Saturday, February 04, 2012

You're A Whore


On my post "The Violent Patient", Anonymous Clinician wrote this comment:

"Frankly, I have little respect for Forensic Psychiatry these days. It is a whore subspecialty until proven otherwise, as it is doing what is financially convenient for the MD and just making general psychiatrists pick up the messes."

The accusation that forensic psychiatrist are 'hired guns' is not a new one. When I was a medical student I did a neurosurgery rotation. Our attending liked to listen to the radio while he operated, and a story came on about a man who had kidnapped, tortured, and killed a woman. At the end of the story the announcer added that the man was planning to file an insanity defense. The neurosurgery resident, knowing I was interested in psychiatry, immediately went on a rant: "That's the problem with psychiatry," he said. "Somebody does something criminal and there's always a psychiatrist somewhere saying he was crazy and shouldn't go to prison. This guy should be locked up for the rest of his life. They should do the same thing to him that he did to that woman."

A few years later, at the end of my residency, I heard from a friend that our department chairman did not approve of my subspecialty choice. "It's too bad she's going into forensics," he had told my friend. Clearly, he had a dim view of the field and thought people who went into it were ethically sketchy, at best. (Ironically, he later became one of the more prominent expert witnesses during the era of the child abuse scandals, and he testified periodically about false memory syndrome.)

Shortly after I began my fellowship, Dr. Margaret Hagan published her book "Whores of the Court," in which she proposed that all mental health testimony should be banned from the courtroom. (Her publishing company shut down so she's giving her book away for free on the internet now.)

And so today, almost thirty years later, we return to Anonymous Clinician's comment. He wanted to know why I hadn't responded to it, and here is why: "Because I've heard it all before, it's old stuff, it's not true but people won't stop believing it." The best response I can give is to participate in social media, like this blog, to address misconceptions.

Here are the common misconceptions about forensic psychiatry:

1. Forensic psychiatrists 'get people off' from their crimes.

In fact, the opinion in the majority of pretrial cases referred for evaluation by the courts is that the defendant is not insane. Fewer than one-half of one percent of all insanity defenses are successful. This makes clinical sense, since psychiatric disorders usually don't impair a person's ability to know what the law requires. And it's not the psychiatrist making the decision about guilt or innocence: that decision is made by a group of average citizens---the jury---or by a judge. Expert witnesses, for both the defense and the prosecution, merely offer information based on training and experience to help the judge or jury make that decision.

2. Forensic psychiatrist will say what they're paid to say.

A good attorney will not hire a 'hired gun.' They are paying a lot of money for a witness who is credible, and a forensic psychiatrist with a reputation for being a 'whore' is not going to go very far with a judge or jury. Being a 'hired gun' is bad for business for the forensic psychiatrist too since a bad reputation cuts pretty far into your referral base.

Also, remember that in many cases the forensic psychiatrist is not retained by a private attorney. Many forensic psychiatrists are employed by state health departments. They are salaried employees, not private practitioners. As such, their income is independent of the opinions they form.

3. Forensic psychiatrists aren't doing 'real' psychiatry.

In other words, they're not clinicians. Ah, so untrue. Most forensic psychiatrists will tell you that it's important to retain at least a part time private practice because it's too demanding to have a 100% evaluation-oriented practice. Some forensic psychiatrists don't do evaluations at all, but devote all their time to providing clinical care to patients in correctional facilities or secure hospitals. Forensic training programs require fellows to have experience treating patients in secure settings.

The post is getting a bit long so I'll stop now. Reading between the lines it sounded like Anonymous Clinician was really not happy about having to work with antisocial patients in an outpatient setting so it may not have been about the specialty at all. But there's my response.

(Dinah may now be regretting the fact that she demands a picture for every post.)

38 comments:

Anonymous Human said...

Clink,
Forgive me if I don't quite understand. Dinah is taking a break from posting because she is upset,hurt and frustrated by the substance or tone of some comments. Then you devote an entire post responding to Anon Clinician, who paints all of forensic psychiatry with the same dirty brush and when not busy doing that, claims that commenters who complain about hospitals are Axis 2. Is the message here that the blog tolerates nastiness if it comes from a (supposed) clinician but not from regular people? I am really not sure what to make of what seems to be a double standard.

ClinkShrink said...

