Forensic Hospitals, Maximum Security Essay ⋆ Criminal Justice Essay Examples ⋆ EssayEmpire

A maximum security forensic (MSF) hospital is a licensed inpatient state facility which specializes in providing both forensic assessments as well as psychiatric treatment to patients with violent felony charges. The physical structure of a MSF hospital often appears similar to a correctional facility in that it has a secure fence surrounding the perimeter of the facility, watch towers containing security officers, and a central security center where all individuals exiting or entering the facility must pass through metal detectors and have belongings searched for possession of contraband. Additionally, all doors within the facility are secured with locks and require keys for passage. Individuals typically admitted to MSF hospitals include criminal defendants who have been adjudicated as not guilty by reason of insanity (NGRI) or Incompetent to stand trial (IST) for one or more violent felony charges, with the majority (approximately 70 to 80 percent) of the individuals committed for competency restoration. Moreover, many of these individuals also present with severe mental illness. A minority of residents in a MSF hospital include psychiatric patients who have been determined by a review board of a less restrictive or general psychiatric hospital to be so imminently violent as to require admission to a MSF hospital despite having no pending criminal charges. Psychologists, as well as professionals of various disciplines, are expected to abide by professional as well as ethical standards of practice.

Dual Relationships

Psychologists working within MSF hospitals have complex and challenging roles that can be dramatically different in their purpose, most notably their role on treatment teams and as treatment providers and forensic evaluators. However, psychologists may only conduct evaluations with patients for whom they have not provided treatment. On the other hand, it is permissible for a psychologist to become involved in the treatment of a patient following the completion of a forensic evaluation and disposition of the case with regard to the question asked by the court. For example, with regard to a competency to stand trial (CST) evaluation, the evaluator has the legal obligation to maintain an unbiased, objective perspective regarding the patient’s ability to demonstrate trial competency skills and knowledge at the time of the evaluation.

Had the psychologist been involved in the treatment or the supervision of treatment for the patient, their findings would likely be skewed and they would be in violation of the professional ethics code for psychologists. This clinician could potentially become involved in the patient’s treatment after conducting an evaluation with that patient if it is decided that his or her objective forensic opinions regarding the patient will no longer be needed in the future. This could occur, for example, if a patient was evaluated and opined to be competent to stand trial and subsequently was determined to be NGRI by the court of jurisdiction and returned to the same MSF hospital for treatment.

Another possible scenario is a patient who is adjudicated as incompetent to stand trial for his pending felony charge and admitted to a MSF hospital for competency restoration, including psychiatric treatment for his mental illness. Dr. Z, a staff psychologist, has been the psychologist on the patient’s treatment team (i.e., a multidisciplinary group of professionals involved in the care and treatment of a caseload of patients), and has been involved in the patient’s competency training. Dr. A, also a staff psychologist, has not been involved in the patient’s treatment, nor has she had any formal interactions with him during his admission. Therefore, Dr. A is the only psychologist who can ethically and objectively conduct a trial competency evaluation of the patient. Dr. A evaluates the patient and opines that he remains incompetent to stand trial, and the court of jurisdiction agrees and recommits the patient to the hospital for an extended period of time for competency restoration. Ethically, Dr. A may now be involved in his treatment, but if she does so, she may no longer be involved in conducting future forensic evaluations of her patient.

The MSF hospital requires that all professionals, even those not directly involved in patients’ treatment, remain responsible for ongoing patient care and security. It is notable that Dr. A in the above example had no formal interactions with the patient, but certainly had been exposed to his behavioral presentation through reports at staff meetings where pertinent information regarding patients’ behaviors exhibited during the shift are discussed. Due to the inevitable exposure to information regarding patients’ behaviors throughout their admission, it is the imperative responsibility of the assigned forensic evaluator to refrain from assessing a patient if an objective perspective regarding the patient’s trial competency cannot be maintained. Thus, with regard to this hypothetical case, if Dr. A felt any biases about the patient and believed she could not provide a fair and nonbiased report of his functional capacities related to trial competency, Dr. A would need to seek consultation and/or identify another psychologist who could conduct the evaluation, such as a forensic evaluator employed on a different unit within the hospital or an external, contractual evaluator.

Limits of Confidentiality/Informed Consent

Another important ethical challenge inherently present for those clinicians working in MSF hospitals involves the limits of confidentiality. At the time of their admission as well as multiple times throughout their hospitalization, patients are reminded that their statements are often documented, can be accessed by the criminal court system by way of subpoena or court order, and could potentially be used against them in court. This is significant as the majority of patients are admitted to MSF hospitals as incompetent to stand trial and have not yet been convicted of the alleged offenses against them.

