Susan Hatters Friedman, MD and the Group for the Advancement of Psychiatry, Recipient of the Guttmacher Award - American Academy of Psychiatry and ...
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Fall 2020 • Vol. 45, No. 3
Susan Hatters Friedman, MD and have critically different prevention
strategies.
the Group for the Advancement The presentation highlighted topics
from the book, outlining various
of Psychiatry, Recipient of the murders within the family, their
Guttmacher Award motives, and prevention approaches
flowing from these motives. The types
Renée Sorrentino, MD of family murder discussed included
intimate partner violence, neonaticide,
on epidemiology, motivations, unique infanticide/filicide, siblicide, parricide
assessment needs and prevention, and and familicide. Motives for family
each chapter is authored by a forensic murder include mental health-relat-
psychiatrist with content expertise ed motives such as those caused by
on the topic. The chapter authors are psychosis, as well as non-psychiatric
the members of GAP’s Committee on reasons of jealousy, greed, pride,
Psychiatry and the Law. anger and revenge.
Dr. Hatters Friedman’s presenta- Like the book, the presentation
tion began with acknowledgment that began with intimate partner homicides
cases of murder within the family and progressed through the life cycle
frequently appear in media headlines, of the family. Dr. Hatters Friedman
citing Susan Smith, the Menendez introduced the categories of family
brothers, and Nicole Brown Simpson. murder including both the forensic
The book utilizes such high-profile and clinical aspects of the specific
cases as a framework to discuss the type of homicide. The role of psychi-
psychiatric understanding of each atric illness in each type of familial
category of family murder. Identi- murder was reviewed.
fying violence and homicide within In conclusion, Dr. Hatters Fried-
the family as important public health man discussed preventive measures
issues, Dr. Hatters Friedman drew such as addressing dynamic risk
attention to the frequency with which factors for family violence includ-
mental health professionals are con- ing treating serious mental illness.
fronted with violence within the fam- Preventative strategies such as Safe
The Manfred S. Guttmacher ily. Furthermore, she suggested that it Havens, anonymous delivery and
Award, co-sponsored by AAPL and is critical that psychiatrists understand baby hatches, were discussed in the
the APA and established in 1975, rec- the various motives for these homi- neonaticide section of the talk. These
ognizes an outstanding contribution cides, because the various motives (continued on page 4)
to the literature of forensic psychiatry.
The 2020 Guttmacher Award recip-
ient is Susan Hatters Friedman, MD
and the Group for the Advancement
of Psychiatry (GAP), for the book,
Family Murder: Pathologies of Love
and Hate (published 2019). The an-
nual Guttmacher Award Lecture was
given remotely as part of the APA On
Demand 2020, an online collection
of expert-led presentations, in lieu of
the cancelled APA annual meeting.
This book provides a comprehensive
analysis of the different types of
murder within families. The chapters Members pictured: Phil Resnick, Peter Ash, Susan Hatters Friedman, Jacob
are organized similarly, with sections Appel, Deborah Giorgi-Guarnieri, Rick Frierson
Members not pictured: Alec Buchanan, Jacqueline Landess, Debra Pinals
American Academy of Psychiatry and the Law Newsletter Fall 2020 • 1
American EDITOR’S COLUMN
Academy of
Psychiatry 2020: The Unprecedented Year
and the Law Joseph R. Simpson, MD, PhD
Editor The COVID-19 experience as a policeman and federal
Joseph R. Simpson, MD, PhD pandemic has agent to examine possible causes of
Associate Editors inflicted great racism and misconduct in law en-
Philip J. Candilis, MD suffering and forcement, as well as solutions.
Ryan C. W. Hall, MD hardship on the Faithful readers of this Newsletter
Stephen P. Herman, MD globe and has may remember that my last column
Neil S. Kaye, MD created numerous had a QR code for a brief survey
Britta K. Ostermeyer, MD, MBA
changes in every- about the Newsletter. I am sorry to
Karen Rosenbaum, MD
Renée M. Sorrentino, MD day life that are so report that the response was decidedly
Joel Watts, MD familiar to us all that they need no underwhelming. The link (below) re-
recounting here. Similarly, the social mains active, and I encourage every-
AAPL Photographer protests that began in the late spring one to take just a couple of minutes
Eugene Lee, MD in the US and many other nations are to scan the QR code on this page with
Former Editors sure to be well-known to all who read your smartphone, or type the link
Susan Hatters Friedman, MD (2016-2018) this Newsletter. This last edition for into your web browser of choice and
Charles Dike, MD, MPH (2008-2016) 2020 has several timely contributions complete the survey. AAPL is also
Victoria Harris, MD, MPH (2003-2008) exploring aspects of these ongoing, planning to send an email to all mem-
Michael A. Norko, MD (1996-2003) historic phenomena which you are bers with the link. I will report the
Robert Miller, MD PhD (1994-1996)
Alan R. Felthous, MD (1988-1993)
sure to find enlightening. results in a future issue. For now, I’ll
Robert M. Wettstein, MD (1983-1988) AAPL President Dr. Newman just comment that a more than two-to-
Phillip J. Resnick, MD (1979-1983) completes his discussion of wellness one majority of the (admittedly very
Loren H. Roth, MD, MPH (1976-1979) in forensic psychiatry – a subject few) respondents were opposed to
which is more important now than eliminating the hardcopy Newsletter
Officers
ever before – and announces AAPL’s in favor of a digital-only product. But
President new peer support program. Medical the Newsletter’s Editorial Board wants
William J. Newman, MD
Director Dr. Janofsky reflects on the everyone’s voice to be heard, so that
President-elect
Liza H. Gold, MD
impact of COVID-19 on the APA and the Newsletter can continue to meet
AAPL this year and what it may mean the needs of the AAPL membership.
