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CLINICAL SYNTHESIS
Published Online: 1 October 2003

Quick Reference for Forensic and Ethical Issues in Psychiatry

The tables in this section are from Simon RI: Concise Guide to Psychiatry and Law for Clinicians, 3rd ed. Washington, DC, American Psychiatric Publishing, 2001. Copyright 2001 American Psychiatric Publishing, Inc.
Table 1. The Four Ds of a Malpractice Claim
A doctor-patient relationship must be present, creating the following:
DUTY of care.
DEVIATION from the standard of care must have occurred.
DAMAGE to the patient must have occurred.
The damage must have occurred DIRECTLY as a result of the deviation from the standard of care.
Table 2. Actions by Therapists That May Create a Doctor-Patient Relationship
Giving advice to prospective patients, friends, and neighbors
Making psychological interpretations during an independent evaluation
Writing a prescription or providing sample medications
Supervising treatment by a nonmedical therapist
Having a lengthy phone conversation with a prospective patient
Treating an unseen person by mail
Giving a prospective patient an appointment
Telling walk-in prospective patients that they will be seen
Acting as a substitute therapist
Providing treatment during an evaluation
Table 3. Suggested Guidelines for Termination of Patient Treatment
1.
Thoroughly discuss treatment termination with patient.
2.
Indicate the following in a letter of termination:
b.a.
Fact of discussion of termination
b.b.
Reason for termination
b.c.
Termination date
b.d.
Availability for emergencies only until date of termination
b.e.
Willingness to provide names of other appropriate therapists
b.f.
Willingness to provide medical records to subsequent therapist
b.g.
A statement of the need for additional treatment, if appropriate
3.
Allow the patient reasonable time to find another therapist (length of time depends on availability of other therapists).
4.
Provide the patient’s records to the new therapist upon proper authorization by the patient.
5.
If the patient requires further treatment, provide the names of other psychiatrists or refer the patient to a local or state psychiatric society for further assistance.
6.
If the need for further treatment is recommended, a statement about the potential consequences of not obtaining further treatment should be provided.
7.
Send the termination letter certified or restricted registered mail, return receipt requested.
Table 4. Examples of Statutory Disclosure Requirements
Evidence of child abuse
Initiation of involuntary hospitalization
“Duty to warn” endangered third parties or law enforcement agencies
Commission of a past treasonous act
Intention to commit a future crime
Human immunodeficiency virus (HIV) infectiona

a Some states require that the patient’s name be reported.

Table 5. Informed Consent: Reasonable Information to Be Disclosed
Although there exists no consistently accepted set of information to be disclosed for any given medical or psychiatric situation, as a rule of thumb, five areas of information are generally provided:
1.
Diagnosis: description of the condition or problem
2.
Treatment: nature and purpose of proposed treatment
3.
Consequences: risks and benefits of the proposed treatment
4.
Alternatives: viable alternatives to the proposed treatment, including risks and benefits
5.
Prognosis: projected outcome with and without treatment
Table 6. Indications for Seclusion and Restraint
To prevent clear, imminent harm to the patient or others
To prevent significant disruption to treatment program or physical surroundings
To assist in treatment as part of ongoing behavior therapy
To decrease sensory overstimulationa
To comply with patient's voluntary reasonable requestb

a Seclusion only

b First seclusion; then, if necessary, restraints

Table 7. Contraindications to Seclusion and Restraint
For extremely unstable medical and psychiatric conditionsa
For patients with delirium or dementia who are unable to tolerate decreased stimulationa
For overtly suicidal patientsa
For patients with severe drug reactions, those with overdoses, or those requiring close monitoring of drug dosagesa
For punishment of the patient or convenience of staff

a Unless close supervision and direct observation are provided.

Table 8. Demonstration of a Rapid, Competent Suicide Risk Assessment
Risk FactorFacilitating SuicideInhibiting
AnxietyM 
Loss of pleasure and interest in childH 
Depressive turmoilM 
Diminished concentrationL 
Therapeutic alliance H
Family relations M
HopelessnessL 
Psychiatric diagnosisM 
Prior attemptsOO
Current attempt (lethality)H 
Specific planOO
Living situation H
Employment L
Availability of gunM 
Suicidal ideation/intentL (passive) 
Family historyH 
ImpulsivityM–H 
Drug/alcoholO 
Depression/postpartumM 
Religion L–M
InsomniaL 
Other children H
Physical condition M
Cognition/competence M–H
Marital relationship M–H

Overall Risk Rating: moderate–high (at discharge) L = low; M = moderate; H = high; 0 = nonfactor

Table 9. Clinical Risk Factors Associated With Violence
The stated desire to hurt or kill another
History of violence
Alcohol and substance abuse
Inability to control anger
Impulsivity (e.g., previous violence toward others or self, reckless driving, unrestrained spending, sexual promiscuity)
Paranoid ideation, thought insertion or control, fear of harm
Command hallucinations
Psychosis
Personality disorders: antisocial, borderline, and organic personality disorder (explosive type)
“Soft” neurological signs
Substance abuse
Low intelligence
Table 10. Demonstration of a Rapid, Competent Violence Risk Assessment
Risk FactorFacilitating ViolenceInhibiting Violence
Specific person threatenedO (in hospital)O
Past violenceH (stabbed cousin) 
Accessible victimH (mother) 
Therapeutic alliance L–M (with staff)
Psychiatric diagnosisH 
Command hallucinationsO (in hospital)O
Employment L
Specific planOO
Treatment response H
Medication compliance H (in hospital)
Structured environment H
Alcohol dependenceH 
Substance abuseOO
History of impulsivityH 
Guns L (none at home)
Compliance with aftercareH 
RelationshipsM–H (loner) 

Overall Risk Rating: low (at discharge) L = low; M = moderate; H = high; 0 = nonfactor

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Published online: 1 October 2003
Published in print: October 2003

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