Forensic Psychiatry: Introduction

00:00 Now, I’m going to introduce you to the topic of Forensic Psychiatry, and we’ll see how the legal system can overlap with mental health. There are a lot of things we’re going to consider here including confidentiality, civil commitment, informed consent, criminal matters. We’re going to look at competency versus capacity and medical malpractice. So, let’s get started now on the civil side of things by talking about confidentiality. Information between a doctor and a patient should be confidential. It is the physician’s duty to hold matters revealed by the patient in the course of treatment in strict confidence from unauthorized third parties. In the United States, we have something called HIPAA, which is the Health Insurance Portability and Accountability Act.

00:51 This is a federal statute that imposes a number of requirements on the disclosure of information and the protection of patient privacy in clinical care and research. So, I want to introduce you to Jane, and we’re going to follow the story of Jane in this case study throughout this lecture.

01:09 "Jane is a 33-year-old woman. She comes to the emergency room by ambulance and is in an acute state of distress. She is sobbing uncontrollably. She has cuts on her arms that are actively bleeding.

01:22 She talks about wanting to end it all. She is unable to provide any further history to you and is very agitated. She is so agitated that an empty bottle of pills falls out of her purse and you notice it’s a bottle of alprazolam. You know that that’s a controlled substance, a benzodiazepine, that’s highly addictive, could be deadly in both overdose and withdrawal." So, how would you proceed now with your assessment of this woman who is agitated and not giving you a lot of information and has arrived in the emergency room? So, there are a lot of things that you’re going to consider. So, there are emergent issues here and you’re going to address them immediately.

02:06 Once she is medically cleared, you’re going to be thinking about wanting to get a psychiatric consult involved down the road. There are going to be then some next steps in her management and safety plan, and eventually when she’s well you’re going to be thinking about her disposition and transfer outside of the hospital. But, first things first. She is in the emergency room and you’re assessing her for safety and also for possibly acute intoxication or withdrawal from benzodiazepines, and she is refusing to talk to you because she is too agitated. So, what do you do next? Well, you’re going to, of course, emergently treat her by checking her vital signs and so forth. You’re also going to consider calling collateral information. You’ll review the EMS record that brought her to the hospital. So, as a provider, when you learn that this patient has a history of suicide attempts because you’ve reviewed previous medical records from your hospital, you see that she’s had suicide attempts, she has abused benzodiazepines, and also has an alcohol use disorder. You also learn from EMS that there’s a small child that was in the home. You’ve checked her vital signs and also gotten a blood alcohol level and you’ve made sure to secure her ABC’s and make sure she’s medically okay. Once she’s medically stabilized, you’ll assess her further for safety. So, you’ll probably put her on a benzodiazepine taper because she’s going to be at risk for withdrawal, which could be deadly. You’ll treat her with thiamine and folate and you’ll probably going to admit her once she’s emergently stabilized but ready for transfer.

03:50 She’ll probably go to the intensive care unit for a little while and you’re going to get a social worker involved to consult regarding what’s happening with this child at home. Once you’re ready, you’ll consider psychiatry consult to the medical unit once the patient has been stabilized in the ICU. The purpose of the psychiatric consult is to do a more thorough risk assessment to find out, you know, what the best setting of care for Jane will be. So, when is it okay to breach confidentiality? Well, when you don’t have a lot of information about a patient and you are in an emergent setting, that’s one place where confidentiality can in fact be breached. A patient can waive the right to confidentiality and tell you to call whomever you like. When a patient is found to be incompetent, then you can breach confidentiality. When records are requested for legal purposes, that’s sometimes okay to breach confidentiality, and whenever there’s a risk of harm to a third party, then you must intervene as a physician. So, you learn from collateral sources who you contacted because Jane was emergently at risk where you learn from them that Jane has a psychiatrist and that she is actually a single mother with a small child at home. She has been seeking psychiatric care for a while. The EMS team tells you that the home was in severe disarray with dirty dishes everywhere and empty pill bottles lying around and there is a 4-year-old at home crying who appeared malnourished with bruises on her arms, legs, and abdomen. So, what’s your obligation now regarding this child? So, remember, you have a duty to protect third parties from harm. So, you want to also make sure that, because this is a a minor, that you have your social services team or you yourself make sure that child is actually protected. This was probably done by EMS, but you want to confirm that in fact Child Protective Services are involved in this case. So, what is the physician’s duty if here she suspects child abuse? Well, although it varies by jurisdiction, the duty is to report all cases of suspected child abuse to the appropriate government entity. A breach of confidentiality is ethically permissible when there is a need to protect the patient or third parties. That’s important to remember.

