Abstract
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.
Organized medicine in general and organized psychiatry in particular have an extensive and rich tradition of governmental advocacy and public engagement. Organizations such as the American Medical Association (AMA) and the American Psychiatric Association (APA) have long encouraged these pursuits, both for their individual members and their organizations as a whole. For example, the AMA Advocacy Office is more than 70 years old, and the AMA fields two Councils related to this office. Similarly, the APA has been involved in public relations, governmental advocacy, and judicial action for decades. The APA's Office of Government Relations has operated for approximately 70 years, and the Council on Psychiatry and the Law has been active for more than 50 years.
The AMA's and APA's commitment to advocacy are codified in the organizations' ethics directives. For example, and as other members of the American Academy of Psychiatry and the Law (AAPL) have noted (e.g., Jennifer Piel, JD, MD, in a recent Journal of the American Academy of Psychiatry and the Law (JAAPL) article1), the AMA encourages physicians to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being” (Ref. 2, p 147). Similarly, the APA's Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry states, “Psychiatrists are encouraged to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government …” (Ref. 3, p 9). The Annotation does not directly address the topic of organizational advising and consulting. However, it stands to reason that the collective wisdom and expertise of an organization, tempered by consultation among its members, might be even more valuable to members of the executive, legislative, and judicial branches and the general public than individual consultation.
Advocacy is admittedly a term that can be interpreted quite broadly. In its most extreme contexts, it may involve specifically endorsing political candidates, parties, or controversial topics or positions. Similarly, advocates can be individuals, organizations, professions, or other entities. As this pursuit relates to organized medicine and psychiatry, however, this endeavor generally has involved the education of legislatures, administrative agencies, regulators, and the judiciary, hereafter referred to collectively as policymakers (members of the judiciary functionally make policy by their rulings), as well as the media, the general public, and others, hereafter referred to as the public, to apprise them of current scientific principles, new developments, and pragmatic concerns related to the practice of medicine and psychiatry. This assists them in making informed decisions about topics related to their interface with these disciplines.
The rationale for psychiatric governmental advocacy and public engagement is perhaps self-evident and may be both ethical and altruistic (i.e., better understanding by policymakers and the public of topics related to psychiatry, to the betterment of patients and society) and professionally pragmatic. Regardless of the motivation for advocacy, the benefits potentially extend to patients, evaluees, the public at large, and the profession itself.
AAPL and Advocacy
In AAPL's first three decades of existence (1969–99), its focus was on establishing the academic subspecialty of forensic psychiatry and educating its members about topics of interest in forensic psychiatry. Selected AAPL members developed standards for the accreditation of forensic psychiatry fellowships to achieve the first goal. Subsequently, these standards (or variants thereof) were utilized by AAPL's Accreditation Council for Forensic Psychiatry Fellowships and, later, the Accreditation Council for Graduate Medical Education to begin accreditation of forensic psychiatry fellowship programs. AAPL members also facilitated and participated in initial site visits by the Accreditation Council for Graduate Medical Education. Similarly, AAPL members were crucial in developing the first American Board of Psychiatry and Neurology certification exam in Forensic Psychiatry, with the first exam being authored by 10 AAPL members.
In addition to establishing the discipline of forensic psychiatry and shepherding it through various accreditation and certification processes, AAPL has also flourished in educating its members. AAPL membership and attendance at annual meetings have generally trended up over the past 50 years; JAAPL continues to educate members about multiple commonly-encountered and more niche topics related to psychiatry and the law; the AAPL Newsletter informs members about special-committee topics of interest, recent organizational happenings, and new case law; and a growing number of new and updated practice resource documents help guide members as they conduct a variety of forensic psychiatric evaluations. AAPL also has attempted to expand its membership and scope by actively recruiting and encouraging the involvement of correctional psychiatrists, with varying degrees of success.
Regarding advocacy and educating policymakers and the public, AAPL has made some forays into this field, although its involvement has been significantly less substantial than other similarly situated professional organizations. For several decades AAPL has been reviewing, offering feedback on, and sometimes endorsing amicus briefs to appellate courts related to forensic mental health topics (including correctional mental health). AAPL occasionally fields calls from media outlets and the public regarding forensic psychiatric topics that are in the news. AAPL has issued one position statement in the past, although it is not currently active. AAPL also has delegates to other organizations that are more actively involved in influencing policy (e.g., AMA, APA).
