Shrink Rap News

Recently, I came across a news story about a woman in a public psychiatric hospital who had been attacked and seriously injured by another patient. While I’ve seen stories like this before, this story was particularly shocking, because it contained a YouTube clip of the attack taken from a surveillance video. The video showed the woman calmly sitting in an outdoor smoking area near a male patient who also sat smoking calmly for several minutes. The two didn’t appear to interact or speak, and there was no clear precipitant for the attack. The male patient suddenly stood up and punched her in the face repeatedly. The woman was hospitalized with serious facial injuries but fortunately lived.

The video immediately brought back a memory of another attack. I was sitting in my prison clinic when a prisoner was carried into the dispensary, a victim of a gang fight in the recreation yard. He was brought in on a stretcher carried by five black-uniformed correctional officers. He was moaning, and there was blood running between his fingers as he held his hands over his face. Later, I found out that six other inmates had been sent out to the emergency room with stab wounds. Again, this assault victim was lucky to survive.

Police officers and firefighters know that their work is inherently dangerous and that there is a risk of serious injury or death. Other vocations like construction workers, roofers, and electrical linesman are at risk for accidental injuries. Forensic psychiatry is a little different. Although forensic patients can be potentially dangerous, or have a proven history of violence, we work in facilities where security procedures and custody staff can almost always mitigate that risk. When people learn I work in a prison and ask if I feel afraid to work there, I can honestly answer in the negative.

Public psychiatric hospitals face a bigger challenge when it comes to staff safety issues. There must be a balance between the right of forensic patients to be free from restraint and the employees’ right to a safe work environment. Over the last 10 years, various professional organizations and the Joint Commission have worked to reduce the use of seclusion and restraint in psychiatric facilities. Some hospitals have recently experienced an increase in patient-on-staff assaults, and labor unions have alleged that this is caused by the decreased use of restraints. Patient-on-staff assaults have drawn the attention of the Occupational Safety and Health Administration, which has fined hospitals in Maine, New York, and Massachusetts for failing to protect staff.

As the YouTube clip demonstrated, patient violence can be sudden and unanticipated. Safety regulations are no substitute for good verbal de-escalation skills, rapid and reliable security staff, and personal awareness of safety policies. Inpatient treatment teams must know their patients well enough to recognize early signs of impending aggression and to help the patient identify and use strategies to manage anger appropriately. Involuntary medication, seclusion and physical restraints are only the endpoint of a safety management plan. If these elements are in place, forensic mental health professionals will be able to look at news reports like the one I found without thinking, “That could have been me.”

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, I came across a news story about a woman in a public psychiatric hospital who had been attacked and seriously injured by another patient. While I’ve seen stories like this before, this story was particularly shocking, because it contained a YouTube clip of the attack taken from a surveillance video. The video showed the woman calmly sitting in an outdoor smoking area near a male patient who also sat smoking calmly for several minutes. The two didn’t appear to interact or speak, and there was no clear precipitant for the attack. The male patient suddenly stood up and punched her in the face repeatedly. The woman was hospitalized with serious facial injuries but fortunately lived.

The video immediately brought back a memory of another attack. I was sitting in my prison clinic when a prisoner was carried into the dispensary, a victim of a gang fight in the recreation yard. He was brought in on a stretcher carried by five black-uniformed correctional officers. He was moaning, and there was blood running between his fingers as he held his hands over his face. Later, I found out that six other inmates had been sent out to the emergency room with stab wounds. Again, this assault victim was lucky to survive.

Police officers and firefighters know that their work is inherently dangerous and that there is a risk of serious injury or death. Other vocations like construction workers, roofers, and electrical linesman are at risk for accidental injuries. Forensic psychiatry is a little different. Although forensic patients can be potentially dangerous, or have a proven history of violence, we work in facilities where security procedures and custody staff can almost always mitigate that risk. When people learn I work in a prison and ask if I feel afraid to work there, I can honestly answer in the negative.

Public psychiatric hospitals face a bigger challenge when it comes to staff safety issues. There must be a balance between the right of forensic patients to be free from restraint and the employees’ right to a safe work environment. Over the last 10 years, various professional organizations and the Joint Commission have worked to reduce the use of seclusion and restraint in psychiatric facilities. Some hospitals have recently experienced an increase in patient-on-staff assaults, and labor unions have alleged that this is caused by the decreased use of restraints. Patient-on-staff assaults have drawn the attention of the Occupational Safety and Health Administration, which has fined hospitals in Maine, New York, and Massachusetts for failing to protect staff.

As the YouTube clip demonstrated, patient violence can be sudden and unanticipated. Safety regulations are no substitute for good verbal de-escalation skills, rapid and reliable security staff, and personal awareness of safety policies. Inpatient treatment teams must know their patients well enough to recognize early signs of impending aggression and to help the patient identify and use strategies to manage anger appropriately. Involuntary medication, seclusion and physical restraints are only the endpoint of a safety management plan. If these elements are in place, forensic mental health professionals will be able to look at news reports like the one I found without thinking, “That could have been me.”

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, I came across a news story about a woman in a public psychiatric hospital who had been attacked and seriously injured by another patient. While I’ve seen stories like this before, this story was particularly shocking, because it contained a YouTube clip of the attack taken from a surveillance video. The video showed the woman calmly sitting in an outdoor smoking area near a male patient who also sat smoking calmly for several minutes. The two didn’t appear to interact or speak, and there was no clear precipitant for the attack. The male patient suddenly stood up and punched her in the face repeatedly. The woman was hospitalized with serious facial injuries but fortunately lived.

The video immediately brought back a memory of another attack. I was sitting in my prison clinic when a prisoner was carried into the dispensary, a victim of a gang fight in the recreation yard. He was brought in on a stretcher carried by five black-uniformed correctional officers. He was moaning, and there was blood running between his fingers as he held his hands over his face. Later, I found out that six other inmates had been sent out to the emergency room with stab wounds. Again, this assault victim was lucky to survive.

Police officers and firefighters know that their work is inherently dangerous and that there is a risk of serious injury or death. Other vocations like construction workers, roofers, and electrical linesman are at risk for accidental injuries. Forensic psychiatry is a little different. Although forensic patients can be potentially dangerous, or have a proven history of violence, we work in facilities where security procedures and custody staff can almost always mitigate that risk. When people learn I work in a prison and ask if I feel afraid to work there, I can honestly answer in the negative.

Public psychiatric hospitals face a bigger challenge when it comes to staff safety issues. There must be a balance between the right of forensic patients to be free from restraint and the employees’ right to a safe work environment. Over the last 10 years, various professional organizations and the Joint Commission have worked to reduce the use of seclusion and restraint in psychiatric facilities. Some hospitals have recently experienced an increase in patient-on-staff assaults, and labor unions have alleged that this is caused by the decreased use of restraints. Patient-on-staff assaults have drawn the attention of the Occupational Safety and Health Administration, which has fined hospitals in Maine, New York, and Massachusetts for failing to protect staff.

As the YouTube clip demonstrated, patient violence can be sudden and unanticipated. Safety regulations are no substitute for good verbal de-escalation skills, rapid and reliable security staff, and personal awareness of safety policies. Inpatient treatment teams must know their patients well enough to recognize early signs of impending aggression and to help the patient identify and use strategies to manage anger appropriately. Involuntary medication, seclusion and physical restraints are only the endpoint of a safety management plan. If these elements are in place, forensic mental health professionals will be able to look at news reports like the one I found without thinking, “That could have been me.”

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

My community has a listserv – an email forum that lets any member send a message to every other member – with more than 900 families and e-mails that go from morning to night.  I can't begin to describe the spectrum of what transpires here, but this is not the neighborhood where it goes unnoticed if you drive too fast, don’t clean up after your dog. And if you need to borrow crutches for a few weeks, or  need a referral for almost anything from a chimney repairman to a dermatologist, it often takes only minutes to get your needs met. The sense of community that the listserv fosters is quite remarkable.

So what about a listserv for psychiatrists?  If there’s a question about the availability of resources, or curiosity about the efficacy of a new treatment,  or even just a desire to share a reaction to an article in the newspaper, why shouldn’t the local district branches have such a forum?  After all, a listserv can be started as a Google Group for free, by anyone, anywhere.

In Maryland, the Maryland Psychiatric Society started such a listserv in May of 2009. It turns out that psychiatrists, as a group, are prone to worry.  It wasn’t long before a member wanted to know if a patient could sue him for a suggestion he gave to another doctor on the listserv.  It got the MPS leadership to poke around.  MedChi did not think this was a good idea, though they couldn’t say why.  I called my malpractice insurer and spoke with counsel there.  I was told that they knew of no cases of litigation related to e-mail communications between physicians, and suggested that I stop speaking to lawyers.  The MPS proceeded with the listserv, and today we have more than 180 members who have posted on more than 550 different topics. 

“I used to work in a psychiatric hospital and enjoyed the collegiality and access to such conversations,” wrote Dr. Mark Komrad, a psychiatrist in private practice in Towson, Md. “One of the biggest downsides of leaving that environment and spending the majority of my week in a private solo office, without even a secretary, was the lack of that collegiality.... The listserve lets me once again enjoy the breadth of more free-wheeling, collegial, dialogue that has dramatically expanded the compass of my working experience.”

“It serves my needs in so many ways” Dr. Komrad continued, “including informal consultations on difficult cases, learning from the similar queries of others, asking about experiences with certain medications, learning new treatment techniques, and having colleagues reflect on the ethical implications of certain clinical approaches, and similarly reflect on their queries.” Finally, Dr. Komrad noted he enjoys, “speculating with others about psychiatric dimensions of certain events in the news, and discussing and debating controversial issues in the profession.”

Listservs for psychiatrists are not breaking news: the APA has one, and Ivan Goldberg has run a large psychopharmacology bulletin board for years. Does your district branch have one? Should they? 

<[QM—Dinah Miller, M.D.

If you are a health professional and would like to comment on this article, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

My community has a listserv – an email forum that lets any member send a message to every other member – with more than 900 families and e-mails that go from morning to night.  I can't begin to describe the spectrum of what transpires here, but this is not the neighborhood where it goes unnoticed if you drive too fast, don’t clean up after your dog. And if you need to borrow crutches for a few weeks, or  need a referral for almost anything from a chimney repairman to a dermatologist, it often takes only minutes to get your needs met. The sense of community that the listserv fosters is quite remarkable.

So what about a listserv for psychiatrists?  If there’s a question about the availability of resources, or curiosity about the efficacy of a new treatment,  or even just a desire to share a reaction to an article in the newspaper, why shouldn’t the local district branches have such a forum?  After all, a listserv can be started as a Google Group for free, by anyone, anywhere.

In Maryland, the Maryland Psychiatric Society started such a listserv in May of 2009. It turns out that psychiatrists, as a group, are prone to worry.  It wasn’t long before a member wanted to know if a patient could sue him for a suggestion he gave to another doctor on the listserv.  It got the MPS leadership to poke around.  MedChi did not think this was a good idea, though they couldn’t say why.  I called my malpractice insurer and spoke with counsel there.  I was told that they knew of no cases of litigation related to e-mail communications between physicians, and suggested that I stop speaking to lawyers.  The MPS proceeded with the listserv, and today we have more than 180 members who have posted on more than 550 different topics. 

