Journal of the American Academy of Psychiatry and the Law最新文献

The notion of human dignity remains a relatively complex concept that has roots in classical Greek and Roman antiquity and links to religious teachings and Kantian philosophical notions. From the Latin dignitas, human dignity means worth and implies excellence and distinction. Human dignity, also found in 20^th century constitutions and international declarations, has been considered in bioethics, general medicine, and psychiatry. The application of dignity to forensic psychiatry practice has received less attention. Through a review of texts in medicine and related fields, such as philosophy and anthropology, we aim to clarify the concept of human dignity and its application in forensic psychiatry practice. We first outline the historical origins of the term. We then consider several varieties of human dignity applied in medical ethics and psychiatry. We review individuals' lived experiences of indignity and dignity's place in forensic practice in different loci. We present recent scholarship related to human dignity and highlight the importance of dignity in forensic practice. Focusing on dignity in evaluator-evaluee and doctor-patient relationships should improve forensic work. Training in dignity-imbued forensic practice should remind us of the human dimensions of those we serve in the forensic arena.

Male sexual trauma presents multiple clinical challenges. Although the topic has received increased attention in the last couple decades, male sexual trauma continues to be underreported and underrecognized. This study aimed to investigate the long-term effects of sexual trauma for men who were victimized within an institutional environment by a person in a position of power. This study included data from 47 adult men who were victims of sexual abuse or misconduct by an assigned physician at a higher education academic institution between 1966 and 2003. A primary finding was elevated rates of intimacy and sexual problems and erectile dysfunction, which started shortly after the abuse and persisted over time. We found that there was an association between intimacy and sexual problems and difficulty maintaining employment, drug addiction, erectile dysfunction, and loss of meaningful and romantic relationships. Levels of potential psychopathology were prominently linked to loss of sexual interest or pleasure, intimacy concerns, and loss of intimate and other personal relationships. Men who experienced sexual abuse as adults within an institutional environment developed long-standing patterns of interpersonal and professional problems. This study emphasizes the need for nuanced screening, evaluation, and treatment for male sexual trauma.

The practice of forensic psychiatry requires balance; the forensic psychiatrist encounters the need for balance routinely and in a variety of areas. Balance is necessary for sound judgment and objectivity when striving for excellence in the field. It is also necessary to effectively balance a career in forensic psychiatry with one's personal life. The American Academy of Psychiatry and the Law (AAPL) has stressed the virtue of balance in the preamble of its ethics guidelines, noting the importance of balancing competing obligations to the individual and society. Keeping in mind the importance of balance will assist forensic psychiatry with the many challenges of a postinternet era, such as rapidly changing technology, culture, and society. A substantial challenge for forensic psychiatry, now and in the future, involves data overflow and the so-called big data explosion. Information now flows too fast and in such vast amounts that a single individual can no longer keep pace. Balance may be pursued by adapting and leveraging certain skills to confront these challenges more effectively. The current inflection point of rapid technological, social, and cultural change, stresses the importance of balance through teamwork, technology, and prioritizing civil discourse.

During the COVID-19 pandemic, problem-solving courts adopted virtual hearings. We conducted an online nationwide survey with a convenience sample of court staff to elicit their perceptions of court participants' attendance, engagement, willingness to talk, and ability to form connection with judges during in-person versus virtual hearings. Sign tests compared ordinal ratings for perceptions of court participant outcomes during in-person versus virtual hearing modalities, and for audiovisual technology versus audio-only technology. The final analysis included 146 staff. Staff felt that during in-person hearings judges could form closer relationships with participants, quality of information exchanged was higher, and participants were more willing to talk. Staff rated attendance as high regardless of the modality. Staff felt participant engagement was higher with audiovisual technology than audio-only technology. Our results suggest that staff have concerns about effects of virtual hearings on court participant engagement and ability to form relationships with judges. Courts should address these potential negative effects of virtual hearings. We are concerned that staff perceived participants more negatively when participants used audio-only versus audiovisual technology, because technology access could be associated with participant demographic characteristics. Further research is needed to examine court participant perceptions and outcomes.

The challenge of achieving an acceptable balance between respecting the autonomy of criminal defendants by allowing them to self-represent, and protecting the integrity of the judicial process by limiting this right when mental illness impedes such efforts, has been longstanding. Although courts have long tended to allow self-representation, a recognized ability of states to limit such rights was articulated by the U.S. Supreme Court in Indiana v. Edwards (2008). Because Edwards outlined no specific test for representational competence, numerous scholars have proposed criteria over the last 15 years, with variable frameworks and points of emphasis. We synthesized the published literature since Edwards on the evaluation of pro se competence. A search of electronic databases was conducted using relevant search terms, yielding 31 identified articles after review of titles, abstracts, full-text articles, and reference lists. Overall, in evaluating pro se competence, experts advise assessing whether a defendant can demonstrate the cognitive, communicative, and emotional abilities to conduct an adequate defense, engage in constructive social intercourse, provide a rational reason for pursuing self-representation, and willingly work with standby counsel. Using these factors, we propose a representational competence standard that balances defendant autonomy with court paternalism. Implications for future research are discussed.

Defendants who are facing criminal charges in the United States have a constitutional right to be present at trial. This right can be voluntarily waived; for such a waiver to be valid, the defendant must be competent to waive the right to be present at trial. There have been several cases where a defendant is absent from trial because of a suicide attempt, and in these cases the courts must determine whether it is necessary to pause the criminal trial to allow for a competence hearing to take place. The U.S. Supreme Court offered guidance on this matter in its ruling in Drope v. Missouri; however, the Court did not clearly define the threshold for requiring a competence hearing when defendants attempt suicide during trial. Subsequent judicial rulings have provided insights into how courts might proceed when a criminal defendant is absent from trial following a suicide attempt. This topic has relevance to forensic psychiatry, as forensic psychiatrists may be called upon to participate in evaluations of adjudicative competence in these scenarios.

As racial influences on forensic outcomes are identified in every aspect of practice, scholars are exploring methods to disentangle race from its historical, economic, and attitudinal antecedents. Because jurisdictions vary in these influences, definitions and data may differ among them, creating inconsistencies in analysis and policy. This retrospective database review compared differences in racial outcomes among 200 pretrial defendants, 160 Black and 40 White, exploring a wide range of socioeconomic, clinical, and forensic influences before, during, and after hospitalization. Because of the tight relationship of socioeconomic factors and race, investigators hypothesized that it would be difficult to distinguish racial influences alone. Using a confirmatory approach to data collection and a statistical analysis based in logistic regression, only differences in referral for psychological testing were identified. Application of this method based on local demographics and culture may prove useful for institutions interested in evaluating racial influences on forensic outcomes.