Showing papers in "Journal of the American Academy of Psychiatry and the Law in 1985"

Development of a rational taxonomy for the classification of rapists: the Massachusetts Treatment Center system.

Abstract: Many attempts to classify sexual offenders have focused either on the direct application of broad psychiatric diagnostic categories or on specific offense characteristics, such as the nature of the act (e.g., rape versus exhibitionism) or the age of the victim (adult versus child).1-6 Investigators have either looked at the incidence of neurosis, personality disorder, and psychosis among sexual offenders I. 7.8 or have compared psychiatric or legal subgroups of sexual offenders on various dimensions.15 Another approach has yielded more promising results. It attempts to generate and test rational taxonomic models based upon clinical experience with sexual offenders. 16-27 While most of these efforts have not produced elaborated rape taxonomies, they nevertheless provided the groundwork for future developments. Guttmacher' and Guttmacher and Weihofen,28 for example, described three types of rapists. The first type are those cases in which the offense is an explosive expression of a pent-up sexual impulse. The second type are those cases in which the offense is sadistic and the third type are those cases in which the offense is committed by an aggressive antisocial criminal. In the first group, designated "true sex offenders," the aim is primarily sexual, whereas in the second group, aggression is at least as important, if not more important, than sex. The last group, labeled "aggressive offenders," is composed of men for whom rape is an undifferentiated part of a generic criminal record. KOpp22 dichotomized rapists on the basis of whether the offense behavior could be seen as ego-syntonic or ego-dystonic. In one type of rapist, the behavior resulted from a break in the individual's character defense. Such an individual is more likely than not to experience guilt and remorse as well as concern for the victim after the assault. The other type of rapist is the antisocial, psychopathic individual, characterized as unempathic, cold, and without the experience of guilt. In their prodigious study of 1,356 sex offenders, Gebhard et al. 19 distin-

Explanations of Pedophilia: Review of Empirical Research

Abstract: This article reviews empirical research to discover what support exists for theories that attempt to explain why adults become sexually interested in and involved with immature children. These theories are first organized into four basic categories: (1) emotional congruence-why the adult has an emotional need to relate to a child; (2) sexual arousal-why the adult could become sexually aroused by a child; (3) blockage-why alternative sources of sexual and emotional gratification are not available; or (4) disinhibitionwhy the adult is not deterred from such an interest by normal prohibitions. The review shows (1) that the best experimental research has been directed toward establishing that pedophiles do show an unusual pattern of sexual arousal toward children, although no good evidence yet exists about why this is so; (2) a number of studies have concurred that pedophiles are blocked in their social and heterosexual relationships; (3) the use of alcohol is well established as a disinhibiting factor that plays a role in a great many pedophile offenses; (4) at least one study gives support to the "emotional congruence" idea that children, because of their lack of dominance, have some special meaning for pedophiles; and (5) there is evidence that many pedophiles were themselves victims of pedophile behavior when they were children. The article also demonstrates that pedophilia research is, in general, characterized by some serious theoretical and methodological flaws. As a result, caution should be exercised in generalizing findings until more careful research is undertaken. This article reviews the empirical evidence concerning theories of pedophilia. Many theories have been proposed,l-4 but there exist few comprehensive reviews of the problem that have looked at these theories in the light of empirical research, a gap that this article will try to remedy.

The detection of malingered amnesia in accused murderers

Abstract: Malingering, as defined by DSM-III, involves "voluntary production and presentation of false or grossly exaggerated physical or psychological symp­ toms. The symptoms are produced in pursuit of a goal that is obviously recognizable with an understanding of the individual's circumstances rather than of his or her psychopathology." Whenever an individual is evaluated in forensic settings, psychiatrists have to look at malingering as a possible diagnosis because a patient may present psychotic symptomatology or amnesia to avoid being considered fit to stand trial or to escape responsibility for his/her actions. The object of this article is to discuss characteristics of true amnesia versus malingered amnesia in men charged with first-degree or capital murder. A defendant who malingers and convinces a psychiatrist that he has amnesia has won a Pyrhhic victory, because courts will not find a person incompetent to stand trial or not responsible for the crime because of amnesia alone. A primary reason for this policy is the concern that many defendants would escape punishment or being brought to trial by malinger­ ing amnesia, which is easy to do and hard to detect. I If a method to detect malingered amnesia was developed, the legal policy concerning it could be changed to benefit those with true amnesia. In most studies of amnesia, memory loss is considered to be genuine only if it has an organic base. Possible psychogenic bases are rarely considered as sufficient evidence to accept the alleged amnesia as genuine. In several studies the alleged amnesia was judged to be malingered solely upon the absence of evidence for organic etiology or the presence of a history of lying. 2 - 5 Review of the literatuce reveals that the relationship of amnesia to crime has been discussed for many years. The incidence of amnesia in accused murderers has been reported to be anywhere from 10 to 70 percent. 6 - 8 In