“I used to work in a psychiatric hospital and enjoyed the collegiality and access to such conversations,” wrote Dr. Mark Komrad, a psychiatrist in private practice in Towson, Md. “One of the biggest downsides of leaving that environment and spending the majority of my week in a private solo office, without even a secretary, was the lack of that collegiality.... The listserve lets me once again enjoy the breadth of more free-wheeling, collegial, dialogue that has dramatically expanded the compass of my working experience.”

“It serves my needs in so many ways” Dr. Komrad continued, “including informal consultations on difficult cases, learning from the similar queries of others, asking about experiences with certain medications, learning new treatment techniques, and having colleagues reflect on the ethical implications of certain clinical approaches, and similarly reflect on their queries.” Finally, Dr. Komrad noted he enjoys, “speculating with others about psychiatric dimensions of certain events in the news, and discussing and debating controversial issues in the profession.”

Listservs for psychiatrists are not breaking news: the APA has one, and Ivan Goldberg has run a large psychopharmacology bulletin board for years. Does your district branch have one? Should they? 

<[QM—Dinah Miller, M.D.

If you are a health professional and would like to comment on this article, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

My community has a listserv – an email forum that lets any member send a message to every other member – with more than 900 families and e-mails that go from morning to night.  I can't begin to describe the spectrum of what transpires here, but this is not the neighborhood where it goes unnoticed if you drive too fast, don’t clean up after your dog. And if you need to borrow crutches for a few weeks, or  need a referral for almost anything from a chimney repairman to a dermatologist, it often takes only minutes to get your needs met. The sense of community that the listserv fosters is quite remarkable.

So what about a listserv for psychiatrists?  If there’s a question about the availability of resources, or curiosity about the efficacy of a new treatment,  or even just a desire to share a reaction to an article in the newspaper, why shouldn’t the local district branches have such a forum?  After all, a listserv can be started as a Google Group for free, by anyone, anywhere.

In Maryland, the Maryland Psychiatric Society started such a listserv in May of 2009. It turns out that psychiatrists, as a group, are prone to worry.  It wasn’t long before a member wanted to know if a patient could sue him for a suggestion he gave to another doctor on the listserv.  It got the MPS leadership to poke around.  MedChi did not think this was a good idea, though they couldn’t say why.  I called my malpractice insurer and spoke with counsel there.  I was told that they knew of no cases of litigation related to e-mail communications between physicians, and suggested that I stop speaking to lawyers.  The MPS proceeded with the listserv, and today we have more than 180 members who have posted on more than 550 different topics. 

“I used to work in a psychiatric hospital and enjoyed the collegiality and access to such conversations,” wrote Dr. Mark Komrad, a psychiatrist in private practice in Towson, Md. “One of the biggest downsides of leaving that environment and spending the majority of my week in a private solo office, without even a secretary, was the lack of that collegiality.... The listserve lets me once again enjoy the breadth of more free-wheeling, collegial, dialogue that has dramatically expanded the compass of my working experience.”

“It serves my needs in so many ways” Dr. Komrad continued, “including informal consultations on difficult cases, learning from the similar queries of others, asking about experiences with certain medications, learning new treatment techniques, and having colleagues reflect on the ethical implications of certain clinical approaches, and similarly reflect on their queries.” Finally, Dr. Komrad noted he enjoys, “speculating with others about psychiatric dimensions of certain events in the news, and discussing and debating controversial issues in the profession.”

Listservs for psychiatrists are not breaking news: the APA has one, and Ivan Goldberg has run a large psychopharmacology bulletin board for years. Does your district branch have one? Should they? 

<[QM—Dinah Miller, M.D.

If you are a health professional and would like to comment on this article, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

MedPAC recently released a proposal for fixing the annual exercise that Congress conducts where it threatens to cut Medicare physician fees by 25%, then increases them by 1%. The Medicare Payment Advisory Commission (MedPAC) is an independent congressional commission that provides advice to Congress about Medicare issues.

The Sustainable Growth Rate formula (SGR) was created in 1997 to keep annual Medicare cost increases in line with U.S. gross domestic product levels. This formula is flawed such that every year results in a decrease in provider fees (physicians, psychologists, social workers, nurse practitioners, etc.), despite the inflation rate increasing. And every year, the Congress says it must reduce the fees for the following year, resulting in an outcry from providers to block the decrease and fix the SGR permanently. But Congress makes a short-term fix and passes the buck for another year.

In 2012, the SGR cut is scheduled to be 30%. Taking a stab at fixing the SGR formula, MedPAC described a proposal that would keep fees for primary care providers flat for 10 years, and reduce specialist fees for 5.9% per year over the next 3 years, then keeping specialist fees flat for the following 7 years.

The specialist cuts amount to nearly 18% over 3 years. We are already having trouble finding psychiatrists to accept Medicare patients because of the current level of fees. An 18% cut would result in many more psychiatrists and other mental health providers dropping out of Medicare just when the aging Baby Boomer generation will be needing us most. This cut will force these older people to either pay out of pocket for psychiatric care or wait months for a new appointment with one of the providers still accepting Medicare.

MedPAC explained that providers can make up the difference by just seeing more patients. This belies the fact that a psychiatrist’s services are primarily time-based, so we can not just squeeze more patients into an 8-hour day. Additionally, to the extent that physicians’ overhead and malpractice costs will continue to escalate over 10 years, having an 18% cut followed by 7 years of no increases amounts to an additional 21% cut given a 3% annual inflation. A 39% cut over 10 years would result in large-scale abandonment of Medicare by many physicians and other specialty providers.

I think Medicare needs to reinvent its game by moving away from per-visit payments -- which reward volumes -- toward payments based on severity-adjusted episodes of care combined with quality and outcomes multipliers -- which rewards quality and efficiency.

By re-inventing the way Medicare pays all providers, not by quantity but by quality and efficiency, it has a chance to bend the cost curve without making it harder for beneficiaries to find a doctor who will accept Medicare. Medicare enrollees deserve to be treated better. If Congress messes this up, there will be hell to pay at the ballot box.

Steven Roy Daviss, M.D., DFAPA, co-author of Shrink Rap: Three Psychiatrists Explain Their Work, is chair of the department of psychiatry at the University of Maryland Baltimore Washington Medical Center.

MedPAC recently released a proposal for fixing the annual exercise that Congress conducts where it threatens to cut Medicare physician fees by 25%, then increases them by 1%. The Medicare Payment Advisory Commission (MedPAC) is an independent congressional commission that provides advice to Congress about Medicare issues.

The Sustainable Growth Rate formula (SGR) was created in 1997 to keep annual Medicare cost increases in line with U.S. gross domestic product levels. This formula is flawed such that every year results in a decrease in provider fees (physicians, psychologists, social workers, nurse practitioners, etc.), despite the inflation rate increasing. And every year, the Congress says it must reduce the fees for the following year, resulting in an outcry from providers to block the decrease and fix the SGR permanently. But Congress makes a short-term fix and passes the buck for another year.

In 2012, the SGR cut is scheduled to be 30%. Taking a stab at fixing the SGR formula, MedPAC described a proposal that would keep fees for primary care providers flat for 10 years, and reduce specialist fees for 5.9% per year over the next 3 years, then keeping specialist fees flat for the following 7 years.

The specialist cuts amount to nearly 18% over 3 years. We are already having trouble finding psychiatrists to accept Medicare patients because of the current level of fees. An 18% cut would result in many more psychiatrists and other mental health providers dropping out of Medicare just when the aging Baby Boomer generation will be needing us most. This cut will force these older people to either pay out of pocket for psychiatric care or wait months for a new appointment with one of the providers still accepting Medicare.

MedPAC explained that providers can make up the difference by just seeing more patients. This belies the fact that a psychiatrist’s services are primarily time-based, so we can not just squeeze more patients into an 8-hour day. Additionally, to the extent that physicians’ overhead and malpractice costs will continue to escalate over 10 years, having an 18% cut followed by 7 years of no increases amounts to an additional 21% cut given a 3% annual inflation. A 39% cut over 10 years would result in large-scale abandonment of Medicare by many physicians and other specialty providers.

I think Medicare needs to reinvent its game by moving away from per-visit payments -- which reward volumes -- toward payments based on severity-adjusted episodes of care combined with quality and outcomes multipliers -- which rewards quality and efficiency.

By re-inventing the way Medicare pays all providers, not by quantity but by quality and efficiency, it has a chance to bend the cost curve without making it harder for beneficiaries to find a doctor who will accept Medicare. Medicare enrollees deserve to be treated better. If Congress messes this up, there will be hell to pay at the ballot box.

Steven Roy Daviss, M.D., DFAPA, co-author of Shrink Rap: Three Psychiatrists Explain Their Work, is chair of the department of psychiatry at the University of Maryland Baltimore Washington Medical Center.

MedPAC recently released a proposal for fixing the annual exercise that Congress conducts where it threatens to cut Medicare physician fees by 25%, then increases them by 1%. The Medicare Payment Advisory Commission (MedPAC) is an independent congressional commission that provides advice to Congress about Medicare issues.

The Sustainable Growth Rate formula (SGR) was created in 1997 to keep annual Medicare cost increases in line with U.S. gross domestic product levels. This formula is flawed such that every year results in a decrease in provider fees (physicians, psychologists, social workers, nurse practitioners, etc.), despite the inflation rate increasing. And every year, the Congress says it must reduce the fees for the following year, resulting in an outcry from providers to block the decrease and fix the SGR permanently. But Congress makes a short-term fix and passes the buck for another year.

In 2012, the SGR cut is scheduled to be 30%. Taking a stab at fixing the SGR formula, MedPAC described a proposal that would keep fees for primary care providers flat for 10 years, and reduce specialist fees for 5.9% per year over the next 3 years, then keeping specialist fees flat for the following 7 years.

The specialist cuts amount to nearly 18% over 3 years. We are already having trouble finding psychiatrists to accept Medicare patients because of the current level of fees. An 18% cut would result in many more psychiatrists and other mental health providers dropping out of Medicare just when the aging Baby Boomer generation will be needing us most. This cut will force these older people to either pay out of pocket for psychiatric care or wait months for a new appointment with one of the providers still accepting Medicare.

MedPAC explained that providers can make up the difference by just seeing more patients. This belies the fact that a psychiatrist’s services are primarily time-based, so we can not just squeeze more patients into an 8-hour day. Additionally, to the extent that physicians’ overhead and malpractice costs will continue to escalate over 10 years, having an 18% cut followed by 7 years of no increases amounts to an additional 21% cut given a 3% annual inflation. A 39% cut over 10 years would result in large-scale abandonment of Medicare by many physicians and other specialty providers.

I think Medicare needs to reinvent its game by moving away from per-visit payments -- which reward volumes -- toward payments based on severity-adjusted episodes of care combined with quality and outcomes multipliers -- which rewards quality and efficiency.

