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In this paper, we consider the use of e-mail in psychotherapy and its impact on the experience of therapy for both patient and clinician. We discuss in detail the potential for boundary compromise by e-mail use and consider how e-mail may undermine the therapeutic alliance and the cultivation of empathy. Case studies illustrate the possible positive aspects of e-mail and elucidate several fundamental problems with any use of e-mail in psychodynamic treatment. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

After brief review of the background and context of the Tarasoff case and its impact on clinicians, the author examines the "Tarasoff warning," proposed in the 1974 Tarasoff opinion, from a moral position, with brief discussion of its clinical and risk management dimensions. Moral issues considered include confidentiality itself, agency, fiduciary duty, a shift in the victim paradigm, the emergency context, a novel risk, and a proposed approach. The dilemma presented by the original Tarasoff fact situation is re-examined. The author stresses the need for individualized responses to the risks posed by patients. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented that cites a case regarding psychopharmacologic interventions.

A letter to the editor about bruxism and its relation with sexual abuse is presented.

There has been robust interest in the influence of cognitive and implicit biases that can hamper a forensic mental health evaluator's ability to provide objective opinion evidence. By contrast, literature exploring the biasing effects of the examiner's unacknowledged and unprocessed emotions has been scanty. Borrowing from concepts originating from psychodynamic treatment literature, this article explores how a forensic mental health evaluator's emotional and transferential reactions can affect the assessment process and formulation of findings. We make the case that forensic mental health evaluators are not impervious to their own mental health concerns, including vicarious trauma. We ultimately argue for a cultural shift in forensic practice that acknowledges the unavoidable existence and influence of a forensic evaluator's human emotions, personal reactions, and conflicts, so that strategies can be developed for compassionate but careful management in training programs, supervision, and beyond. We suggest that self-reflection, sometimes with the aid of consultation and psychotherapeutic support, is not only important for clinical trainees but also could serve forensic practitioners throughout their careers, especially during challenging junctures in their personal and professional lives., (© 2023 American Academy of Psychiatry and the Law.)

This article summarizes the current literature on clinical knowledge and practical gaps regarding the confidentiality and privacy for smartphone and connected devices in child and adolescent psychiatry and offers practical solutions and consideration for the next steps for the field. Important issues to consider include disclosure of information sharing, access privilege, privacy and trust, risk and benefit analysis, and the need for standardization. Through understanding the privacy and confidentiality concerns regarding digital devices, child and adolescent psychiatrists can guide patients and parents though informed decision-making and also help shape how the field creates the next generation of these tools., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Mobile health (mHealth) apps are becoming much more widely available. As more patients learn about and download apps, clinicians are sure to face more questions about the role these apps can play in treatment. Clinicians thus need to familiarize themselves with the clinical and legal risks that apps may introduce. Regulatory rules and organizations that oversee the safety and efficacy of mHealth apps are currently fragmentary in nature and clinicians should pay special attention to categories of apps which are currently exempt from significant regulation. Uniform HIPAA protection does not apply to personal health data that are shared with apps in many contexts which creates a number of clinically relevant privacy and security concerns. Clinicians should also consider several relatively novel potential adverse clinical outcomes and liability concerns that may be relevant to specific categories of apps, including apps that target (i) medication adherence, (ii) collection of self-reported data, (iii) collection of passive data, and (iv) generation of treatment recommendations for psychotherapeutic and behavioral interventions. Considering these potential pitfalls (and disclosing them to patients as a part of obtaining informed consent) is necessary as clinicians consider incorporating apps into treatment.

Background: Previous research in the area of medical decision-making capacity has demonstrated relatively poor agreement between experienced evaluators in "gray area" cases. We performed a survey to determine the level of agreement about gray area decision-making capacity case scenarios within and between individuals of different professional backgrounds., Method: Participants received a survey consisting of 3 complicated decision-making capacity vignettes with an accompanying "yes/no" question regarding capacity and a certainty scale for each vignette. Participants were identified from mailing lists of professional organizations and local hospitals. We received responses from psychiatry trainees, consultation-liaison psychiatrists, forensic psychiatrists, and lawyers with experience in health care law. Results were analyzed using SPSS., Results: Across the 3 vignettes, the percentage agreeing that the individual described had capacity to refuse medical treatment ranged between 35% and 40% for trainees, 33% and 67% for consult psychiatrists, 41% and 76% for forensic psychiatrists, and 40% and 83% for health care lawyers. Only question 2 reached significance between-group differences (Pearson χ(2) = 11.473, p < 0.01). Across vignettes, trainees were less likely to consider patients to have capacity for decision-making than were forensic psychiatrists and lawyers., Conclusions: As found in previous research, agreement among experienced evaluators appears generally low in gray area capacity cases. It is noteworthy that individuals of different professional backgrounds at times offer divergent between-group opinions on capacity., (Copyright © 2016 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.)