Vice President
Michael K. Champion, MD for AAPL’s future. Dr. Herman’s I urge everyone to think positive
Vice President
Child Column reviews a historical thoughts for those who have been
Charles C. Dike, MD episode of racism almost exactly one ill, or who have lost loved ones this
Secretary hundred years ago. The Ask-the- year. If you’re in a position to help
Paul Fedoroff, MD Experts Column by Drs. Kaye and and support someone impacted by the
Treasurer Glancy is an important tutorial on pandemic, keep it up, or start! Many
Stuart A. Anfang, MD keeping oneself as safe as possible people around the world have been
Immediate Past President from threats by those we evaluate. demonstrating the positive attitude
Richard L. Frierson, MD The stresses caused by the pandemic and can-do spirit that is so often
might be anticipated to provoke more revealed when adversity strikes. I’m
The AAPL Newsletter is published by
AAPL, One Regency Drive, PO Box
people subject to forensic examination sure many of you have seen the home-
30, Bloomfield, CT 06002. Opinions to make threats when they believe the made signs around your town, thank-
expressed in bylined articles and columns expert’s report may not be favorable, ing first responders and healthcare
in the Newsletter are solely those of the and possibly to try to act on those professionals for their bravery and
authors and do not necessarily represent threats, so now is certainly the time sacrifice. One implicit message these
the official position of AAPL or to review the measures you take. signs convey is: Working together will
Newsletter editors. AAPL’s representatives to the AMA help us get through this.
Manuscripts are invited for publication in
the Newsletter. They should be submitted
(Drs. Piel and Wall) and APA (Dr.
to the editor via email to NewsletterEdi- Kushner) discuss how those organiza-
tor@aapl.org tions are responding to the unfolding
The Newsletter is published in events of 2020. We are also fortunate
Winter (deadline for submission is in this issue to have not one but two
November 15), Spring (deadline Fellows’ Corner articles. Drs. Dorn-
March 1), and Fall (deadline July 1).
feld and Spina describe the impact of
www.aapl.org the pandemic on the training experi-
© 2020 AAPL. ALL RIGHTS RESERVED. ence, while Dr. Brennan draws on his
https://www.surveymonkey.com/r/CVDZZVM
2 • Fall 2020 American Academy of Psychiatry and the Law Newsletter
PRESIDENT’S REPORT
Professional Existential Crises in at an institutional level (9). However,
it has not yet been implemented at an
Forensic Psychiatry organizational level.
William J. Newman, MD Given the challenges unique to
forensic psychiatrists, AAPL will
Wellness in of child sexual abuse before immedi- be rolling out a new peer support
forensic psychi- ately transitioning to a family func- program in late 2020. The program
atry has received tion. Similarly, there are challenges will be designed to provide structured
limited attention associated with transitioning from an support from fellow members to
to date, despite eight-hour day of deposition or trial members experiencing professional
the considerable testimony to a relaxed social event stressors in a prompt, confidential,
risks to forensic with friends or family. There exists and empathetic manner. We hope to
psychiatrists. In no consensus on how best to accom- be able to provide insights to other
this three-part plish these transitions. Discussing professional organizations regarding
series, I aimed to stimulate discussion these skills is not currently part of the best practices for peer support.
about specific challenges to long- curriculum for forensic psychiatry fel-
term wellness. The first two pieces lowships, though perhaps it should be. References:
(1) Hertzberg TK, Rø KI, Vaglum PJW, et
discussed resilience as a potential As I have gotten to know many
al.: Work-Home Interface Stress: An Import-
protective factor and potential long- forensic psychiatrists, it has become ant Predictor of Emotional Exhaustion 15
term deleterious effects of chronic increasingly apparent that many have Years into a Medical Career. Ind Health 54:
stress. This final entry is focused on experienced moments or periods 139-148, 2016
additional issues unique to forensic involving a degree of existential crisis (2) Carnes AM: Bringing Work Stress
psychiatry. about the career. The thoughts may Home: The Impact of Role Conflict and
Forensic psychiatry involves chal- occur in the setting of unwanted con- Role Overload on Spousal Marital Satisfac-
lenges that are not routinely experi- tact from an evaluee, an undesirable tion. J Occu Org Psychology 90: 153-176,
enced in other medical disciplines, outcome in a case, or exhaustion after 2017
including general psychiatry. Many late-night or early-morning report (3) Coleman J, Coleman J: Don’t Take Work
who train in forensic psychiatry are writing while trying to meet actual (or Stress Home with You. 2016. https://hbr.
org/2016/07/dont-take-work-stress-home-
naturally perfectionistic. The disci- self-imposed) deadlines. Regardless with-you. Accessed July 19, 2020
pline provides the allure of rewarding of the impetus, many forensic psychi- (4) Isobel S, Angus-Leppan G: Neuro-Rec-
those who strive for perfection, while atrists at some point question aspects iprocity and Vicarious Trauma in Psychia-
balancing the understanding that of this peculiar career, even if they trists. Australasian Psychiatry 26: 388-390,
none of us can be perfect. Typos and enjoy most aspects of the work. 2018
miscommunications are part of life, Vicarious trauma has received (5) Nikischer A: Vicarious Trauma Inside
even for the most skilled and cautious increasing attention as one aspect of the Academe: Understanding the Impact of
forensic psychiatrist. However, in promoting and maintaining wellness Teaching, Researching, and Writing Vio-
forensic cases, outcomes can hinge on in individuals routinely exposed to lence. Higher Education 77: 905-916, 2019
the interpretation of a single phrase. distressing work content (4-6). The (6) Pirelli G, Formon DL, Maloney K:
Preventing Vicarious Trauma (VT), Com-
There is additionally risk that a con- potential impact of work-related
passion Fatigue (CF), and Burnout (BO) in
siderable misstep can haunt a forensic trauma was deemed sufficiently Forensic Mental Health: Forensic Psychol-
practitioner for the rest of their career, problematic as to be incorporated into ogy as Exemplar [published online ahead of
resurfacing each time they testify. the DSM-5’s “A-Criteria” for PTSD, print, 2020 Feb 10]. Professional Psycholo-
Attorneys’ access to prior testimony as follows: “Experiencing repeated or gy doi:10.1037/pro.000293, 2020
is plentiful, particularly in the digital extreme exposure to aversive details (7) Posttraumatic Stress Disorder. In: Diag-
age. of the traumatic event(s) (e.g., first nostic and Statistical Manual of Mental Dis-
In addition to the workplace chal- responders collecting human remains; orders, Fifth Ed. Arlington, VA: American
lenges, we are developing an in- police officers repeatedly exposed to Psychiatric Association; 2013: 271–280
creased understanding of the potential details of child abuse)”. The DSM-5 (8) Firth S: AMA to Promote Use of Peer
impact of allowing stress from work clarifies that the exposures must be Support Groups. 2019. https://www.medpag-
etoday.com/meetingcoverage/ama/80467.
to impact home life (1, 2). Some work-related (7).
