An Assessment of the Quality of Competence Restoration Research

A systematic review of the literature on restoration of competence to stand trial identified a predominance of retrospective case studies using descriptive and correlational statistics. Guided by National Institutes of Health (NIH) quality metrics and emphasizing study design, sample size, and statistical methods, the authors categorized a large majority of studies as fair in quality, underscoring the need for controlled designs, larger representative samples, and more sophisticated statistical analyses. Implications for the state of forensic research include the need to use large databases within jurisdictions and the importance of reliable methods that can be applied across jurisdictions and aggregated for meta-analysis. More sophisticated research methods can be advanced in forensic fellowship training where coordinated projects and curricula can encourage systematic approaches to forensic research.

Searching for the Whole Truth: Considering Culture and Gender in Forensic Psychiatric Practice

Contemporary forensic psychiatrists practice in a system that has gender and cultural biases. Though we are only one small piece of the criminal justice system, learning about cultural and gender concerns is critical so that we properly engage and fulfill our mission of striving toward objectivity. Paternalism or chivalry are not the answer when faced with gender questions, as presuming color-blindness is not the answer when faced with cultural questions. Rather, we need to examine our own biases and educate ourselves. Many opportunities for teaching and public health exist in our field, each of which can help address these challenges on a larger scale as well.

A Multi-Site Survey of General Psychiatry Residents' Forensic Training

The authors surveyed general psychiatry residents across the United States to better understand residents' experiences with forensic training and to identify variables with the greatest impact on residents' exposure to, comfort with, and desire to learn more about forensic populations and settings. The survey inquired about these topics and the forensic psychiatry resources available at residents' training institutions. Respondents (n = 129) spanned eight of ten U.S. census regions. Residents' comfort with forensic psychiatry was low, whereas desire to learn was high. Residents' number of exposures and comfort increased with greater forensic experience in residency. Fewer than half of residents had completed a forensic rotation, were required to complete a forensic rotation, or had robust forensic resources available to them. Residents who had completed a dedicated forensic rotation had significantly greater forensic exposures and comfort; a finding that remained significant even after controlling for participants' PGY status. Among residents pursuing fellowship training, residents interested in forensic fellowship had more exposures during residency. This study represents the first published effort to survey general psychiatry residents from multiple residency programs regarding their forensic experiences in training. These results have implications for educators interested in developing broader exposure to and comfort with forensic psychiatry.

Toward a New Model of Training in Canadian Forensic Psychiatry

The Royal College of Physicians and Surgeons of Canada has recently introduced a new model of training for residents and fellows in all specialties and subspecialties, including forensic psychiatry. This model, Competence by Design, is intended to improve the training of residents with the goal of increasing the competence of practicing specialists. In the Competence by Design model, training is broken down into four distinct phases. Residents prompt their supervisor proactively when they are ready to be assessed on a specific task, and the feedback is specific and corrective. A resident's performance of each designated task is reviewed by a competency committee, which decides when the trainee is ready to move on to the next phase. In this article, we review some of the problems with the current model of training and explore how this new model will improve upon this training. We anticipate that this model will prove effective at improving training in forensic psychiatry.

Variations in Application Instructions for Forensic Psychiatry Fellowships

OBJECTIVE

In this study, the authors examined the consistency and the transparency of application instructions for forensic psychiatry fellowships in the USA.

METHODS

The authors collected the names of US forensic psychiatry fellowships listed in the Directory of Forensic Psychiatry Fellowships maintained by the American Academy of Psychiatry and the Law. Using data from active fellowship websites, the authors extracted for each program: (1) timelines for applications and interviews, (2) whether an application form was supplied, and (3) the presence of specific application requirements (e.g., curriculum vitae, personal statement, letters of recommendation, residency training director evaluations, writing samples).

RESULTS

Among 45 fellowship websites, 31 (68.9%) did not provide specific dates or months when their application cycle opened, nor did they indicate whether they accepted applications on a rolling basis. Fourteen (31.1%) did not have an application form, and 8 (17.8%) did not list application requirements. Among 37 programs that listed specific requirements on their websites, 36 (97.3%) required a curriculum vitae or letters of recommendation, 35 (94.6%) required a personal statement and/or letter of interest, and 27 (73.0%) required writing samples and/or evaluation materials from residency program directors.

CONCLUSIONS

This study found considerable variations among online application instructions for US forensic psychiatry fellowships. Although many factors shape recruitment into forensic psychiatry fellowships, improving the consistency and the transparency of application instructions might decrease stress related to the application cycle and streamline recruitment into the field.

A Review of Forensic Fellowship Training: Similar Challenges, Diverse Approaches

OBJECTIVE

As the specialty of forensic psychiatry and the numbers of justice involved individuals with mental illness continue to grow, forensic education is receiving more attention. To add to this discussion, the authors reviewed current training practices in forensic psychiatry fellowship programs.