Anonymous Human: No double standard. Anon Clinician wasn't addressing me (or commenters) personally in the comment that I responded to. He (or she) raised an opinion that I have heard so often over the last thirty years that it didn't surprise or upset me. I thought the comment raised a good opportunity to clarify misconceptions about my specialty, which is a primary purpose of the blog.

Dinah said...

Clink, You are a Nun. Be true to yourself.

I am frustrated by having my words manipulated to repeated prove that I have bad intentions. I'm not hurt. I'm no longer upset. I do have another project going on and when that's done, and the trolls have taken cover, or have found more productive ways to change the world, I will be back. Could be weeks, days, or hours.

I am reading the comments (Roy thought that because he said "don't" I wouldn't. How funny is that?)

Anonymous said...

As a clinician, I am grateful to have forensic psychiatrists out there. I have yet to meet one that has been a hired gun, and from my humble opinion, find that they end up doing the most emotionally draining, and tedious work in the field.

I have just recently stumbled across the blog, so I haven't read the history of the trouble you have run into, but would like to just mention "therapeutic silence"... sometimes it is more powerful not to respond to a comment made, beyond acknowledging that they have been heard.

We can provide education about the field, but preconceived biased beliefs will sadly not be changed by reading a post, or a blog, change in thoughts or behaviors, as we all know is a process, so please do not be discouraged when you run across "pre-precontemplation" folks. Your posts are great, I hope you continue to write them, and please consider the notion of having the comments just as an opportunity for folks to be heard.

anonymous clinician said...

Let's be honest here, ClinkShrink, many, if not 50% at least more than 25% of Forensic Psychiatrists, take cases with payment up front. It is about the payment first in assessing and representing people in felony AND civil matters until proven otherwise, and that is the behavior of a whore. Sorry, the term is emotionally charged, and, with the lack of attention to matters when just addressed kindly or nonspecifically, the issue should be noted and with much concern, so, the tough terms do make the point!

Plus, what a provocative picture with your last post! What was that about?

I have never said in any comment at any blog that everyone in a group is guilty or representative of a concern or behavior I address. But, if I believe a group by in large is acting inappropriately or irresponsibly, and part of the group is just ignoring or being passive in a detrimental way, that needs to be said. Omission as much as commission are both wrong.

I have been practicing long enough to know what is right, what is standard of care, and what is respected and understood by colleagues. Giving a pass to letting antisocial and immature/irresponsible people to gain access to mental health treatment and then basically disrupt the care process needs to be addressed and changed.

With money on the line for a good portion of those who work for the court, I doubt you will see this subspecialty speak out for such concerns and changes. The deeds speak louder than the words, and in this case, the absence of speech is the deed!

Anonymous said...

I agree--sometimes people just need to be heard. And I don't agree that if dozens of people on a public forum all complain about the same thing, it can't make a difference. I really didn't see anyone attacking Dinah or twisting her words at all. They were just stating their own opinions. I don't know why that is considered an attack. I am one who is very against the way psych hospitals don't respect patients' rights to respect and dignity, yet I think Dinah would be a great shrink to have. I think she'd be wonderful. My opinions of hospitals and private practitioners are completely different. I also wonder why Roy never weighs in on a subject he is much closer to than Dinah is. Isn't he a hospital shrink? He is really the one who should be posting about such things. But maybe he doesn't because he's more aware of what a contentious issue it is. I recommend Dinah, if you don't like upset people commenting, that you just stay away from that issue and all will be relatively, quiet and calm.

Anon Anon said...

I've never been able to understand why anybody who's working for cash, in exchange for a service that is not sexual, could be considered a whore. I mean, isn't that what everybody does? Isn't the clinician who made the comment also a whore for working for cash, instead of volunteering his services? I just don't get it.

Also, I've never been able to understand why people wouldn't consider more criminals insane. It's not like most people want to do the things some of them do. And it seems completely irrational to think such criminal behaviours will lead to anything good in one's life. A lot of criminals seem nuts to me and I think more psychiatrists and research should be devoted to figuring out how to help them not be so irrational. As far as I can tell that's what Clink Shrink is trying to do--help them find some sanity.

Anonymous said...