Accessed July 19, 2020
authors have suggested mechanisms Peer support is one mechanism that (9) Shapiro J, Galowitz P: Peer Support for
for limiting the impact of work-relat- can be utilized to limit the potential Clinicians: A Programmatic Approach. Acad
ed stress on home life (3). Compart- impact of vicarious trauma. The Med 91: 1200-1204, 2016
mentalizing work stress is especially American Medical Association has
important in forensic psychiatry. Few publicly supported the use of peer
understand the difficulty of reviewing support systems for physicians (8).
hours of records about horrific acts Peer support has been implemented
American Academy of Psychiatry and the Law Newsletter Fall 2020 • 3
MEDICAL DIRECTOR’S REPORT
AAPL and the COVID-19 World the future). There were 1452 ballots
mailed and 316 returned, with 313 yes
Jeffrey S. Janofsky, MD votes and 3 no votes, so the amend-
ments passed.
I wrote my last lel to or to replace our face-to-face So where will AAPL be in the first
newsletter article October 2020 annual meeting. The few years of its second 50 years? We
in November Executive Committee appointed a are in a rapidly changing and unpre-
2019. It was titled workgroup chaired by AAPL member dictable world. However, our organi-
AAPL: Beginning Anne Hanson to outline what such a zation, with your help, will continue
the Next 50 years. virtual meeting would look like, and to strive through our staff, leadership,
None of us could to find and vet service providers for and membership to adapt. We will
have known then that meeting. continue to be the leading organi-
that the novel As I finalize this article at the end zation of psychiatrists dedicated to
coronavirus and the disease it caus- of June 2020, it is not clear what excellence in practice, teaching, and
es, now named COVID-19, was just the state of the pandemic will be in research in forensic psychiatry in the
beginning its advance through China the United States by October. Right United States.
and that by March 2020 it would ig- now, there are significant upticks in I hope all of you and your families
nite a worldwide pandemic. National outbreaks in Arizona, Texas, Florida, are well and stay safe.
and state emergencies have been de- and California. Health and Human
clared, shutting down many industries Services Secretary Alex Azar warned Reference:
and essentially stopping national and today that the “window is closing” for (1) CNN, “State of the Union,” June
international travel. As physicians are the United States to get the pandem- 28, 2020.
therefore essential personnel, all of ic under control (1). Air travel is
us began running at 10,000 miles an slowly opening up, but it was recently
hour to quickly adapt our general and reported that some air carriers will not Cover Article
forensic practices, so that we could keep middle seats open during travel continued from page 1
continue safely treating patients and and that therefore there would be no
continue to safely evaluate forensic way to achieve social distancing on strategies are aimed at providing al-
clients. Many of us moved to video flights. The consultant that AAPL uses ternative options for mothers to leave
apps so that our outpatients could to contract our meeting hotels (and unwanted infants in safe circumstanc-
remain safely in their homes, and these contracts are made five to six es without the fear of prosecution.
we could safely distance from them years in advance) has not been able to Dr. Hatters Friedman summarized
and still provide effective treatments. get in touch with the convention staff the complex relationship between
Those of us who had general psychi- at the Marriott in Chicago where our stressors and mental health, explain-
atric inpatient or correctional practices meeting is scheduled to be held, be- ing that the motives in family murder
had to make multiple modifications cause there is literally no one there to are multifactorial and often extreme
in our practices as well to keep answer the phone. Given all the above versions of emotions everyone has
ourselves, our colleagues, and our I think it is likely, but not yet certain, experienced. In some cases, men-
patients safe. The shortage of personal that we will have a virtual meeting tal illness is the direct cause of the
protective equipment and changing only in October 2020. murder, in other cases it is related but
safety recommendations have made As you may recall from my pre- not causal. Prevention efforts must
safe practice even harder. vious article, AAPL Past President consider antecedents and motives.
With only several weeks’ notice, Richard Frierson asked me to chair For those who missed this year’s
the American Psychiatric Association a Task Force to update the Bylaws, online version of the Guttmacher
canceled its in-person April 2020 which had not been substantially Award lecture, it is available via the
meeting, thus AAPL had to cancel its updated for many years. Along with APA library. The book itself is now
semiannual meeting as well. With the many technical changes, our group available as an audiobook as well.
help of Jackie Coleman and the AAPL recommended adding one Early Congratulations to the Group for the
central office staff, we were able to Career Councilor, one Minority/Under Advancement of Psychiatry and to Dr.
hire a remote video provider so that Represented (M/UR) Councilor, and Hatters Friedman for this important
the nominating committee, the AAPL one Women’s Councilor to the AAPL contribution to the field, delivered
Council, and the general membership Council Structure. These changes with the wit, compassion and knowl-
could meet via Zoom. (I wonder how were approved by AAPL Council, edge that we all have come to know
many of us had even heard of Zoom published on the Web, and were sent her for.
before March 2020?) out by mail for a membership vote.
The AAPL Council instructed the (You will probably be happy to know
Executive Committee to prepare for that one of the technical amendments
a virtual meeting to either run paral- was to allow electronic voting in
4 • Fall 2020 American Academy of Psychiatry and the Law Newsletter
CHILD COLUMN
Bisbee and Beyond she would keep her children safe
from their father. But the bishop
The Clergy-Penitent Privilege never reported the ongoing abuse.
Neither did his successor. The man
Stephen P. Herman, MD
continued to abuse his daughter and
Bisbee, Arizona the Union, those who could not read another daughter just six months old.
lies in Cochise and explain sections of the United He posted videos of his abuse on the
County, in the States Constitution were prohibited Internet which were discovered by the
southeastern part from voting. Department of Homeland Security.
of the state, 11 Poorly paid Anglos and near-desti- The father was charged with multiple
miles from the tute Mexicans joined in strikes against crimes. The mother was indicted on
Mexican border. the companies. The miners were 12 criminal counts and pleaded no
Named after supported by the Industrial Workers contest to two counts of child abuse.