METHODS

As part of a project funded by the state legislature looking at psychiatry and psychology training, with special focus on state hospital partnerships, the authors interviewed and surveyed forensic psychiatry fellowship program directors and conducted site visits to select programs. Given the mandate, special attention was given to programs with state hospital and psychology training affiliations.

RESULTS

The literature and fellowship directors identified several key features and challenges for forensic training programs. Forensic fellowships focused primarily on evaluations and consultations but differed in their offerings related to training in treatment, scholarship, and particular types of evaluations. Common concerns included maintaining adequate funding, variety of training experiences, adequate faculty time, and adequate institutional support. Directors described cultivating institutional support by demonstrating mutual benefit as particularly important for securing resources.

CONCLUSION

Forensic fellowships operational during the 2016-2017 academic year offered a range of forensic training activities, but experienced common challenges such as inadequate funding and faculty supervision. Empirical studies are needed to evaluate the relationship between programmatic offerings, the noted challenges, and acquired competencies.

Examining the Past and Advocating for the Future of Forensic Psychiatry Training

The American Academy of Psychiatry and the Law (AAPL) has been devoted to the teaching of forensic psychiatry, and as AAPL celebrates its 50th Anniversary, it seems fitting to examine the history and the current status of forensic psychiatry teaching in general psychiatry residencies and forensic psychiatry fellowships. After a brief review of the history of AAPL and forensic psychiatry training, this article explores the current state of graduate medical education (GME) in the United States, the growing popularity of psychiatry as a specialty and forensic psychiatry as a subspecialty, the Accreditation Council for Graduate Medical Education's requirements for forensic training, and the methods currently used to teach forensic psychiatry to general psychiatry residents. This article also examines the current status of forensic psychiatry fellowship training in the United States. Finally, future challenges to forensic training in both residencies and fellowships will be discussed, as well as the need for AAPL and others in the profession to advocate for increased forensic teaching in a manner that leads to the production of both general and forensic psychiatrists who are competent to practice independently and who are sufficient in number to meet the growing demands for forensic expertise.

Teaching Forensic Concepts to Residents Using Interactive Online Modules

Psychiatrists without specialty forensic training routinely encounter forensic questions and treat justice-involved patients, which underscores the importance of adequate forensic training in general psychiatry residency. Some programs may face challenges providing adequate forensic instruction due to a lack of local forensic psychiatrists or other forensic resources. Novel training approaches are needed to fill this gap. This article describes the development, dissemination, and preliminary impact of two online learning modules designed to teach general psychiatry residents about basic forensic psychiatry principles: confidentiality and the duty to third parties. The modules are based on adult learning theory and synthesize clinically relevant vignettes from historically significant legal cases. We disseminated the modules nationally with built-in pre-tests and post-tests. The module responses demonstrate three significant themes: the modules reached learners across the United States; even advanced residents had relatively low subject matter knowledge prior to module completion; and module completion was associated with a significant improvement in resident learners' knowledge of these two topics. This work shows one potential avenue for filling gaps in forensic education within general psychiatry training, although further studies are needed to appreciate the impact of such educational interventions on clinical practice.

Practice Resource for Forensic Training in General Psychiatry Residency Programs

Full Document: Alonso-Katzowitz JS, Cardasis W, Cerny-Suelzer CA, et al: Practice Resource for Forensic Training in General Psychiatry Residency Programs. Journal of the American Academy of Psychiatry and the Law Online Supplement 2019, 47 (1). Available at: http://www.jaapl.org/content/47/1_Supplement.

A Seat at the Table

Organized medicine and psychiatry have a long tradition of governmental advocacy and public engagement. The American Academy of Psychiatry and the Law (AAPL), since its founding 50 years ago, has made some forays into these fields. However, its involvement has been less substantial than other similarly situated professional organizations. With its increasing membership and expertise, AAPL now possesses the capacity to dedicate some of its organizational attention, energy, and resources to educating policymakers and the public on current and future topics related to forensic mental health. In addition, an increasing number and type of professional activities related to this discipline are affected by governmental regulation and public opinion. Therefore, the need to become involved in shaping policy is more urgent, particularly in light of the fact that other forensic mental health organizations have been actively involved in governmental advocacy for decades. Finally, as a field and in the near future, we likely will deal with life-changing technological innovations related to the practice of forensic psychiatry. AAPL and its members are perhaps uniquely qualified and have a responsibility to help ensure that these innovations are developed, implemented, and utilized appropriately. This can only be accomplished by having a proverbial seat at the table in the process.

The Benefits of Required Forensic Clinical Experiences in Residency

OBJECTIVE

The growth of forensic psychiatry has spurred efforts to improve forensic psychiatry training in general psychiatry residency. The Accreditation Council for Graduate Medical Education requires that residencies provide an experience that "exposes" residents to forensic issues, but leaves the specifics to individual programs. However, there is growing need for psychiatrists to understand the unique circumstances of individuals with mental illness involved in the criminal justice system.

METHODS

The authors developed a new mandatory forensic rotation for general psychiatry residents and conducted a pilot study to assess its impact on residents' interest and comfort working with criminal justice-involved patients, interest in forensic fellowship, and knowledge of available resources for consultation and supervision.

