Thomas G. Gutheil

Talisman or taboo: the controversy of the suicide-prevention contract.

&NA; 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.

Drug therapy: Alliance and compliance

Abstract The non-chemical aspects of prescribing psychotropic drugs are discussed as they embody and illuminate various aspects of the physician-patient relationship. Inclusion of prescribing phenomena within the framework of the therapeutic exploration, and maintenance of an alliance that permits “participant prescribing,” enhance the value of prescribing in the overall therapy program.

Avoiding Bias in Expert Testimony

SUMMARY This review has been intendedto assist the general psychiatristentering the forensic arena eitheras a case-based necessity or as anascent career. The systematicawareness of potential biasing fac-tors and their mechanisms of oper-ation may better equip that practi-tioner to accomplish the role func-tions of the expert witness in aprofessional and objective manner. REFERENCES 1. American Academy of Psychiatry andLaw. Ethical guidelines for the practice offorensic psychiatry. 1995. Availableonline at: http://www.emory.edu/AAPL/ethics.htm. Accessed February 20,2004.2. Gutheil TG. The Psychiatrist as ExpertWitness . Washington, DC: American Psy-chiatric Press; 1998.3. Gutheil TG, Simon RI. Mastering Foren-sic Psychiatric Practice:Advanced Strate-gies for the Expert Witness . Washington,DC: American Psychiatric Press; 2002.4. Lynette E, Rogers R. Emotions overridingforensic opinions? The potentially biasingeffect of victim statements. J PsychiatryLaw . 2000;28(4):449-457.5. Gutheil TG, Commons ML, Miller PM.Personal questions on cross examination:a pilot study of expert witness attitudes.

Non-sexual boundary crossings and boundary violations: the ethical dimension

The ethical principles relative to nonsexual boundary issues derive from the first principle of respect for the dignity of the patient. Using a case vignette, the authors have explored the mutual derivation and inter-relations of these principles, with clinical approaches to patient care. Clinicians should be aware of the ethical underpinnings of sound therapeutic techniques that manifest respect for the patient.

Promise and perils of digital psychiatry

Internet interventions and digital tools like cellular phones have tremendous potential to affect patient care positively; effects are rapidly expanding around the world, including in Asia (Aggarwal, 2012). However, in utilizing digital tools, such as text messaging or telepsychiatry, psychiatrists must be cognizant of the risks that their technology use may infringe on duties to maintain clinical, ethical, and legal standards of care. Because technologies, such as social media, are advancing at rates that may outpace professional or legal/ethical standards, it is difficult for clinicians to remain current with best practices; this difficulty affects many digital psychiatric tools, including text messaging, email, video chatting, social networking, websites, and blogs. This article aims to provide clinicians with information regarding potential pitfalls in technology usage, as well as to offer suggestions to ameliorate risk. Of course, nothing in this article should be construed as legal advice.

Boundary issues and personality disorders.

The author first presents an overview of the basic elements of boundary theory and clarifies the distinction between boundary crossings and boundary violations. The concepts of context dependence, power asymmetry, and fiduciary duty as they relate to boundary problems are also discussed. The intrinsic and extrinsic consequences of boundary problems are reviewed. The extrinsic consequences fall into three major categories: civil lawsuits, complaints to the board of registration, and complaints to professional societies. The author then reviews types of boundary issues that arise in relation to histrionic, dependent, antisocial, and borderline personality disorders. Countertransference issues that arise in working with patients with personality disorders are discussed, as well as cultural differences that may affect the perception of boundary problems. The article ends with a list of risk management principles and recommendations for avoiding boundary problems in the therapeutic relationship.

Clinical aspects of treatment refusal

Abstract A patients refusal of psychotropic medications is often dealt with as a legal problem requiring a legal solution. Such an approach, however, may severely compromise future therapeutic efforts with that patient. Rather than immediately attempting to override a patients refusal, the clinician should examine the factors underlying the refusal, with the aim of resolving the issue within the framework of the therapeutic alliance. Relevant factors may include reality-based concerns, idiosyncratic meanings of treatment, primary and secondary gains, transference effects, and familial and cultural factors. The effect of the refusal on other patients and staff who share the same milieu should also be considered.

Preventing “Critogenic” Harms: Minimizing Emotional Injury from Civil Litigation

Litigation is always stressful for the parties involved, and certain emotional injuries from litigation itself, termed “critogenic” (law-caused) harms, can be identified to aid attorneys in recognizing them. These harms include delay, adversarialization, retraumatization, violation of boundaries, loss of privacy, and arrested healing. After discussing critogenic benefits of litigation for balance, the authors offer approaches for minimizing the impacts of the above harms on clients.

Mobile Mental Health: Navigating New Rules and Regulations for Digital Tools

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.

The Decision-Analytic Approach to Medical Malpractice Law: Formal Proposals and Informal Syntheses

The close relationship between difficult medical decisions with potentially tragic outcomes and feared malpractice litigation has been an impetus to seeking analytic tools to aid decision makers. Although psychiatric decision making has been subject to well-publicized legal scrutiny, such scrutiny extends to all areas of medicine. During the past decade a decision-analytic reckoning of costs and benefits has been proposed as an improvement over traditional legal standards (particularly those of professional custom) for determining negligence in medical malpractice actions. For the most part, however, the courts have not adopted the mathematical approach to negligence determination used in Helling v. Carey in 1974. Nonetheless, the courts today do weigh costs and benefits, though in a less precisely numerical way, in deciding whether a physician has acted as a &dquo;reasonable and prudent&dquo; practitioner. Careful assessment of risks is specifically mandated by the informed-consent requirement, by which the physician is held responsible for disclosing the risks of alternative