Assaults in hospitals

Abstract: Psychiatric News reported several deaths of psychiatrists at the hands of their patients in 1982. This year a psychiatry resident was murdered by a patient in her office. Two years ago an intern was the fatal victim of a former psychiatric patient as he worked in a Kansas City emergency room. These striking reports do little to describe accurately the incidence and severity of assaults in hospitals. There is a need for valid, reliable data concerning potential dangers to psychiatrists, other medical staff, and patients in medical care settings. It is important to know the baselines from which to measure deviations in assault incidence, to discuss what is being done to whom, and to prevent and manage such situations. Unfortunately, most common sense approaches to this problem have limited usefulness. Bromides such as "paranoids are more dangerous" or "female staff hardly ever get assaulted" may have some merit in certain situations; however, our group is now fairly certain that one should put only very limited credence in any of them. One reason for the limited value of these sayings has to do with the great range of health care settings in which violence may occur. In addition, different ways of defining and reporting assaultive incidents significantly alter the form and content of one's results. Recent studies have reported rates of significant assault as low as 25 cases per 27,000 patients per ten years. I Most studies have found a higher incidence. 2 -4 In a large survey of clinicians, one of us (W.H.R.) found data to agree with other investigators that up to one-half of all psychiatrists experience at least one serious assault during their careers. S Tardiff and Sweillam 4 report that about 7.5 percent of patients in the New York State hospital system have committed at least one assault in the hospital. Finally, unpublished data from the Veterans Administration indicates some 12,000 assaultive incidents were reported within the system over a recent five-year period.

Reasonable medical certainty.

Abstract: Reasonable medical certainty. What is that? I am afraid to report that after having attempted to study the subject for many, many hours, I have discovered that the status of reasonable medical certainty is quite uncertain. In fact, I can make the statement that I am certain that reasonable medical certainty is an uncertain legal concept. From the cases I have reviewed, it appears that the law may even attempt to avoid the use of these words. What is reasonable medical certainty? Is it-more likely than not? Is it-that level of certainty upon which a physician relies when making an important medical decision such as whether or not to perform an appen-dectomy, whether or not to prescribe an antibiotic before obtaining a throat culture, whether or not to place the patient on antidepressant or antipsy-chotic medication, or is it certainty within some percentage range such as 51 to 75 percent or 90 percent? How certain can one be that a heart attack which occurs after being exposed to an armed robbery was caused by the stress of the robbery, and therefore was the legal cause of the heart attack or that, in another case, the stresses of the job were the cause of the depression in the patient? What is reasonable medical certainty in such a situation? I am uncertain. What about testimony that something could, might be, possibly was, seems connected to, may be related, could have, might have, etc. Is such testimony within reasonable medical certainty? For this article, I will consider reasonable medical probability or similar semantic efforts the same as reasonable medical certainty. You might ask, why am I so uncertain, why is this so confusing? It is confusing because we are dealing with an evanescent concept, \"reasonable,\" and attempting to define it across professions. The law is trying to tell us how they would like us to answer a legal question in legal language utilizing Our medical knowledge and medical mind. Lawyers know what reasonable medical certainty means, but they cannot define it. Doctors testify to it daily, but they do not know what it means. Each jurisdiction appears to have its own interpretation of these magic words, so that an expert witness is advised to be sure that he/she understands the rules of evidence in the jurisdiction in which he/she is testifying and then hopes that he/she can This is a slightly expanded version …

Suicide litigation and risk management: a review of 32 cases.