Forensic psychiatry involves an adaptation to a role that is very different from the psychiatrist's previous clinical experiences. To render an unbiased forensic opinion, psychiatrists have to rise above their countertransference feelings. This takes years of practice and experience. The following is an account of a forensic trainee who faced several countertransference problems as he evaluated a patient charged with attempted murder. The case report is interspersed with a review of the relevant literature.

Treating psychiatrists may precipitously and unwittingly be thrust into the role of expert witness because of certain actions they may take on behalf of their patients and may suffer adverse consequences as a result of lack of training and experience. The authors review this problem and suggest means of avoiding the pitfalls involved. Recommendations include warning patients of the uses that will be made of communications between their treaters and third parties, recording the sources of clinical data for use in communications with the legal system, separating the roles of treating psychiatrist and expert witness, and consulting with attorneys or experienced forensic practitioners.

A series of empirical pilot studies, performed during workshops at meetings of the American Academy of Psychiatry and Law (AAPL), and examining various aspects of the attorney-expert witness relationship are presented and their implications are discussed. The author calls for further investigation of a topic that--although constantly a feature of discussion among both experts and attorneys--lacks extensive empirical investigation.

Unlabelled: Although many clinicians have reported anecdotally that patients occasionally ask that treatment or evaluation notes or records not be kept, the issue has not been addressed in the literature. This article deals with the problems arising from patients' requests that their therapists refrain from record keeping, first from a legal and regulatory perspective, and then from a clinical perspective., Method: The authors' consultative experience provides examples of variations on the theme of patients' requests not to take notes., Results: While records must usually be kept, there exist narrow exceptions to this rule. Risk-management suggestions are offered as well., Conclusions: All such requests should be met first with exploration, but limits may have to be set in granting the request.

The authors explore the forensic, legal, and ethical issues involved in a spectrum of attorney practices involving designating experts without notifying them. Recommendations are offered for dealing with this unethical practice, including exposure of the practice, reportage to bar association ethics committees, and continued open discussion and research.

This pilot study follows up an earlier study of the strategies and rationales by which psychiatric expert witnesses bill for their time on a case. Questionnaires were answered by participants at a workshop at the Annual Meeting of the American Academy of Psychiatry and Law (AAPL). In this follow-up, additional novel billing issues were addressed, some subtler than in the original study. In addition, responses to one question supported the previous finding that experts billed more reasonably when a case was simple. Additional issues included use of fee agreements and returning an unpaid-for case. The implications of these findings are discussed.

Objective: The authors sought a rational approach to implementing informed consent within the practice of psychotherapy., Method: The history of informed consent in psychotherapy was reviewed to define a common synthesis that maximizes the potential benefits and minimizes the potential hazards., Results: The benefits of informed consent in psychotherapy include fostering a positive treatment outcome through enhancing patient autonomy, responsibility, and self-therapeutic activity; lessening the risks of regressive effects and therapist liability; and helping the practice of psychotherapy extend beyond particular parochialisms by providing checks and balances on therapist judgments. The hazards include the unpredictability of interactional outcomes and the possibilities of replacing positive expectancy with negative suggestion, replacing a therapeutic alliance with a legalistic stance, and misimplying that patients are passive recipients., Conclusions: Practical implementation of informed consent in psychotherapy must balance such tensions in service of optimal treatment. As a guiding principle, the authors recommend that psychotherapists convey to a prospective patient information that is material to the particular patient's decision. The level of detail needed in informed consent discussions varies directly with the cost and risks of the proposed treatment, the presence of viable alternatives and their relative grounding in scientific data and professional acceptance, and the presence of significant controversy. Unresolved is the question of how to address problematic or controversial psychotherapeutic trends that temporarily enjoy wide professional support.

After defining the role of expert witness, the article reviews the basics of courtroom testimony under the rubrics of (a) truth (presenting under oath only that testimony that one can "swear to," to a reasonable degree of medical certainty); (b) testing (including both psychological testing and tests to assess admissibility standards); and (c) theater (including elements of drama, solemnity, and ritual as well as persuasiveness to the "audience"). Pathways to effectiveness are discussed, including use of visual materials, adjustment of language level for the jury's comprehension and attention to the narrative dimension of the case. Areas of excluded testimony are identified, such as the "ultimate issue" in the case, comments on credibility of other witnesses and comments on the legal process itself. Pitfalls that lie on the path to effectiveness are described, including narcissistic arrogance, anger, and using testimony in a personal crusade; means of avoiding these pitfalls are noted. The author concludes that effective courtroom testimony fulfills expert witness functions necessary to the legal system.