Judge DeWitt of the World, also called “Wobblies,” There was also a criminal investiga-
Bisbee, the town flourished because from their slogan, One Big Union. tion into the church’s role.
of the discovery of large deposits of While Americans went “Over An attorney is preparing to sue the
copper, gold and silver. Phelps Dodge There” to fight in World War I, the two Latter-Day Saints bishops. A
was one of the largest copper mining price of copper hit the stratosphere. member of the Arizona Legislature
companies in the area. Judge Bisbee As patriotic fervor gripped the nation, has vowed to eliminate the “confes-
was the principal financial backer the mine owners though it a perfect sional exemption” which has protect-
of the Copper Queen Mine. Copper time to neutralize the strikers. They ed clergy from being mandated report-
supplies seemed infinite. Bisbee planned how to get rid of the strikers ers. Another legislator has vowed to
shimmered with the beautiful colors for good. make sure the exemption remains in
of copper minerals: galena, cuprite, The miners who were thought to be place.
azurite and malachite. traitors were pulled from their homes The religious exemption takes its
However, racism was rampant. and paraded at gunpoint down the cues from an Alice-in-Wonderland
Mexicans, the largest group of min- main streets of Bisbee to a ballpark. approach. Yes, Arizona’s mandato-
ers, continually fought the Czechs, Twenty-three boxcars of the El Paso ry reporting law requires clergy to
French, Italians and other ethnic and Southwestern Railroad pulled report suspected, ongoing child abuse.
groups who had come seeking work. into the nearby station and 1,186 men However, if they are told of the abuse
There were also frequent battles with were jammed into them. They were during a formal confession, they are
the Apaches. Still, Phelps Dodge and taken to southwestern New Mexico not under obligation to report. Each
other companies needed more miners. and let out in the desert, dehydrated cleric makes his or her own decision.
They brought in Chinese laborers. and starving. This became known Attorneys representing religious in-
Anglos and Mexicans – usually sus- as the Bisbee Deportation. Despite stitutions argue that this privilege has
picious of each other – united in their countless federal and state indictments existed for centuries and is protected
abhorrence of the Chinese. against the leaders – and thanks to the by the First Amendment. For exam-
But as more Mexicans crossed limitless funds of Phelps Dodge and ple, in the ninth century, priests who
the border into Bisbee, violence and other companies – not a single person violated the privilege were punished.
racism were directed toward them was ever convicted. Today, Catholic priests can be excom-
by their former allies, the Anglos. This horrible chapter of American municated if they reveal anything, in-
Mexicans were called “peons” and history was told in a recent film, cluding a confession of sexual abuse,
“dark-skinned like the Indians.” Bisbee 17, which featured towns- by a penitent.
Native Americans were forced into people reenacting the deportation. In the earliest US case regarding the
reservations with squalid conditions. Young people did not know about the privilege, People v Phillips (1813),
The mining corporations segregated deportation; adults were reluctant to the Court of General Sessions of the
Mexican camps from those of the talk about it. Bisbee grew into a fine City of New York opined, “It is essen-
white miners. The owners justified and friendly Arizona town. It still had tial to the free exercise of a religion,
their racism based upon the “science” its secrets, but many of these occurred that its ordinances should be admin-
of social Darwinism. behind closed doors, drowned out by istered – that its ceremonies as well
Mexicans continued to ford the Rio the thrumming of air conditioners. as its essentials should be protected.
Grande, hearing about work oppor- Bisbee made news again in 2020. Secrecy is of the essence of penance.
tunities in Bisbee. These newcomers One of its citizens told his Mormon The sinner will not confess, nor will
were permitted to work only if they bishop that he was sexually abusing the priest receive his confession, if the
spoke English. his five-year-old daughter. The bishop veil of secrecy is removed: To decide
As late as 1909, three years before provided “counseling,” involving that the minister shall promulgate
the Arizona Territory was admitted to the mother in the sessions. He hoped what he receives in confession, is to
(continued on page 26)
American Academy of Psychiatry and the Law Newsletter Fall 2020 • 5ASK THE EXPERTS
In considering attacks upon fo-
Ask the Experts rensic psychiatrists and psychiatrists
Neil S. Kaye, MD, DFAPA in general, the following literature,
although fairly sparse, is sobering.
Graham Glancy, MB, ChB, FRC Psych, FRCP (C)
Antonius et al. (1), while describing
Neil S. Kaye and Graham Glancy uee? Are there windows in the office a case study of a psychiatric resident
will answer questions from members allowing other people to observe what who was attacked by a patient, notes
related to practical issues in the real is taking place? that a third of psychiatrists have been
world of forensic psychiatry. Please If I believe the person is a signif- assaulted at least once, and 36–56%
send questions to nskaye@aol.com. icant risk, I will often do the evalua- of psychiatric residents have expe-
This information is advisory only, tion at their lawyer’s office or ask for rienced physical assault. Davies (2)
for educational purposes. The authors a staff member to be present. This is surveyed psychiatrists and found
claim no legal expertise and should one case where I find recording things 70% reported one or more assaults in
not be held responsible for any action can be helpful, as people are less the last year and 32% reported one
taken in response to this educational likely to act out if there is a camera on or more threats. Regarding forensic
advice. Readers should always consult them. I might leave the door ajar to psychiatrists, Leavitt et al. (3) sur-
their attorneys for legal advice. allow colleagues to monitor the noise veyed forensic clinicians and found
level, should it heighten. If the person 76 out of 190 (40%) reported distress-
Q: How do you handle being threat- has a real history of threats, I often ing incidents but noted that there was
ened during an evaluation? ask them how the last evaluation went no greater risk of aggressive behavior
and then assure them I am gentler in in the forensic context. Madden et al.