Abstract: Thirty-two cases of suicide or self-injury in which I served as a medicolegal consultant are reviewed. Suits involving suicide have increased to 18 to 25 percent of psychiatric practice litigation. The demography of suicide is discussed and contrasted with the population studied; this study stresses the problem of the young, unstable, and poorly predictable patient. Consider­ ations in risk management include adequate and timely records, documen­ tation for decisions (particularly involving privileges), clear hospital policies and procedures, and adherence to those policies. In this study, at least 10 percent of the cases did reflect defects in care by the psychiatrist or hospital staff. Lawsuits against psychiatrists have increased rapidly. In 1975, an AMA study indicated that the claims rate against psychiatrists was 2.27 percent per year, the second lowest of physician groups. 1 A claim means that an action against a physician has been reported to an insurance company, and the percentage refers to the ratio of claims as related to numbers in that specialty in a one-year period. Slawson 2 reported that claims against psy­ chiatrists have increased from 2 percent in 1978 to 4 percent in 1983 (the rate for non-psychiatrists is now about 25 percent). Psychiatric malpractice costs in five years have increased four-fold; in that series, negligence leading to suicide was invoked in 18 percent of threatened suits against psychiatrists. Bellamy3 reported earlier that 14 percent of claims against psychiatrists involved suicide. Slawson, in another article,4 stated that claims in Southern California against psychiatrists for all causes from 1958 to 1967 were only 1.5 percent (1.5 per hundred psychiatrists per year), increasing by 1979 to 4 percent per year in California, with 25% involving suicide. s I have previously discussed the law regarding suicide liability and how it should reasonably be applied.6-9 Litman 10 noted that 1 percent of suicides occurred in hospitals, general and psychiatric; with one-third resulting in lawsuits, of which one-half were against psychiatric hospitals. He analyzed seven lawsuits as a suicidologist expert witness. I will report on 32 cases where I was a consultant to attorneys in litigation involving suicide (includ­ ing cases of self-injury involving similar principles).

Decision-making in child abuse and neglect.

Abstract: Social attachment theory can be of value in examining the wide variety of abuse and neglect situations that come to the attention of authorities. We consider evaluation of the parent-child relationship as a crucial part of the judicial process. We have suggested parameters that can be used to evaluate the relationship. We have outlined some of the more common distortions in this relationship that have, in our experience, been associated with the mistreatment of children. The use of social attachment theory has been of great help in understanding the emotional reactions of the many children we have seen for evaluation and treatment. The theory also serves as a potential guide for improvements in social policy. If we are more sensitive to the psychological world of these children, we will be better able to truly protect them. Language: en

Offenders in a Silent World: Hearing Impairment and Deafness in Relation to Criminality, Incompetence, and Insanity

Abstract: Hearing impairment is so often an invisible disability that it does not often enter the awareness of those whose senses are intact. A textbook knowledge of the physiology and pathology of hearing does not prepare the clinician to cope with a hearing-impaired family member, friend, or colleague, with whom we feel embarrassed, lest our raised voices attract too much attention. We are even less prepared to evaluate or treat hearing-impaired persons in the course of our professional activities. Yet hearing impairment is common, and the profoundly deaf probably suffer mental disorders at a rate in excess of that of their hearing peers. Profound deafness, the absence of functional or remediable hearing, is extremely disabling. Profound deafness that occurs prior to complete acquisition of verbal language is socially and psychiatrically devastating. , · Such deafness, also known as prelingual deafness, is believed to result in uneven, incomplete, or arrested personality developmentl· 4 and behavioral disturbances, S the understanding of which is complicated by the natural language barrier. Prelingually deaf offenders are said to have special problems within the criminal justice system,6-9 analogous in some respects to the diagnostic difficulties known to accompany such deafness. ' '2 At least since the late nineteenth century, commentators have questioned whether hearing impairment is associated with criminality. The legal status of the "deaf-mute" defendant has been coupled with that of the mentally disordered for centuries. Observations on these issues are scattered throughout the writings of disparate disciplines, and we are unaware of efforts to systematize the inconclusive and sometimes conflicting findings. In this article, we touch upon the historical legal status of the deaf-mute defendant, present data on a study of deaf defendants admitted to a maximum security psychiatric facility, and review studies exploring possible relationships between hearing impairment and adult criminality and between hearing impairment and juvenile delinquency. We bear no pretension that this is a