@anonymous clinician

If a doctor demands payment at the end of a session/appointment, is s/he a whore, too? Or is that term only appropriate (in your opinion) for a medical doctor who demands payment before beginning work on a case? Do those 10-15 minutes spent on a med-check, or 20 minutes spent on an "extended appointment" separate the whores from the good guys?

Just wondering when that line into whoredom is crossed. It would seem that my kid's orthodontist would be in trouble, at least by your definition of a whore. Same thing with the obstetrician who delivered our children. Heck, maybe even some of your colleagues.

RH

ClinkShrink said...

Anonymous Clinician: I have no idea how many forensic psychiatrist have a private evaluation practice versus purely clinical practice so your guess is as good as mine. Yes, private practice forensic psychiatrists do ask for a retainer. This is a standard business practice and attorneys understand that this does not guarantee a favorable opinion. Government employed forensic psychiatrists work on salary and their is no relationship between payments and opinion at all.

As far as the pic goes, there's a standing rule among the Shrink Rappers that each blog post must be accompanied by a picture. I thought that one captured the sentiment of the post topic. It's traditional Shrink Rap culture.

verification word:
"scidlaen" oh, I'm not even going to try defining that one after this post....

Anonymous clinician said...

Payment BEFORE providing a service is much different than AFTER one. Just curious, having never been involved with prostitution, isn't that the gist of that profession, like, lawyers as well?

jesse said...

Clink, you were being overly generous in not moderating out Anon Clinicians overtly rude and inflammatory statements. The three Shrink Rappers encourage good debate, but his (don't believe it's a woman) remarks are over the top, particularly coming when they did, after all the problems Dinah faced.

To paraphrase Evelyn Beatrice Hall on Voltaire, "Sir, I disapprove of what you say, but will defend to the death your right to say it politely."

Anonymous said...

@Anonymous Clinician

It is the nature of the "service" that defines prostitution, not the timing of a payment.

By your definition, the orthodontist and obstetrician I used in my earlier post are both prostitutes. As is the plumber I recently called out to my house.

A few questions for you: Do you and your colleagues not obtain financial information from new patients before seeing them? I have always been asked to turn up to first appointments "ten or fifteen minutes early to fill in some paperwork" which always includes the doctor's office making a copy of my insurance card and getting me to sign a declaration to the effect that "payment is due at time of service."

So, from then on, whether the payment is made before or after the 10 minute consultation, or I skip out without paying at all, the doctor has the goods on me. I know this, the doctor knows this, so it makes it easy for him or her to wait those 10 minutes that divides the BEFORE from the AFTER.

Indeed, do you not have a friendly office manager - receptionist person that brings up the subject of payment before making that first appointment at all?

RH

anonymous clinician said...

Historically, the people who clamor for censorship at sites like this wind up being the most hypocritical in wanting alleged honest debate.

It does go back to my original comment at the post a few days ago by Dinah regarding the role of axis 2 in threads like these. Rigid, extreme individuals who often are "failed" by what psychiatry can provided as of this millennium are quick to dismiss, demean, and just attack anyone who defends or explains what are reasonable and fair standards of care for mental health. I have seen it in the office, in the community, and in personal life.

Yes, what I write at times is harsh. So are the growing failures of what goes on in psychiatry. You can read this at other sites that are not afraid to raise it. The usual commenters know who and where they are.

And, I never said once the author of this blog was a whore or guilty of inappropriate behaviors. Make sure that is on record here at the thread! It is amazing how quickly things can devolve into such accusations!!

I am beginning to wonder if this is replacing Furious Seasons.

Anonymous said...

http://www.suicideforum.com/showthread.php?111872-What-is-a-troll

My question is, can the bloggers themselves be trolls sometimes?

Anonymous said...

Furious Seasons? I must go have a look, ha, ha. Sounds like fun.

Sunny CA said...

I was a wedding photographer for 25 years and was paid a substantial deposit on booking, then received the balance 30 days before the event, which is standard in the industry. Mortgage lenders can foreclose, the gas and electric company can turn off your service. What is an unpaid photographer or psychiatrist supposed to do after the fact to get their money? If we all did our profession for "the love" of it, we would not eat.

I agree with "anon anon" who said "I've never been able to understand why people wouldn't consider more criminals insane. It's not like most people want to do the things some of them do. And it seems completely irrational to think such criminal behaviours will lead to anything good in one's life. A lot of criminals seem nuts to me.."