A. Kaye: my approach and want them to feel (4) found that about 40% of foren-
The best ad- heard. I tell them I am aware of what sic psychiatrists had been assaulted,
vice I can offer is happened from the records I reviewed including 1.5% who had been shot.
to be prepared for and I remind them that they can stop Miller (5) reported that 42% of AAPL
every evaluation. and take a break at any time. I use my members had been harassed in some
Reviewing the clinical skills to monitor the situation way outside of court, noting that more
relevant docu- and if I see the person getting irrita- than half the assaults arose from “at-
ments in advance ble, I suggest we take a break or tell torneys, relatives and others.”
of any evaluation them I need to use the bathroom and I divide the type of threat into three
is critical for many reasons, including stand up to demonstrate that we are categories. First, the evaluee may
personal security. Does the person taking a break. make a simple direct physical threat.
have a history of manipulative threats I might remind them that I am try- Second, they may threaten to report
or do they have a history of genuine ing to do a good job and that I don’t you to your licensing body or other
antisocial personality and/or criminal think as clearly when I am threat- disciplinary body. Third, they may
history involving harm to others? If ened and anxious, so if they want threaten to harm you or your family at
you know the person’s history of me at my best, they need to take a a later date.
threats and violent actions in the past deep breath and give me time to hear Whatever the type of threat, deal-
you will be better at avoiding trigger- them. In general, I abide by the old ing with threats can be divided into
ing the evaluee. If the person has a adage that one catches more flies with three phases. First, and most import-
history of threatening prior evaluators honey than with vinegar. In other ant, is prevention. Second is goals
or of bringing a weapon to an evalu- words, high-pressure, confrontational management and de-escalation. Third
ation you can prepare for this likeli- interviewing isn’t my style, nor does is dealing with the consequences,
hood. If they do, I will ask them if the literature show it produces better which might involve anxiety, stress,
they have a weapon on them and if so, results. and various administrative problems.
I ask them to lock it in their vehicle In terms of prevention, one of the
before we start. A. Glancy: most important issues is obtaining
Next, I would review my logistics When consider- informed consent. This helps to
and office set-up. It’s different seeing ing this question, manage expectations right from the
someone alone in a private office one of my first beginning. For instance, explaining
compared to a busy unit in a forensic thoughts was to that your role is to strive for honesty
setting. Do you have a panic button honor and remem- and objectivity lets the evaluee know
available to summon help if needed? ber our respected that you are not necessarily on a
Is the furniture arranged so that the colleague and late particular side right from the begin-
evaluee can get to the door directly friend, Dr. Steve Pitt, who was shot ning. Thus, they may not be as angry
without having to go through (or over) and killed outside his office in 2018. at you when they realize that you are
you? Can you also egress immediate- This should serve as a reminder to not heading in the direction of giving
ly without directly crossing the eval- take security seriously.
(continued on page 7)
6 • Fall 2020 American Academy of Psychiatry and the Law NewsletterASK THE EXPERTS
Ask the Experts it sound as though these are their the rest of your career. My view,
continued from page 6 ideas. In short, you should be nearest although somewhat idiosyncratic, is
to the emergency button, you and the that a single training session in these
them whatever goal is on their mind. evaluee should be equidistant from techniques gives people a false sense
It is also important to advise them at the door, and if it can be arranged, of security and unless they are of the
the start of the limited confidentiality you should not be in their way when most basic kind, such as put both
of the report. During an assessment they want to storm out. One of my hands up to cover your face, they give
that I did of a schoolteacher’s fitness colleagues who teaches de-escalation people a false sense of security, which
to work, a complaint was filed with for mental health workers in the jail, might end up with them getting into
my disciplinary body stating that I made the clever observation that when physical altercations (James Knoll,
should not have shared his psychiatric sitting on the “picnic table” that we MD, personal communication). The
diagnosis. I was able to produce a are often stuck with in jails, try not to best techniques are psychological.
signed consent form which specifi- have both legs underneath the table, They involve addressing the evaluee’s
cally stated that anything he told me since if you have to make a hasty exit obvious escalation and discomfort.
or that I concluded may go in a report this can make it very difficult. You should also pay attention to
to the responsible body. It is helpful In your own office, if you are antic- physical space. If the situation arises,
if this procedure is in writing so that ipating any sort of threats, you should as it does sometimes in assessments
it can be produced later for these have a security plan worked out with in jails, that you are standing face-to-
purposes. the office staff. It is helpful if this face with an evaluee, I always shuffle
I also inform the evaluee that I am involves set procedures, and that you to their right side. This de-escalates
trying to write things down verbatim have had a chance to rehearse it. the aggressive face-to-face contact
and I may not react to what they are It may also be important to be and also makes it more difficult for
saying in a way that they expect. This aware of linguistic and cultural them to hit me with their right hand,
is an attempt to head off possible issues, whereby your behavior may which is usually how people try to
irritation that they just told me, for ex- be particularly insulting or aggressive strike.
ample their wife left them, and I may as perceived by the evaluee. Prior In dealing with the third threat-
not have reacted with concern. This awareness of these issues may prevent ening situation, when the evaluee
is partly because of my own personal the situation from deteriorating and utters the dreaded “I know where you
style, as I am trying to maintain the spinning out of control. It is also live,” you should be in the situation
stance of what Kenneth Appelbaum, helpful to clearly set limits of behav- where you can say “No, you proba-
MD called the forensic equivalent ior prior to beginning the interview. bly don’t.” As the literature shows,
of empathy (6) – what I like to call Another aspect of prevention is to victims of stalking often feel that they
detached concern. consider another person either accom- are under siege. This may involve
Dr. Kaye has rightly pointed out panying you or being right outside the letters or messages or even gifts being
to pay attention to the physical layout door, especially if prior information dropped off at your office or even
of the examination room. Foren- on file suggests that the interview worse at your home. It is helpful if
sic psychiatrists are often “playing could result in aggression. The other you do not use your home address for
away from home” and we have to person may be a colleague, but in anything, except when you are legally
see people in jails, detention centers, some circumstances may be a security required to do so (7). For instance,
or spaces not really designed with officer, a correctional officer, or a po- when registering at a fitness club,
our safety in mind. Consequently, lice officer. Sometimes this will meet dance class, or theater subscription,
we often lose control of the situation with opposition from the evaluee, as use your office address if at all possi-
right from the beginning. It is most well as confidentiality issues. How- ble. Nowadays the medium of elec-
helpful if you try and slow the process ever, if your physical safety is really tronic communication makes stalking
down. When you are shown into the at risk, compromises will need to be even easier. In order to prevent this,
examination room, ask the person made. it is helpful if you keep your social
hosting about their opinion regarding In terms of managing the inci- media presence to an absolute mini-
safety procedures. This demonstrates dent, de-escalation techniques are mum. This means either not having
to them that you respect their opinion, obviously helpful. Many institutions a presence on Facebook, Instagram,
and they then take responsibility for offer training in de-escalation, and etc., or if you really need to consider
the situation. Thus, they may say you should take the opportunity to paying attention to such, anonymizing
that the evaluee should sit in a certain do this if at all possible. On a side them or paying the highest possible
place, that you should be nearest to note, the same training sessions often attention to security settings. Con-
the alarm button, and that they will be demonstrate self-defense techniques. sider using such techniques as having
vigilant for any signs of hostility or These techniques likely are helpful, unlisted home phone numbers, PO
agitation. At this stage, you can guide but only if you are willing to then boxes, and home and office security
the ideas based on your knowledge practice them two or three times a systems. Cars should be parked in
of safety procedures, and even make week for about a year, and then for
(continued on page 29)
American Academy of Psychiatry and the Law Newsletter Fall 2020 • 7RAPPEPORT FELLOWSHIP AWARDS, 2020-2021
Britta K. Ostermeyer, MD, MBA, and Susan Hatters Friedman, MD
Co-Chairs, Rappeport Fellowship Committee
The prestigious AAPL Rappeport Fellowship was named in honor of AAPL’s founding president, Jonas Rappeport, MD.