Why has organized forensic psychiatry (i.e., AAPL) been somewhat hesitant to become more involved in the education of policymakers and, to a lesser extent, the public about forensic mental health topics? One possibility is that, 50 years ago, founding AAPL members were necessarily limited in this pursuit by virtue of their focus on other important endeavors, such as the establishment and increasing the general acceptance of the field of forensic psychiatry. Another possibility is that this hesitance may have been a result of a cohort of forensic psychiatrists having a more circumscribed view of their professional roles (i.e., as a forensic evaluator only). By extension, organized forensic psychiatry took on a similarly circumscribed role, namely education of its members.
Regarding the first possibility, AAPL has accomplished its initial objectives and continues to excel at educating its members and others in forensic mental health professions. With 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. Even if AAPL's original educational mission were narrower in scope, that educational mission certainly could (and should) now be construed more broadly to include policymakers and the public. Obviously, organizations must evolve as their field grows (e.g., a more expansive view of psychiatry and the law), their members' perspectives and priorities shift, and contingencies change.
Concerning the second possibility, the scope of topics about which AAPL is or should be concerned appears to have grown significantly since its founding a half-century ago. For example, over the past 25–30 years, AAPL increasingly has embraced the field of correctional psychiatry and has become the professional home of many correctional psychiatrists. These psychiatrists are subject to a variety of local rules, state statutes, federal regulations, case law, and sometimes United States Department of Justice (USDOJ) consent decrees or settlement agreements. Shouldn't these psychiatrists' professional organization keep apprised of these developments and attempt to influence legislation, case law, and policy in a manner beneficial to patients, evaluees, the profession, and the public?
In addition to an overall responsibility to society, professionally pragmatic considerations argue for AAPL's current involvement in shaping policy and public opinion. Standards-developing organizations, the USDOJ, and other entities are fashioning standards related to the practice of forensic science, to which forensic psychiatrists eventually may be subject. Other forensic mental health organizations (e.g., the American Academy of Forensic Sciences (AAFS) and the American Psychology-Law Society) are already involved in shaping policy and in interfacing significantly with the public and media.
Finally, and perhaps most importantly, revolutionary technological advances related to forensic psychiatry loom large on the horizon. Organized forensic psychiatry might help policymakers ensure the appropriate implementation of these advances in a variety of arenas (e.g., legal). In addition, these advances have the potential to affect forensic psychiatric practice immensely. For the sake of professional survival, it would be wise to stay abreast of these innovations and help facilitate their proper use.
For these reasons, a broader educational mission, which may include governmental advocacy on selected topics about which AAPL has expertise and concern, should be part of AAPL's vision going forward. AAPL can maximize its influence by also partnering more with the APA, AMA, and other forensic mental health organizations (e.g., the AAFS). In doing so, AAPL should hold fast to the scientific literature and our collective experience, while acknowledging the limitations of our expertise. However, we must not have such a high bar of certainty that we never provide input to policymakers or the public.
Care must be taken to avoid becoming political during this organizational growth. This can be accomplished by interfacing with governmental entities and the public with the primary goal of advancing scientific understanding and practice-related concerns, rather than advancing an ideology. And as the APA's Annotations, which are applicable to all United States' AAPL members via their required APA membership (and variants of which may be applicable to international members and members of the American Academy of Child and Adolescent Psychiatry), remind us: “Psychiatrists are encouraged to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government …” (Ref. 3, p 9). Fortunately, a growing number of AAPL members appear to share this view, at least in regard to how it pertains to legislative advocacy.
Evolving Perspectives
Two important articles were published in the June 2018 issue of JAAPL. The articles, one written by Jennifer Piel, JD, MD, and the other by Chinmoy Gulrajani, MD, and George Realmuto, MD, were novel in highlighting the need for forensic psychiatrists to become involved in the legislative advocacy process.1,4 In her article, Dr. Piel described a curriculum to educate forensic psychiatric residents about the legislative advocacy process, thereby preparing them to engage in this endeavor in their professional careers. Drs. Gulrajani and Realmuto spoke to the need for forensic psychiatrists to become involved in legislative advocacy now, noting, “There is little doubt that forensic psychiatrists, by their unique skill set in the legal arena, are suited to take on the mission of legislative advocacy. […] How then do forensic psychiatrists fulfill their obligations toward professional advocacy if not through legislative advocacy?” (Ref. 4, p 156).