RESULTS

Rotation completion was associated with a significantly increased interest in working with forensic populations and pursuing forensic fellowship, but no changes in residents' level of comfort or knowledge of supervisory and consultative resources.

CONCLUSIONS

This study adds to the growing body of literature describing the benefits of expanding forensic education for residents.

[Development of a forensic psychiatric curriculum in Belgium and the Netherlands]

Forensic psychiatry attracts considerable attention from media and politicians. All psychiatrists, not only those working in the forensic field, should be able to evaluate safety for society on the one hand and qualitative health care for psychiatric patients on the other. However, little attention is paid to specific forensic issues, in both psychiatric training and in medical school.<br/> AIM: To map relevant topics for a forensic psychiatric curriculum in medical schools and psychiatric residency training.<br/> METHOD: The main findings regarding educational topics in forensic psychiatry are discussed based on policy papers and scientific articles.<br/> RESULTS: Four important topics should be covered in general psychiatric training, i.e. mental health legislation, risk assessment and management, professionalism and ethics, and expert witness training. The Netherlands has a specific training programme for psychiatrists interested in expert report writing and testimony for criminal courts. In Belgium, psychiatrists can acquire specific professional competence in forensic psychiatry.<br/> CONCLUSION: Acknowledgement of the above-mentioned topics in the general medical and psychiatric curriculum will lead to better knowledge and competencies for all psychiatrists, both in Belgium and the Netherlands. Continuing attention and evaluation will be necessary given the high societal relevance.

The Barriers and Benefits to Developing Forensic Rotations for Psychiatry Residents

Psychiatry residents' experiences in forensic psychiatry vary greatly across the country, and many psychiatry programs meet the Accreditation Council for Graduate Medical Education requirements for a forensic experience through general psychiatry rotations (e.g., on a consult-liaison service) or classroom-based activities. Forensic clinical experiences during psychiatry residency are important for preparing future general psychiatrists for practice with justice-involved patients, generating interest in forensic psychiatry, and easing the transition from "healer to evaluator" for future fellows. Unfortunately, residency programs interested in expanding their forensic training may face many challenges because of current regulatory frameworks, the nature of forensic practice, and competing demands within residency training programs. This article describes these challenges, and the experience of the authors at one institution with developing a novel forensic experience in a criminal justice diversion setting. The authors conclude with some practical considerations for educators interested in developing forensic experiences at their institutions.

Role of Forensic Psychiatry in Legislative Advocacy

Dr. Piel presents a model curriculum for elective legislative advocacy training of general psychiatry residents at the University of Washington. In this commentary, we discuss the role of the physician as a leader in legislative advocacy and emphasize the need for training in this neglected arena. We highlight the common ground between legislative advocacy and forensic psychiatry and make a case for increased involvement of forensic psychiatrists.

Legislative Advocacy and Forensic Psychiatry Training

Very few residency and fellowship programs offer mandatory or elective rotations in health advocacy. Where there are formal training opportunities, they are commonly didactic or clinical community rotations, where trainees participate in a clinically oriented project with a local community organization. Fewer programs offer specific training opportunities in legislative advocacy and the legislative process. The University of Washington assembled two task forces to advise the general psychiatry residency program on training needs in the areas of (1) Forensic Psychiatry and (2) Advocacy and Public Policy. Both task forces identified, as an aspirational goal, resident involvement in legislative and regulatory processes as means of advocacy. This article describes a model curriculum in legislation developed at the University of Washington that is suitable for trainees at different stages in their professional development (including residents and fellows), and an explanation of how the curriculum supports training in forensic psychiatry. Challenges in creating the elective training opportunity are also discussed.

Forensic Psychiatry Milestones: Experience After 1 Year

OBJECTIVE

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties identified six core competencies for medical practice. In 2013, the milestones were introduced to demonstrate these educational outcomes across each specialty. This study represents the first examination of the sub-specialty Forensic Psychiatry Milestones.

METHODS

Members of the Association of Directors of Forensic Psychiatry Fellowships were surveyed. Areas of inquiry included whether milestones assisted in identifying areas of deficiency in fellows or programs, whether the graduation milestones matched the goals of training, and what changes were planned, or had been made, based on their implementation.

RESULTS

Twenty-six of 35 programs responded, for a response rate of 74%. The majority found the milestones somewhat or very useful, half found the graduation-level milestones matched the program's graduation goals, and a significant majority reported that the milestones assisted in identifying improvements, change, or intended change. In choosing terms to describe the milestones, however respondents chose a variety of negative or neutral terms, rather than positive ones.

CONCLUSIONS

The milestones provided a standard mechanism for identifying areas for improvement and a common language to standardize practice. However, due to the variability across fellowship programs and the limitations of educational resources and time, implementation of the new ACGME requirement was characterized in largely negative terms. Recommendations for improvement included modification of the milestones themselves, flexibility in their implementation, and evidentiary support for their use.