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E-mail correspondence between psychiatrists and patients raises numerous legal concerns with respect to the ethics of the doctor-patient relationship. Case law has shown that a doctor-patient relationship may be established in the absence of face-to-face contact. Despite this, a surprisingly high number of physicians respond to unsolicited e-mails, some even going so far as to suggest diagnoses or to offer advice. Courts may decide that a doctor-patient relationship exists where a psychiatrist has corresponded with a patient by e-mail. Psychiatrists may be faced with difficult ethics-related decisions regarding unsolicited e-mails from members of the public as well as e-mail from current patients and third parties, such as family members of patients. This article addresses relevant law and ethics guidelines and seeks to assist psychiatrists in making sound, ethical decisions about the professional use of e-mail.

Shared (Induced) Delusional Disorder commonly occurs in close relationships and involves a varying number of participants who may be nonconsanguineous. The disorder has been associated with forensic and fatal consequences. Its occurrence in three nonrelated, incarcerated individuals is described in this article. This case of folie à trois has forensic implications and raises several questions of ethics that relate to autonomy, confidentiality, safety, and risk estimation. The presentation, management, and outcome of the patients suggest that a high index of suspicion is needed to detect cases in similar settings. The report concludes that the rarity of the disorder in a forensic mental health population may be the result of underdetection, given that conditions are conducive to the development of the disorder. Telltale signs of its manifestation are hypothesized as being responsible for some events in incarcerated populations. Physical separation and antipsychotic medications remain the mainstay of treatment.

A scenario common to several boundary violation/sexual misconduct cases is reviewed and discussed. Common features include an articulate patient whose high functionality concealed more primitive dynamics that arose in the therapy; boundary problems, often on an "attempted rescue" basis; and eventual litigation in some form. The patient's high functioning appeared to cause the therapists to underestimate the severity of the patients' disturbances. Drawing on forensic experience, the author analyses the cases and suggests risk management approaches.

Dr. Thomas Gutheil, in his article, "Boundaries, Blackmail, and Double Binds: A Pattern Observed in Malpractice Consultation," provides readers with some important and useful recommendations regarding the avoidance of real or perceived boundary violations and how to avoid the pitfalls of difficult therapy. However, in doing so, he moved away from the usual even-handedness and objectivity that characterizes his work. Forensic mental health professionals rely on evidence, and always wait until they have carefully considered both (or all) relevant sides of an issue before rendering an opinion.

Twenty-three states have enacted Tarasoff statutes applicable to psychiatrists. Since the first such statute was enacted in California in 1985, a significant number of courts in states with this and similar statutes have reviewed Tarasoff-type claims. This article reviews courts' analyses in 76 such cases. There were five basic categories identified, including cases that (I) did not reference the statute; (2) referenced the statute, but did not analyze it; (3) referenced the statute, analyzed it, and found it created a duty; (4) referenced the statute, analyzed it, but found it did not create a duty; and (5) referenced the statute in the context of testimonial privilege. Review of these cases revealed that even in states that have Tarasoff statutes, clinicians must continue to rely on their clinical and ethical judgment, rather than statutory guidance, when considering potential protective disclosures or future drafts of protective disclosure statutes.

This article gives a U.K.-based perspective on the involvement of forensic psychiatry organizations in questions of political controversy. Medical professional bodies are fundamentally concerned to uphold good standards of clinical practice and patient welfare, and to uphold professional medical ethics. In our specialty, when acting as individual expert witnesses, we seek to serve the courts with objectivity and respect for the law. However, as members of our professional bodies we have a legitimate medical concern about how the law affects the mentally disordered as a class. We should articulate a collective view about what treating the mentally disordered justly and appropriately in the legal system means and should challenge the law when it fails to achieve this.

Competency to Stand Trial (CST) evaluations are common in the U.S. criminal justice system. Of those defendants found Incompetent to Stand Trial (IST), psychotic disorders are the most common diagnoses, and active psychotic symptoms are strongly correlated with impairments in trial-related abilities. If a defendant is rendered IST because of psychosis, restoration will be unlikely without antipsychotic medication. Last term, in Sell v. U.S., the U.S. Supreme Court dealt with medication refusal in the context of competency restoration. The Court held that involuntary medication, under certain circumstances, is appropriate. This article includes a review of earlier relevant legal decisions and an analysis and discussion of the Sell decision.

In this study, the willingness of psychiatric inpatients to volunteer for research and their capacity to consent to and distinguish between protocols offering different levels of risk and benefit were assessed. Twenty-two inpatients with major depressive disorder, 21 inpatients with schizophrenia, and 21 community control subjects were asked to consider participation in a lower-risk study offering the potential for direct medical benefit and a higher-risk study offering no direct medical benefit. Consent-related capacities were assessed with the MacArthur Competence Assessment Tool-Clinical Research. Depressed inpatients, while having a greater degree of impairment than control subjects, still demonstrated relatively high decision-making capacity and were able to distinguish levels of risk between studies. Their pattern of preferences did not differ from control subjects. However, they were more likely to decline to participate in the research, being six times more likely to decline the lower-risk study and 1.4 times more likely to decline the higher-risk study. Schizophrenic subjects demonstrated greater impairments in decision-making capacity and were even more likely than depressed subjects to decline to participate.