Providing patients with information regarding the limits of confidentiality is imperative due to the potential implications of them making incriminating statements in treatment teams, therapy groups, or during diagnostic, social, or medical evaluations, which could be presented in court at a later date. With respect to CST evaluations, forensic evaluators must include only information relevant to a patient’s trial competency abilities. Information stated within the CST evaluation is protected or cannot be used against a criminal defendant or be introduced during the guilt/innocence phase of a trial unless the defendant submits the plea of NGRI or chooses to testify in his criminal trial, opening the door for psychiatric testimony and permitting the CST evaluator to be called as a rebuttal witness. The evaluator should not provide unnecessary information that could violate privacy or be unnecessarily prejudicial in these reports. For example, providing potentially prejudicial information (e.g., a diagnosis of pedophilia) could bias a jury during a competency hearing against the criminal defendant.

In most nonforensic mental health settings, informed consent is considered the acquisition of permission to provide treatment to patients, while informing them of the potential risks and benefits of this care. If an individual does not sign and agree to the terms of informed consent, services are not rendered. However, in forensic settings, evaluation and treatment are typically ordered by the court and the actual client is the court rather than the patient; thus, verbal and/or written consent is not legally required. It is still ethically necessary to provide the patient with information about the services that will be rendered or the limits of confidentiality associated with CST and other forensic evaluations.

For example, most patients in a MSF hospital are committed via court order and cannot refuse their admission. Upon admission, however, a patient has the legal right to refuse treatment, including treatment groups, competency training, social rehabilitation classes, and psychotropic medications. Similarly, patients occasionally refuse to participate in their competency evaluation. In these cases, the patient is informed that, although they have the right to refuse participation, a report will be produced and sent to the court despite their refusal to participate in the assessment. Often times, a patient refuses prescribed psychotropic medications, and a court order for compelled medications can be pursued and, if granted, the patient can receive medication by injection against their will. Sell v. United States was a landmark ruling by the U.S. Supreme Court, indicating that a criminal defendant who had been determined to be incompetent to stand trial could be medicated against their will only if specific criteria for court-ordered treatment had been met. The criteria includes: if a defendant is a danger to themselves or others, medication is the only way to render a defendant less dangerous, the benefits of forced medications outweigh the risks, and the medications are significantly likely to return the defendant to competency.

Cultural Competency

It is an ethical obligation to provide culturally sensitive treatment and evaluation services to patients in a MSF hospital. Cultural differences include diversity with regard to age, race, ethnicity, gender, sexual orientation, and socioeconomic status. It is vital that MSF hospitals are equipped to provide both treatment and assessment with consideration of cultural differences and language barriers. For example, if a patient from a non-Western country is admitted to a MSF hospital for trial competency restoration, the treatment team must be certain to meet his or her needs with regard to culture and language. All verbal and written communication with the patient must be facilitated in the patient’s primary language via a certified interpreter, and the CST evaluation for the court must be conducted with a court-certified interpreter (i.e., an interpreter with specialized training in legal jargon and vocabulary).

Competency restoration must initially begin with an introduction to the Western criminal justice system, as many patients from countries with dictatorial government systems often mistakenly believe they have already been convicted of the charge alleged against them. This belief is influenced soley by their arrest and admission to the MSF since they lack familiarity with the U.S. criminal justice system. Following education regarding the general criminal justice system, the patient should be provided with the same study materials and training opportunities as their Western peers in their primary language or via a certified interpreter. During the CST evaluation, it is strongly suggested that an interpreter be readily available during the interview, even if a patient states they desire to speak English for their assessment. This way, if a patient does not know how to say what he or she means while responding to an inquiry or does not adequately understand the question, the patient can refer to the interpreter for assistance in communicating.

Professionals of various disciplines working within a forensic context are expected to abide by professional as well as ethical standards of practice The MSF hospital setting is challenging and replete with potential conflicting roles and ethical pitfalls. Further examples of topics that also necessitate careful consideration when working or practicing within a MSF hospital include professional boundaries, professional competence, abuse and neglect, and empathy biases.

Bibliography:

Bo, S., A. Abu-Akel, M. Kongerslev, U. H. Haahr, and E. Simonsen. “Risk Factors for Violence Among Patients With Schizophrenia.” Clinical Psychology Review, v.31/5 (2011).
Dvoskin, J. A. and L. S. Guy. “On Being an Expert Witness: It’s Not About You.” Psychiatry, Psychology and Law, v.15 (2008).
Mossman, D., S. G. Noffsinger, et al. “AAPL Practice Guideline for the Forensic Psychiatric Evaluation of Competence to Stand Trial.” Journal of the American Academy of Psychiatry and the Law, v.35/4 (2007).
Shipley, S. L. “Competency to Stand Trial: Legal Foundations and Practical Applications.” In Criminal Psychology, J. B. Helfgott, ed. Santa Barbara, CA: ABC-CLIO, 2013.
Shipley, S. L. and B. A. Arrigo. Introduction to Forensic Psychology: Court, Law Enforcement, and Correctional Practices. 3rd ed. New York: Elsevier/Academic Press, 2012.
Shipley, S. L. and M. L. Borynski. “Mental Illness and Violence: a Misunderstood Relationship.” In Criminal Psychology, J. B. Helfgott, ed. Santa Barbara, CA: ABC-CLIO, 2013.

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