The harassment of forensic psychiatrists outside of court

Abstract: Violence by psychiatric patients has received increasing attention; there have been reports of attacks by inpatients, 1-4 emergency room visitors,5 and surveys of assaults by all types of patients.13 Despite their association with patients who might be expected to be more dangerous than the general psychiatric population, there have been few attempts to study the experiences of forensic psychiatrists. There are a few studies of assaults in maximum security hospitals;14-17 in the only one of these to differentiate types of staff assaulted, 15 no psychiatrists were assaulted. Forensic psychiatrists have come to expect verbal harassment in court by cross-examining attorneys, but there has been little written about the verbal or physical harassment, outside of court, of psychiatrists as a result of their participation as expert witnesses in civil or criminal proceedings. After a personal experience in which I was subject to threats of physical harm by the family of the victim in a murder trial, I decided to examine the extent of this problem.

A comparison between men charged with domestic and nondomestic homicide

Abstract: Two hundred thirteen males charged with mur4er and who received pretrial psychiatric evaluations were divided into two groups of domestic and nondomestic homicide defendants. Demographics, developmental and family background, prior criminal records, victim characteristics, and psychiatric status at the time of the crime were used to compare these groups. Those who were charged with intrafamilial homicide tend to be older, have a more stable adjustment in the community, but have more evidence of early childhood behavioral problems. Also, they are more likely to have committed prior crimes against persons. Two psychosocial stressors which were found to be important were the recent loss of employment and recent release from a psychiatric hospital. Post-offense suicidal attempts and psychotic/bizarre behavior were more prevalent for the intrafamilial murderers. Implications of these results for forensic psychiatry and future directions of research are discussed. The significance of violence in the family as a major public health issue in the U.S. was highlighted by the appointment of the President's Task Force on Family Violence (1983). Although violence between family members is rarely viewed as criminal, intrafamilial homicide is a well-defined entity and has been investigated extensively by criminologists. However, the psychiatric literature on homicide within the family seems to be sparse. Murders within the family constitute one-third of all homicides in the U.S. Spouses kill spouses in 50 percent of intrafamilial murders; in the rest, parents kill children, children kill parents, and other relatives kill one another. Several types of family murder are recognized: (1) filicide (murder of a child by parents); (2) neonaticide l (murder of the newborn child); (3) parricide which is either matricide (murder of mother by a child) or patricide (murder of father); (4) uxoricide (spouse murder); (5) fratricide (sibling murder); and (6) familicide2 (murder of the entire family). A review of specific categories3 of intrafamilial murder suggests that

Reasonable medical certainty, diagnostic thresholds, and definitions of mental illness in the legal context.

Abstract: The treating psychiatrist can change his initial clinical impression as a result of his ongoing relationship with the patient and his evaluation of response to treatment. Such monitoring is difficult. if not impossible, in the usual practice of forensic psychiatry. Also, the legal consequences of judicial decisions based on psychiatric opinion may be quite serious. If the psychiatric opinion is to be influential in determining the final decision, it should be offered with as high a level of confidence as possible.

The effect of mental health system changes on civil commitment.

Abstract: In recent reports we have described unexpected and significant local varia­ tions in the effects of new civil commitment statues l and how key decisions in the commitment process are made in both urban 2 and rural 3 areas. We have recommended that commitment procedures be divided into specific steps in order to identify the decisions to be made at each point, who makes the important decisions, and the factors that determine the outcome of the process. We believe a number of important factors in addition to the commitment laws combine to determine ultimately the observed effects in any area. These include the characteristics of the mental health system and the attitude and cooperation of judges, law enforcement personnel, and selected mental health professionals. We have also suggested that detailed analyses of commitment processes might be valuable for both local and state administrators charged with developing effective and efficient mental health programs. In this article we continue our study of civil commitment with an analysis of the changes that occurred in one Oregon county mental health program (CMHP) over a six-year period and the effect of these changes on the commitment process. We begin with a brief review of Oregon's commitment procedures and present data which demonstrate the significant changes in the study county during the fiscal years (FY) 77-78 to FY 82-83. We compare the data with a timetable of changes that took place in the local mental health system and then examine the characteristics of patients before and during the period of change as well as other mental health system factors that might have affected the data. We conclude with a discussion of Our results and their programmatic and research implications.