By re-inventing the way Medicare pays all providers, not by quantity but by quality and efficiency, it has a chance to bend the cost curve without making it harder for beneficiaries to find a doctor who will accept Medicare. Medicare enrollees deserve to be treated better. If Congress messes this up, there will be hell to pay at the ballot box.

Steven Roy Daviss, M.D., DFAPA, co-author of Shrink Rap: Three Psychiatrists Explain Their Work, is chair of the department of psychiatry at the University of Maryland Baltimore Washington Medical Center.

When I meet one of my prison patients for the first time and introduce myself, the response I sometimes get is, “So, what can you do for me?” This question is a natural segue to explore the goals, parameters, and limitations of the therapeutic relationship. A good therapeutic relationship is important in any clinical practice, but in the correctional setting it’s particularly important, because a poor or adverse relationship can lead to noncompliance, bad medical outcomes and even violence. Therapeutic relationships in jail and prison are difficult to create and maintain for several reasons.

The physician-patient relationship is inherently imbalanced; in a jail or prison there is the added complication that the patient has no choice of provider and constrained treatment options. An inmate may believe that treatment recommendations are driven solely by the financial interests of the physician, or that an intervention is being recommended simply to protect the physician from litigation. Correctional patients are more likely to be cognitively limited, mentally ill, or poorly educated, which can compromise the physician’s ability to explain treatment options and risks. Prisoners may hold values or priorities that differ from that of the clinician. For example, an inmate may decline needed medications or treatments if this would prohibit him from participation in rehabilitation programs or institutional work assignments. A prison culture that values strength and independence might stigmatize an inmate who feels a need to talk to a therapist. Finally, the therapeutic relationship in jail or prison is time-limited and occasionally disrupted by institutional transfers.

Clinician factors also can affect the physician-patient relationship in prison. An inexperienced physician may be intimidated by a patient who directly threatens him, or who implies a threat of violence or litigation. Experienced clinicians face the risk of therapeutic nihilism with prison patients who are repeatedly noncompliant or demanding. Extra patience is required for working with prisoners who value immediate relief over longterm improvement, or whose risk-taking tolerance is higher than that of the clinician. Cultural differences between the physician and the prison patient also affect the relationship, when the prisoner values family or “outside” advice over the advice given by a trained medical professional.

The physician’s imperative is to act in the best interests of the patient, even when this conflicts with the patient’s stated interests or desires. The goal of the correctional clinician is to retain patient trust while building patient self-reliance and personal responsibility.

Much has been written about the physician-patient relationship, but in general there are three predominant models: the paternalistic model, the autonomous or informed consent model, and the shared decision-making model. The paternalist model requires the physician to be the sole decision-maker, with the patient as the passive recipient of medical advice. The autonomous model places the patient (or “consumer”) at the focal point of treatment while the physician plays a peripheral service-provider role. Most medical encounters today employ the shared decision-making model, in which an informed and educated patient makes a decision about treatment with the trusted guidance of a physician.

A collaborative physician-patient relationship can be created through the use of decision aids, such as patient education materials and practice guidelines. Some facilities already use education-appropriate, culturally informed pamphlets for patient education regarding sexually transmitted diseases and other medical illnesses. Similar materials could be adapted for use by correctional psychiatrists. The physician-educator can explain the use of disease-specific practice guidelines when making treatment recommendations, so that the prisoner can understand that recommendations are consistent with best professional practices. Finally, allowing the inmate time to consider the decision and seek advice from family members can create a feeling of autonomy and responsibility in the treatment process.

With some adaptation in current practices, correctional health care need not be an adversarial process.

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

When I meet one of my prison patients for the first time and introduce myself, the response I sometimes get is, “So, what can you do for me?” This question is a natural segue to explore the goals, parameters, and limitations of the therapeutic relationship. A good therapeutic relationship is important in any clinical practice, but in the correctional setting it’s particularly important, because a poor or adverse relationship can lead to noncompliance, bad medical outcomes and even violence. Therapeutic relationships in jail and prison are difficult to create and maintain for several reasons.

The physician-patient relationship is inherently imbalanced; in a jail or prison there is the added complication that the patient has no choice of provider and constrained treatment options. An inmate may believe that treatment recommendations are driven solely by the financial interests of the physician, or that an intervention is being recommended simply to protect the physician from litigation. Correctional patients are more likely to be cognitively limited, mentally ill, or poorly educated, which can compromise the physician’s ability to explain treatment options and risks. Prisoners may hold values or priorities that differ from that of the clinician. For example, an inmate may decline needed medications or treatments if this would prohibit him from participation in rehabilitation programs or institutional work assignments. A prison culture that values strength and independence might stigmatize an inmate who feels a need to talk to a therapist. Finally, the therapeutic relationship in jail or prison is time-limited and occasionally disrupted by institutional transfers.

Clinician factors also can affect the physician-patient relationship in prison. An inexperienced physician may be intimidated by a patient who directly threatens him, or who implies a threat of violence or litigation. Experienced clinicians face the risk of therapeutic nihilism with prison patients who are repeatedly noncompliant or demanding. Extra patience is required for working with prisoners who value immediate relief over longterm improvement, or whose risk-taking tolerance is higher than that of the clinician. Cultural differences between the physician and the prison patient also affect the relationship, when the prisoner values family or “outside” advice over the advice given by a trained medical professional.

The physician’s imperative is to act in the best interests of the patient, even when this conflicts with the patient’s stated interests or desires. The goal of the correctional clinician is to retain patient trust while building patient self-reliance and personal responsibility.

Much has been written about the physician-patient relationship, but in general there are three predominant models: the paternalistic model, the autonomous or informed consent model, and the shared decision-making model. The paternalist model requires the physician to be the sole decision-maker, with the patient as the passive recipient of medical advice. The autonomous model places the patient (or “consumer”) at the focal point of treatment while the physician plays a peripheral service-provider role. Most medical encounters today employ the shared decision-making model, in which an informed and educated patient makes a decision about treatment with the trusted guidance of a physician.

A collaborative physician-patient relationship can be created through the use of decision aids, such as patient education materials and practice guidelines. Some facilities already use education-appropriate, culturally informed pamphlets for patient education regarding sexually transmitted diseases and other medical illnesses. Similar materials could be adapted for use by correctional psychiatrists. The physician-educator can explain the use of disease-specific practice guidelines when making treatment recommendations, so that the prisoner can understand that recommendations are consistent with best professional practices. Finally, allowing the inmate time to consider the decision and seek advice from family members can create a feeling of autonomy and responsibility in the treatment process.

With some adaptation in current practices, correctional health care need not be an adversarial process.

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

When I meet one of my prison patients for the first time and introduce myself, the response I sometimes get is, “So, what can you do for me?” This question is a natural segue to explore the goals, parameters, and limitations of the therapeutic relationship. A good therapeutic relationship is important in any clinical practice, but in the correctional setting it’s particularly important, because a poor or adverse relationship can lead to noncompliance, bad medical outcomes and even violence. Therapeutic relationships in jail and prison are difficult to create and maintain for several reasons.

The physician-patient relationship is inherently imbalanced; in a jail or prison there is the added complication that the patient has no choice of provider and constrained treatment options. An inmate may believe that treatment recommendations are driven solely by the financial interests of the physician, or that an intervention is being recommended simply to protect the physician from litigation. Correctional patients are more likely to be cognitively limited, mentally ill, or poorly educated, which can compromise the physician’s ability to explain treatment options and risks. Prisoners may hold values or priorities that differ from that of the clinician. For example, an inmate may decline needed medications or treatments if this would prohibit him from participation in rehabilitation programs or institutional work assignments. A prison culture that values strength and independence might stigmatize an inmate who feels a need to talk to a therapist. Finally, the therapeutic relationship in jail or prison is time-limited and occasionally disrupted by institutional transfers.

Clinician factors also can affect the physician-patient relationship in prison. An inexperienced physician may be intimidated by a patient who directly threatens him, or who implies a threat of violence or litigation. Experienced clinicians face the risk of therapeutic nihilism with prison patients who are repeatedly noncompliant or demanding. Extra patience is required for working with prisoners who value immediate relief over longterm improvement, or whose risk-taking tolerance is higher than that of the clinician. Cultural differences between the physician and the prison patient also affect the relationship, when the prisoner values family or “outside” advice over the advice given by a trained medical professional.

The physician’s imperative is to act in the best interests of the patient, even when this conflicts with the patient’s stated interests or desires. The goal of the correctional clinician is to retain patient trust while building patient self-reliance and personal responsibility.

Much has been written about the physician-patient relationship, but in general there are three predominant models: the paternalistic model, the autonomous or informed consent model, and the shared decision-making model. The paternalist model requires the physician to be the sole decision-maker, with the patient as the passive recipient of medical advice. The autonomous model places the patient (or “consumer”) at the focal point of treatment while the physician plays a peripheral service-provider role. Most medical encounters today employ the shared decision-making model, in which an informed and educated patient makes a decision about treatment with the trusted guidance of a physician.

A collaborative physician-patient relationship can be created through the use of decision aids, such as patient education materials and practice guidelines. Some facilities already use education-appropriate, culturally informed pamphlets for patient education regarding sexually transmitted diseases and other medical illnesses. Similar materials could be adapted for use by correctional psychiatrists. The physician-educator can explain the use of disease-specific practice guidelines when making treatment recommendations, so that the prisoner can understand that recommendations are consistent with best professional practices. Finally, allowing the inmate time to consider the decision and seek advice from family members can create a feeling of autonomy and responsibility in the treatment process.

With some adaptation in current practices, correctional health care need not be an adversarial process.

Dr. Annette Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The patient leaves and the psychiatrist writes a note. What does the doctor say? Does a psychiatrist write a standard medical SOAP note, a detailed process note, a quick few sentences, or no note at all? In hospitals and clinics, there are requirements for documentation that come from regulatory agencies, but in private practice there is no such oversight. Do you know what the standard of care requires?

There is a good deal of variety regarding what psychiatrists choose to document. Some write very detailed notes; others focus their notes on symptoms and medication but omit personal events they believe a patient would not want documented, and finally, some simply do not write notes on every psychotherapy session. The psychiatrist is faced with the questions of what is the purpose of the note and who might see it.

Medical notes are written with several potential “readers” in mind. The psychiatrist writes for himself so that he can review details of the patient’s life and treatment. He writes for the patient – that is, to enable continuity of care if the patient should later need to see another psychiatrist. Finally, the psychiatrist writes for his own protection, and he writes what he believes will be helpful to him in the event that he is sued or that his records are reviewed by a state licensing board. What benefits one audience may harm another.

Dr. Michael Spodak is the chair of the Maryland Psychiatric Society’s Peer Review Committee, which provides services to the Maryland Board of Physicians.  Dr. Spodak writes: “To date, there is no agreement as to a standard for therapy notes. At a minimum, they probably should contain a date of service. We have felt the purpose of the note is for another psychiatrist to pick up where you left off if you suddenly became unavailable, such as through death. So if a patient is suicidal, a note should probably contain information on how that is being addressed.” Dr. Spodak says that for medication management, psychiatrists are held to the same standard that other physicians hold, and he faxed a one-paragraph statement from the medical board that states that physicians must keep “adequate” records. Such are records are defined to be legible and include “dates of visits, chief complaints, historical, physical and laboratory data, diagnosis and a treatment plan.” It further states that doctors should give reasons for ordering medications and tests.

