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Brief History

The following text serves as a brief history of The Program in Psychiatry and the Law (PIPATL) at the Massachusetts Mental Health Center.
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 Wilkins, 1991.


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 modern practice.
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 (3), 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) and 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.

References

Core Issues

  1. Doctor-Patient (Supervisor-supervisee, etc.) Relationship and its clinical, ethical and legal basis
    1. Sex
    2. Resisters and succumbers
    3. Boundary
    4. Resisters
    5. Perception of
    6. Attachment (alliance, transference, counter-transference, beneficence)
    7. Emotions
  2. Decision-Making
    1. Fairness, Unbiased-ness, etc.
    2. Uncertainty
  3. Competence
    1. Understanding right from wrong
    2. Conforming one's behavior
    3. Standing Trial
    4. Taking care of oneself and what kind of conservator if any
    5. Understanding other's behavior, emotions, feelings, perceptions and preferences
  4. Dangerousness, Violence and Antisocial Behavior
    1. Diagnosis, assessment and treatment strategies
    2. Prediction
    3. Its development
    4. Stalking
    5. Liability
  5. Atmosphere
    1. Work relations, politics, and cases
    2. Do other doctors do in some doctors
    3. Scrutiny of work
    4. Atmosphere
    5. Litigiousness
    6. Defensive Medicine
  6. Consulting and Professional Issues
    1. Conflict of interest
    2. Relationship between medical, caregiving role and forensic role
    3. Treatment and Evaluation Roles
    4. Plaintiff witness and Defense witness roles
    5. False accusations
  7. Standard of Care
    1. Standards in Systematic Assessment

 


REFERENCES

1. 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.

2. Appelbaum PS, Gutheil TG. Drug refusal: a study of psychiatric inpatients. Am J Psychiatry 1980; 137:340346.

3. 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.

4. 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.

5. 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.

6. 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.

7. Appelbaum PS, Reiser SJ. Ethics rounds: a model for teaching ethics in the psychiatric setting. Hosp Community Psychiatry 1981;32:555-560.

8. 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.

 
 

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The Program in Psychiatry and The Law meets Wednesday mornings at 11:00 AM in Room 340 3rd floor of the new Mass Mental Health Center at 75 Fenwood Road. Left from the elevator and all the way down the hall.

Check our meetings page regularly to find out about our upcoming meetings.

Our file library includes copies of the Amicus Briefs to which we have contributed: Althaus v. Cohen (PA) and Citizens for Health v. Thompson (Third Circuit).

 Tuesday, September 1, 2015
First meeting of the new academic year = Wednesday, September 9!
 Sunday, February 23, 2014
PIPATL Meeting Location:
Room 340 on the 3rd floor of Mass. Mental Health Center, 75 Fenwood Rd. Left from the elevator and all the way down the hall. The room has a communications center that allows more than one person to call in at a time!!
 
 
 
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