A pilot questionnaire surveyed forensic psychiatrists and psychologists about information they would feel it appropriate to disclose to their retaining attorneys about an opposing expert witness. A spectrum of hypothetical disclosures was offered, varying in their relevance to the case at hand and in their degree of "public" versus "personal" information. Respondents agreed significantly that "public" information could be disclosed to one's attorney, but responses about disclosing "personal" information varied widely. The findings and their implications are briefly discussed.

The author performed a preliminary empirical study of forensic fee agreements. A survey of forensic psychiatrists produced samples of fee agreements used for expert witness work. The samples were analyzed to determine patterns of usage, critical elements, styles of agreement design, and other observations. Despite uncertainties of payment in this field, a surprising number of experts do not use formal fee agreements. This and other results are discussed.

Psychiatrists share with the public some confusion and uncertainty about two highly visible forensic psychiatric examinations: competence to stand trial and criminal responsibility (insanity). The author reviews the content and context of these examinations, examines legal issues that define and underlie them, and clarifies commonly encountered areas of ambiguity and misunderstanding. The competence examination, which assesses a defendant's ability to participate in the trial process, focuses on the present state of the defendant's mental capacities. Two standards generally used are whether the defendant has a rational and factual understanding of the charges and penalties and has the ability to cooperate with the defense attorney. The examination for insanity is one of the most challenging and comprehensive in forensic psychiatry. The criteria in general address the defendant's awareness of the fact that the act was illegal, wrong, or a crime. Additional criteria address the defendant's ability to control behavior.

We report a patient with dementia due to B-12 deficiency and syphilis who presented to a forensic hospital after killing his ex-wife with a gun. Despite current awareness on the occurrence of aggression and violence in patients with dementia, there has been no report discussing dementia secondary to an infectious or nutritional origin causing homicide or severe violent behavior. We discuss possible mechanisms and several predisposing factors for violent behavior in the elderly. We also discuss use and access of a gun in demented patients and its complications. We recommend availability of neuropsychiatric assessments in the elderly, limitation of gun access to demented patients and inquiry about weapon possession in the elderly.

While most attorneys practice ethically and treat their retained experts fairly, there are a few that do otherwise. The authors describe "early warning signs" of the likelihood that the attorneys attempting to retain the psychiatric expert witness may compromise the expert's honesty and striving for objectivity. Experts themselves may have certain vulnerabilities that interfere with their ability to detect those early warning signs. Recommendations for the expert are offered.

Objective: The patient who voices suicidal intent in terms of the future or in terms of certain life contingencies presents special difficulties for the therapist. The authors outline the challenges posed by this problem for assessment, clinical management, and risk management., Method: The authors examined and analyzed case examples from both clinical and risk-management aspects., Results: Problematic cases can be grouped into categories that offer insight as to management. The authors discuss this area and offer suggestions for appropriate clinical responses to this challenge., Conclusions: The authors recommend that therapists 1) treat the expressed "date with death" as a communication to be explored, 2) explore the problem of helplessness while monitoring their own countertransference responses, 3) assess the patient's competence to inform clinicians about suicidal state, and 4) readily use involuntary commitment.

The suicide-prevention contract is a widely used but overvalued clinical and risk-management technique. The scant information on this topic in the psychiatric and mental health literature is reviewed, along with the literature on collateral subjects including suicide prediction, medicolegal aspects of treating suicidal patients, the therapeutic alliance, and countertransference with suicidal patients. A group of 112 psychiatrists and psychologists was surveyed about their use of suicide-prevention contracts; the majority of them had never received any formal training on the topic. A combination of factors--the unpredictability of suicide, the many different antecedents to completed suicides, the complex psychological reactions of clinicians (including fear of litigation), the incongruity between clinical and legal usages of the contract concept, and the hazards that come of collapsing a complex treatment process into a few words--limit the applicability of suicide-prevention contracts. We reason that the use of these contracts is based upon subjective belief rather than on objective data or formal training. We recommend an alternative approach to suicide risk management rooted in the well-known and well-defined principles of informed consent.

Objective: This paper outlines a number of misapplications of boundary theory in both regulatory settings and clinical situations., Method: The authors review clinical vignettes that illustrate the difference between boundary crossings, which lead to productive work in psychotherapy, and boundary violations, which are harmful to the patient and exploit the patient's vulnerable position. They also discuss developments in the field that have led to an excessively rigid and defensive posture on the part of some clinicians that may lead to less than optimal psychiatric treatment. They survey recent developments in the wording of state statutes that broadly define sexual misconduct in psychotherapy., Results: This review of the current status of boundary theory in both the law and clinical practice suggests that an overreaction has occurred that requires corrections., Conclusions: The critical role of context must be considered whenever a boundary problem has been alleged, and boundaries must be regarded as flexible standards of good practice rather than lists of generically forbidden behavior.

A pilot study was performed, by questionnaire, on the strategies that expert witnesses use in calculating billing for travel on forensic cases. The authors tentatively conclude that as the complexity of the travel situation increases, a tendency toward redundant billing emerges. The results--the first of their kind--are presented with their implications for this and future studies.

