They Are Like Us: Human Advocacy in Forensic Psychiatry

The Journal of the American Academy of Psychiatry and the Law | 2025, No. 1., Vol. 53,  pp. 11- 18.

Applying AAPL Ethics and Mission in Forensic Treatment

Charles C. Dike, MBChB, MPH - Professor of Psychiatry, Yale School of Medicine, New Haven, Connecticut, and Medical Director, Connecticut Department of Mental Health and Addiction Services, Hartford, Connecticut.

The increased visibility of the patients’ rights movement in medicine in recent years has left the erroneous impression that patients and their physicians are on equal footing in the physician-patient relationship. The reality is that vulnerability of patients in this relationship leaves them at the mercy of health care professionals. This is most acute in psychiatry, where patients reveal aspects of their inner being to their psychiatrist, including strange beliefs they would never disclose to their closest friends and family members, whereas psychiatrists, in contrast, reveal close to nothing of themselves to patients. Additionally, distortions of reality can strip patients of social mores and basic humanity and sometimes cause them to commit crimes. American Academy of Psychiatry and the Law (AAPL) scholars have espoused the values of treating evaluees professionally and with compassion and respect while upholding their dignity and humanity. These worthy forensic psychiatric writings, however, have unfortunately not always transitioned into the clinical treatment of forensic patients. Reports of patient abuse by staff in psychiatric hospitals, including forensic psychiatric hospitals, remain rampant. Using real-life examples, I apply forensic psychiatric ethics to patient care and offer suggestions of practices and policies that would enhance treatment of patients and decrease the potential for patient abuse in psychiatric hospitals.

forensic treatment; ethics; psychiatric hospitals; advocacy; administration; education

“Stories of abuse… invite deep scrutiny and raise several questions, such as why these abuses happen, how many people know of an abuse incident but keep silent, if hospital leadership are aware or complicit in the abuse, and what could have prevented these incidents… Forensic psychiatrists, however, can model ethics principles to other disciplines and paraprofessional staff… The examples presented [focus] heavily on forensic psychiatric hospitals [-] the recommendations proposed apply to psychiatric units in prisons and jails and in general psychiatric hospitals…

Forensic psychiatry is a vocation as observed by Norko, ‘wherein we are present to and give witness to suffering, where we regularly exercise empathy and compassion in all aspects of the work’... In forensic treatment, it is not uncommon for individuals to be defined by their crime, whereas little attention is paid to the human being. Not much effort is expended to understand how the patients drifted from being fellow human beings to individuals referred to as criminals by the public and some clinicians” (p. 12).

“The example described below shows how the ethics principle of respect for persons, through thoughtful and less disparaging narratives and appreciation of our shared humanity, could be applied in a forensic inpatient treatment environment…

•  Male patients on a maximum-security psychiatric hospital unit engage in power struggles in the shower room every morning during morning routines… The psychiatrist proposed that creating a desired activity in the morning and inviting only patients who have been free of aggression could solve the problem. A 30-minute news group where hot coffee is served to the patients after the morning routine appeared to be the perfect activity… The psychiatrist informed them that only patients who were free of aggression in the past 12 hours will qualify for the news and coffee group. Patients enthusiastically supported the plan, including the qualifying condition… After a brief period of silence, a staff member spoke up for the group: “I am sorry doctor. We do not serve coffee to criminals.” Here, the staff’s chosen narrative of the patients is that of criminal, the patients being defined by their crime and not their human condition. The staff did not see the patients as members of their community who should be served as brothers and sisters as recommended by Griffith. Their crime had justified their loss of basic respect that should be accorded to all human beings… Aware that the patients had kept to their end of the bargain and there had been no restraints or seclusion in the past 12 hours (including during the morning routine), the psychiatrist determined that the news and coffee group must run. Patients were excited to be asked to assist with making the coffee as they had done for years in the past, before their crime. The first news group was a huge success. Patients discussed the morning news in real time with each other while drinking coffee, a normal routine they had lost on account of their institutionalization. The psychiatrist continued making coffee with the patients daily for seven business days, during which there were no restraints or seclusion, a finding that surprised the staff. Staff members subsequently agreed to take over the coffee making and preparation of the patients for the news group as the behavior modeled by the forensic psychiatrist had yielded a favorable outcome. A positive outcome was the breaking of the myth surrounding regular coffee and aggression” (p. 13).