When I read of crimes such as shooting all of that person's family members or drowning all one's kids I can only think that person is "nuts". Nobody in their right mind would do that.

Also, I can't figure out why it is that when a psychotic person commits a crime, that "they" send the person to jail to take psych drugs so that they can become "normal" to stand trial. Weren't they mentally impaired at the time of the incident? Why would we, as a society, not consider the state that person was in at the time of the crime? I wonder how those people feel, when they "wake up" from a psychosis to find that they killed people. It must be awful.

jesse said...

One of the reasons for a forensic psychiatrist being paid in advance is that one is then freed from the threat of being judged on the outcome. If one is to be paid after testifying there is great likelihood that the payment will depend on the testimony and on the result. So the truth is quite the opposite of what AC is alleging. Being paid in advance increases the likelihood of honesty.

It is hard to ignore that Anonymous Clinician appeared here right after all the nasty remarks led Dinah to leave, with himself using the word "whore" to describe an entire profession. Efforts to appeal to reason elicited further nastiness cloaked in logic. I think he is simply one of the trolls now wearing clinician clothes.

Anon Anon said...

I agree Sunny. When I see that sort of thing happening it makes me think the whole world has gone mad. How is it rational to make someone sane so that you can put them to death for something they did while psychotic? The people who make such laws are either incredibly cruel or also insane.

Minder said...

Thank you for this thoughtful and gutsy post. In a clinician in corrections, but not a psychiatrist, and I found this post eye opening: I had no idea of the hostility forensic psychiatrists experienced from their peers. I confess I'm no little bit shocked to learn that. I thought doctors generally prided themselves on their profession's staunch moral stand to succor all suffering, without judgment of the merit of the patient. To hear of MDs scorning psychiatrists practicing in prisons is like hearing of lawyers scorning public defenders.

A question: where you are, is it typical that MDs do assessments of competency to stand trial? I'm in Massachusetts, and where I am in the system, it's rare for such a report to cross my desk, but when it does, it's been by a psychologist (PhD), not a psychiatrist.

Zoe Brain said...

How competent are forensic psychs?

By that I mean, what numbers do we have regarding post-case analysis so that we can estimate the likelihood of their assessments being accurate?

Do we gave this data, and if not, why not? Are there patterns to be found?

Anonymous said...

"It is hard to ignore that Anonymous Clinician appeared here right after all the nasty remarks led Dinah to leave, with himself using the word "whore" to describe an entire profession. Efforts to appeal to reason elicited further nastiness cloaked in logic. I think he is simply one of the trolls now wearing clinician clothes."

Jesse,

Forgive me if I am misinterpreting your post. But it sounds like you are saying that because anonymous clinician is being nasty, that he can't be a mental health professional. I think many people who have had the experiences from h-ll with various folks in your field would beg to differ.

Also, my opinion is based on discussions with people who were in the mental health field who also reported dealing with professionals like anonymous clinician.

Anonymous clinician, this blog is about as much like the now defunct Furious Seasons site as Rick Perry is a socialist. And no, I am not comparing this blog to Rick Perry before anyone gets upset. I just like using political analogies to make my point.

AA

ClinkShrink said...

Sunny and Anon Anon: You might also be interested in a New York Times story today Killer's Families Left to Confront Fear and Shame, little-known stories about effects of crime on criminals' family. Pretty awful.

Minder: Twenty or thirty years ago in our state only medical doctors were allowed to express opinions about sanity since it required a medical diagnosis. Case law changed this to include psychologists, I think in the 1970's. More recently lay witnesses were allowed to testify as to the facts of a defendant's mental state (eg. "I saw him talking to himself.") without express an opinion about sanity. Social workers may testify as experts related to child abuse issues in our state, but not sanity.

Zoe: Good to hear from you again! Don't be a stranger. I need clarification before I can address your question. When you mean post-case analysis, do you mean expert testimony regarding the insanity defense? Off the top of my head, this is what I can tell you:

-The majority of the time pretrial evaluators of any profession will find a defendant sane.

-When an evaluator finds a defendant insane, the case is rarely contested by the state. Both sides recognize that there is 'something really wrong' with this guy and the state knows the jury would, too.