Neither article explicitly addressed organized forensic psychiatry's need to do the same, although this appeared to be implied in both. Regardless, this is a topic of discussion that is long overdue and urgent. Given AAPL's organizational expertise and potential gravitas, it is uniquely qualified to positively influence forensic mental health policy, law, and the public's perception by imparting and applying its members' individual and the organization's collective knowledge to these domains.
Unique Expertise and Opportunities
As its name suggests, the American Academy of Psychiatry and the Law occupies a unique professional nexus at the interface of the disciplines of psychiatry and the law. It is one of the preeminent forensic mental health organizations in the United States, if not the world. AAPL has more than 2,000 members from every state in the United States and multiple other countries, representing a wide variety of areas of expertise. AAPL fields committees in 31 different specialty areas (including two standing committees), including Addiction, Child and Adolescent Psychiatry, Forensic Neuropsychiatry, Law Enforcement Liaison, and Trauma and Stress. Clearly, AAPL possesses and cultivates unique individual and organizational knowledge.
Despite the potential value this knowledge might have in informing policymakers and the public, in the past and for reasons mentioned previously, AAPL has in practice viewed its educational mission primarily as geared toward members and other forensic psychiatrists. Therefore, AAPL's expertise has remained somewhat cloistered and has not been maximally utilized to positively shape broader policy topics or public opinion, even though the latter goal appears to be part of AAPL's initial mission statement. Of course, multiple AAPL members have served as consultants to the judiciary, legislatures, the media, and the public, with much success and positive impact. However, these consultations typically are done outside of AAPL's organizational framework and without the gravitas of an esteemed organization's imprimatur. They could be significantly more impactful if such a framework were utilized.
A multitude of current subjects would benefit from organizational forensic psychiatric input, including:
Use of artificial intelligence (AI) in forensic psychiatry
Malingering detection using biometric or physiological data
Criminal justice reform, diversion, or alternatives to incarceration
Improving school violence risk assessment
Use of genetic testing and biological determinants in risk assessment
Drugs of abuse as therapeutic agents (e.g., ketamine, Ecstasy, marijuana)
Technology's impact on youth's mental health
Prevention and early intervention measures to decrease delinquency
Opioid epidemic (prescription drug-monitoring programs, standard of care concerns, criminal liability of prescribers)
Federal legislators, multiple federal administrative agencies, courts, and other policymakers currently are grappling with how to address some of these problems and are actively seeking forensic mental health input on multiple aspects of these concerns.
Changing Landscape and Conditions
Standards and Certification
The forensic science community has been under increasing scrutiny since the 2009 National Academy of Sciences National Research Council Report titled “Strengthening Forensic Science in the United States: A Path Forward.”5 The report was quite critical of the United States' forensic science system, although forensic psychiatry was not specifically mentioned. The report recommended wholesale changes in the system's infrastructure and operational models:
The forensic science system, encompassing both research and practice, has serious problems that can only be addressed by a national commitment to overhaul the current structure that supports the forensic science community in this country. This can only be done with effective leadership at the highest levels of both federal and state governments, pursuant to national standards, and with a significant infusion of federal funds (Ref. 5, p 194).
The report also recommended improvements in forensic science practices that would be based in large part on certification and standards:
Standards and best practices create a professional environment that allows organizations and professions to create quality systems, policies, and procedures and maintain autonomy from vested interest groups. Standards ensure desirable characteristics of services and techniques such as quality, reliability, efficiency, and consistency among practitioners. Typically, standards are enforced through systems of accreditation and certification, wherein independent examiners and auditors test and audit the performance, policies, and procedures of both laboratories and service providers (Ref. 5, p 194).