What about the usefulness of notes when a psychiatrist is sued? Eric Marine, the vice president of claims and risk management for American Professional Agency, a medical malpractice insurer, says that few psychiatrists get sued. “There are about 100,000 psychiatrists in the United States, and there are less than 1,000 claims a year.”

“The biggest problem with notes,” Mr. Marine said, “is the disagreement about what is supposed to be in them. When you’re talking about these issues, it’s as if there is some mythical thing called ‘standard of care.’ What would a reasonable doctor do? But outcome is never guaranteed.”

So there is no standard and so the psychiatrist is left to guess at what might be important down the line. In the event that a patient dies of an unanticipated suicide and the family sues the psychiatrist, Mr. Marine confirms that it is helpful if the psychiatrist has documented that the patient was not suicidal.  This may lead to the conclusion that every patient should be assessed for suicide at every visit, regardless of the relevance to the clinical issues at hand, or that a psychiatrist must be clairvoyant to predict which patients might sue him for what so that he can document accordingly. It also suggests that if the psychiatrist didn’t ask about suicidal ideation, then he was at fault in the case of a suicide!

Another concern is that information in a patient’s records might be used in a manner that is harmful to the patient. Jesse Hellman is a psychiatrist who has been in private practice in Towson, Md., for 35 years. Dr. Hellman worries about confidentiality with medical records. “The need to protect the patient is a primary issue, and since notes are really not confidential, the only way to protect the patient is to not record anything that you would not want known.”

Dr. Spodak agrees that the issue of keeping notes on therapy sessions can be problematic. “Do we have a duty to inform the patient that the notes may be disclosed to an insurance company, medical board and others? After that warning, will anyone disclose things of substance if the psychiatrist makes notes?”

Regardless of how the psychiatrist documents treatment, there is the potential for problems. Dr. Hellman notes, “No matter how well you record a psychotherapy note, it is never enough if the goal is to find fault with it.”

<[Q—Dinah Miller, M.D.

If you are a health professional and would like to comment on this article, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here and go to the September 7, 2011, post entitled What’s in a Note? Psychiatrists and Medical Records. Comments on Shrink Rap are open to all readers.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

The patient leaves and the psychiatrist writes a note. What does the doctor say? Does a psychiatrist write a standard medical SOAP note, a detailed process note, a quick few sentences, or no note at all? In hospitals and clinics, there are requirements for documentation that come from regulatory agencies, but in private practice there is no such oversight. Do you know what the standard of care requires?

There is a good deal of variety regarding what psychiatrists choose to document. Some write very detailed notes; others focus their notes on symptoms and medication but omit personal events they believe a patient would not want documented, and finally, some simply do not write notes on every psychotherapy session. The psychiatrist is faced with the questions of what is the purpose of the note and who might see it.

Medical notes are written with several potential “readers” in mind. The psychiatrist writes for himself so that he can review details of the patient’s life and treatment. He writes for the patient – that is, to enable continuity of care if the patient should later need to see another psychiatrist. Finally, the psychiatrist writes for his own protection, and he writes what he believes will be helpful to him in the event that he is sued or that his records are reviewed by a state licensing board. What benefits one audience may harm another.

Dr. Michael Spodak is the chair of the Maryland Psychiatric Society’s Peer Review Committee, which provides services to the Maryland Board of Physicians.  Dr. Spodak writes: “To date, there is no agreement as to a standard for therapy notes. At a minimum, they probably should contain a date of service. We have felt the purpose of the note is for another psychiatrist to pick up where you left off if you suddenly became unavailable, such as through death. So if a patient is suicidal, a note should probably contain information on how that is being addressed.” Dr. Spodak says that for medication management, psychiatrists are held to the same standard that other physicians hold, and he faxed a one-paragraph statement from the medical board that states that physicians must keep “adequate” records. Such are records are defined to be legible and include “dates of visits, chief complaints, historical, physical and laboratory data, diagnosis and a treatment plan.” It further states that doctors should give reasons for ordering medications and tests.

What about the usefulness of notes when a psychiatrist is sued? Eric Marine, the vice president of claims and risk management for American Professional Agency, a medical malpractice insurer, says that few psychiatrists get sued. “There are about 100,000 psychiatrists in the United States, and there are less than 1,000 claims a year.”

“The biggest problem with notes,” Mr. Marine said, “is the disagreement about what is supposed to be in them. When you’re talking about these issues, it’s as if there is some mythical thing called ‘standard of care.’ What would a reasonable doctor do? But outcome is never guaranteed.”

So there is no standard and so the psychiatrist is left to guess at what might be important down the line. In the event that a patient dies of an unanticipated suicide and the family sues the psychiatrist, Mr. Marine confirms that it is helpful if the psychiatrist has documented that the patient was not suicidal.  This may lead to the conclusion that every patient should be assessed for suicide at every visit, regardless of the relevance to the clinical issues at hand, or that a psychiatrist must be clairvoyant to predict which patients might sue him for what so that he can document accordingly. It also suggests that if the psychiatrist didn’t ask about suicidal ideation, then he was at fault in the case of a suicide!

Another concern is that information in a patient’s records might be used in a manner that is harmful to the patient. Jesse Hellman is a psychiatrist who has been in private practice in Towson, Md., for 35 years. Dr. Hellman worries about confidentiality with medical records. “The need to protect the patient is a primary issue, and since notes are really not confidential, the only way to protect the patient is to not record anything that you would not want known.”

Dr. Spodak agrees that the issue of keeping notes on therapy sessions can be problematic. “Do we have a duty to inform the patient that the notes may be disclosed to an insurance company, medical board and others? After that warning, will anyone disclose things of substance if the psychiatrist makes notes?”

Regardless of how the psychiatrist documents treatment, there is the potential for problems. Dr. Hellman notes, “No matter how well you record a psychotherapy note, it is never enough if the goal is to find fault with it.”

<[Q—Dinah Miller, M.D.

If you are a health professional and would like to comment on this article, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here and go to the September 7, 2011, post entitled What’s in a Note? Psychiatrists and Medical Records. Comments on Shrink Rap are open to all readers.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

The patient leaves and the psychiatrist writes a note. What does the doctor say? Does a psychiatrist write a standard medical SOAP note, a detailed process note, a quick few sentences, or no note at all? In hospitals and clinics, there are requirements for documentation that come from regulatory agencies, but in private practice there is no such oversight. Do you know what the standard of care requires?

There is a good deal of variety regarding what psychiatrists choose to document. Some write very detailed notes; others focus their notes on symptoms and medication but omit personal events they believe a patient would not want documented, and finally, some simply do not write notes on every psychotherapy session. The psychiatrist is faced with the questions of what is the purpose of the note and who might see it.

Medical notes are written with several potential “readers” in mind. The psychiatrist writes for himself so that he can review details of the patient’s life and treatment. He writes for the patient – that is, to enable continuity of care if the patient should later need to see another psychiatrist. Finally, the psychiatrist writes for his own protection, and he writes what he believes will be helpful to him in the event that he is sued or that his records are reviewed by a state licensing board. What benefits one audience may harm another.

Dr. Michael Spodak is the chair of the Maryland Psychiatric Society’s Peer Review Committee, which provides services to the Maryland Board of Physicians.  Dr. Spodak writes: “To date, there is no agreement as to a standard for therapy notes. At a minimum, they probably should contain a date of service. We have felt the purpose of the note is for another psychiatrist to pick up where you left off if you suddenly became unavailable, such as through death. So if a patient is suicidal, a note should probably contain information on how that is being addressed.” Dr. Spodak says that for medication management, psychiatrists are held to the same standard that other physicians hold, and he faxed a one-paragraph statement from the medical board that states that physicians must keep “adequate” records. Such are records are defined to be legible and include “dates of visits, chief complaints, historical, physical and laboratory data, diagnosis and a treatment plan.” It further states that doctors should give reasons for ordering medications and tests.

What about the usefulness of notes when a psychiatrist is sued? Eric Marine, the vice president of claims and risk management for American Professional Agency, a medical malpractice insurer, says that few psychiatrists get sued. “There are about 100,000 psychiatrists in the United States, and there are less than 1,000 claims a year.”

“The biggest problem with notes,” Mr. Marine said, “is the disagreement about what is supposed to be in them. When you’re talking about these issues, it’s as if there is some mythical thing called ‘standard of care.’ What would a reasonable doctor do? But outcome is never guaranteed.”

So there is no standard and so the psychiatrist is left to guess at what might be important down the line. In the event that a patient dies of an unanticipated suicide and the family sues the psychiatrist, Mr. Marine confirms that it is helpful if the psychiatrist has documented that the patient was not suicidal.  This may lead to the conclusion that every patient should be assessed for suicide at every visit, regardless of the relevance to the clinical issues at hand, or that a psychiatrist must be clairvoyant to predict which patients might sue him for what so that he can document accordingly. It also suggests that if the psychiatrist didn’t ask about suicidal ideation, then he was at fault in the case of a suicide!

Another concern is that information in a patient’s records might be used in a manner that is harmful to the patient. Jesse Hellman is a psychiatrist who has been in private practice in Towson, Md., for 35 years. Dr. Hellman worries about confidentiality with medical records. “The need to protect the patient is a primary issue, and since notes are really not confidential, the only way to protect the patient is to not record anything that you would not want known.”

Dr. Spodak agrees that the issue of keeping notes on therapy sessions can be problematic. “Do we have a duty to inform the patient that the notes may be disclosed to an insurance company, medical board and others? After that warning, will anyone disclose things of substance if the psychiatrist makes notes?”

Regardless of how the psychiatrist documents treatment, there is the potential for problems. Dr. Hellman notes, “No matter how well you record a psychotherapy note, it is never enough if the goal is to find fault with it.”

<[Q—Dinah Miller, M.D.

If you are a health professional and would like to comment on this article, please register with Clinical Psychiatry News. If you are already registered, please log in to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here and go to the September 7, 2011, post entitled What’s in a Note? Psychiatrists and Medical Records. Comments on Shrink Rap are open to all readers.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

Warning: Satire ahead.

The field of psychiatry has been a pioneer in the use of telemedicine. Providing therapy by phone has been used for years, but this is limited due to lack of nonverbal cues. Because our exam can generally be performed in a hands-off manner, remote audio and video allow close approximation to a face-to-face exam. Skype, Facetime, Google+ Hangouts, and similar applications are being increasingly used to provide ongoing treatment for existing patients, especially when they may be out of town or cannot travel because of illness or weather.

©Lack-O&#039;Keen/Fotolia.com

When these modalities are not available, some have also used e-mail to make decisions, such as decreasing a medication dose based on side effects or refilling a prescription. Text messaging is being used to deliver reminders and communicate changes in appointments or even medication doses. This had me wondering about the typical lack of nonverbal cues in these text-based communications.