Treating the not guilty by reason of insanity outpatient: a two-year study.

Abstract: Issues concerning the safety and effectiveness of treatment of not guilty by reason of insanity (NGRI) patients in the community have come under increased public scrutiny and professional discussion in recent years. I Despite the intensity of controversy in this area, few objective data exist relative to these concerns. 2 Thus, meaningful decisions regarding safe and effective treatment of the NGRI patient in the community are difficult to make in the absence of valid, empirically based data. The aim of this study was to address this limitation by presenting objective data as to the psychi­ atric and psychologic functioning of NGRI outpatients in response to treatment. Although studies of institutional management of the NGRI hospitalized population are available, few published reports exist regarding the function­ ing of NGRI patients in court-ordered treatment within the community. One unpublished study (Lebow and Madden, personal communication, 1978) suggests that after an adequate course of hospitalization, a five-year intensive court-supervised outpatient treatment program for NGRI patients can be effective in reducing psychologic decompensation and criminal recidivism. Additionally, Silve~ and Bloom et al. 4 have recently presented follow-up data for NGRI acquittees discharged into community treatment programs, which suggest that under such conditions, a substantial reduction in rearrest/recidivism rates may be possible. The major objective of the present study, therefore, was to evaluate more comprehensively the ade­ quacy of psychologic adjustment of NGRI outpatients through repeated longitudinal assessments, utilizing standardized clinical interviews and a select battery of self-rating instruments.

Beyond the scientific limits of expert testimony.

Abstract: Dr. Pollack l • 2 has often argued that a major basis for the legal value and credibility of expert courtroom testimony lies in the neutrality and objec­ tivity with which the forensic psychiatrist can apply his expertise to legal issues for legal ends. The testifying expert is required to present data and opinion in an adversarial arena where pressures may often exist toward overextension of expert testimony. These pressures on forensic psychiatry make it vulnerable to distortion or abuse by the legal system. 3 It is proposed

The Mental-Mental Muddle and Work Comp in Oregon. II.

Abstract: To summarize, in the state of Oregon at this time, mental illness caused by employment is covered by workers' compensation insurance. There have recently been some legislative attempts to seriously restrict this and there probably will be some more in the future. As the law now stands, the job stress must be the major contributing cause as measured against any off the job stress. The on the job events producing the stress must exist in reality. A stress emanating primarily from a worker's misperception or paranoid thinking does not constitute an acceptable causative agent. Obviously it is not always that easy to distinguish between on the job causes and off the job causes and objective stresses and merely perceived stresses. And what about the individual who has faulty perceptions which lead to actions that provoke an objective response? As a psychiatrist, I am glad to see more recognition given to mental illness caused by the work place. I applaud the Oregon Supreme Court for pointing out that an organization has an obligation to somehow deal with stress-producing supervisors. I think we have to be on guard against those forces working through the legislature which try to minimize or deny the importance of mental illness. At the same time, though, we have to try to enlighten rather than confuse. Our expertise is in diagnosing and treating, not in constructing legal terminology. In my evaluation of the Leary case, I tried to explain to the best of my ability just what was going on.(ABSTRACT TRUNCATED AT 250 WORDS)

The consultation model and forensic psychiatric practice.

Abstract: Seymour Pollack developed three categorizing definitions which provided forensic psychiatry with a logical framework for development as a subspe­ cialty of general psychiatry. The first definition separated the body of information related to the interaction oflaw and psychiatry required by the general psychiatrist from information specific to the subspecialty of forensic psychiatry. The general psychiatrist in any setting should practice with a working knowledge of statutory and case law affecting the practice environ­ ment. Familiarity with the law on such issues as informed consent, confi­ dentiality, right to treatment, right to refuse treatment, and involuntary treatment, among many others, provides the practitioner with a legal framework for occurrences that are common to general psychiatric practice. Having made this distinction, Pollack turned his attention to forensic psychiatry. Pollack characterized forensic psychiatry as a subspecialty area of general psychiatry based on a consultation model. 1,2 Pollack's often debated and controversial definition of forensic psychiatry flows clearly from his view of forensic psychiatry in a consultation framework. Pollack 3 defined forensic psychiatry as the "application of psychiatry to legal issues for legal ends, with the chief goal being the augmentation and support of the rule of law." Pollack's distinctions between law and psychiatry and forensic psychiatry and his definition of forensic psychiatry are familiar. His view of forensic psychiatry as a branch of consultation psychiatry is less well known and his contribution in this area has tended to be lost. In this article, we attempt to elaborate on the consultation model in some detail and to see how others have conceptualized the field of forensic psychiatry. In addition, we will look at the legal view of the forensic psychiatrist, as an expert, for the purpose of illustrating that this is a term of art in the law which has been misused in the psychiatric literature to describe the role of the forensic psychiatrist. Writings in psychiatry that have attempted to define the parameters of forensic psychiatry reflect a conflict between the attempt to remain objective