-When there is a contested insanity trial (a 'battle of the experts' as it's sometimes called), the opposing experts almost always agree about the diagnosis, but disagree about the relationship between the diagnosis and the crime (causation rather than illness).

-Out of about 50,000 felonies per year in our state, fewer than one-half of one percent will result in a successful insanity defense.

-Insanity acquittees are hospitalized longer than they would have been incarcerated, had they been convicted.

-Recidivism rates for insanity acquittees are (off the top of my head, it's been a while since I've reviewed this) about one or two percent per year---a miniscule fraction of the recidivism rate of convicted felons. When they do recidivate, it's usually for non-violent offenses.

OK, I probably still didn't answer your question :)

...but hopefully there's something useful in there.

If you want a really good resource, the American Academy of Psychiatry and Law voted last year to keep its journal open to the public in full text, free of charge. Lots of good stuff there.

anonymous clinician said...

Perhaps this perspective will enlighten some: my first lecture as a resident for forensic education started with this question by the lecturer, "what is the most important thing in forensic psychiatry work?, getting paid up front."

I kid you not, that is what a psychiatrist teaching residents chose to start a course with. And while ClinkShrink's comment about a sizeable amount of providers do work in state jobs as support for the prosecutors and hopefully maintain more impartiality, what she is not saying outright, in my opinion, is there are also a number who work independently and for a buck, and, to offer Jesse an alternative viewpoint, become a hired gun in being paid upfront.

Don't be so narrow minded to say getting paid up front maintains impartiality. When someone, especially a client or lawyer is paying you, what, Clinkshrink can clarify, $300+ an hour to provide an "opinion", you think this kind of money is going to maintain an objective unbiased perspective? Ha!

I have met very responsible colleagues in forensic work, Jonas Rappaport comes to mind up front, but, as other colleagues in various subspecialties in psychiatry have shown, even a minority (but a quantifiable number) of those who are inappropriate, self serving, and not advocating for the good of the patient population can ruin it for those who are invested in doing the correct thing. God knows some of the commenters here and at other sites are quick to tell everyone even one bad doc should condemn the field. Go to www.furiousseasons.com and read some of those threads before the author "retired".

As to anonymous AA, I have read your comments at other sites, including what you have written at FS, and the difference here versus there is Phillip chose to not censor at all until providers did come on and try to offer opposing views, and the attacks by some, not you from what I can recall, did force him to step in then. But, having just come here this week, and reading the same old attack and conquer attitude per Dinah's perspective, there are similarities, at least right now.

The difference between me and a majority of my colleagues is, in my true humble but outspoken opinion, is they are too polite and overly cautious to engage with those who want to shout down honest debate. Having had personal experiences with Axis 2 in my upbringing, I have learned when to be quiet, and when to challenge. And in this medium, unabated berating will be validated by the quiet readership.

So, I have my opinion, I may voice it less than favorably at times, but, my experience hopefully validates my point of view. Not looking for support from some, but hope the readers get the rounded debate sites like this should offer.

The overall concern I would like to finish with this last comment is this, it is tragic to see true psychiatric patients be incarcerated for minor crimes, and it is equally tragic society to this day is discriminatory and biased when it comes to mental health. Even by judges who are to be unbiased and objective in ruling on cases in front of them.

However, that said, what I see of late is putting entrenched criminals or treatment resistant psychotic patients who have violent pasts hospitalized with a general population in chronic state facilities is yet another crime. And again in my opinion, the silence of the forensic specialty in trying to redirect this debacle is not saying much positively for the field!

But, to hopefully answer those of you asking why I am vocal about axis 2 sociopathy being forwarded to outpatient providers is this: people who care and are empathetic are often easy prey for the sociopath. And many providers either take too long to identify someone is not appropriate for the level of service, or, are too over tolerant to set limits and often put other colleagues at risk who are more in line of fire. Am I wrong in this point of view, Clinkshrink?

Anonymous said...

I believe ClinkShrink's link should be: Killers’ Families Left to Confront Fear and Shame

I also believe Anonymous Clinician to be a troll, clinician or not. I like this blog very much and don't want it destroyed. Please be careful.

TrulyAnonymousMostlyHuman said...