Controversy over cases involving so-called recovered memories of sexual abuse has threatened to divide the mental health field, just as lawsuits based on recovered memories have sometimes divided children from parents and others. The authors review issues in this controversy, including the role of misdirected advocacy for recovered memory by some practitioners, the distinction between the actual events and patient's narrative truth as a factor in the therapeutic alliance, and the contrast between therapeutic and legal remedies. They recommend nine clinically based risk management principles to guide clinicians in dealing with cases involving recovered memory. They include the need for documentation and consultation; the value of psychotherapeutic neutrality, maintaining a calm perspective, and understanding the difference between historical and narrative truth; the incompatibility of the roles of treater and forensic expert; the risks of special therapies such as hypnosis; awareness of the roles of other professionals and the significance of the patient's family; and the importance of knowing when to end treatment.

Background: The aim of the present study was to evaluate if Proportional Assist Ventilation (PAV), when applied noninvasively via face mask, can reduce ventilatory effort in patients with respiratory failure. We present preliminary results of an ongoing study., Patients and Methods: In 5 patients with respiratory failure due to different underlying disorders (pulmonary fibrosis, bilateral diaphragm paralysis, COPD) we compared the transdiaphragmal pressure-time integral. PTdi (integral off Pdi dt) after 15 minutes of noninvasive PAV to the baseline values without ventilatory support., Results and Conclusion: Four patients showed reduction of PTdi to various extend. One patient who presented low diaphragmal activity at baseline due to diaphragmal paralysis showed a slight increase in PTdi during ventilation. Mean PTdi decreased by 26.7%. PaCO2 in the 5 patients showed no significant change after 15 minutes of ventilation, thus indicating that with noninvasive PAV patients can maintain constant ventilation with reduced effort.

Objective: This article explores the clinical, legal, and ethical problems that typically occur when a psychotherapist serves as both a treating clinician and forensic evaluator (or expert witness) in the same case., Method: The professional literature, ethics codes, opinion surveys, and the changing economic and institutional contexts of psychotherapy are reviewed in order to identify obstacles to widespread recognition of this straightforward ethical issue. The processes of psychotherapy and forensic evaluation are then analyzed so as to reveal fundamental incompatibilities between the psychotherapist's clinical and legal functions., Results: Attempting to treat and evaluate the same person typically creates an irreconcilable role conflict. This role conflict manifests itself in different conceptions of truth and causation, different forms of alliance, different types of assessment, and different ethical guidelines., Conclusions: Although circumstances sometimes compel a practitioner to assume the dual role of treater and evaluator, the problems that surround this practice argue for its avoidance whenever possible.

The boundary between spiritual and psychotherapeutic issues is not well defined; indeed, the two may be interwoven. A patient's sense of a therapist may closely relate to the patient's assessment of the therapist's spirituality, and a therapist's recognition of the differences between psychopathological and spiritual beliefs may depend on a recognition of his or her own belief system. Changing the profession's approach to this issue is made difficult by 1) a traditional sense within many schools of psychotherapy that spirituality is outside the sphere of appropriate investigation and knowledge; 2) discomfort with personal spiritual issues in educators and trainees; 3) decreased emphasis on aspects of the therapist as important factors in patient outcome; and 4) decreased use of intensive supervision for psychotherapy in some training programs.

A case of adult sibling incest serves as the occasion to review relevant literature and discuss issues related to competence to consent to sexual relations between adults. The case was presented at ethics rounds at the Massachusetts Mental Health Center (Boston, MA), and the resulting discussion is analyzed as to the decision making with which the treatment team is faced. The relationships among competence and competence assessment, autonomy, morality, and countertransference issues are also considered in this provocative case.

To study the role of parens patriae and "police powers" considerations in an individual judge's civil commitment decisions, the judge's reports of the impact of various characteristics of the patient were analyzed. The validity of this methodology was tested by comparing it to an alternative technique based on objective statistical analysis of the dependence of the judge's decisions upon patient characteristics. A probate court judge filled out a questionnaire after each civil commitment hearing over which he presided during a seven-month study. For each of 26 decisions, the judge rated the patient on 26 features and indicated the impact of each feature on the decision. The judge's responses were analyzed to measure the role of various statutory and nonstatutory considerations (expressed as patient characteristics) in the judge's decisions. Results using self-reported impacts are compared with an objective, statistical characterization of the judge's decision-making policy. As in previous studies, the parens patriae model more closely described the individual judge's decision process than the "police powers" model. Contextual variables (e.g., the patient's family favoring commitment) also were influential. Results with the two methods were similar. The methodology developed here can be used not only in further research on judicial commitment decisions but also to educate judges and other decision-makers individually faced with potentially tragic choices as to their personal implicit decision-making strategies.