I then realized that emoticons, those smiley faces people use to express emotion, can be extremely useful in helping us to assess our patients’ mood, and even side effects, based on their e-mails and text messages to us. Their use of common Internet shorthand, such as LOL for laughing out loud, can also be helpful. But it can be hard for some of us, especially those who did not grow up with an Internet, to tell the difference between, for example, a :-) [smile] and a ;-) [wink]. or to know that :-p is a tongue sticking out or :-* is a kiss.

I have compiled a highly refined guide below to help psychiatrists make appropriate treatment decisions based on their e-mail or text message communications with their patients. This guide is derived from the latest evidence-based medicine research on textual language processing of emotionally-laden content based on fMRI evidence from frequent web-using subjects. I hope it is helpful to you in your practice.

If you have additions to this guide, please share them in the comments section.

<[QM]>—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, clinical assistant professor at University of Maryland, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. Find him @HITshrink on Twitter and on the Shrink Rap blog, where humor and seriousness mix regularly.

Warning: Satire ahead.

The field of psychiatry has been a pioneer in the use of telemedicine. Providing therapy by phone has been used for years, but this is limited due to lack of nonverbal cues. Because our exam can generally be performed in a hands-off manner, remote audio and video allow close approximation to a face-to-face exam. Skype, Facetime, Google+ Hangouts, and similar applications are being increasingly used to provide ongoing treatment for existing patients, especially when they may be out of town or cannot travel because of illness or weather.

©Lack-O&#039;Keen/Fotolia.com

When these modalities are not available, some have also used e-mail to make decisions, such as decreasing a medication dose based on side effects or refilling a prescription. Text messaging is being used to deliver reminders and communicate changes in appointments or even medication doses. This had me wondering about the typical lack of nonverbal cues in these text-based communications.

I then realized that emoticons, those smiley faces people use to express emotion, can be extremely useful in helping us to assess our patients’ mood, and even side effects, based on their e-mails and text messages to us. Their use of common Internet shorthand, such as LOL for laughing out loud, can also be helpful. But it can be hard for some of us, especially those who did not grow up with an Internet, to tell the difference between, for example, a :-) [smile] and a ;-) [wink]. or to know that :-p is a tongue sticking out or :-* is a kiss.

I have compiled a highly refined guide below to help psychiatrists make appropriate treatment decisions based on their e-mail or text message communications with their patients. This guide is derived from the latest evidence-based medicine research on textual language processing of emotionally-laden content based on fMRI evidence from frequent web-using subjects. I hope it is helpful to you in your practice.

If you have additions to this guide, please share them in the comments section.

<[QM]>—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, clinical assistant professor at University of Maryland, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. Find him @HITshrink on Twitter and on the Shrink Rap blog, where humor and seriousness mix regularly.

Warning: Satire ahead.

The field of psychiatry has been a pioneer in the use of telemedicine. Providing therapy by phone has been used for years, but this is limited due to lack of nonverbal cues. Because our exam can generally be performed in a hands-off manner, remote audio and video allow close approximation to a face-to-face exam. Skype, Facetime, Google+ Hangouts, and similar applications are being increasingly used to provide ongoing treatment for existing patients, especially when they may be out of town or cannot travel because of illness or weather.

©Lack-O&#039;Keen/Fotolia.com

When these modalities are not available, some have also used e-mail to make decisions, such as decreasing a medication dose based on side effects or refilling a prescription. Text messaging is being used to deliver reminders and communicate changes in appointments or even medication doses. This had me wondering about the typical lack of nonverbal cues in these text-based communications.

I then realized that emoticons, those smiley faces people use to express emotion, can be extremely useful in helping us to assess our patients’ mood, and even side effects, based on their e-mails and text messages to us. Their use of common Internet shorthand, such as LOL for laughing out loud, can also be helpful. But it can be hard for some of us, especially those who did not grow up with an Internet, to tell the difference between, for example, a :-) [smile] and a ;-) [wink]. or to know that :-p is a tongue sticking out or :-* is a kiss.

I have compiled a highly refined guide below to help psychiatrists make appropriate treatment decisions based on their e-mail or text message communications with their patients. This guide is derived from the latest evidence-based medicine research on textual language processing of emotionally-laden content based on fMRI evidence from frequent web-using subjects. I hope it is helpful to you in your practice.

If you have additions to this guide, please share them in the comments section.

<[QM]>—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at Baltimore Washington Medical Center, clinical assistant professor at University of Maryland, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. Find him @HITshrink on Twitter and on the Shrink Rap blog, where humor and seriousness mix regularly.

Let’s imagine this thought experiment:

We take a group of college students and randomly assign them to two roles. One group is told that they will play young 20-something urbanites from Manhattan. The other group is told they will play young fourth-generation farmers from the Upper Midwest. Put them in a room together and listen to the conversation. Before long you will hear arguments about farm subsidies, labor unions, conservative values, literature, the role of the humanities in education, and whether or not the New York Times is the ne plus ultra of journalism.

Some of the college students may really be from Manhattan, some may really be from small agricultural communities, but the rest are just doing what they are told and filling the role as they expect it should be played. None of it is real. None of it has anything to say about whether farmers ever read the New York Times or whether Manhattanites really have no interest in agriculture (that Starbucks-sipping yuppie may be a trader in wheat futures). There’s a serious limit to what you could conclude about political opinions, cultural values, and human behavior based upon a bunch of kids playing roles.

Yet, this is exactly the theory behind Stanford psychologist Philip Zimbardo’s oft-celebrated prison experiment, which was remembered recently in a BBC news story about its 40th anniversary. In 1971 Zimbardo randomly assigned college students to play either prison guards (back then they were never called correctional officers) or prison inmates. Within a matter of days, the “guards” became brutal and sadistic, while the prisoners became either broken and helpless or defiant. The students’ psychological reactions to the experiment were so extreme that the project had to be ended after 1 week.

The experiment would have quickly been forgotten had it not been followed within months by two major prison riots, one at San Quentin and another at Attica in New York. The San Quentin and Attica riots involved thousands of inmates and the deaths of both correctional officers and prisoners. Public attention and the news media quickly focused on harsh prison conditions at both facilities, and Zimbardo – in spite of no actual training or experience in the field – hit the spotlight as a prison reform “expert,” testifying before Congress and in a number of criminal trials about the psychodynamics of power.

The political fallout of the experiment was so great that people today tend to overlook the fact that the experiment was simply bad science. It was an unblinded study, with no control groups, in a non-correctional environment. The prison “guards” were given none of the training given to all correctional officers: training about the law, the use of force, civil rights, cultural diversity, and how to work with the mentally ill. They did not belong to a professional organization or subscribe to the correctional officers’ code of ethics. In short, there was nothing resembling reality.

As one of the pseudo-guards put it in the BBC story:

“After the first day I noticed nothing was happening. It was a bit of a bore, so I made the decision I would take on the persona of a very cruel prison guard,” said Dave Eshleman, one of the wardens who took a lead role.

But one former “prisoner” said it better:

“The worst thing is that the author, Zimbardo, has been rewarded with a great deal of attention for 40 years so people are taught an example of very bad science.”

This is not to say that brutality and mistreatment does not exist in correctional facilities. But it is not the inevitable result of working in a controlled, punitive environment. While prospective correctional officers are given pre-employment screening for obvious mental illness, personality disorders and criminal involvement, this will not necessarily prevent future on-the-job problems due to marital stress, depression, substance abuse or financial issues. These risk factors are common to many high stress professions and are also present in impaired physicians.

This may be the biggest drawback of the Stanford prison project. If all officer misconduct is attributed to the prison environment we may fail to recognize misconduct risk factors that can be caught early and treated.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Let’s imagine this thought experiment:

We take a group of college students and randomly assign them to two roles. One group is told that they will play young 20-something urbanites from Manhattan. The other group is told they will play young fourth-generation farmers from the Upper Midwest. Put them in a room together and listen to the conversation. Before long you will hear arguments about farm subsidies, labor unions, conservative values, literature, the role of the humanities in education, and whether or not the New York Times is the ne plus ultra of journalism.

Some of the college students may really be from Manhattan, some may really be from small agricultural communities, but the rest are just doing what they are told and filling the role as they expect it should be played. None of it is real. None of it has anything to say about whether farmers ever read the New York Times or whether Manhattanites really have no interest in agriculture (that Starbucks-sipping yuppie may be a trader in wheat futures). There’s a serious limit to what you could conclude about political opinions, cultural values, and human behavior based upon a bunch of kids playing roles.

Yet, this is exactly the theory behind Stanford psychologist Philip Zimbardo’s oft-celebrated prison experiment, which was remembered recently in a BBC news story about its 40th anniversary. In 1971 Zimbardo randomly assigned college students to play either prison guards (back then they were never called correctional officers) or prison inmates. Within a matter of days, the “guards” became brutal and sadistic, while the prisoners became either broken and helpless or defiant. The students’ psychological reactions to the experiment were so extreme that the project had to be ended after 1 week.

The experiment would have quickly been forgotten had it not been followed within months by two major prison riots, one at San Quentin and another at Attica in New York. The San Quentin and Attica riots involved thousands of inmates and the deaths of both correctional officers and prisoners. Public attention and the news media quickly focused on harsh prison conditions at both facilities, and Zimbardo – in spite of no actual training or experience in the field – hit the spotlight as a prison reform “expert,” testifying before Congress and in a number of criminal trials about the psychodynamics of power.

The political fallout of the experiment was so great that people today tend to overlook the fact that the experiment was simply bad science. It was an unblinded study, with no control groups, in a non-correctional environment. The prison “guards” were given none of the training given to all correctional officers: training about the law, the use of force, civil rights, cultural diversity, and how to work with the mentally ill. They did not belong to a professional organization or subscribe to the correctional officers’ code of ethics. In short, there was nothing resembling reality.

As one of the pseudo-guards put it in the BBC story:

“After the first day I noticed nothing was happening. It was a bit of a bore, so I made the decision I would take on the persona of a very cruel prison guard,” said Dave Eshleman, one of the wardens who took a lead role.

But one former “prisoner” said it better:

“The worst thing is that the author, Zimbardo, has been rewarded with a great deal of attention for 40 years so people are taught an example of very bad science.”

This is not to say that brutality and mistreatment does not exist in correctional facilities. But it is not the inevitable result of working in a controlled, punitive environment. While prospective correctional officers are given pre-employment screening for obvious mental illness, personality disorders and criminal involvement, this will not necessarily prevent future on-the-job problems due to marital stress, depression, substance abuse or financial issues. These risk factors are common to many high stress professions and are also present in impaired physicians.

This may be the biggest drawback of the Stanford prison project. If all officer misconduct is attributed to the prison environment we may fail to recognize misconduct risk factors that can be caught early and treated.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Let’s imagine this thought experiment:

We take a group of college students and randomly assign them to two roles. One group is told that they will play young 20-something urbanites from Manhattan. The other group is told they will play young fourth-generation farmers from the Upper Midwest. Put them in a room together and listen to the conversation. Before long you will hear arguments about farm subsidies, labor unions, conservative values, literature, the role of the humanities in education, and whether or not the New York Times is the ne plus ultra of journalism.