Comment on Goldstein's Posttrial Competency Examination of Jurors

Abstract: As one surveys the many battlefields of the great war between law and psychiatry and as one counts the losses on our side, it is astonishing to come upon a psychiatrist who is calling for a fresh assault on the law's ultimate stronghold, the sanctum sanctorum the jury. Not only do the timing and the target boggle the mind, but this new psychiatric foray is premised not on any therapeutic or psychiatric objective, but on the premise that expert psychiatric opinion is necessary to further the law's own objectives of fairness and due process. Goldstein is apparently prepared to forgive and forget, or at least to overlook, a decade of legal opinion and scholarship hostile to expert psychiatric testimony; hostility grounded on the claim that expert psychiatric testimony offends due process and fairness. 1 Putting aside these strategic considerations, Goldstein's proposal should be examined on its merits. He would have courts order posttrial psychiatric evaluation of a juror when "strong evidence" exists "that it is likely that a particular juror suffered from incompetence to understand the issues or to deliberate at the time of service." The need for what more explicitly might be called an after the verdict evaluation can only arise under the following circumstances: 1. The mentally ill juror was not excused from jury duty because of his disorder. 2. The mentally ill juror survived the voir dire (screening before trial) including questioning and peremptory challenges to prosecution and defense. 3 3. The jury itself, during its deliberations, did not recognize the difficulty which could have led to the juror's dismissal and his replacement by an alternate. 4. The judge failed to recognize the juror's incompetence at any time during the trial. S 5. No third party came forward during the trial to raise the question of the juror's competency.s We must assume that the supposedly "incompetent" juror has overcome all of these hurdles in order to participate in the verdict. Therefore, under

The post-Vietnam stress syndrome: some cautions.

Abstract: Because of his alleged post-Vietnam stress disorder, a veteran was found not responsible by reason of mental disease in a shooting incident. The outcome of his subsequent malpractice suite against the Veterans Administration raises some important cautions. With the publication of DSM-III, the term posttraumatic stress disorder has increasingly come into use. I Yost and Williams, among others, have particularly applied this diagnosis, including the delayed type, to Vietnam veterans. Atkinson et al.3,4 have written about the increasing number of Veterans Administration claims for disability based on this disorder, and they believe that their studies do validate the DSM-II1 criteria. Having served as an Army psychiatrist in Vietnam in 1968 and 1969, I am well aware of the burdens which that unpopular war placed on our very young military personnel. As always, though, some cautions are in order. Baskir and Strauss have pointed out that those who served in Vietnam were primarily quite young Americans who had limited coping devices in civilian life. Staying in college with a certain grade point average, for example, was one way of avoiding the military. At the 67th Evacuation Hospital in Qui Nhon, where I worked, I studied 100 consecutive cases of soldiers who were having trouble adapting. I found that 99 of the 100 were high school dropouts. Even with all of the emotional and intellectual resources available to me personally and even though I was in a relatively protected setting, I returned from Vietnam with a lot of anger and mistrust which threatened my civilian adjustment. Surprisingly, though, our actual psychiatric casualty rate in the war zone was quite low when compared with that of Korea and World War 11.6 The one-year rotation, our overwhelming air and naval superiority, the usual absence of prolonged battles, and our extensive mental health services are some of the reasons given to explain this low rate. So the first caution involves not attributing too many current adjustment problems to Vietnam, especially if we sent there many individuals who had already demonstrated some impaired coping devices and who apparently did adequately while there. The interaction is a complicated one which defies easy analysis. Grant and Coons have warned against the simplistic connection of too much Current behavior to Vietnam duty, just because a person had had some