It offers the opportunity for outstanding senior residents with a dedicated career interest in forensic psychiatry to receive
mentorship by senior forensic psychiatrists. Rappeport Fellows will receive a scholarship to attend the AAPL forensic psy-
chiatry review course and the annual AAPL meeting, and a one-year mentorship by two Rappeport Fellowship Committee
members. We wish to thank the AAPL Executive Leadership, the Rappeport Fellowship Committee members, and all Rap-
peport preceptors for their ongoing support of this superb training opportunity! The Rappeport Fellowship Committee and
AAPL are excited to announce the 2020-21 Rappeport Fellows: Dr. Kathryn Baselice, Dr. Ayala Danzig, Dr. Tyler Durns,
Dr. Gregory Iannuzzi, Dr. Laura Sloan, and Dr. Tianyi Zhang. Congratulations! Please join us in extending a warm welcome
our 2020 Rappeport Fellows!
Kathryn Baselice, MD
Dr. Kathryn Baselice is a PGY-4 in the Adult Psychiatry Residency at New York University. She
completed her undergraduate education in psychology at Johns Hopkins University and was named to
the Phi Beta Kappa honor society. Dr. Baselice decided on a career in forensic psychiatry during her
undergraduate years, and interned at the National Institute for the Study, Prevention, and Treatment of
Sexual Trauma in Baltimore, working with sexual offenders. She completed her medical school educa-
tion at the University of Virginia School of Medicine. Throughout her time at UVA, she was an active
participant and presenter at The Institute of Law, Psychiatry and Public Policy in Charlottesville, VA.
During her final year of medical school, she designed and implemented a project educating various
groups within the lay and medical community about postpartum psychosis. She was also asked to present on postpartum
psychosis at the Judge Advocate General (JAG) School at UVA. She has co-presented several Grand Rounds presentations
on topics such as Not Guilty by Reason of Insanity pleas, postpartum psychosis and online dating. She recorded a lecture
on online dating with several of her co-residents for the American Psychiatric Association (in lieu of a scheduled workshop
that was accepted to the 2020 Annual Meeting). She has co-authored book chapters on evolutionary psychology, with vari-
ous themes including “evil,” violence, arrogance, and eroticism. In 2021, she will begin her forensic psychiatry fellowship
at the University of Virginia. Her Rappeport mentors are Dr. Sara West and Dr. Gary Chaimowitz.
Ayala Danzig, MD
Dr. Ayala Danzig is a PGY-4 in the Department of General Psychiatry at the Yale University School of
Medicine. Originally from New York City, she completed a Master of Social Work at New York Uni-
versity and had a career in elementary education prior to medical school. Dr. Danzig graduated from the
University of Rochester School of Medicine and Dentistry as a member of both the Alpha Omega Alpha
and the Gold Humanism honor societies. She was also awarded the Leonard Tow Humanism Award by
her medical school class. During residency, Dr. Danzig has been actively involved in advocacy and med-
ical education, both areas of passion and interest. She has also co-authored three publications in JAAPL
including a legal digest article about helping psychiatric patients navigate the legal system. At the con-
clusion of her PGY-2 year Dr. Danzig received a resident teaching award and an award for clinical excellence. Dr. Danzig’s
interests include criminal justice reform, balancing patient rights with community safety and addressing racial inequities in
medicine. Dr. Danzig is an APA Leadership Fellow as well as the Chair of the Assembly Organization of Residents and Fel-
lows of the APA. In 2021, she will begin her forensic fellowship in the Law and Psychiatry department at Yale University.
Her Rappeport mentors are Dr. Susan Hatters Friedman and Dr. Renee Sorrentino.
Tyler Durns, MD
Dr. Tyler Durns is currently a Chief Resident at the University Neuropsychiatric Institute with the
University of Utah, where he also serves on the Ethics and Safety Committees for the hospital. As a
medical student at the University of Arizona, he began working in mental health advocacy, starting a
free full-service psychiatric clinic that is still running today. He has carried this sentiment through in
residency, now working as part of a legislative action committee to institute an insanity defense in the
state of Utah. Having taught and helped create undergraduate courses prior to medical school, Dr. Durns
has since been involved in educational endeavors. This includes instituting a forensic curriculum for
residents and fellows at the University of Utah, and lecturing on other topics central to the residency
curriculum. Dr. Durns has published and presented numerous works in peer-reviewed journals and at national/international
conferences including the APA and AAPL, where he serves on the Law Enforcement Liaison, Neuropsychiatry, and Psycho-
pharmacology Committees. His areas of research range from risk assessment to psychotherapy and the use of novel com-
pounds for treatment-resistant mood disorders. In 2021, he will begin his forensic psychiatry fellowship at the University of
California, Davis. His Rappeport mentors are Dr. Nathan Kolla and Dr. Catherine Lewis.
8 • Fall 2020 American Academy of Psychiatry and the Law NewsletterRAPPEPORT FELLOWSHIP AWARDS, 2020-2021
Gregory Iannuzzi, MD
Dr. Gregory Iannuzzi currently serves as Chief Fellow for the Child and Adolescent Psychiatry Fellow-
ship at the University of South Florida Morsani College of Medicine. He completed his undergraduate
degree in biochemistry at the University of Maryland, College Park and earned his medical degree at
the University of Maryland, Baltimore. During medical school, he became interested in forensic psy-
chiatry while working with juvenile offenders through a volunteer mentorship program. He completed
the General Psychiatry Residency at the University of South Florida and “fast-tracked” into child and
adolescent fellowship. He received the 10th Annual AAPL Research Poster Award for his submission,
‘The Prevalence of Adverse Childhood Experiences in Florida Youth Referred to the Department of Ju-
venile Justice’. He has presented nationally at APA and AAPL and was twice awarded Outstanding Resident Teacher. He is
the primary author for the chapter on suicide risk evaluation in the emergency setting for the second edition of Emergency
Psychiatry: Principles and Practice. He currently serves on both AAPL’s Addiction and Child and Adolescent committees.
