Critical Issues in American Psychiatry and the Law – Serie

We would expect a successful series such as Critical Issues in American Psychiatry and the Law to present timely, relevant issues in a high-quality manner, and such is the hallmark of this outstanding series. But we might not expect the editors to dive into the especially controversial issues, e.g., ethics, and I applaud them for doing so and in such a comprehensive and thorough fashion. Public and professional concern about ethical aspects of psychiatrists' be­ havior and practice is growing, and exponentially. Concern about the ethical practice of modern forensic psychiatry is paralleled by deep-seated apprehen­ sion not only about the ethical dilemmas of psychiatry and medicine (e.g., societal versus individual patient values, the corporatization of medicine, access to versus cost of medicine) but also about the widely publicized ethical trans­ gressions of religious and political leaders. That's why this volume is so timely and important. Ethics-the principles and rules of right conduct. Sounds simple. We know it is not. When I'm asked by colleagues to consider the perceived unethical behavior of a fellow professional, I often find that, like obscenity, they can't always define it but they are definite that they know it when they see it. The perception of ethical conduct often appears to be in the eyes of the beholder. read this volume. It may not always please you, Well, that's why you will want to it may upset you and even offend you, but it will definitely inform you.

During the 1980s, those of us who were involved in forensic psychiatry have seen an increase in the interest in our subspecialty. This increased interest has been from psychiatrists, lawyers, judges, and correctional officials as well. As a part of this demand for our services, there has also been an increase in the demand for detailed quality in our reports and testimony. Whether this is the result of the educational efforts of the American Academy of Psychiatry and the Law, the establishment of the American Board of Forensic Psychiatry, the stimulation of thought by the publication of this series, Critical Issues in American Psychiatry and the Law, or Supreme Court decisions such as Ake v Oklahoma is anybody's guess. My experience as an observer of the development of the patient's rights movement was that there was a coalescence of numerous forces, such as the new human rights movement, the active mental health bar, and the development of neuroleptics. I therefore suspect that there are a multitude of factors contributing to the new interest in forensic psychia­ try and the elevation of the standards of forensic experts. Regardless of the causes, those who are practicing forensic psychiatry today are ex­ pected to conduct more thorough evaluations and to report findings more completely. No longer will simple conclusory statements be accept­ able. The forensic psychiatrist is expected to present data in a clear, understandable, detailed, reliable, and competent fashion whether testi­ fying or in a report.

As President of the American Academy of Psychiatry and the Law (AAPL), it is my pleasure to provide this Foreword for the third volume of Critical Issues in American Psychiatry and the Law. Through Dr. Richard Rosner's creativity and effort, the first volume of the series was pub­ lished in 1982. It represented the first major publishing activity of the AAPL other than the Bulletin and the Newsletter. Dr. Rosner carefully nurtured the project and the second volume, once again addressing a broad range of forensic issues, was published in 1985. The appearance of the third volume brings two major changes to the series. Dr. Rosner shares editorship of this volume with Harold I. Schwartz, and this is the first of the series to be devoted entirely to one area in forensic psychiatry, the elderly. This is a priority subject. As the baby boom ages and technology for extending life increases, the profile of our population is maturing. The aging of the nation brings with it problems of chronic care, the dementias, the fear of prolonging dying rather than extending meaningful life, the social question of increasing health care costs, and the medical and human question of legal and ethical protection of the elderly patient. This volume could not be more timely. As Bernice Neugarten has pointed out, we must avoid stereotyping the elderly.l Many individuals bring to older age a rich repertoire of interests, abilities, and insights. Among the elderly are the young-old.

As President of the American Academy of Psychiatry and the Law (AAPL), it is a pleasure to write this foreword. Dr. Richard Rosner deserves full credit for helping AAPL pursue its educational goals by publishing a series of books. Consumerism and the civil rights movement have dramatically changed the practice of American psychiatry over the last 2 decades. Extensive legal regulation now makes it necessary for both general and forensic psychiatrists to keep abreast of changing laws. The contents of Volume II of Critical Issues in American Psychiatry and the Law demonstrate Dr. Rosner's gift for selecting and editing important theoretical and practical articles. This volume addresses a broad range of forensic issues. The pen­ dulum-like swings of laws regarding civil commitment and insanity are clearly illuminated by Dr. Quen's contribution, "Violence, Psychiatry, and the Law." A review of historical psychiatric testimony supporting insanity defenses on the bases of homicidal mania, moral insanity, and phrenological evidence should make modern forensic psychiatrists hum­ ble. However, some of our colleagues continue to testify that defendants were unable to refrain from criminal conduct because of CT evidence of schizophrenia, pathological gambling, or the effects of junk food. Excellent theoretical discussions are presented by Dr. Macklin ("A Philosophical Perspective on Ethics and Forensic Psychiatry") and Mr. Hughes ("Legal Aspects of Predicting Dangerousness"). These chapters present thorough, up-to-date, scholarly analyses of complex issues from the vantage point of non psychiatrists.

I am not sure when a series of volumes becomes an "institution"; this is the fourth annual volume of Critical Issues in American Psychiatry and the Law, and each has been an extraordinary summary of important forensic topics. This book makes the point that the interface of psychiatry and law is not merely a legal one, but has a great deal to do with clinical issues such as diagnosis and treatment. Children and adolescents are not adults. This may come as something of a shock to those who proselytize for equal rights for children, and to those adults (including some psychiatrists, attorneys, and judges) who advocate giving the child adult choices and/or responsibilities. Children differ from adults in many ways. The specialist in child or adoles­ cent psychiatry knows not only that one must attend to special social and family issues for juveniles, but that juveniles are more complex internally as well. They attempt to survive in the world while rapidly growing and learning, usually with physically and emotionally immature resources. They have had few years in which to develop experience, and do not have the psyche with which to integrate that experience in ways one would expect of a mature adult. Sometimes this frightens the patient, as in the case of a physically large teen­ ager whose impulse control is impaired. Sometimes it is frustrating, as in the case of a healthy child unable to escape from a dysfunctioning family. It is always confusing, and usually uncomfortable.