empirical verification. This article summarizes the reformers' description; provides an overview of relevant empirical findings; and then draws on a theoretical literature in political science dealing with agenda-setting in the public policy process to answer that interesting question. The article concludes that the image persists because it is successful in a political, not rational, process in which appeals to emotion overshadow reasoned argument. [ABSTRACT FROM AUTHOR]

Recent legislative and regulatory developments have focused attention on older adults' capacity for involvement in health care decision-making. The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) focused attention on the rights of nursing home residents to be involved in health care decision-making to the fullest extent possible. This article uses data from the 1987 National Medical Expenditure Survey (NMES) to examine rates of incapacity for health care decision-making among nursing home residents. Elements of the Oklahoma statute were used to operationalize decision-making incapacity: disability or disorder, difficulty in decision-making or communicating decisions, and functional disability. Fifty-three percent of nursing home residents had a combination of either physical or mental impairment and an impairment in either self-care or money management. The discussion focuses on the policy and practice implications of significant rates of incapacity among nursing home residents. [ABSTRACT FROM AUTHOR]

Attorneys, philosophers, bioethicists and health care professionals have vigorously debated how much state control there should be over an individual's or family's decision to discontinue life-sustaining treatment. Where treatment of a minor is involved, the debate becomes even more complex. The purposes of this study were to identify cases involving the withdrawal of life-sustaining treatment in children, to described the legal-sustaining treatment in children, to describe the legal response to, and the management of, these cases, to examine variables that influence decision making, and to determine what legal—ethical standards are used and how they are applied. In addition, the author reviewed the literature on children's understanding of death and competence to participate in treatment decision making and applied those findings to argue for greater involvement of children in decision making related to the use of life-sustaining treatment. [ABSTRACT FROM AUTHOR]

Physicians often use verbal expressions of probability to characterize their uncertainty about outcomes and the risks or side effects of proposed therapies. However, there is an extensive literature that documents the inherent vagueness of such expressions. Because of the potential importance of probability terms to physician-patient communication and decision-making, we asked patients to tell us the odds they thought applicable to the term ‘rare,’ as used by their physician to discuss the likelihood of an adverse outcome from surgery. Patients were randomly assigned to one of three outcome groups: death, severe heart attack, or severe pneumonia. Demographic data were elicited from each subject, as were indicators of present health status, medical history for certain diseases and surgery, and life expectancy. Linear regression and ANOVA analyses of the response indicate that patient age, education level, perceived health status, and recency of experience with disease and medical care influence patients' numeric interpretations. We discuss the implication of these results. [ABSTRACT FROM AUTHOR]

The delivery of services for people with severe mental illness (SMI) is described as healthcare's most difficult challenge because SMI patients suffer from the combined effects of conditions that have 1) a chronic course, 2) disabling consequences, and 3) a high risk of poverty. The fundamental advantages of managed care for persons with chronic, disabling conditions are discussed along with an examination of how well these assumptions hold in actual practice for persons with SMI. The legal risks assumed by clinicians in managed care are reviewed, including the inherent risk of discriminating against high cost enrollees, such as patients with SMI. Finally, recommendations are made regarding the measures that might be taken to increase the ‘match’ between the principles of managed care and the specialized needs of people with severe mental illness. [ABSTRACT FROM AUTHOR]

Although the medical profession's codes of ethics have rightly been criticized for having claimed authority to decide questions of medical ethics for society, codes continue to provide crucial guidance to the individual clinician in matters of ethics. Examination of the code of the American Psychiatric Association (APA) shows that while it emphasizes the psychiatrist's fiduciary responsibility to individual patients, it ignores the crucial dimension of stewardship responsibilities to society. As a result, the ethical pronouncements of the APA have thus far been of little use to clinicians with regard to the major issues posed by managed care. In contrast, the code of the National Association of Social Workers considers the ethics of social institutional as well as those of individual practitioners, and advises clinicians on how to manage the inevitable and legitimate tensions between fiduciary and stewardship commitments. Until the APA extends the scope of its ethical vision, it will not be able to help clinicians struggle constructively with the questions of how it is possible to ‘care about patients’ and ‘care about money.’ [ABSTRACT FROM AUTHOR]