His interests include youth violence risk assessment and restorative justice. In 2021, he will begin the Forensic Psychiatry
Fellowship at the University of South Florida under the tutelage of past Rappeport Fellows Dr. Ryan C. Wagoner and Dr.
Isis Marrero. His Rappeport mentors are Dr. Joseph Penn and Dr. Ryan C.W. Hall.
Laura Sloan, MD
Dr. Laura Sloan is a PGY-4 resident at the University of Minnesota. She completed her undergraduate
studies at Tufts University and earned her medical degree from Tufts University School of Medicine.
Prior to medical school, she served as an AmeriCorps volunteer in an HIV department. Dr. Sloan was
a Health Justice Scholar in medical school for students interested in underserved medicine. She has
authored publications in JAAPL including a legal digest and an editorial “Where We Are on the Twen-
tieth Anniversary of Olmstead v. L.C.” Dr. Sloan has an interest in the care of individuals with devel-
opmental disabilities and has presented on this at the Minnesota Department of Human Services Grand
Rounds. She is an APA Public Psychiatry Fellow and is a workgroup member for the APA Foundation’s
Justice and Behavioral Health Tool. Dr. Sloan is the head of advocacy programing for her residency and has led psychiatry
residents to lobby at the Minnesota State Capitol. She hopes to pursue clinical and research work in criminal justice reform.
She is currently interviewing for a forensic psychiatry fellowship position. Her Rappeport mentors are Dr. Jackie Landess
and Dr. Alan Newman.
Tianyi Zhang, MD
Dr. Tianyi Zhang is in her fourth year of adult psychiatry residency at the University of California, San
Francisco. She earned her bachelor degrees in Latin American literature and biology from the University
of California, Berkeley and conducted research on tuberculosis detection in Brazil through a training
grant from the National Institute on Minority Health and Health Disparities. She then completed medi-
cal school at UCSF. Her long-standing interest is in correctional forensic psychiatry. Her research in the
San Francisco county jail system has evaluated the implementation of a peer health educator program
and explored the outcomes of making long-acting reversible contraception available to women who are
incarcerated. She has received a resident teacher award, taught medical student didactics on legal issues
in psychiatry, and led medical students in facilitating a weekly women’s health empowerment class at the San Francisco
County Jail. She presented on the use of expert witness testimony in sex trafficking prosecutions at our 2019 AAPL meet-
ing. In 2020, she will start forensic psychiatry fellowship at UCSF. Her Rappeport mentors are Dr. Britta Ostermeyer and
Dr. Ryan Wagoner.
AAPL is pleased to announce the 34th Annual Rappeport Fellowship competition. Registration
to the Forensic Review Course and 2021 Annual Meeting along with travel, lodging, and edu-
cational expenses are provided to the winners. Contact the AAPL Executive Office for details.
American Academy of Psychiatry and the Law Newsletter Fall 2020 • 9FACES OF AAPL
Britta K. Ostermeyer, MD, MBA It was an opportunity to expand foren-
sic programming – especially through
Philip J. Candilis, MD connections with city and state
agencies treating correctional popula-
Growing up in for the AAPL Rappeport Fellowship, tions. Today, Britta heads the mental
the countryside of which she won in 2002. Dr. Charles health team at Oklahoma County
Hanover, Germa- Scott became her Rappeport mentor, Detention Center in her relatively
ny, Britta Klara who in turn introduced her to Dr. new role as the institution’s Mental
Ostermeyer is an Phillip Resnick – a trifecta of men- Health Authority. Not only was this an
unexpected Bay- tors who cemented the transition to opportunity to improve the care of the
ern Munich fan. forensic psychiatry. Because Saul was neediest, but also to bring resources
The region is daft not initially eager to leave New York, into her Department. She consequent-
for Hanover 96, Phil invited them both to Cleveland, ly expanded interdisciplinary training
the soccer club representing Lower winning over the reluctant neuroscien- across her county and at OU, in-
Saxony since 1896. Dr. Ostermey- tist. Britta subsequently completed her creased her Department’s capabilities
er may be forgiven for her turncoat forensic fellowship at Case. for forensic assessment, and improved
ways, given Bayern’s extraordinary access to care. Most importantly, she
flair and success over the decades. In made a profound personal contribu-
her defense, Britta, who is proud of “Britta, who considers tion to the medical profession: her
her Jewish heritage, notes that Bayern son, Anim, is currently a medical stu-
is the world’s largest sports club and AAPL her organizational dent at the OU College of Medicine.
was founded by Kurt Landauer, a Ger- home, is a firm believer Presently, Dr. Ostermeyer serves
man Jew. Some may even speculate AAPL as a Councilor, and as co-chair
that it was the team’s brainy attacking that the united voice of of the Rappeport Committee, mento-
style that inspired her interest in neu- ring the next generation of forensic
rosurgery as a teen. professional organiza- psychiatrists and integrating them
Indeed, Britta served as a medical
school teaching assistant in neuro- tions offers much greater into AAPL. She finds this to be an
important aspect of her leadership
anatomy and underwent neurology
training. Dr. Ostermeyer took on
political impact.” obligations as a Department Chair
as well, enjoying the hiring of new
prestigious fellowships and rotations faculty and residents, and mentoring
from the combined National Institute Soon, Baylor was once again Dr. each group as they pass through. The
of Neurology and National Hospital Ostermeyer’s practice setting, this APA recognized her talent in this are-
for Neurology and Neurosurgery in time for a lengthy academic appoint- na, awarding Britta the 2019 George
Queen Square, London, to the Univer- ment. Britta committed her energy to Tarjan Award for her work on behalf
sity of Vienna, Austria, and eventually the city’s access-to-care challenges, of international medical graduates
the Baylor College of Medicine in teaching trainees about vulnerable, and their incorporation into Ameri-
Houston. With a full-year stipend to underserved groups, improving can psychiatry. Britta, who considers
visit Baylor, Britta eventually settled connections with primary care, and AAPL her organizational home, is
on psychiatry. It was her best friend developing a forensic curriculum. In a firm believer that the united voice
from medical school who finally 2007, she won APA’s Gold Achieve- of professional organizations offers
convinced her: “She knew more about ment Award for founding and serving much greater political impact. In this
the patients than anyone,” Britta says; the Community Behavioral Health spirit, Britta holds offices in Oklaho-
“Their personal history, related treat- Program in Houston. This integrat- ma’s psychiatric associations and in
ment options. It wasn’t all steroids ed primary care-behavioral health the American Association of Chairs
and immuno-suppressants.” program may now be the largest in the of Departments of Psychiatry, serving
Dr. Ostermeyer ultimately trained nation, with behavioral health special- the latter as President-Elect.
