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

  1. determine whether mental illness present
  1. if mentally ill, are they dangerous to self/others/gravely disabled (not meeting basic needs)/least restrictive alternative
  1. 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