Some of the college students may really be from Manhattan, some may really be from small agricultural communities, but the rest are just doing what they are told and filling the role as they expect it should be played. None of it is real. None of it has anything to say about whether farmers ever read the New York Times or whether Manhattanites really have no interest in agriculture (that Starbucks-sipping yuppie may be a trader in wheat futures). There’s a serious limit to what you could conclude about political opinions, cultural values, and human behavior based upon a bunch of kids playing roles.

Yet, this is exactly the theory behind Stanford psychologist Philip Zimbardo’s oft-celebrated prison experiment, which was remembered recently in a BBC news story about its 40th anniversary. In 1971 Zimbardo randomly assigned college students to play either prison guards (back then they were never called correctional officers) or prison inmates. Within a matter of days, the “guards” became brutal and sadistic, while the prisoners became either broken and helpless or defiant. The students’ psychological reactions to the experiment were so extreme that the project had to be ended after 1 week.

The experiment would have quickly been forgotten had it not been followed within months by two major prison riots, one at San Quentin and another at Attica in New York. The San Quentin and Attica riots involved thousands of inmates and the deaths of both correctional officers and prisoners. Public attention and the news media quickly focused on harsh prison conditions at both facilities, and Zimbardo – in spite of no actual training or experience in the field – hit the spotlight as a prison reform “expert,” testifying before Congress and in a number of criminal trials about the psychodynamics of power.

The political fallout of the experiment was so great that people today tend to overlook the fact that the experiment was simply bad science. It was an unblinded study, with no control groups, in a non-correctional environment. The prison “guards” were given none of the training given to all correctional officers: training about the law, the use of force, civil rights, cultural diversity, and how to work with the mentally ill. They did not belong to a professional organization or subscribe to the correctional officers’ code of ethics. In short, there was nothing resembling reality.

As one of the pseudo-guards put it in the BBC story:

“After the first day I noticed nothing was happening. It was a bit of a bore, so I made the decision I would take on the persona of a very cruel prison guard,” said Dave Eshleman, one of the wardens who took a lead role.

But one former “prisoner” said it better:

“The worst thing is that the author, Zimbardo, has been rewarded with a great deal of attention for 40 years so people are taught an example of very bad science.”

This is not to say that brutality and mistreatment does not exist in correctional facilities. But it is not the inevitable result of working in a controlled, punitive environment. While prospective correctional officers are given pre-employment screening for obvious mental illness, personality disorders and criminal involvement, this will not necessarily prevent future on-the-job problems due to marital stress, depression, substance abuse or financial issues. These risk factors are common to many high stress professions and are also present in impaired physicians.

This may be the biggest drawback of the Stanford prison project. If all officer misconduct is attributed to the prison environment we may fail to recognize misconduct risk factors that can be caught early and treated.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Your friends are on Facebook, your patients are on Facebook, and they talk about their interactions during sessions. Even your mother is on Facebook. If you’re like most psychiatrists, you’re not on Facebook. A survey conducted by the Maryland Psychiatric Society revealed that only 22% of MPS members had Facebook or MySpace pages. Thirty-six percent said they limit their use of technology because they are psychiatrists.

Why do psychiatrists shy away from social media? I’m not aware that anyone has done research on this, but I have a few theories. Psychodynamic psychotherapy has placed an ideologic burden on psychiatrists to keep their private lives private; the work of therapy includes the interpretation of transference, and transference develops best when the patient knows little about the psychiatrist’s personal life. If transference can be tainted by having photographs of one’s children in the office, think how counterproductive it is to see the psychiatrist’s beach vacation pictures or to know he “likes” a certain political figure!

Psychiatrists often value their privacy, especially since they may see patients who are dangerous, and may worry that it makes them vulnerable to have personal information easily available. It may be difficult to see a positive side to social media, and there are certainly stories of people, including physicians, who have lost their jobs because they have posted information on their Facebook pages without using discretion, and this year the mandatory risk management session at Johns Hopkins Hospital included an entire presentation on the dangers of social media. These warnings boiled down to common sense: Don’t write about your patients on Facebook, don’t post photographs of your patients on Facebook (yes, doctors have done this), and don’t “friend” your patients.

Finally, some psychiatrists worry that their patients will try to “friend” them and will feel hurt if their request is denied, and have decided it is easier to simply not belong.

Why would anyone – much less a psychiatrist – even consider having a Facebook page? For starters, it’s fun. It’s an easy way to connect with people from the past, to communicate with people, and to keep up on information. It’s now part of many aspects of mainstream daily life, and many things transpire on Facebook: The American Psychiatric Association has a page it updates regularly, as does Johns Hopkins Medicine. If you “like” an organization, its updates come to your news feed, and it’s no longer just about gossip. It’s a great way to promote a service or a product, especially when there is news associated with it. Definitely “friend” or “fan” your favorite restaurants and news sources.

If you’ve been considering joining Facebook, here are some guidelines:

• If it will make you too anxious, don’t do it.

• If you don’t join, don’t assume you’re not there. If you’ve ever been to a wedding or a party or in a 4th grade class photo, someone else may have posted your picture.

• You can join with a pseudonym or some variant of your name. If you join under a fake name, you can reach out to others and tell them it’s you, but the public won’t know how to find you.

• You can join and quietly lurk: You don’t need to post photos, information, or post to anyone’s wall.

• If you include personal information or photographs, you may want to learn about privacy settings and set them so that only “friends” can see.

• Unless your page is set up as a professional practice page, it’s probably a good idea not to “friend” patients or to accept their friend requests. I have never had a patient ask to be my Facebook friend. If patients ask: “Why won’t you be my friend?” a reasonable answer is to say that it may be considered a boundary violation, it’s frowned upon in the field, and some hospitals forbid patient-doctor Facebook friending.

• No matter how anonymous you believe you are, or how high your privacy controls are set, with anything you post on the Internet, assume it’s possible that your patients, your mother, your boss, your residency director, and every malpractice attorney may see it. If that would present a problem, it doesn’t belong anywhere on the Internet.

• If you do join Facebook, by all means “fan” our Shrink Rap book page!

Steve Daviss will tell you that Google+ is the social networking site of the future, that it allows for higher privacy, better control of where information disseminates to, and videoconferencing. I’ll leave that discussion to him.

<[QM]>—Dinah Miller, M.D.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

If you are a health professional and would like to comment on this article, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here and go to the Aug. 17, 2011, post entitled “Is Facebook for Everyone?” Comments on Shrink Rap are open to all readers.

Your friends are on Facebook, your patients are on Facebook, and they talk about their interactions during sessions. Even your mother is on Facebook. If you’re like most psychiatrists, you’re not on Facebook. A survey conducted by the Maryland Psychiatric Society revealed that only 22% of MPS members had Facebook or MySpace pages. Thirty-six percent said they limit their use of technology because they are psychiatrists.

Why do psychiatrists shy away from social media? I’m not aware that anyone has done research on this, but I have a few theories. Psychodynamic psychotherapy has placed an ideologic burden on psychiatrists to keep their private lives private; the work of therapy includes the interpretation of transference, and transference develops best when the patient knows little about the psychiatrist’s personal life. If transference can be tainted by having photographs of one’s children in the office, think how counterproductive it is to see the psychiatrist’s beach vacation pictures or to know he “likes” a certain political figure!

Psychiatrists often value their privacy, especially since they may see patients who are dangerous, and may worry that it makes them vulnerable to have personal information easily available. It may be difficult to see a positive side to social media, and there are certainly stories of people, including physicians, who have lost their jobs because they have posted information on their Facebook pages without using discretion, and this year the mandatory risk management session at Johns Hopkins Hospital included an entire presentation on the dangers of social media. These warnings boiled down to common sense: Don’t write about your patients on Facebook, don’t post photographs of your patients on Facebook (yes, doctors have done this), and don’t “friend” your patients.

Finally, some psychiatrists worry that their patients will try to “friend” them and will feel hurt if their request is denied, and have decided it is easier to simply not belong.

Why would anyone – much less a psychiatrist – even consider having a Facebook page? For starters, it’s fun. It’s an easy way to connect with people from the past, to communicate with people, and to keep up on information. It’s now part of many aspects of mainstream daily life, and many things transpire on Facebook: The American Psychiatric Association has a page it updates regularly, as does Johns Hopkins Medicine. If you “like” an organization, its updates come to your news feed, and it’s no longer just about gossip. It’s a great way to promote a service or a product, especially when there is news associated with it. Definitely “friend” or “fan” your favorite restaurants and news sources.

If you’ve been considering joining Facebook, here are some guidelines:

• If it will make you too anxious, don’t do it.

• If you don’t join, don’t assume you’re not there. If you’ve ever been to a wedding or a party or in a 4th grade class photo, someone else may have posted your picture.

• You can join with a pseudonym or some variant of your name. If you join under a fake name, you can reach out to others and tell them it’s you, but the public won’t know how to find you.

• You can join and quietly lurk: You don’t need to post photos, information, or post to anyone’s wall.

• If you include personal information or photographs, you may want to learn about privacy settings and set them so that only “friends” can see.

• Unless your page is set up as a professional practice page, it’s probably a good idea not to “friend” patients or to accept their friend requests. I have never had a patient ask to be my Facebook friend. If patients ask: “Why won’t you be my friend?” a reasonable answer is to say that it may be considered a boundary violation, it’s frowned upon in the field, and some hospitals forbid patient-doctor Facebook friending.

• No matter how anonymous you believe you are, or how high your privacy controls are set, with anything you post on the Internet, assume it’s possible that your patients, your mother, your boss, your residency director, and every malpractice attorney may see it. If that would present a problem, it doesn’t belong anywhere on the Internet.

• If you do join Facebook, by all means “fan” our Shrink Rap book page!

Steve Daviss will tell you that Google+ is the social networking site of the future, that it allows for higher privacy, better control of where information disseminates to, and videoconferencing. I’ll leave that discussion to him.

<[QM]>—Dinah Miller, M.D.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

If you are a health professional and would like to comment on this article, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here and go to the Aug. 17, 2011, post entitled “Is Facebook for Everyone?” Comments on Shrink Rap are open to all readers.

Your friends are on Facebook, your patients are on Facebook, and they talk about their interactions during sessions. Even your mother is on Facebook. If you’re like most psychiatrists, you’re not on Facebook. A survey conducted by the Maryland Psychiatric Society revealed that only 22% of MPS members had Facebook or MySpace pages. Thirty-six percent said they limit their use of technology because they are psychiatrists.

Why do psychiatrists shy away from social media? I’m not aware that anyone has done research on this, but I have a few theories. Psychodynamic psychotherapy has placed an ideologic burden on psychiatrists to keep their private lives private; the work of therapy includes the interpretation of transference, and transference develops best when the patient knows little about the psychiatrist’s personal life. If transference can be tainted by having photographs of one’s children in the office, think how counterproductive it is to see the psychiatrist’s beach vacation pictures or to know he “likes” a certain political figure!

