Information about The Program in Psychiatry and the Law
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The following text serves as a brief history of The Program
in Psychiatry and the Law (PIPATL) at the Massachusetts Mental
It is copied from the preface of the book Decision Making in
Psychiatry & the Law by Thomas G. Gutheil, Harold J.
Bursztajn, Archie Brodsky and Victoria Alexander. Williams and
This book you are holding represents, among other things, a
compilation of ideas from the Program in Psychiatry and the Law
at the Massachusetts Mental Health Center and Harvard Medical
School- ideas that have evolved over a decade of collaborative
work. The members of the Program, past and present, are listed
elsewhere in this book. However, it may be valuable to place
members' contributions into perspective by offering a conceptual
biography, as it were, of the Program's ideas. In addition to
placing this book into context, such a review may also convey
some idea of the functioning of the Program itself.
The Program in Psychiatry and the Law (the Program) was founded
in 1979/1980 at the Massachusetts Mental Health Center (the
Center) through the efforts of Paul S. Appelbaum, M.D. Its
original mandate was to serve as a training program for young
forensic psychiatrists, who would learn through performing,
under supervision, medicolegal and ethical consultations with
the trainees and staff at the Center. To date the Program has
trained eleven Chief Residents in Legal Psychiatry who form an
informal nationwide group of Program associates; some still
attend meetings. In the early 1980s this medicolegal training
mandate was enlarged by the confluence of several conceptual
streams. The first was the problem in medicine as a whole of
making decisions under conditions of uncertainty, in the teeth
of the possibility of tragic outcomes. Models for guiding such
decision making were first outlined in a seminal text (1).
A second conceptual stream flowed from the demonstrated need of
medical decision theory to transcend the limited model offered
by the simplifying, certainty-driven mechanistic paradigm of
medicine and to reach the probabilistic paradigm, a concept both
more realistic and more suited to the inherent uncertainty of
A third stream flowed from the unequivocal need in the
medicolegal (or forensic) field for careful empirical study of
medicolegal events and the decision making that informed or
produced those events. We view this need for applied empiricism
as so fundamental to our thinking that it has become the
Program's motto: "Nobody's done the study to find out what
actually happens." Investigation in this area led to
empirical study of drug refusal (2), involuntary commitment
risk perceptions of psychotropic medication (4), and suicide
liability (see the discussion in Chapter 10).
The fourth stream flowed from the need for new ideas to enrich
the dialogue between clinical and legal realms. In particular,
although both legal and clinical realms have in common the
process of decision making-indeed, that is the fundamental
assumption of this book -there exists no methodology for
exploration of the intuitive decision making that all
practitioners employ in real life. Such reasoning had been
treated by theorists as a "black box," impervious to systematic
and reliable empirical analysis. The development by members of
the Program of a "gray box model," which "opens up" such
intuitive reasoning for scrutiny, is an important contribution
by the Program to the field (5).
A fifth conceptual stream flowed from issues of the therapeutic
alliance and the notion of informed consent as dialogue and
ethical construct rather than legalistically mandated transfer
of data. These wellsprings led to the Program's exploration of
both the alliance and informed consent as forces directed toward
liability prevention through their improvement of the
doctor-patient relationship, the central incubator for the
emotional substrate of liability (6).
A sixth conceptual stream flows from the notion that ethics
represents a valuable mechanism for decision making that is
older than both medicine and law and is most useful when both
those disciplines have exhausted their possibilities; ethics is
not merely a philosophical abstraction or a form of preaching of
"right behavior." Program members apply these concepts in the
regularly scheduled "Ethics Rounds" in the various departments
of the Center and in their writings (7).
The newest conceptual stream to enrich the Program flows from
Kohlberg's theories of the stages of moral development (8)
the manner in which these stages influence decision making.
These theories have colored much of the thinking in this book
and are summarized in the final chapter.
