Forensics
competency
competency = legal, determined by judge
capacity = clinical, determined by MD
can fluctuate over time
to stand trial
to plead guilty, be own attorney
to be sentenced/executed
testamentary: capacity to execute a will
testimonial: to serve as witness in court
to make tx decision
legal req to proceed w/ trial: sufficient ability to consult w/ lawyer w/ reasonable degree of rational understanding (rational/factual understanding of proceedings against them)
if incompetent --> sent to psych hospital to have competency restored (returns to court)
examining mental state
competency is evaluated in the current moment
"insanity defense"/criminal responsibility - at the time of the crime, did they have the ability to tell right from wrong?
civil commitment
voluntary or involuntary
legal basis for involuntary
parens patriae - state takes responsibility for those unable to take care of themselves
police power - state has authority to prevent harm to community/harm to self
we've moved from parens patriae to police power (increasing emphasis on individual autonomy)
institutionalization in mental hospitals has dropped since the 60s; prisons and jails have increased (instead of community based services)
when deciding to admit someone
- determine whether mental illness present
- if mentally ill, are they dangerous to self/others/gravely disabled (not meeting basic needs)/least restrictive alternative
- is this something that can be treated?
procedural interventions to help ensure their rights protected
right to counsel
right to request trial
right to call witnesses and cross-examine
right to refuse tx
allowed to tx for emergencies (including behavioral)
varies by state as to procedures required to proceed w/ tx over objection
full adversarial court proceeding
OR professional judgment and administrative review
arguments for right to refuse
right to privacy
right to generate ideas
cruel and unusual punishment
right to due process
arguments against right to refuse
patient suffering
risks safety of inpatient units
excessively long inpatient stays
"you'll thank me later"
risk assessment for violence
difficult to predict infrequent events (lots of false positives bc of low base rate)
hx of violence is most reliable predictor of future violence
classification for intervention and decision making (static - historical vs dynamic - current)
demographic risk factors: late teens/early 20s (PFC development not complete); M>F (but equal in mentally ill), low SES, low IQ, job/housing instability, hx of SUD
mental illness and violence
psychosis/schizophrenia
similar violence compared to MDD/bipolar
specific s/s with increased risk
paranoid, persecutory delusions
command auditory hallucinations
disorganized thinking and behavior
depression: increased anger/irritability
bipolar: impulsive aggression; irritable/angry; paranoia; grandiose delusions (omnipotent)
substance use: alcohol abuse increases risk of violence 12 times!
personality disorders: antisocial, borderline, paranoid
organic: intellectual disability, seizure disorders, CNS tumor, ADHD
danger to self: SAD PERSONS for suicide risk
confidentiality
privilege: patient's right - evidentiary concept
confidentiality: clinician's obligation - ethical obligation
respecting privacy/autonomy
exceptions
infectious disease
Tarasoff case
child/elder abuse
impaired auto driver
suicidal/homicidal patient
breaches when there is a need to protect patient or 3rd party - basic duty to protect potential victim
Tarasoff I - duty to warn
Tarasoff II - duty to protect
liability: failure to ID dangerous patient who has threatened to harm a 3rd party results in ACTUAL harm to intended victim
APA recommendations: if patient makes explicit threat to victim with intent and ability to carry out threat OR has known hx of violence and therapist has reasonable basis to believe there's a clear and present danger - THEN need to take reasonable steps to warn victim, notify law enforcement, arrange voluntary hospitalization or take steps to commit involuntarily
informed consent
legally requires
discussing pertinent info: facts about intervention, benefits, risks, alternatives (including NO intervention)
patient agrees w/ plan
freedom from coercion
practical
patient makes and communicates choice
patient is informed
decision is stable over time
decision consistent w/ patient's values and goals
decision not a result of delusion or hallucination
exceptions
lacking decision making capacity (not legally competent)
implied consent in emergency
therapeutic privilege (withholding info when disclosure would cause harm/undermine informed decision making)
waiver by patient
malpractice
4 D's
Duty; physician has duty to patient
Dereliction: physician has breached that duty
Damage: patient suffers harm
Direct: breach of duty is what caused harm