Clarification of our Clinical versus Forensic Function: Dual Relationship

Huron Valley Center is a psychiatric hospital within the Department of Community Health therefore, the scope and nature regarding the treatment of the Mentally Ill seems clear and unequivocal. The status of Huron Valley Center�s inception stems from a Consent decree, which dictated humane and appropriate treatment of the mentally ill prisoners. Thus, this unique arranged partnership between the Department of Correction and Community Health was forged.

From a community health perspective the mission appears clear that the Huron Valley Center�s goal is to treat the mentally ill. Although, this has been duly qualified by the Department of Corrections, who reminds us all that these are prisoners first and patients second. Understandable, security issues take an obvious priority in this relationship. These two factors represent a dual-relationship, which, we continue to struggle with ethically when treating the mentally ill prisoner.

Although these two perspectives are difficult to integrate in a circumscribed manner, it has been at best a tedious balancing act. Not only have these divergent perspectives affected the prisoner/patient treatment but also the treatment/custody staff members understanding of their treatment roles as well. The dichotomy between maintaining a certain level of control versus effective treatment remains a critical issue. Again, roles are less transparent when you consider that staff members have been merged from both treatment/ custody orientations in spite of having the similar clinical credentials. For instance, some clinical psychologists are pulled from a purely mental health hospitals background in contrast to the forensic or correctional psychologists orientation. This distinct difference appears to extend up and down the chain of command and affects every aspect of the patients stay in the psychiatric hospital under the auspices of the department of corrections.

An article by Strasburger et al. (1997) elucidated a few of the point/counterpoints arguments between both the clinical and forensic functions. Clinicians have an ethical obligation to advance their patient�s interests and to avoid harming them in the therapeutic process. This is reflective of both the values of �beneficence and nonmaleficence principles� Appelbaum (1997). In revealing information, it is only to protect others from harm. The information provided from the patient�s disclosure would only be used to further the individual�s best interest.

Forensic clinicians work from a contrasting ethical prospective. Their orientation is built around the legitimate �needs to know� of the justice or correctional system. The principle of revealing the truth whether or not it advances the interests of the individual is the main role. Although there are reasonable boundaries that the forensic clinicians must adhere too, for instance by maintaining, �respect for the individual under their care and a principle that excludes the use of deception in their quest for the truth� Appelbaum (1997). In fact, this is why the forensic interview begins with a disclosure of the limits of confidentiality and the exact nature and type of the examination being requested.

Combining clinical and forensic roles in the course of treatment, enhances inherent risks that the information gathered with the understanding that it will be used for the patients benefit may be used for other purposes. Paradoxically, the information may be detrimental to the patient best interest. The maxim �if one can not help the patient at the very least do no harm.� Thus, it becomes questionable as to how open the patient will be in self-disclosure after they are made aware of the nature of the forensic examination. We must be constantly vigilant in our role identification otherwise as Appelbaum (1997) stated, �In either of these contrasting events, the outcome is unfair to the patient�.

Clearly, the formulation of policies is a difficult and challenging endeavor in order to present a balance approach between the needs of the patient and those of the system.

Note: (The author accepts full responsibility for the content of the article but acknowledges the critical input from (Mr. Don Smith, Mr. Mark Michniewicz, Mr.Todd Morgan and Ms. Hemamalini Surrendran) July 1, 2003.

References

American Academy of Psychiatry and the Law: Ethical Guidelines for the Practice of Forensic Psychiatry. Bloomfield, Conn, AAPL, 1995.

American Nursing Association: Code of Ethics for Nurses, Washington, D.C., 2002.

American Psychological Association: Code of Ethics. American Psychologist, Dec. 2002, Washington, D.C.

Appelbaum PS: A theory of ethics for forensic psychiatry: Presidential address, in Abstract of the 27th Annual meeting of the American Academy of Psychiatry and the Law. Bloomfield, Conn, AAPL, 1996

Appelbaum, P.S. (1997) Ethics in Evolution: The Incompatibility of Clinical and Forensic Functions. American Journal of Psychiatry. 154:4, April 1997. National Association of Social Workers: Code of Ethics. NASW Press, (1997-2003).

Strasburger (1997). On wearing two hats: Role conflict in serving as both psychotherapist and expert witness. American Journal of Psychiatry 154:4, April 1997.

Comment

The term forensic, as used by Dr. Hayter, is commonly applied in the context of legal controversies for which a psychiatricor psychological opinion is sought by a court or an attorney. Such opinions need to be objective, and a treating clinician is not objective in the sense required. Furthermore, the treating clinician must preserve the privacy of information obtained by virtue of the therapeutic relationship, whilst the forensic examiner is obligated to reveal any information pertinent to the forensic question. Accordingly, it is generally not a good idea for the treatment and forensic functions to be vested in the same clinician. Conflicts of this sort arise from time to time at HVC, as when a team determines whether a prisoner is responsible for misconduct tickets, or when a social worker is asked to prepare a case summary for the parole board. It is partly because of these types of concerns that we have tried to draw a clearer line between actions that are clinical in nature (e.g., seclusion and restraint) and those that are triggered mainly by security considerations (e.g., CALM).

Dr. Hayter's key point, if I read him correctly, is that we must not let the trappings of a high security prison divert us from our mission of providing compassionate care. To this extent we are in perfect agreement. Where we might differ, however, is in seeing essential and inherent contradictions between the priorities of security and treatment. While custody and therapy staff may, from time to time, have legitimate differences of opinion on the best way to manage dangerous prisoners, I have yet to meet the patient whose mental illness was cured because he had the opportunity to assault his staff or peers. While it is clear that there certain environmental conditions imposed by custody can be hazadous to a prisoner's mental health (prolonged segregation being the most important of these), we rarely impose comparable environments at HVC, and MDOC has never asked us to do so. Indeed, it is not by any means obvious to me that, on the whole, prisoners fare any worse under DOC supervision than they would fare, left to their own devices, in the community.

In any event, we appreciate Dr. Hayter's thoughtful observations and look forward to additional contributions from him and his many clinical colleagues.

Jim Dillon, MD

Administrator and CCA

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