Anonymous Human wrote: "Forgive me if I don't quite understand. Dinah is taking a break from posting because she is upset,hurt and frustrated by the substance or tone of some comments. Then you devote an entire post responding to Anon Clinician, who paints all of forensic psychiatry with the same dirty brush and when not busy doing that, claims that commenters who complain about hospitals are Axis 2."
Jesse wrote: "Clink, you were being overly generous in not moderating out Anon Clinicians overtly rude and inflammatory statements. The three Shrink Rappers encourage good debate, but his (don't believe it's a woman) remarks are over the top, particularly coming when they did, after all the problems Dinah faced."
Later,Jesse wrote: "It is hard to ignore that Anonymous Clinician appeared here right after all the nasty remarks led Dinah to leave, with himself using the word whore" to describe an entire profession. Efforts to appeal to reason elicited further nastiness cloaked in logic."
Clink said there is no double standard. Still, it does seem odd and inconsistent, even more so since Anonymous Human's comment elicited a response to say, no you are wrong, while Jesse has been allowed to comment without being told he is wrong.

jesse said...

@AA, I can see what you mean. Yes, he could well be a mental health professional of any type. I did not mean to imply otherwise and see that what I wrote was not clear enough. A troll has the genetic capability of coming from anywhere and masquerading as anything, and medicine and mental health are not exempt.

jesse said...

@TrulyAnonymousMostlyHuman: I don't quite understand. If I write anything that is a nasty attack on anyone I should be moderated out, too. I do think the three Shrink Rappers, in encouraging good spirited debate, have often allowed comments that in themselves were nasty and inflammatory. The hope would be that being polite and respectful of others encourages that behavior in return, and almost always it does.

Anonymous said...

Anonymous Clinician wrote: Perhaps this perspective will enlighten some: my first lecture as a resident for forensic education started with this question by the lecturer, "what is the most important thing in forensic psychiatry work?, getting paid up front."

What I take away from that is that your opinion is based on some other guy's opinion -- or perhaps just some guy's opening throw-away line. It strikes me that the lecturer may have been joking, or purposely raising hackles, to get the audience to pay attention. Both those things are common public speaking tactics.

In any event, after such an opening line, one would have to take the rest of the lecture with a pinch of salt.

RH

Dinah said...

Jonas Rappaport is/was Clink's mentor.

The Shrink Rappers don't like moderating comments, we prefer the open discussion, but when it starts to feel disrespectful and malicious, it stops feeling open and leaves some of our commenters feeling like they don't want to post.

Thank you everyone for your concern, but really I am fine. I am not "hurt' but I have been frustrated that I say one thing and then read it back as meaning something else, and I did find myself thinking too much about the blog. And I didn't really like being called immature or being told I was anyone's nightmare of a psychiatrist (...now how would it go over if I told a commenter that I was so glad they weren't my patient?).

I'm still reading and commenting and enjoying very much what Clink and Roy have to say.

Please try to be nice. It's not that hard to express controversial opinions without being rude.

Anon Clinician, you are welcome here, but please be aware that some of us find Axis II diagnoses to be imprecise and pejorative terms, and so please don't refer to our readers as such, unless of course you've met them, done a full evaluation, and gotten their signed permission!

Please don't worry about me. I'm excited about another SR-related projected at the moment, and will be back, probably too soon.

anonymous clinician said...

I appreciate the direct comment from you, Dr Miller, but, as a colleague I am concerned people just automatically assume the use of axis 2 as pejorative until otherwise. It is what it is, inflexible, rigid and extreme behaviors and interactions that cause dysfunction, and in my opinion, on the internet can cause much disruption if not reeled in with boundaries and limit setting that more often goes on with some success in the carbon based settings that is life apart from the screen.

I came into this site at the height of the discord you seem to relate in your posts last sunday and monday, so my mistake. I personally find the title of this post to be a bit accusatory in stating as "you're a whore". If your colleague took that interpretation, that is her right, but I never said that and the tone of this thread is not going in any direction that is promoting dialogue, just more hostility. I'll acknowledge I added a bit, but I am quite concerned what is going on in state hospitals and outpatient settings that is frequently started by forensic evaluations.

