Marilyn Price

Competence to stand trial: a neuropsychological inquiry.

How might the deconstruction of the legal theory of competence be related to modern neuropsychological models of cognition? To address this question, we examined retrospectively the relationship between clinical judgments of competence of defendants committed to a maximum security psychiatric facility and their neuropsychological test scores on measures of intelligence, memory, attention, academics, and executive function. In addition, based on both neuropsychological and legal theory, we examined whether subtypes of memory, namely episodic and semantic, and intelligence, specifically social intelligence, would have special relevance to these clinical judgments of competence. Results indicated that in relation to the defendants recommended as incompetent to stand trial (IST), defendants recommended as competent to stand trial (CST) scored significantly higher on summary indexes of psychometric intelligence, attention, and memory, especially verbal memory, but not significantly higher on tests of academics or executive function. Moreover, CST defendants scored significantly higher than did IST defendants on selective tests of episodic memory and social intelligence, but not on measures of semantic memory. Partial correlation also revealed a significant relationship between the likelihood of an IST recommendation and lower scores on tests of episodic memory and social intelligence, but not on measures of semantic memory. These findings illustrate the theoretical import of neuropsychological methods and concepts to the burgeoning nomological net known as competence.

Firearm Laws: A Primer for Psychiatrists

Persons with mental illness or substance abuse have been perceived by the public to pose an increased risk of violence to themselves and others. As a result, federal and state laws have restricted the right of certain categories of persons with mental illness or substance abuse to possess, register, license, retain, or carry a firearm. Clinicians should be familiar with the specific firearm statutes of their own states, which describe the disqualifying mental health/substance abuse history and the role and responsibility of the psychiatrist in the process. State statutes vary widely in terms of the definitions of, and reporting requirements relating to, prohibited persons with mental illness or substance abuse. States also vary in the duration of the prohibition and in the timing of the appeals process. Some of the statutes have specific provisions for the removal of a firearm when a prohibited person is identified. States may maintain a mental health database that is used to determine firearm eligibility and may forward information to the National Instant Criminal Background Check System. The National Instant Criminal Background Check System Improvement Amendments Act of 2007 will likely increase the number of persons identified as belonging to the prohibited class.

Sexual harassment in medical education: liability and protection.

The prevalence and frequency of sexual harassment in medical education is well documented. On the graduation questionnaire administered by the Association of American Medical Colleges in 2003, 15% of medical students reported experiences of mistreatment during medical school. On items that specifically address sexual mistreatment, over 2% of students reported experiencing gender-based exclusion from training opportunities, and unwanted sexual advances and offensive sexist comments from school personnel. Sexual harassment of medical trainees by faculty supervisors is obviously unethical and may also be illegal under education discrimination laws. In two cases in 1998 and 1999, the U.S. Supreme Court clarified that schools may be held liable under Title IX of the Education Amendments of 1972 for the sexual harassment of their students. In 2001, the Office of Civil Rights of the Department of Education released revised policy guidelines on sexual harassment that reflect the Supreme Court rulings. Medical school administrators should undertake formal assessments of the educational environment in their training programs as a first step toward addressing the problem of sexual harassment. The authors recommend that medical schools implement measures to both prevent and remedy sexual harassment in their training programs. These constructive approaches include applying faculty and student education, establishing a system for notification and response, and creating an institutional structure to provide continuous evaluation of the educational environment.

Supervisor-trainee relationship boundaries in medical education

Despite concerns about the prevalence and ramifications of medical student mistreatment, the boundaries of faculty-student relationships have not been studied systematically in medical training programs. This study aimed to identify behaviours that occur with some frequency and potentially raise issues related to boundaries in the supervisor-trainee relationship. An anonymous questionnaire was distributed to the mailboxes of 154 residents in the departments of psychiatry, internal medicine, and obstetrics and gynaecology at four hospitals affiliated with Brown University Medical School. Residents were asked to report whether they had encountered specific behaviours from supervisors during medical training, the frequency of these experiences, and the professional status of the supervisor involved in each episode. There was a significant reported incidence of behaviours related to academic/professional boundaries, personal boundaries, and dating boundaries. Some of these behaviours raise issues related to exploitation. The major sources of these reported boundary behaviours were hospital-based clinical faculty, university-based academic faculty, and senior house staff. The potentially adverse effects of boundary behaviours on the individual student, the teacher-student relationship, and the doctor-patient relationship are discussed. Future research is recommended to clarify the limits of appropriate behaviour between supervisors and trainees in the medical learning environment.