Psychiatrists often value their privacy, especially since they may see patients who are dangerous, and may worry that it makes them vulnerable to have personal information easily available. It may be difficult to see a positive side to social media, and there are certainly stories of people, including physicians, who have lost their jobs because they have posted information on their Facebook pages without using discretion, and this year the mandatory risk management session at Johns Hopkins Hospital included an entire presentation on the dangers of social media. These warnings boiled down to common sense: Don’t write about your patients on Facebook, don’t post photographs of your patients on Facebook (yes, doctors have done this), and don’t “friend” your patients.

Finally, some psychiatrists worry that their patients will try to “friend” them and will feel hurt if their request is denied, and have decided it is easier to simply not belong.

Why would anyone – much less a psychiatrist – even consider having a Facebook page? For starters, it’s fun. It’s an easy way to connect with people from the past, to communicate with people, and to keep up on information. It’s now part of many aspects of mainstream daily life, and many things transpire on Facebook: The American Psychiatric Association has a page it updates regularly, as does Johns Hopkins Medicine. If you “like” an organization, its updates come to your news feed, and it’s no longer just about gossip. It’s a great way to promote a service or a product, especially when there is news associated with it. Definitely “friend” or “fan” your favorite restaurants and news sources.

If you’ve been considering joining Facebook, here are some guidelines:

• If it will make you too anxious, don’t do it.

• If you don’t join, don’t assume you’re not there. If you’ve ever been to a wedding or a party or in a 4th grade class photo, someone else may have posted your picture.

• You can join with a pseudonym or some variant of your name. If you join under a fake name, you can reach out to others and tell them it’s you, but the public won’t know how to find you.

• You can join and quietly lurk: You don’t need to post photos, information, or post to anyone’s wall.

• If you include personal information or photographs, you may want to learn about privacy settings and set them so that only “friends” can see.

• Unless your page is set up as a professional practice page, it’s probably a good idea not to “friend” patients or to accept their friend requests. I have never had a patient ask to be my Facebook friend. If patients ask: “Why won’t you be my friend?” a reasonable answer is to say that it may be considered a boundary violation, it’s frowned upon in the field, and some hospitals forbid patient-doctor Facebook friending.

• No matter how anonymous you believe you are, or how high your privacy controls are set, with anything you post on the Internet, assume it’s possible that your patients, your mother, your boss, your residency director, and every malpractice attorney may see it. If that would present a problem, it doesn’t belong anywhere on the Internet.

• If you do join Facebook, by all means “fan” our Shrink Rap book page!

Steve Daviss will tell you that Google+ is the social networking site of the future, that it allows for higher privacy, better control of where information disseminates to, and videoconferencing. I’ll leave that discussion to him.

<[QM]>—Dinah Miller, M.D.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, recently released by Johns Hopkins University Press.

If you are a health professional and would like to comment on this article, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

If you would like to join the discussion on our original Shrink Rap blog, please click here and go to the Aug. 17, 2011, post entitled “Is Facebook for Everyone?” Comments on Shrink Rap are open to all readers.

URAC, the accrediting body for many of the nation’s health insurance plans, has just added new accreditation standards that require health insurance plans to ensure that they are compliant with the Mental Health Parity and Addiction Equity Act. It is the first accreditation standards organization to add requirements that help health plans ensure that they do not violate the provisions of the parity law.

There have long been two different playing fields when it comes to health insurance coverage for physical and for mental health problems. Health plans had been able to establish more stringent treatment limitations for mental health benefits, such as a maximum of 20 visits per year, higher copays than for primary care visits, and more stringent utilization review criteria than for physical health care. One could have no limits to the number of primary care visits for, say, diabetes management that the plan would cover or no preauthorization requirements for management of hypertension.

This type of insurance discrimination against people with mental health and addiction problems was felt to be unfair, so Congress passed the 1996 Mental Health Parity Act to correct such behaviors. However, health plans found numerous loopholes in the original act that allowed them to continue to discriminate against people with behavioral health problems. A new law was passed in 2008 to close those loopholes.

The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) requires group health plans (more than 50 employees) that provide mental health and substance abuse benefits to provide them with no greater financial requirements or treatment limitations than that of their medical and surgical benefits. One of the challenges to adding teeth to this law has been the challenge in comparing health plan benefits for physical and for behavioral health. Because many plans subcontract, or carve out, their behavioral health benefits to another organization, it becomes even harder for them to ensure that the benefits provided on both sides are equivalent in nature, and that the utilization methods used to limit benefits are equivalent.

Additionally, given that enforcement of compliance with MHPAEA is split among three different government entities -- Departments of Labor, Treasury, and Health & Human Services -- it remains unclear as to who is making sure that plans are following the rules.

URAC has recently stepped up to the plate by adding parity provisions to its Health Plan accreditation standards. The new standards, which are not yet in effect, include the following requirements regarding accredited health plans:

• performance of a thorough review of federal and state laws, and regulations related to “parity of health care services,” including MHPAEA;

• performance of a detailed analysis of documenting compliance with MHPAEA (unless exempt);

• provision of a detailed analysis demonstrating that their utilization management protocols do not have more restrictive treatment limitations;

• coordination with any contracted behavioral health carve-outs to ensure that there are not more stringent quantitative and nonquantitative treatment limitations, including pharmacy services; and

• inclusion within informational documents for consumers and employer purchasers descriptions of the processes used to ensure parity act compliance, if applicable.

As part of the accreditation process, URAC will review contracts between health plans and their behavioral health carve-outs to ensure there is language that specifies how parity compliance is ensured.

These new standards are a huge step toward ensuring that the implementation of parity act requirements in health plans does not get lost among all the other health care reform activities currently underway. They also provide providers and consumers with an avenue of complaint when a plan appears to be violating these standards. The URAC website has a page for receiving complaints against accredited organizations.

<[QM]>— Steven R. Daviss, M.D., DFAPA

Dr. Daviss, co-author of Shrink Rap: Three Psychiatrists Explain Their Work, is chair of the department of psychiatry at the University of Maryland Baltimore Washington Medical Center and has served as the representative for the American Psychiatric Association on URAC’s Health Standards Committee since 2004. More information about MHPAEA can be found on mentalhealthparitywatch.org.

URAC, the accrediting body for many of the nation’s health insurance plans, has just added new accreditation standards that require health insurance plans to ensure that they are compliant with the Mental Health Parity and Addiction Equity Act. It is the first accreditation standards organization to add requirements that help health plans ensure that they do not violate the provisions of the parity law.

There have long been two different playing fields when it comes to health insurance coverage for physical and for mental health problems. Health plans had been able to establish more stringent treatment limitations for mental health benefits, such as a maximum of 20 visits per year, higher copays than for primary care visits, and more stringent utilization review criteria than for physical health care. One could have no limits to the number of primary care visits for, say, diabetes management that the plan would cover or no preauthorization requirements for management of hypertension.

This type of insurance discrimination against people with mental health and addiction problems was felt to be unfair, so Congress passed the 1996 Mental Health Parity Act to correct such behaviors. However, health plans found numerous loopholes in the original act that allowed them to continue to discriminate against people with behavioral health problems. A new law was passed in 2008 to close those loopholes.

The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) requires group health plans (more than 50 employees) that provide mental health and substance abuse benefits to provide them with no greater financial requirements or treatment limitations than that of their medical and surgical benefits. One of the challenges to adding teeth to this law has been the challenge in comparing health plan benefits for physical and for behavioral health. Because many plans subcontract, or carve out, their behavioral health benefits to another organization, it becomes even harder for them to ensure that the benefits provided on both sides are equivalent in nature, and that the utilization methods used to limit benefits are equivalent.

Additionally, given that enforcement of compliance with MHPAEA is split among three different government entities -- Departments of Labor, Treasury, and Health & Human Services -- it remains unclear as to who is making sure that plans are following the rules.

URAC has recently stepped up to the plate by adding parity provisions to its Health Plan accreditation standards. The new standards, which are not yet in effect, include the following requirements regarding accredited health plans:

• performance of a thorough review of federal and state laws, and regulations related to “parity of health care services,” including MHPAEA;

• performance of a detailed analysis of documenting compliance with MHPAEA (unless exempt);

• provision of a detailed analysis demonstrating that their utilization management protocols do not have more restrictive treatment limitations;

• coordination with any contracted behavioral health carve-outs to ensure that there are not more stringent quantitative and nonquantitative treatment limitations, including pharmacy services; and

• inclusion within informational documents for consumers and employer purchasers descriptions of the processes used to ensure parity act compliance, if applicable.

As part of the accreditation process, URAC will review contracts between health plans and their behavioral health carve-outs to ensure there is language that specifies how parity compliance is ensured.

These new standards are a huge step toward ensuring that the implementation of parity act requirements in health plans does not get lost among all the other health care reform activities currently underway. They also provide providers and consumers with an avenue of complaint when a plan appears to be violating these standards. The URAC website has a page for receiving complaints against accredited organizations.

<[QM]>— Steven R. Daviss, M.D., DFAPA

Dr. Daviss, co-author of Shrink Rap: Three Psychiatrists Explain Their Work, is chair of the department of psychiatry at the University of Maryland Baltimore Washington Medical Center and has served as the representative for the American Psychiatric Association on URAC’s Health Standards Committee since 2004. More information about MHPAEA can be found on mentalhealthparitywatch.org.

URAC, the accrediting body for many of the nation’s health insurance plans, has just added new accreditation standards that require health insurance plans to ensure that they are compliant with the Mental Health Parity and Addiction Equity Act. It is the first accreditation standards organization to add requirements that help health plans ensure that they do not violate the provisions of the parity law.

There have long been two different playing fields when it comes to health insurance coverage for physical and for mental health problems. Health plans had been able to establish more stringent treatment limitations for mental health benefits, such as a maximum of 20 visits per year, higher copays than for primary care visits, and more stringent utilization review criteria than for physical health care. One could have no limits to the number of primary care visits for, say, diabetes management that the plan would cover or no preauthorization requirements for management of hypertension.

This type of insurance discrimination against people with mental health and addiction problems was felt to be unfair, so Congress passed the 1996 Mental Health Parity Act to correct such behaviors. However, health plans found numerous loopholes in the original act that allowed them to continue to discriminate against people with behavioral health problems. A new law was passed in 2008 to close those loopholes.

The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) requires group health plans (more than 50 employees) that provide mental health and substance abuse benefits to provide them with no greater financial requirements or treatment limitations than that of their medical and surgical benefits. One of the challenges to adding teeth to this law has been the challenge in comparing health plan benefits for physical and for behavioral health. Because many plans subcontract, or carve out, their behavioral health benefits to another organization, it becomes even harder for them to ensure that the benefits provided on both sides are equivalent in nature, and that the utilization methods used to limit benefits are equivalent.

Additionally, given that enforcement of compliance with MHPAEA is split among three different government entities -- Departments of Labor, Treasury, and Health & Human Services -- it remains unclear as to who is making sure that plans are following the rules.