I'll accept blame in using the term whore and sincerely apologize for anyone who genuinely thinks I was rude. That said, do you really think Dr Rappaport would be supportive of the direction forensic psychiatry as a whole has taken in the past 15 years or so? I have interacted with him before he left the field, and from what little I know of him, doubt he would say anything positive of what is too often going on and silently approved by the lack of challenges. Do you, even if you are fully responsible and appropriate with standards of care, put up with poor behaviors by colleagues? That is the issue I was trying to raise, I guess not as effectively as hoped.

My mistake for coming here and commenting, it was not the path I was looking for of late. Perhaps this recent blog week will be enlightening and provide insight for future posts. I would also offer for what it is worth, zero tolerance for overt abuse and extreme commentary of psychiatry unless the writer him/herself of a post or comment is called to task.

Why so many sites still allow venting without boundaries does not feed into healthy dialogue, that I feel I can conclude. Good luck in your writings.

TAnonMHuman said...

@Jesse,
i think you misunderstood my point. Much of what you said was in sync with Anon Human but you were not told that your pov was wrong. I don't think you were wrong,that is the point.

ClinkShrink said...

Anonymous Clinician brings up two points: the role of money and bias in forensic evaluations and the appropriateness of referring Axis II pathology to outpatient clinics (or housing them on inpatient units).

Regarding the reference to "get paid up front", I'd like to provide the full context of that remark. It's an introduction to forensic psychiatry in which a very experienced (and ethical) forensic faculty member gives advice to trainees with no forensic experience. RH has it exactly right---the statement is a tongue in cheek throw-away line designed to catch people's attention in a humorous way. The talk then goes on to address, as the #1 issue, the topic of ethical issues in forensic practice. Particularly bias as it relates to payments, ways it can be expressed and what to do to avoid it. Current trainees also get a copy of the AAPL ethical guidelines, which also documents the prohibition against contingency fees (only getting paid if 'your' attorney wins). And I will pick a small quibble with one statement: "...a sizeable amount of providers do work in state jobs as support for the prosecutors." Health department evaluators do not work for the prosecution.

I agree that it would be naive (or simply false) to assume that money has no influence whatsoever. If a free pen from a drug rep can influence prescribing, then cash certainly could! No judge is 100% unbiased, no therapist totally free from countertransference, and no evaluator totally unburdened by their own personal experience and opinions. The real question being posed is how strong is the influence: total? none at all? somewhat more strong than less? I don't know. And in truth, neither can Anonymous Clinician. This is the factor that gets held up to public scrutiny, in front of a jury, during cross-examination. The brilliance of our adversarial system is that whores will be revealed. Attorneys and private forensic psychiatrists know this too, which also serves to moderate or correct for bias.

Regarding the second issue, whether or not people with antisocial traits or personality disorders should be referred to outpatient clinics or treated on the same unit as "true" psychiatric patients...well...I've yet to find a way to truly separate the 'mad' from the 'bad' and I think it's wrong and unproductive to make that dichotomy. People with antisocial personality disorders also develop affective disorders and substance abuse issues, both of which are valid ("true") conditions which could benefit from treatment. People with treatment-resistant psychotic disorders still require care. Dropping them from the public mental health system or isolating them from the rest of society is neither good nor productive. Certainly, if a clinic determines that there is no treatable condition present then there would be no reason to keep someone on a clinic caseload but that is always up to the judgment of the outpatient clinician.

Anon Anon said...

Read your link, Clink. It was very interesting. I thought it was another fine example of the world gone mad when it comes to crime. People truly lose their heads in playing the blame game and more victims ensue. Blaming the closest person available is the way simple minds find explanations.

Minder said...

*raises hand*

Could we please stop conflating "outpatient providers" with "clinicians untrained and unprepared to deal with criminal and dangerous Axis II patients"? It's not even that I disagree that most outpatient treaters don't have any particular training or preparation with such a challenging clientele.

But I do. And so do all my colleagues participating in the (national) outpatient program I am in, treating pre-release felons in community based programs, and so do my colleagues getting referrals from probation officers. There may not be many of us, compared to the great numbers of outpatient clinicians with other specialties, but we're out here.

Thanks.

CatLover said...

I didn't know recidivate was a word. I only ever saw "recidivism." Hmmm. Learn something new every day.

ClinkShrink said...

Minder: Good point. We don't have an outpatient program like that here separate from the parole and probation department. Good to know they exist.

bonzeblayk said...