Psychiatric Injury in the Women’s Workplace

Abstract: is neither frivilous nor a luxury that can be easily dispensed with. With this accelerating presence of women in the workplace have come increasing reports of problems they encounter by virtue of them being women. Some of these problems, such as lower economic compensation, unequal education and employment opportunities, and cultural barriers to integrating work and family life, while important as social policy issues,3 are not immediately relevant to this article. Sexual discrimination and harassment on the job are more relevant because their agents of cause are more easily indentifiable and their psychiatric consequences, when present, are sharper and more pronounced. While sexual discrimination and harassment are two different concepts, there is also an area of overlap. Essentially, discrimination occurs when women as a group are treated less favorably than men in terms of job opportunities, compensation, etc. 4 Perhaps this would better be called gender discrimination because there are no explicit sexual overtones. Sexual harassment occurs when sexuality enters the picture. It has been defined as "the exploitation of a powerful position to impose sexual demands or pressures on an unwilling but less powerful person."4 There are two types of sexual harassment. 5 The quid pro quo situation occurs when sexual favors are demanded in exchange for job opportunities and/or when refusal of such favors brings retaliation. The persistant condi­ tion of work situation occurs when sexual conversation or touching contin­ ually occurs in the workplace. There may be persistent comments, propo­ sitions, attempts to discuss the employee's sex life, repeated "accidental" bumpings, more obviously intentional touching, or even rape. 5 Surveys have indicated that 49 to 81 percent of working women experience sexual pressure on the job. 6 ,7 While these surveys may be flawed because of sampling problems and because what men may perceive as innocent behav

Violence and official diagnostic nomenclature.

Abstract: There have been increasing concerns about the relationship between mental disorders and violence during the past 15 years. Monahan I notes that there is a persistent belief in a positive association between the two, despite empirical evidence suggesting that such an association is anecdotal at best. He further suggests that inadequate definitions are a major problem in studying this relationship. One measure of the degree to which we have officially accepted the belief in a positive association between mental disorders and violence would be to compare the proportions of disorders with descriptive phrases or diag­ nostic criteria, including words about violent acts among our past and present diagnostic nomenclatures. Although these diagnostic schemata are different, this would provide a rough index of our changing conceptualiza­ tion of this relationship. In this article, I report the change in these proportions and discuss some medicolegal and basic research implications of this observation.

The use of legal rhetoric in a clinical setting: advocating the advocates.

Abstract: The continuing intervention by courts and legislatures in the decisions traditionally reserved to psychiatry is generally perceived by mental health professionals as a threat to their practice. As jurists insist upon supervising therapists' decisions to medicate, I to hospitalize patients,2 and, indeed, to discharge them, clinicians, as might reasonably be expected, retreat into a \"siege mentality\"4 as their expertise is called into question: Commentators remark that \"legal developments ... presage a depressing future for psychiatry\";5 and the law is portrayed as hindering effective patient care, rather than as protecting the rights of the neglected and underprivileged. In view of the uncomfortable liaison between law and psychiatry, it would seem odd indeed were practitioners to be assisting the efforts of those whom they see as the intruders while, at the same time, complaining of that intrusion. Yet this very phenomenon may be occurring. Ironically, clinicians are unwittingly encouraging the expansion of legal influence by adopting legal rhetoric in the treatment setting. Legal rhetoric appears more frequently in the daily dialogue between therapists and the severely disturbed patient. In that dialogue, it promotes antagonism between the treatment team and the patient and among members of the team themselves. The psychiatric community believes that the lawyers have introduced this antagonism. Yet therapists' own use of legal rhetoric in the context of psychiatric treatment may, paradoxically, lead to advocacy of the advocates and away from the invaluable task of further developing psychiatric expertise and defining more closely the parameters of decent care for the severely disturbed.