•  “A unit in a maximum-security psychiatric hospital had 10 males and one female… She was often forcibly removed from the bathroom, causing her significant agitation and behavioral dysregulation that would sometimes lead to locked seclusion or restraints… Staff members were unsure how else to proceed as installing a mirror in her room was out of the question because it could be broken and used as a dangerous weapon in a maximum-security psychiatric hospital… The question shifted to how we can accommodate similar needs for this woman, albeit a patient in a maximum security setting… After some brainstorming by the staff, they agreed that a nonbreakable plexiglass that would serve the function of a mirror could be installed in the patient’s room. It worked and the patient was very grateful. Here, application of the Golden Rule elicited compassion in the staff members, changed the dynamic, and led to a positive outcome” (p. 14).
  
  
• “Referring to human beings as brutes or animals may justify abusive conduct toward them. The question of how to humanize the patients in the eyes of the clinical staff plagued the unit psychiatrist for months… The psychiatrist asked family members of patients to send photos of the patients as babies, toddlers, elementary and high school children, playing sports, or while engaged in ordinary activities ahead of treatment planning meetings. The psychiatrist, with the help of staff, then created a collage of these photos and hung them in the treatment room for a couple of days before the treatment planning meeting… Seeing the photos at various stages of a patient’s life suddenly struck staff members to the core; they could see themselves or their family members in the patients. Gradually, the patients were no longer brutes or animals but human beings” (p. 15).

“Advocacy for just and equitable treatment of individuals in the legal system should not be debatable or controversial, nor should advocacy for high-quality, patient-centered care in forensic settings, destigmatization and decriminalization of mental illness, alternatives to incarceration, and humane treatment and rehabilitation of incarcerated individuals” (p. 16).

“...Keeping and maintaining safety in the environment of care is crucial. A safe and secure environment allows for effective treatment interventions and decreases the risks of patient abuse as described earlier” (p. 17).

“...Compassion occurs when one has a deep awareness of the suffering of another accompanied by a desire to bring relief… 

AAPL should develop a certification for psychiatrists working in forensic treatment settings… Certified Forensic Treatment Specialist (CFTS), with its affiliation to AAPL, will enhance the professionalism and reputation of psychiatrists in these settings through mentorship, education, and engagement, and provide a professional home for them… Enhancement of professionalism in the psychiatrists will benefit the patients they treat and model professional behavior to the staff members they work with, thereby decreasing the risks of abuse in the institution…

Additionally, AAPL can and should advocate for improvements in social conditions that affect individuals in the criminal-legal and mental health systems, such as appropriate housing, employment, education and training, and access to transportation and health care. Challenges confronting forensic patients include landlords’ reluctance or refusal to rent apartments to felons and employers’ reluctance or refusal to hire felons. These have direct impact on access to health care because most Americans access health care through health insurance provided by their job. Thus, for forensic patients, social determinants of health are also social determinants of justice” (p. 14- 16).

“Clinical administrators should also be alert to the culture of the environment of care and work to foster a culture that expects respect and compassion for all, disavows violence in speech and behavior, and encourages respectful speech. Equally important is a culture of accountability and close monitoring of the facility for early detection of patient abuse and prompt response” (p. 17).

“Do clinicians seek to understand the psychological and sociocultural truth about forensic patients and their behavior?… Is there a sincere effort to engage in a cultural formulation of the patients to appreciate who they are and what motivates them? What narrative do clinicians apply in describing these individuals?... Do clinicians ask the question trauma specialists encourage clinicians to ask: what happened to this person rather than what the person did?” (p. 12).

“Therein lies the challenge of forensic treatment: how to recognize the humanity of individuals caught in the dual stigmas of severe mental illness, with its attendant destruction of personhood, and illness-driven criminal behavior” (p. 14).

As always, please join the discussion below if you have thoughts or comments to add!

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