What does the Program actually look like in action? The earliest
meetings of three members on a weekly basis to pool ideas and
work on drafts of articles unwittingly served as the embryo for
the present "think tank" component of the Program's functioning
(the Program at present serving as think tank, consultation
service, and clinical research unit). As interested individuals
asked or were invited to attend to share ideas, discuss
medicolegal points of interest, gain forensic sophistication,
study decision analysis, exchange information, and nurture
academic interests and concerns, the Program has grown to about
twenty active participants meeting weekly; another dozen
individuals, some former "actives," drop in occasionally.
Attorneys, psychiatrists and forensic psychiatrists,
psychologists, research methodologists, students of various
disciplines, and individuals with mixed degrees (especially
clinical-legal) participate; as policy the Program bars no one
and invites participation without "admission requirements." The
opportunity thus provided for egalitarian debate, discussion,
and mutual peer enrichment around problematic cases, thorny
conceptual issues, and empirical investigations has drawn
practitioners experiencing the loneliness of solo practice,
investigators seeking guidance on research design,
undergraduates considering forensic careers, clinicians eager to
sharpen awareness of medicolegal matters, and others to sit in.
One of the Program's most important structural innovations has
been to include gifted medical writers as integral members to
capture ephemeral ideas generated in brainstorming sessions and
to edit successive drafts of those materials aimed at
publication in profes-sional journals. As a result the Program
has been a prolific source for "think pieces," empirical studies
(some unprecedented), and education on risk management, and a
stimulus for conceptual advances in the field. The fruits of the
first decade of this exhilarating process are in your hand.
- Doctor-Patient (Supervisor-supervisee, etc.) Relationship and
its clinical, ethical and legal basis
- Resisters and succumbers
- Perception of
- Attachment (alliance, transference, counter-transference,
- Fairness, Unbiased-ness, etc.
- Understanding right from wrong
- Conforming one's behavior
- Standing Trial
- Taking care of oneself and what kind of conservator if any
- Understanding other's behavior, emotions, feelings, perceptions
- Dangerousness, Violence and Antisocial Behavior
- Diagnosis, assessment and treatment strategies
- Its development
- Work relations, politics, and cases
- Do other doctors do in some doctors
- Scrutiny of work
- Defensive Medicine
- Consulting and Professional Issues
- Conflict of interest
- Relationship between medical, caregiving role and forensic role
- Treatment and Evaluation Roles
- Plaintiff witness and Defense witness roles
- False accusations
- Standard of Care
- Standards in Systematic Assessment
Bursztajn HJ, Fembloom RI, Hamm RM, Brodsky A. Medical choices,
medical chances: how patients, families, and physicians can cope
with uncertainty. New York: Rutledge, Chapman and Hall, 1990.
Appelbaum PS, Gutheil TG. Drug refusal: a study of psychiatric
inpatients. Am J Psychiatry 1980; 137:340346.
Bursztajn HJ, Gutheil TG, Mills MJ, Hamm RM, Brodsky A. Process
analysis of judges' commitment decisions: a preliminary
empirical study. Am J Psychiatry 1986;143:170174.
Bursztajn HJ, Chanowitz B, Kaplan E, Gutheil TG, Hamm RM.
Contrasting risk perceptions between medical and legal
professionals regarding use of antipsychotic medication.
submitted for publication.
Bursztajn HJ, Gutheil TG, Hamm RM, Brodsky A, Mills MJ, Levy L.
Transitions in clinicians self reports of the assessment of
commitability. Int J Psychiatry Law, in press.
Gutheil TG, Bursztajn HJ, Brodsky A. Malpractice prevention
through the sharing of uncertainty: informed consent and the
therapeutic alliance. N Engl J Med 1984;31 1:49-51.
Appelbaum PS, Reiser SJ. Ethics rounds: a model for teaching
ethics in the psychiatric setting. Hosp Community Psychiatry
Kohlberg L. Essays on moral development. Vol.2: The psychology
of moral development: moral stages; their nature and validity.
San Francisco: Harper and Row, 1984.