06:17 The bottom line really is that there is a basic duty to protect a potential victim if a therapist knows of a patient's potential for substantial harm to an identified or readily identified individual.

06:32 When it comes to protecting third parties, we go back to the key case of Tarasoff versus California.

06:39 Although this case can vary state to state, it really sets the president for the need to either warn or protect third parties from harm. Let’s talk now about commitment. So, commitment is the process of hospitalizing a person against his or her will. This is referred to as involuntary civil commitment. In the Supreme Court case of O'Connor versus Donaldson ruled that a harmless patient cannot be confined against their will without treatment if they could survive in a less restrictive setting. So, that’s something very important to understand. When a patient is hospitalized against their will, they have a right to what is called a writ of habeas corpus. Now, what is that? Well, it’s a petition that a person can file with the court if they feel that they have been illegally deprived of their liberties. Let’s go back to the case of Jane who appears to have made a suicide attempt. So, in the case of Ms. Jane, when she eventually sobers up and she’s doing a bit better, you learn that she is actually feeling very suicidal. She complains of wanting to die and she tells you that she’s hopeless about her future. You recommend to her that she go to the inpatient psychiatry unit for further treatment but Jane knows that Child Protective Services have been called and she’s very upset, and she says, “I won’t follow your recommendations. I’d rather go home and die.” So, how are you going to get Jane the psychiatric treatment that you now know she needs because she is threatening to harm herself? So, here’s where you consider hospitalization and it’s important to know about the different types of admission to an inpatient psychiatry unit, and of course this can vary by states and countries.

08:33 But in general, a voluntary admission is when a patient requests help and they agree to go to the inpatient unit. They agree to the spirit of treatment, working with their doctors and nurses to making a plan and then leaving once they feel safe. An involuntary admission refers to, in the United States, what’s called a commitment process, and an involuntary admission is something that happens when a patient is at risk of harming themselves, others, or cannot meet their basic needs of life. So, what is civil commitment? Well, it’s really the deprivation of fundamental rights guaranteed under the US constitution. So, before a state or entity can deprive an individual of their fundamental rights, a proper procedural protection must be granted, which is called due process. All individuals can only be involuntarily committed only if they are a danger to themselves or others. So, in the case of Jane, she was definitely a harm to herself. It’s possible her child was at harm and also there is a question if she was able to meet her basic needs of life, meaning was she so depressed and suicidal that she had become gravely disabled? There was evidence of that in her home by it being in complete disarray with empty bottles lying around.

10:02 So, again, the commitment criteria or criteria to involuntarily admit someone to an inpatient psychiatry unit requires harm to self, harm to others, or an inability to meet demands of ordinary life such that they're gravely disabled. So, Jane ends up getting admitted to the inpatient psychiatry unit against her will because of a risk of serious harm. Once there, Jane quickly sees the benefit and she agrees to treatment and agrees to become a voluntary patient. She says, “I want to work with my treatment team.” She forgoes her right to file a writ of habeas corpus.

10:43 She forgoes her right to have a court hearing for the purpose of civil commitment but rather she says, “Now, I’d like to be voluntary. I want to stay here and I want to work with my team." So, you end up recommending to Jane that she avail herself of therapy and you also recommend she take some medication to help with her symptoms.