"how's our mood? - Clink is :- )"

Well, I'm happy to see that.-) I hope that my post here today doesn't adversely impact your mood, since I have the impression from reading over your other posts that you do try hard to do a good job in treating mental illness in what we surely agree is "a difficult population"?

I came across this page months ago - adventitiously, on a web-surfing expedition prompted by a comment in a Facebook discussion linking an article on "The Truman Delusion" posted on Shrink Rap - and saw posts relating to forensic psychiatry.

Since as an insanity acquittee myself I have a keen interest in the topic of forensic psychiatry, I wound up reading the comments on your post here, only to find the ubiquitous and inimitable Zoe Brain commenting!

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zoe brain said...

How competent are forensic psychs?
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Zoe and I are Friends on Facebook, so I left a comment in that thread for her with my own reaction to this question:

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Bonze Anne Rose Blayk -

In case you check out this post here, Zoe, I'll keep my response to your question brief, by referring to this quotation:

"One waits in vain for psychologists to state the limits of their knowledge." - Noam Chomsky

Ditto for psychiatrists and the forensic specialists in general, although there are some good clinicians who are aware that they are not omniscient? (They have a problem: they NEVER do "legwork", and most rely extensively on "clinical histories" in their evaluations.)

Summarily, what research there is demonstrates that predictions of dangerousness based on clinical evaluations shows [sic] no correlation with future dangerous acts; the best predictor of future violent behavior is -past- violent behavior; and if you dangle a history rife with inventions of violent behaviors before them?

They bite.

June 2 at 12:35pm
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Recently I got around to posting on of my commentaries on my "care and treatment", in this case an application for "Treatment Over Objection", which I believe is relevant to the question of competence:

"Let's play a game!" - How Many Dates Can One Forensic Psychiatrist Fuck Up In Novel Ways On Just One Page?

So, I'll try to keep this brief: would you accept the treatment recommendations made by this psychiatrist, if you were his patient?

thanks,
- bonzie anne

bonzeblayk said...

PS: In a postscript, I feel free to ramble!

Clink, I admire the motif you employ in your posts on "The End of the Stories"… "They think he is a shy but likable guy, a quiet but kind person."

Well, people think I'm outgoing and highly personable, and probably talk a bit too much, but am a laughable - oops, I meant to say "amusing"? - and "very interesting individual"?

I would like to offer a small bit of sympathy for you and your colleagues in this challenging specialty: Forensic Psychiatrists are supposed to be "whores"? Worse than the average clinician? Or lawyer? Or… politician?

I don't see it…

However, I can't agree with you that psychiatrists in the employ of the government are unbiased simply because they "work on a salary". Every last one of the clinicians employed by the State of New York testified falsely, repeatedly, under oath and in psychiatric reports made in court cases related to my treatment; every one.

Why? Well, they're overworked, for one… they are forced to rely on histories in previously compiled records, in which errors accumulate without correction… they tend to form opinions based on consensus with other clinicians… and they're kind of sloppy to start with - for example: I can't recall any of them taking notes during interviews?

However… I don't find these to be acceptable excuses for violating not just the law, which requires one to testify to "The truth, the whole truth, and nothing but the truth", but also the Ninth Commandment? This behavior was immoral, not merely "technically illegal".

I offer no apologies for my attitude; I am a "strict constructionist" when it comes to matters of truth.

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"Playing guitar is like telling the truth. You never have to worry about repeating the same lie if you told the truth. You don’t have to pretend or cover up. If someone asks you again you don’t have to think about it or worry about it. It’s you.
- B.B. King, in an interview with Guitar Player magazine
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… I used to be a network systems programmer, with a decent reputation prior to "The Disaster" I experienced over Jan/Feb 1997, which was largely caused by an adverse drug reaction (I share more detail about those events - confounding detail, admittedly - in my "tayrot" Photo Album on Facebook).

… now I'm transitioning… "not just my sex, but my profession: I'm going into the music business".

And so, I am, by default, a publicity whore. We all have to make a living, and sometimes we choose to work in a worthwhile field which professes noble ideals, where others with a "bad reputation" have tarnished the image of our profession?

I believe that what's important is that we try to uphold those ideals, difficult though this may prove in an imperfect world.

Thanks, Clink, and have a great day, OK?

Sincerely,
- bonzie anne