URAC has recently stepped up to the plate by adding parity provisions to its Health Plan accreditation standards. The new standards, which are not yet in effect, include the following requirements regarding accredited health plans:

• performance of a thorough review of federal and state laws, and regulations related to “parity of health care services,” including MHPAEA;

• performance of a detailed analysis of documenting compliance with MHPAEA (unless exempt);

• provision of a detailed analysis demonstrating that their utilization management protocols do not have more restrictive treatment limitations;

• coordination with any contracted behavioral health carve-outs to ensure that there are not more stringent quantitative and nonquantitative treatment limitations, including pharmacy services; and

• inclusion within informational documents for consumers and employer purchasers descriptions of the processes used to ensure parity act compliance, if applicable.

As part of the accreditation process, URAC will review contracts between health plans and their behavioral health carve-outs to ensure there is language that specifies how parity compliance is ensured.

These new standards are a huge step toward ensuring that the implementation of parity act requirements in health plans does not get lost among all the other health care reform activities currently underway. They also provide providers and consumers with an avenue of complaint when a plan appears to be violating these standards. The URAC website has a page for receiving complaints against accredited organizations.

<[QM]>— Steven R. Daviss, M.D., DFAPA

Dr. Daviss, co-author of Shrink Rap: Three Psychiatrists Explain Their Work, is chair of the department of psychiatry at the University of Maryland Baltimore Washington Medical Center and has served as the representative for the American Psychiatric Association on URAC’s Health Standards Committee since 2004. More information about MHPAEA can be found on mentalhealthparitywatch.org.

In 1880, a former debt-collection lawyer by the name of Charles Guiteau gave a brief speech at a political rally. He also gave disconnected and rambling lectures at other venues in which he claimed to belong to “the firm of Jesus Christ and Company.” He believed he was well-connected within the Republican Party and that he was worthy of a high government office. He pressed President James A. Garfield to appoint him consulate to Paris, a position for which he was not qualified. Eventually, he came to believe that the president was dividing the Republican Party and that this would lead to another Civil War. He thought that by killing the president he would save the country and be considered a patriot equal to Washington and Grant.

His assassination plan was organized and business-like. He bought a new ivory-mounted pistol for the killing, because he believed the gun would eventually be placed on display as a patriot’s relic. He made arrangements to go to jail afterward.

On July 2, 1881, Guiteau approached Garfield at the Baltimore and Ohio train station in Washington. He shot Garfield several times in front of many horrified onlookers and was arrested immediately. As he was being transported to the police station, he offered to appoint the arresting officer to the position of chief of police. When he was interviewed by police, he hinted that he might some day become president and likened himself to the Apostle Paul. While in jail awaiting trial, he believed his acquittal was inevitable, and he made plans to go on a speaking tour. He also advertised for a bride.

While Guiteau did not believe he was insane, he acquiesced to the need for an insanity defense. At trial, his defense attorney highlighted Guiteau’s family history of mental illness, including that of his mother who died in an insane asylum. Guiteau himself frequently interrupted the trial to object and to put on his own defense. He argued that the killing was a “political necessity.” An onlooker later described his behavior as “... an exhibition in all ways so extraordinary... it would be a disgrace to American jurisprudence were it not explainable on the ground of insanity.” Defense experts testified that Guiteau suffered from chronic mania characterized by “intact intellect and superficial normality but actions based on an insane premise.” The prosecution expert was Dr. John P. Gray, an editor of the American Journal of Insanity. Gray opined that Guiteau was sane, as evidenced by his careful and deliberate planning of the crime. After an hour of deliberation, Guiteau was convicted and he was hung a few weeks later. Some spectators conceded Guiteau was mentally ill; as one put it: “He was crazy perhaps, but not so crazy he should not be hung.”¹

Politically motivated violence is a common theme in today’s news: in the Unabomber’s manifesto, in alleged terrorist plots, in the Oklahoma City bombing and most recently in the acts of Norwegian spree killer Anders Breivik. These cases pose many challenges for forensic psychiatrists because of issues similar to those raised by the Guiteau case: how can someone be insane if a killing is planned and carefully organized? Should political beliefs be considered a sign of mental illness? At what point does an extreme opinion cross the line to delusion? Psychiatrists themselves may be divided on these issues. Some people may think that these crimes are so horrific that they could only be committed by a “crazy” person.

Another complicating factor is that these cases target large numbers of people or popular elected officials. Public opinion is inflamed and passionate, and people react with revulsion to both the act and the defendant. It’s important to remember that the magnitude of the crime should not undermine a careful evaluation of the defendant and a thorough legal review of the offense.

1. Walter Channing, M.D. The Mental Status of Guiteau, the assassin of President Garfield (Cambridge, Mass.: Riverside Press, 1882).

-- Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

If you are a physician and would like to comment on this article, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

In 1880, a former debt-collection lawyer by the name of Charles Guiteau gave a brief speech at a political rally. He also gave disconnected and rambling lectures at other venues in which he claimed to belong to “the firm of Jesus Christ and Company.” He believed he was well-connected within the Republican Party and that he was worthy of a high government office. He pressed President James A. Garfield to appoint him consulate to Paris, a position for which he was not qualified. Eventually, he came to believe that the president was dividing the Republican Party and that this would lead to another Civil War. He thought that by killing the president he would save the country and be considered a patriot equal to Washington and Grant.

His assassination plan was organized and business-like. He bought a new ivory-mounted pistol for the killing, because he believed the gun would eventually be placed on display as a patriot’s relic. He made arrangements to go to jail afterward.

On July 2, 1881, Guiteau approached Garfield at the Baltimore and Ohio train station in Washington. He shot Garfield several times in front of many horrified onlookers and was arrested immediately. As he was being transported to the police station, he offered to appoint the arresting officer to the position of chief of police. When he was interviewed by police, he hinted that he might some day become president and likened himself to the Apostle Paul. While in jail awaiting trial, he believed his acquittal was inevitable, and he made plans to go on a speaking tour. He also advertised for a bride.

While Guiteau did not believe he was insane, he acquiesced to the need for an insanity defense. At trial, his defense attorney highlighted Guiteau’s family history of mental illness, including that of his mother who died in an insane asylum. Guiteau himself frequently interrupted the trial to object and to put on his own defense. He argued that the killing was a “political necessity.” An onlooker later described his behavior as “... an exhibition in all ways so extraordinary... it would be a disgrace to American jurisprudence were it not explainable on the ground of insanity.” Defense experts testified that Guiteau suffered from chronic mania characterized by “intact intellect and superficial normality but actions based on an insane premise.” The prosecution expert was Dr. John P. Gray, an editor of the American Journal of Insanity. Gray opined that Guiteau was sane, as evidenced by his careful and deliberate planning of the crime. After an hour of deliberation, Guiteau was convicted and he was hung a few weeks later. Some spectators conceded Guiteau was mentally ill; as one put it: “He was crazy perhaps, but not so crazy he should not be hung.”¹

Politically motivated violence is a common theme in today’s news: in the Unabomber’s manifesto, in alleged terrorist plots, in the Oklahoma City bombing and most recently in the acts of Norwegian spree killer Anders Breivik. These cases pose many challenges for forensic psychiatrists because of issues similar to those raised by the Guiteau case: how can someone be insane if a killing is planned and carefully organized? Should political beliefs be considered a sign of mental illness? At what point does an extreme opinion cross the line to delusion? Psychiatrists themselves may be divided on these issues. Some people may think that these crimes are so horrific that they could only be committed by a “crazy” person.

Another complicating factor is that these cases target large numbers of people or popular elected officials. Public opinion is inflamed and passionate, and people react with revulsion to both the act and the defendant. It’s important to remember that the magnitude of the crime should not undermine a careful evaluation of the defendant and a thorough legal review of the offense.

1. Walter Channing, M.D. The Mental Status of Guiteau, the assassin of President Garfield (Cambridge, Mass.: Riverside Press, 1882).

-- Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

If you are a physician and would like to comment on this article, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.

In 1880, a former debt-collection lawyer by the name of Charles Guiteau gave a brief speech at a political rally. He also gave disconnected and rambling lectures at other venues in which he claimed to belong to “the firm of Jesus Christ and Company.” He believed he was well-connected within the Republican Party and that he was worthy of a high government office. He pressed President James A. Garfield to appoint him consulate to Paris, a position for which he was not qualified. Eventually, he came to believe that the president was dividing the Republican Party and that this would lead to another Civil War. He thought that by killing the president he would save the country and be considered a patriot equal to Washington and Grant.

His assassination plan was organized and business-like. He bought a new ivory-mounted pistol for the killing, because he believed the gun would eventually be placed on display as a patriot’s relic. He made arrangements to go to jail afterward.

On July 2, 1881, Guiteau approached Garfield at the Baltimore and Ohio train station in Washington. He shot Garfield several times in front of many horrified onlookers and was arrested immediately. As he was being transported to the police station, he offered to appoint the arresting officer to the position of chief of police. When he was interviewed by police, he hinted that he might some day become president and likened himself to the Apostle Paul. While in jail awaiting trial, he believed his acquittal was inevitable, and he made plans to go on a speaking tour. He also advertised for a bride.

While Guiteau did not believe he was insane, he acquiesced to the need for an insanity defense. At trial, his defense attorney highlighted Guiteau’s family history of mental illness, including that of his mother who died in an insane asylum. Guiteau himself frequently interrupted the trial to object and to put on his own defense. He argued that the killing was a “political necessity.” An onlooker later described his behavior as “... an exhibition in all ways so extraordinary... it would be a disgrace to American jurisprudence were it not explainable on the ground of insanity.” Defense experts testified that Guiteau suffered from chronic mania characterized by “intact intellect and superficial normality but actions based on an insane premise.” The prosecution expert was Dr. John P. Gray, an editor of the American Journal of Insanity. Gray opined that Guiteau was sane, as evidenced by his careful and deliberate planning of the crime. After an hour of deliberation, Guiteau was convicted and he was hung a few weeks later. Some spectators conceded Guiteau was mentally ill; as one put it: “He was crazy perhaps, but not so crazy he should not be hung.”¹

Politically motivated violence is a common theme in today’s news: in the Unabomber’s manifesto, in alleged terrorist plots, in the Oklahoma City bombing and most recently in the acts of Norwegian spree killer Anders Breivik. These cases pose many challenges for forensic psychiatrists because of issues similar to those raised by the Guiteau case: how can someone be insane if a killing is planned and carefully organized? Should political beliefs be considered a sign of mental illness? At what point does an extreme opinion cross the line to delusion? Psychiatrists themselves may be divided on these issues. Some people may think that these crimes are so horrific that they could only be committed by a “crazy” person.

Another complicating factor is that these cases target large numbers of people or popular elected officials. Public opinion is inflamed and passionate, and people react with revulsion to both the act and the defendant. It’s important to remember that the magnitude of the crime should not undermine a careful evaluation of the defendant and a thorough legal review of the offense.

1. Walter Channing, M.D. The Mental Status of Guiteau, the assassin of President Garfield (Cambridge, Mass.: Riverside Press, 1882).

-- Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

If you are a physician and would like to comment on this article, please Register with Clinical Psychiatry News. If you are already registered, please Log In to comment.