The authors present three ethical arguments to address the controversy of mandatory community treatment: rights-based versus beneficence, utilitarian, and communitarian. Each approach suggests that mandatory community treatment can be an ethical intervention for individuals with severe mental disorders in well-defined circumstances. It is critical to recognize that such interventions cannot be effective in the absence of an adequately funded, quality mental health service system. Within such a system, the authors believe a program of mandatory community treatment may play an important role. In considering mandatory outpatient treatment, the authors argue that consideration of decisionmaking capacity is preferable to dangerousness criteria, that clinical criteria with some flexibility should be developed so that mandatory community treatment is used only when alternatives have failed, that mandatory community treatment should be implemented long enough to be effective, and that consumers must be involved in the development and implementation of mandatory outpatient treatment programs.

Unlike other jurisdictions in the United States where the basis of the law can be traced more exclusively to the common law of England, the legal system in Louisiana also has origins in the laws of France and Spain. In this article, the authors describe the laws and procedures that developed early in Louisiana's history for the involuntary care and civil commitment of the mentally ill, focusing on the laws that were passed after the American takeover in 1803.

Singleton v. Norris is a decision by the Eighth Circuit Court of Appeals stating that forced psychotropic medication can be continued after the date of execution is set if the medication had been given previously to prevent the inmate from being dangerous in the prison setting under a Harper-type review. The defendant had argued that after the date of execution was set, it was no longer in his medical interests to continue the medication. In the decision, the majority held that the fact that an execution is in the offing does not alter the medical interests for which the medication had been prescribed, and physicians should just continue to treat the medical condition. This decision may raise ethics problems for physicians in such settings, because they may be in violation of the American Medical Association (AMA) Code of Ethics if the original override is dubious.

Psychiatrists and other mental health professionals are presented with special challenges when their patients are involved in covert operations or other matters of national security. The patients' involvement may, by legal necessity, limit disclosures during the evaluation. Such situations may be encountered with varying degrees of frequency by military psychiatrists or consultants to various federal or law enforcement agencies involved in classified or undercover activities. The need to assess relevant psychosocial stressors while avoiding prohibited disclosure, the legal requirements to report potentially adverse information, or the procedure to gain legal permission to discuss classified details may present novel challenges for therapists in such evaluations. In this article, we present a case report illustrating these challenges and review applicable regulations and public law governing the disclosure of classified information. We also discuss common pitfalls and strategies for handling such situations.

A catatonic patient without known relatives or advance directives faced possible death without electroconvulsive treatment (ECT). The authors describe using medication to restore capacity to permit the patient to give critical history and consent to potentially life-saving treatment. Even had a proxy been available, the jurisdiction in which he fell ill forbade substituted judgment for ECT, permitting only recipients themselves to consent. While emergent ECT was not specifically forbidden in this jurisdiction, a full curative course presumably could not have been administered without some form of consent. THus, the intervention prevented a treatment delay while the court was petitioned and also avoided having to insert a judge into the doctor-patient relationship. This case focuses on a specific condition, medication, and jurisdiction, but it outlines a general paradigm of pharmacologic intervention to restore temporary capacity. We encourage physicians to identify situations in which medication can create temporary "lucid intervals," thereby restoring patient autonomy and self-determination that would otherwise be lost to proxies or courts of law.

This study examines self-reported coercion in subjects with severe mental illness who were randomly assigned in an experimental study to continue under, or be released from, involuntary outpatient commitment (OPC) subsequent to hospital discharge. After review of bivariate relationships, multivariable analyses demonstrated significantly higher levels of reported coercion among subjects who experienced longer periods of OPC; who were African American; who were single and not cohabiting; and who had ongoing substance abuse problems, poor insight into illness, and severe symptoms. Case managers' verbal reminders to subjects about the consequences of nonadherence to treatment partially account for higher reports of coercion. Previous reports from this study have found that OPC, if sustained and combined with frequent outpatient mental health services, can improve some outcomes. The current analyses demonstrate that a consequence of OPC is increased perceptions of coercion in the treatment process, which is partially explained by the increased attention by case managers to noncompliance with treatment.

A backlash against the self-actualizing psychotherapy movements of the 1960s and 1970s in concert with recent concerns about professional sexual misconduct has led some forensic psychiatrists to redefine many routine components of therapy as boundary behaviors. This concern has been followed by the development of conservative guidelines for how therapists should conduct themselves at the newly-defined boundary crossings so as to avoid "violations." The slippery-slope argument that seemingly innocuous boundary crossings may lead inexorably to professional sexual misconduct has lent an urgency and legitimacy to the guideline enterprise, obscuring the perspective that the newly postulated boundaries do not represent the consensus of practitioners in the field. Otherwise highly controversial claims about what is ethical and proper behavior in psychotherapy gain a mantle of incontrovertibility when linked to predictions that ignoring published boundary guidelines will result in damage to patient and litigation against therapist. In this article, three widely advanced boundary guidelines are examined (therapist neutrality, therapist anonymity, and stable fee policy) for coherence and relevance to the richly diverse practice of psychotherapy.

Malpractice suits against therapists for either instilling or recovering false memories of sexual abuse have increased in the last few years and some of the awards have been large. Failure to give informed consent, that is, failing to inform patients concerning the risk of recovering false memories, is one of the main allegations increasingly made against therapists in recovered memory cases. In the landmark case on informed consent, Canterbury v. Spence fashioned a standard of disclosure that focused on how material the potential warnings were to the patient's decision and specifically stated the standard would be set by the law, not by the profession. The court ruled that the "risk or cluster of risks" must be disclosed to the patient in a manner that meets the patient's "informational needs." A review of relevant literature shows that a substantial body of information existed by the early 1990s that warned psychotherapists about the risk of false reports of sexual and physical abuse. This article concludes that the "risk or cluster of risks" that must be disclosed to a patient recovering repressed memories in psychotherapy should have included warnings about recovering false memories.