Telephone scatologia: Comorbidity with other paraphilias and paraphilia-related disorders

The term scatologia is derived from the Greek word, skato, for dung and logos for speech (Gayford, 1997). Thus, telephone scatologia, also referred to as telephone scatophilia and telephonicophilia, is a paraphilia (PA) characterized by a pattern of sexual arousal associated with exposing an unsuspecting victim to sexual and obscene material over the phone (Milner & Dopke, 1997; Schewe, 1997). Telephone scatologia remains classified as a PA not otherwise specified (NOS) in the DSM-IV, because there has been insufficient description of the disorder in the literature to merit a separate category (American Psychiatric Association, 1994). Although specific PAs are distinguished by a characteristic paraphilic focus, all PAs feature recurrent, socially deviant, highly arousing sexual fantasies, urges, and activities that have a duration of at least 6 months and cause clinically significant distress or impairment (American Psychiatric Association, 1994). These latter diagnostic criteria would distinguish true telephone scatologists (TS) from telephone callers who just make a few obscene calls as a prank. Obscene telephone calling is a common behavior with more than 22,000 obscene phone call complaints filed in the Washington, DC area alone in 1989. This is particularly impressive considering that only 7–20% of sexually provocative calls are actually reported to the telephone company (Herold, Mantle, & Zemitis, 1979; Smith & Morra, 1994). Surveys

Psychiatric Disability in Law Enforcement Officers

Law enforcement officers all across the world are exposed to violence, confrontation, and traumatic incidents. They regularly witness death and suffering and are at risk of personal injury. Psychiatric sequelae include an increased risk for trauma-related symptoms, depression, alcohol-use disorders, and stress-related medical conditions. Law enforcement officers have been applying for early disability retirement pensions at an increased rate for stress-related psychiatric and medical conditions. As a result, law enforcement agencies are prematurely losing valuable resources, officers with training and experience. Departments have become proactive in trying to address mental health issues to prevent psychiatric disability by implementing employee wellness plans and stress reduction interventions. Programs have been developed to mitigate the effects of stress on law enforcement personnel. Many law enforcement agencies have developed strategies to encourage early confidential referral for psychiatric treatment. They utilize peer support groups and employee assistance programs and develop alliances with mental health professionals. When these approaches fail, a fitness for duty process can be used to identify impairment in work functioning due to psychiatric factors with the prospect of later returning the officer to full duty. Copyright

Fitness-for-Duty of Law Enforcement Officers

Law enforcement personnel are often at greater risk of exposure to critical incidents involving serious trauma and public safety events. Psychiatric sequelae of these events can include increased risk for trauma-related symptoms, substance use, and possibly suicide. Fitness-for-duty issues arise both for clinicians treating law enforcement officers and in disability-related assessments pertaining to an officer’s return to work. These include whether the officer is able to perform essential functions of the job, is able to function in a prior role, or in any role within the police department, whether the job would require access to and handling of firearms, and whether any ongoing symptoms could be accommodated with special arrangements in the workplace. In general, fitness-for-duty evaluations for law enforcement officers require expertise in forensic assessments given the complexity of issues and risks involved especially when the inquiry involves access to firearms. This discussion reviews case examples, the basic legal landscape that an officer may face in a fitness-to-work assessment, as well as clinical factors and recommendations related to fitness-for-duty evaluation assessments.

Fitness-for-Duty Evaluations of Physicians and Health Care Professionals: Treating Providers and Protecting the Public

Health care providers practicing their profession with reasonable skill and safety is essential for the safety and well-being of the public. Physicians and other health care professionals may have their fitness for duty questioned by a variety of agencies tasked with oversight of the behavior of health care professionals. Mental health clinicians performing a fitness-for-duty evaluation of a physician or other health care professional will be required to conduct a comprehensive assessment, taking into account the impact of any disabling conditions, and provide opinions regarding the prognosis with treatment, the side effects of treatment, and the present and future impacts on the practice of medicine. The evaluating clinician will be asked for recommendations about whether treatment or professional workplace supervision may be needed to decrease the risk of future deterioration of professional capacities.