More recently, on August 7, 2017, the USDOJ issued a press release related to its implementing the National Academy of Sciences report's recommendations, noting:
The Department will develop Uniform Language for Testimony and Reports to give clear guidance to what the Department's forensics examiners may discuss in a courtroom, and direct prosecutors to follow the same guidelines. The Department will also develop a new forensic examiner testimony-monitoring program to ensure compliance with the uniform language standards once they are adopted.6
Although the USDOJ likely will not immediately apply these changes to its forensic psychiatrists, it is reasonable to assume that both USDOJ and non-USDOJ forensic psychiatrists will be subject to some set of externally imposed, federal standards in the relatively near future. In addition, partly in response to the report by the National Academy of Sciences, other forensic science organizations such as AAFS have established standards-developing organizations that work with multiple groups of stakeholders to create standards for the practice of forensic science. Some of the contemplated standards involve and affect aspects of forensic psychiatric evaluation and practice. Obviously, this increases forensic psychiatrists' and AAPL's impetus to become involved in the development of these standards so that they are well-designed and appropriate for forensic psychiatrists. Regarding forensic science standards, the AAFS Academy Standards Board has gone so far as to make the following prediction: “In the first quarter of the 21st century, we will witness the widespread promulgation, adoption, and enforcement of recognized standards, and, also likely, the true regulation of our profession.”7
Policies and Positions
It is clear that other organizations for forensic mental health professionals are interested in and have been engaged in guiding and influencing policy and public opinion in the forensic mental health domain. By way of example, consider AAFS's letter to the USDOJ in 2017, which noted:
Our mission is to provide leadership to advance science and its application to the legal system. Representing all 50 states and 70 other countries worldwide, the 6,638 members of AAFS are forensic science or legal practitioners who improve the understanding of forensic science by criminal and civil justice practitioners, policymakers, and the public through education, dissemination of research in forensic science, and public engagement. We encourage other groups, agencies, and organizations to collaborate with us to advance forensic science and its use in the legal system.8
Similarly, the American Psychology-Law Society's vision statement includes the aspirational goals of serving as:
The leading advocate for psychology-law knowledge and practice informing practitioners, policy makers, and the public to use psychology-law knowledge in the pursuit of justice for all citizens.
A principal leader and global partner promoting psychology-law knowledge and methods to improve justice in diverse, multicultural, and international contexts.
An effective champion of the application of psychology-law to promote human rights, dignity, and justice.9
In contrast, AAPL's official position on policy involvement is less clear, although in practice caution has been demonstrated in venturing into this arena. The AAPL Bylaws (Amended May 2009) note, “The Academy is organized exclusively for educational, scientific, and charitable purposes” (Article II, Section 2) but also note that it promotes “in the public interest: the exchange of ideas and experience in those areas where psychiatry and the law overlap” (Article II, Section 2). Could this include exchanging ideas with governmental entities for purposes of influencing policy?
The Bylaws, in Article VI, Section 4, indicate, “Proposed policy statements may be introduced at a business meeting.” Does this suggest an intent to issue such policy statements on a fairly regular basis?
AAPL's 2005 “Ethics Guidelines for the Practice of Forensic Psychiatry” hints at forensic psychiatrists' involvement in influencing policy by noting, “Forensic Psychiatry is a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment” (Ref. 10, I. Preamble).
The AAPL website's homepage is silent on this point, describing AAPL's role as “promot[ing] scientific and educational activities in forensic psychiatry by facilitating the exchange of ideas and practical clinical experience through publications and regularly scheduled national and regional meetings.”11
AAPL's position on education of the public is clearer, though to date and in practice this goal has not been an organizational priority. The AAPL Bylaws list, as one of AAPL's purposes, “providing information to the public regarding problems in the area of psychiatry and the law and the potential contributions from psychiatry” (Article II, Section 2).
Regardless of AAPL's official stance and prior practices regarding policy involvement, a growing number of members acknowledge that important legislative, administrative, and judicial decisions will be made either with or without our input, or with the input of professional organizations representing forensic mental health disciplines other than forensic psychiatry.
Historical Concerns
As mentioned previously, at its inception AAPL initially focused organizational resources on forming and promoting the subspecialty of forensic psychiatry. This focus necessarily lessened its ability to pursue an expanded educational mission. However, other arguments against broadening AAPL's educational mission and engaging in governmental advocacy on selected topics also have been cited. These have involved several general themes, including not wanting to be viewed as a “political” organization and risk alienating a cohort of members, policymakers, or the public; not wanting to be forced to explain differences of opinion with organizational stances, either in practice or during testimony; duplication of effort; and cost.
