I used to work at a community mental health center. A client could be there totally on his or her own (which was the exception) or could have been referred by any of the following, and sometimes by more than one: state probation and parole (which sometimes included out-of-state referrals), community corrections local probation, federal probation and parole, DUI and drug possession probation, child protective services, adult protective services, juvenile probation, direct referral from various court systems, special justice ordered outpatient care in lieu of inpatient hospitalization, etc.
The referral could include an evaluation order or an order for care that might include urine drug screens, alcohol breathalyzers, and attendance at 12-step meetings (despite court rulings finding that unconstitutional). We did work in the jail, and at one point, there was disagreement on who owned the records and who should have access. We also did pre-admission screenings for involuntary hospitalizations, and for a long time you were expected to screen your own clients, which included requesting emergency custody orders and detention orders that resulted in handcuffs and shackles for clients as part of law enforcement transport protocol.
If the person had medical issues, outside medical staff would be involved in care. Children, parents, or whoever had custody would be involved, and often the relationship between parents could be contentious. The norm was there were a lot of stakeholders with a lot of expectations for desired outcomes that could be at odds with each other. There was always the question of how voluntary informed consent was when the other option was incarceration. Clinicians were in the middle as the case manager, therapist, and designated responsible person for care. You were also the advocate, but in a hierarchy, those with power determine the direction of advocacy.
How I wish this book had been around then.
Author Ezra E. H. Griffith is a professor emeritus of psychiatry and of African-American studies at Yale. He has brought together 31 psychiatrists, psychologists, and professors with expertise and a wealth of experience in a variety of ethical situations clinicians face in forensic cases. The authors look at 20 different problem areas ranging from role conflicts (care versus forensic evaluation), to corrections, work with minors, sex offenders, mandated video recording of forensic evaluations, involuntary outpatient commitment, issues with neuroscience, feminist ethics, violence risk assessment, asylum seekers, testing, the Internet and media appearances, boundaries, collaboration and more.
Griffith has done an excellent editing job in that all the chapters follow a consistent format making for a consistent experience throughout the book. There is background on the issue addressed in the chapter, often with vignettes, discussion of the cases, and conclusions to help bring each together. Some are academic in examining ethical decision-making models, and most have scenarios clinicians will empathize with immediately. You get lessons in the relevant history of issues, as well as research tied to the issue.
You may have noticed that in court cases, the mental health experts often line up with whichever side is paying them. There are some “hired guns” out there with agendas, but at times, even when the evaluator has no conscious agenda, adversarial allegiance may come into play. That seems to me to be an almost inevitable function of our adversarial system in which the object is not to find the truth, but to win. Attorneys may even withhold information from evaluators in the process.
The story of James Grigson came up in the chapter on objectivity and boundaries of competence. I first came across Grigson back in 1991, in a book called “Travels With Dr. Death,” by Ron Rosenbaum. Grigson earned the nickname “Dr. Death” by testifying in over 160 death penalty trials in Texas from the 1970s into the 1990s. His expert opinion in over 100 cases was that the defendant “would pose a continuing threat to society if not given a sentence of death.” He was expelled by the American Psychiatric Association in 1995 but continued doing competency evaluations for prosecutors for another eight years. The chapter provides guidance on how to mitigate adversarial allegiance.
I found all of the chapters fascinating and enlightening in their own right. I also thought about the evolution of ethics in mental health overall and in forensic work in particular. When I read about the issues with mandatory video recording of forensic evaluations, the issues raised are certainly valid, but I also thought of Carrie Buck in the Buck v. Bell case in Virginia. This case, decided by the US Supreme Court, made mandatory sterilizations fully legal in America. The evaluation of Buck was terrible in many ways, and when her attorney rested his case, he told the prosecutor that the case should go the state’s way. We have come a long way from the days of strict patriarchy to more feminist principles of justice, but we have a way to go.
The role of psychology in developing “enhanced interrogations” at Guantanamo is examined, as well as dilemmas in evaluating Guantanamo detainees. Mefloquine was given to all detainees as a malaria prevention protocol even though it was not given to Haitians quartered there years before. The issue is that there are newer drugs with less side effects.
Mefloquine can cause anxiety, confusion and hallucinations, and the effects continue after use ends. And that is on top of the effects of enhanced interrogation techniques such as waterboarding. There is already ample evidence that torture does not get good intelligence. Add drug induced psychological problems into the mix and that degrades the outcome even further. The military also gave the drug to soldiers serving in Afghanistan. One contributor points out, “U. S. military authors have subsequently concluded that the lasting psychiatric effects of the drug, even at the lower doses used to prevent malaria, can confound the diagnosis of PTSD among U. S. military personnel.”
Throughout the book, the authors examine responsibilities and research, including ecological validity (whether findings based on someone’s behavior and brain scan activity applies to real world situations), problems with opposing cultural beliefs in the research on the effectiveness of involuntary outpatient commitment, and much more. Issues about roles and how to deal with being pushed into more than one role, and conflicting roles and the difference between forensic and clinical ethics are discussed. Again, and again the authors return to the process in ethical decision making including guidance from professional organizations.
I highly recommend this book for any one working with forensic cases. I also highly recommend it for clinicians in general for the probability is that at some point you will be drawn into a case involving the court system. This book will help guide you, make you think, and even change your own behavior.
Ethics Challenges in Forensic Psychiatry and Psychology
Columbia University Press, March 2018
Hardcover, 364 pages