at Columbia University and the New ists and counselors staffing approx- Britta Ostermeyer finds her focus
York Psychiatric Institute, finding imately 40 large-scale primary care in the advocacy and lobbying for pa-
another reason to remain in the US: centers in the city. tients, colleagues, and the profession.
her husband Dr. Saul Puszkin. A Fortified by an MBA from the She believes in taking on the stigma
neuroscientist, Saul was a presence at University of Tennessee, Britta as- facing patients and their families.
medical meetings they both attended. cended to the Psychiatry chair at the Seeing her work as an opportunity
Together, they made their home in University of Oklahoma, where she for community service, mentorship,
New York City. also received the endowed Paul and and advocacy, Dr. Ostermeyer is at
Dr. Ostermeyer credits Columbia’s Ruth Jonas Chair in Mental Health. the heart of AAPL’s professional and
former residency director, Dr. Ronald She simultaneously became Chief of community mission.
Rieder, with encouraging her to apply Psychiatry for OU’s hospital system.
10 • Fall 2020 American Academy of Psychiatry and the Law NewsletterFELLOWS’ CORNER
Understanding Police Culture from a entity, the public police look much
the same today as they did 30 years
Former Police Officer ago.” (2, 3) In other words, the faces
may have changed, but the underlying
Douglas Brennan, MD
organization has not.
It is impossible varying in size, location and commu- Speaking of the faces of law en-
to read the news nities served (1). There are differenc- forcement, a common concern is that
these days with- es in which laws are enforced, even police departments do not reflect the
out coming across in overlapping jurisdictions as seen racial composition of their communi-
allegations of between county, state and local mu- ties. In years past, this was certainly
police racism that nicipalities. The populations served true. According to data from the
arise following by these organizations range from U.S. Department of Justice, Bureau
violent arrests or rural regions with few inhabitants to of Justice Statistics (4), in 1993,
other police mis- densely populated and more ethnically black officers were 11.3% of the
conduct. These reports are not con- diverse cities. However, most police total full-time work force, Hispanic
fined to one department or region, but departments (over 12,000) are local officers were 6.2% and white officers
rather are occurring nationwide with and serve a defined geographic area were 80.9%. Of this total, 8.8% were
ever-increasing frequency. Although and population; they are responsible female. In 2016, the most recent data
each incident is unique and should for enforcing local and state ordinanc- available (5), these numbers have
be evaluated on a case-by-case basis, es as well as providing a first response changed to 71.5% white, 11.4% black,
there are common elements which to emergencies. It is these local po- 12.5% Hispanic, and 12% of this total
have provoked widespread outrage. lice departments which bear the brunt being female. These numbers more
This has led to demonstrations, civil of increased scrutiny and society’s closely approximate the U.S. pop-
disobedience and riots, and in some indignation. ulation ethnic breakdown of 76.5%
occasions, violence targeted towards white, 13.4% black, 18.3% Hispanic.
the police. This societal reaction sug- Asian and other ethnicities were not
as closely tracked in the past, so these
gests near-universal concern regarding “What is the root cause numbers are not included. Individual
a culture of racism embedded in law
enforcement, particularly towards Af- of racism in law enforce- departments vary in these ratios and
how representative they are of their
rican-Americans. This is a complex
issue, one that is emotionally charged ment? Is there an orga- communities.
Returning to the question of the
and fraught with frustration around
the lack of progress towards the fun-
nizational culture that root cause of racism in law enforce-
ment, in my opinion it is not due to
damental goal of egalitarianism in law molds young officers to the people who are drawn to work
enforcement. Despite this complexity,
it is clear that change needs to happen act a certain way?” in law enforcement. There are bad
and happen soon. What is less clear is actors in all career fields, and law en-
exactly what needs to be changed. forcement is not immune to this, but
What is the root cause of racism in An article in the Journal of Crimi- the overwhelming majority of police
law enforcement? Is there an orga- nal Law and Criminology (2) summa- departments screen their applicants
nizational culture that molds young rizes law enforcement organization for disciplinary and other behav-
officers to act a certain way? Is it due well. “Policing was largely a local ioral issues. And, as noted above,
to the type of person who is drawn to responsibility. Departments were departments increasingly reflect the
this career path? Can it be the result organized hierarchically and qua- demographics of their communities.
of enforcing laws within an inherently si-militarily. Line officers exercised It is also worth noting that in several
racist legal framework? The latter wide discretion. Patrol and detective high-profile cases, some of the offi-
question is more a debate for legal functions were separated, and most cers involved were non-white.
scholars, so I will focus more on the officers were assigned to patrol. De- What then of police culture? As
first two topics, police personnel and tectives, like supervisors, started out a psychiatrist, I work in a specialty
culture. as patrol officers and were promoted clinic that provides mental health ser-
To address these questions, it is from within. The critical operation vices to first responders. In addition
helpful to learn more about the entity unit was the squad: a handful of line to this ongoing and regular contact
known as American law enforcement. officers supervised by a sergeant, or in with police officers, I have the rare
There are a wide range of organiza- the case of detectives, by a lieutenant. perspective of having worked in law
tions who provide this service, with Officers generally began police work enforcement for several years, first
over 15,000 different law enforcement at a young age and made it their ca- as a local police officer and later as a
agencies across the United States, reer.” “As a legal and organizational federal agent. Before attending med-
(continued on page 26)
American Academy of Psychiatry and the Law Newsletter Fall 2020 • 11You can also read