Psychiatric Perspectives on Civil Liability for Suicide

Abstract: However, liability not only for failing to prevent suicide, but also for causing suicide has been found recently with increasing frequency. In many in­ stances courts have moved away from a proximate causation analysis to a simple "but for" causation test to more easily find liability for suicide. Decisions in these areas have broad-reaching consequences which need to be analyzed in light of their psychosocial implications and recent psychiatric knowledge on the causes, predictability, and prevention of suicide. In particular, this article intends to show that such broadening of liability on the basis of simple direct causation is not in line with modem psychiatric thinking, perpetuates the criminal character of suicide, and becomes a convenient method of shifting the naturally expected guilt of survivors. In addition, studies are reviewed which indicate that suicide is not predictable and, therefore, even where a proximate causation test is used the use of foreseeability does not coincide with actual facts or actual foresight. The implications of this in cases of direct causation of suicide as well as failure to prevent suicide are discussed.

The Advisory Review Board and characteristics of patients on warrants of the Lieutenant Governor in Ontario.

Abstract: In recent years, much attention has been focused on the mentally ill offender, particularly those found "not guilty by reason of insanity" and "unfit to stand trial." The more recent trial and verdict involving John Hinckley, Jr., in the United States, has given momentum to the desire on the part of some to completely change the system. In Canada, the 1976 report of the Law Reform Commission on Mental Disorder in the Criminal Process' is still regarded by some as the blueprint for change. This article is an analysis of the Ontario Advisory Review Board and a description of persons held on warrants of the Lieutenant Governor in that province. The Crj minal Code of Canada, 2 specifically Section 16, defines the criteria for mentally ill individuals who came into contact with the law. While the Criminal Code defines the law in terms of the mentally ill offender, it also permits the provinces of the country to develop specific laws and regulations under provincial jurisdiction. This is usually done under the appropriate provincia] mental health legislation. The system in Ontario is one of the oldest and has the largest number of cases on warrants of the Lieutenant Governor in Canada (LGW). Under legislative guidelines provided in the Criminal Code and developed by this individual province, an Advisory Board of Review, consisting (in Ontario) ofa supreme court judge as chairman, two psychiatrists, a member of the provincial bar, and a layman, is appointed to review each person held under a warrant of the Lieutenant Governor anually, sometimes more often, and to make recommendations to the Lieutenant Governor-in­ Council, with regard to each individual. The Lieutenant Governor or Lieutenant Governor-in-Council (cabinet) mayor may not accept the recommendations of the Board. The Board reviews each individual using the following criteria: (1) fitness: Is he now fit? That is, has he recovered from his mental illness enough to stand trial?; (2) dangerousness: Is he a danger to himself or to society?; and (3) public interest: Is it in the interest of the public to release the individual? Persons held under these warrants are rarely released from the maximum

Experts in Church Courts: A Role Not Sacred

Abstract: The increasing number of marriage annulments granted by the Catholic Church in recent years is gaining considerable public attention and arousing some controversy. I Members of the church's clergy2 and hierarchy3 have also expressed concern. This is not surprising in view of the actual data, as shown in Figure 1. Such data give the appearance of a decrease in the emphasis being placed on the permanence of marriage, a well-known church doctrine. Moreover, it is a significant change for some eight million divorced American Catholics that divorce, especially when combined with remar­ riage, might not mean separation from the church. 4 Some have attributed the striking increase to the rising divorce rate; others to the renewal in church life associated with the Second Vatican Council in the 1960s. 5 This renewal encouraged an enrichment in under­ standing of marriage as well as a flourishing ministry to the increasing number of divorced Catholics. In addition, a much earlier and less widely known trend is of more fundamental importance. Shortly after World War II, the Sacred Roman Rota, the church's court of final resort in marriage cases, began to emphasize the psychologic requirements for a valid marriage 6 and to encourage the use of psychiatric experts in the hearing of marriage cases. 7 The public's increasing attention to the phenomenon of growing annul­ ment rates stands in contrast to the psychiatric literature's virtual silence on the expert's role in this process. Thus, there is a need for this significant use of professional expertise to become both more widely known and more carefully appreciated. Accordingly, we report here on pertinent church law literature and on our study of a church court in the northeast. This study included discussion with its officials and experts, participation in its work­ shops, and observation of its annulment hearings. Our purpose is to focus forensic psychiatric attention on the work of church courts and the role of their expert consultants, in support of both the quality of this work and the development of this role.