Confidentiality is widely considered to be of great importance in psychotherapy. With few exceptions, the breaching of confidentiality is an ethical violation and grounds for litigation. One such exception is the mandated reporting of known or suspected child abuse, representing a legally sanctioned limitation of confidentiality. Because clients generally expect unlimited confidentiality in therapeutic relationships, many therapists have begun to "forewarn" clients as a matter of informed consent. This research report: (a) briefly reviews issues surrounding mandatory reporting and confidentiality as they relate to forewarning, (b) defines and discusses forewarning as contrasted with "informing," (c) examines state statutes, case law and ethical guidelines relevant to forewarning, and (d) presents a survey of 428 mental health providers (MHPs) on their forewarning practices in which 36.9% forewarned all clients, 36.4% informed clients only upon suspicion of abuse, and 20.6% informed only after receiving a disclosure of abuse. The implications of these findings are discussed. [ABSTRACT FROM AUTHOR]

The continuing controversy surrounding the Tarasoff inspired duty to protect as developed by the courts and legislatures has not adequately weighed the jurisprudential foundations of such an obligation. The authors argue that the duty's misguided thrust of social control grounded in character and status seriously violates broad principles of political morality underlying the law of social control. They conceptualize an alternative--a clinical duty to protect--that coheres with these underlying values and the limits of professional abilities. They contend that any extra-clinical intervention on the part of the psychotherapist entails a role transformation requiring independent justification. [ABSTRACT FROM AUTHOR]

Therapeutic Jurisprudence provides a conceptual framework for a research agenda designed to promote development of legal rules, procedures, and roles in a manner consistent with the therapeutic mission of the mental health system. As such, it draws attention to the tension between the jurisprudential values of autonomy and well-being that permeates mental health law specifically and the law and ethics of health care generally. This article advances an analysis of these values in the context of the patient-centered approach to health care. The article endorses a priority for the deontic aspect of autonomy over well-being but allows balancing of the consequentialist component of autonomy against well-being. Finally, it applies this framework to several traditionally difficult types of cases. [ABSTRACT FROM AUTHOR]

From their perspective as participant observers, the authors discuss the initial phase of an attempt to remodel the child/family mental health service delivery system. Conceptualizing families as being at varying levels of risk for dismemberment is seen as: (a) providing a politically viable terminology, (b) permitting each agency to develop a continuum of services tailored to its mandate and clientele, and (c) facilitating legislative efforts to analyze simultaneously the budgets of all those state agencies with major responsibilities for children's services. A planning team endorsed cooperative planning between a state-level coordinating council and individual locales. Cultural communities were invited to participate in a manner paralleling the planning role of local communities. A model for a free standing case management entity is proposed. The concept of empowerment is discussed as a criterion for multi-level outcome evaluation. [ABSTRACT FROM AUTHOR]

The manner in which the informed consent process is structured was explored by means of intensive interviews with 17 experienced psychiatric researcher. Despite differing views on informed consent, investigators displayed a commonality of practice. Most investigators were themselves not usually involved in obtaining consents, relegating the process to lower-level assistants. They did not closely monitor the process and generally were unaware of problems that may have arisen. Most protocols called for repeat contact with patients so that a relationship would develop and information could be provided before obtaining a formal consent. The actual signing of a consent form often reflected a decision that had been made much earlier in the process. These findings have significance for both sides in the dispute over informed consent in research. Those who favor tighter controls over psychiatric research will have to consider the implications of monitoring, without destroying, a prolonged and complicated process. Those who argue for a reliance on investigators' integrity must deal with the apparent lack of involvement most investigators have in the consent process. [ABSTRACT FROM AUTHOR]