Research in Forensic Mental Health Institutions: Where Coercion meets Therapy

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1 Research in Forensic Mental Health Institutions: Where Coercion meets Therapy Sean Kaliski Forensic Mental Health Service, Western Cape Valkenberg & Lenteguer Hospitals Dept. of Psychiatry, University of Cape Town

2 Court: Not fit to stand trial? Not criminally responsible? 30-Day Observation at psychiatric Hospital Not Mentally Ill Varying periods of leave in community Charge not violent MENTALLY ILL & Fails the above questions Referred into general psychiatric service Charge involved serious violence STATE PATIENT ADMISSION TO FORENSIC MENTAL HEALTH HOSPITAL - INDEFINATELY DISCHARGE : JUDGE IN CHAMBERS

3 Consequently, Two Populations: Observation Cases Are actually prisoners in remand High turnover Brief length of stay + 75% not mentally ill A report is submitted with all relevant clinical information Court is interested in this particular accused and not general population Court is entitled to subpoena all information gathered about accused State Patients Have serious mental illness Long stay (up to 20 years) Discharge depends on recommendations from multidisciplinary team (MDT) to a Judge They form therapeutic relationships with MDT, but are coerced into treatment Privileges, such as leave into community, ground parole (freedom) depend on behaviour (including substance abuse Breaches of autonomy

4 FIDUCIARY RELATIONSHIP The Principal of Fidelity The trusting relationship that enables people to consign entirely their well-being to a physician Assumes beneficence, respect for privacy, privilege (i.e. Confidentiality), and nonmaleficience (primum non nocere) Informed consent

5 The Problem of Double Agency..the goal of forensic psychiatry is to seek justice and truth while respecting the rights of those are examined. (Sadoff; 2011) The clinician has divided loyalties: to the patient / subject, and to society (via courts) Research findings may be beneficial for society, but directly harmful to the subject The researchers are usually members of the multidisciplinary team that assesses and subsequently treats potential subjects

6 Research Ethics International: ethics concerns have been about the assessment and treatment of forensic patients, not concerned about research (Appelbaum;1997, Adshead;2000, Taborda et al; 2007) Research has accordingly been restricted and hampered by methodological difficulties caused by ethical concerns

7 Research with Observation (Remand) cases Informed consent Have to explain aim of study, and state that it should not impact on their assessment Most agree as they believe, despite the above, that this will aid their cases Reliability of information Collateral information may uncover prejudicial information Poor motivation to participate

8 Case : Unintended consequences A 32 year old shipworker was accused of murdering his 2 friends during a crack cocaine binge. During the psychiatric assessment he was asked to undergo a SPECT scan of his brain, as part of a research project. The SPECT scan displayed multiple hypoperfusion deficits throughout his brain. The radiologists and neurologists could not agree on the significance of these deficits. His advocate subpoena d the scan and results, and insisted that the psychiatrist testify. The court expressed disquiet that an experimental procedure was used, which could unnecessarily create doubt about the accused s criminal responsibility

9 Types of Studies on Observation cases Risk assessment for violence Section 285A of Criminal Procedure Act Patterns of alcohol and substance abuse Intimate Partner Femicide (Kaliski & Artz; 2011) Understanding of court procedure and wrongfulness Ordinary defendants are as clueless as mentally ill defendants (Kaliski et al; 1997) Medical illness in defendants Women who murder (de Clercq; 2011)

10 Studies on State Patients Prevalence of HIV Attitudes of families and leave in community Impulsivity, sensation seeking and violence Therapeutic alliance, risk assessment and aggression Physical health and medication Patterns of substance abuse Drug trials : new and old agents

11 Problems with researching state patients Lack of competence Psychosis, dementia, intellectual disability They may want a quid pro quo Privileges, money, discharge application They have much to hide Aggressive tendencies, substance abuse, psychotic symptoms

12 State patient: Unintended consequence A 45 year old state patient had participated in a 3 month drug trial, for which he provided informed consent. Throughout the trial he repeatedly tried to negotiate periods of leave with his family. He struck up an unusually close relationship with the investigators, psychiatrists who treated him. At the end of each session he was given a parcel of food as payment for his participation. After the completion of the trial he was aggrieved that he was not granted leave, despite having been told that this was not agreed to be part of the trial. He also took to pestering the research nurse for food parcels, and became aggressive when rebuffed. He wrote a letter of complaint to the hospital board.

13 Conclusions Double agency issues may cause breaches of the principles of beneficence and nonmaleficience ( first do no harm ) Subjects do not have adequate autonomy as they are compromised by the power differential they have been coerced into situations in which the research is conducted. Informed consent may not be adequate. Perhaps the issue of the greater good (Justice) does ameliorate these problems