These concerns may be reasonable in the abstract. In practice, however, the possibility of negative consequences seems to have been overestimated, based on observations of existing organizational policy involvement and its lack of negative ramifications. Further, AAPL's involvement in shaping policy and law could be tailored to address gaps in or augment the efforts of the APA and the AMA in these arenas, thereby decreasing the cost of such work and avoiding duplication of effort. Overall, the organizational and societal benefits of AAPL's involvement in shaping policy outweigh the minimal risks outlined here.
As mentioned previously, AAPL can avoid the perception of being political by interfacing with governmental entities and the public with the primary goal of advancing scientific understanding and practice-related concerns, rather than advancing an ideology, and by acknowledging the limitations of our expertise. With regard to being forced to explain differences of opinion with organizational stances, this potential risk has in reality been present for some time. AAPL is already engaged in some forms of an expanded educational mission. For example, the AAPL Council periodically reviews and sometimes signs onto amicus briefs to appellate courts, most notably those to the Supreme Court of the United States. I am unaware of any negative ramifications of this involvement to date. In addition, to the extent that an organization's stance reflects its individual members' views, AAPL members (via their required membership in APA, American Academy of Child and Adolescent Psychiatry, or the APA's equivalent in other countries) are already weighing in on a variety of topics and have a significant degree of policy involvement. For example, in the first half of 2018 alone, the APA had 14 “Public Letters and Comments” related to the opioid epidemic.12 In 2017, the APA issued 16 position statements, many of which involved concerns related to psychiatry and the law.13 Similarly, negative consequence to date seem to be minimal.
Concerns about duplication of effort may stem in part from the fact that both the APA and the AMA engage in a significant amount of governmental advocacy and public relations (many AAPL members are also members of both of these organizations). Some of these endeavors involve topics related to forensic psychiatry and are directed by senior AAPL members. For example, many voting members and chairs of the APA's Council on Psychiatry and Law and the Committee on Judicial Action have been or are AAPL leaders. However, there are lacunae in these organizations' efforts to educate policymakers and the public, such as state-level legislation, court cases in state supreme and lower federal appellate courts, and concerns specifically related to forensic psychiatry (versus medicine or psychiatry as a whole). Why not harness the collective expertise of 2,000 forensic psychiatrists and AAPL's organizational imprimatur to further augment and refine input on these topics or to address topics that may be of interest to AAPL, but not necessarily to the APA or other organizations? In addition, keeping some elements of advocacy in-house would allow AAPL to better track legislation and court cases that focus on forensic mental health topics; afford more junior AAPL members opportunities to participate in these processes and interface with more senior AAPL members; and better serve as an educational resource for members, policymakers, and the public around these topics. This will be described in more detail later.
Finally, regarding cost, certain approaches to advocacy can be cost-prohibitive for smaller, less well-funded organizations (e.g., solely funding a full-time legislative advocate, retaining counsel to author amicus briefs, or launching large public relations campaigns, which can cost millions of dollars). However, keeping abreast of and positively influencing law and policy can be done in a very powerful yet cost-effective manner if different mental health, forensic mental health, and forensic science organizations' resources were pooled to achieve a common goal. AAPL has the opportunity to do so by partnering more with the APA, AMA, other forensic mental health organizations (e.g., the AAFS), and other forensic science organizations (e.g., the Consortium of Forensic Science Organizations (CFSO), described later in this article).
Responsible Application of New Technologies
One of the most fascinating, if sobering and troubling, explorations of new technologies' potential impact on our society's near-term future comes from Yuval Harari, PhD, in his 2017 book Homo Deus.14 Harari, an Oxford-educated Professor of History at Hebrew University of Jerusalem, describes the exponential speed at which new technologies are being developed, refined, and deployed, and he argues that these changes may render our society almost unrecognizable in the near future. The themes into which Harari delves include the effects of automation and artificial intelligence; the rise of the importance of algorithms; “data-ism” as a new, all-encompassing focus; the decoupling of consciousness from intelligence, and non-conscious intelligence (i.e., artificial intelligence) becoming more important than conscious intelligence (i.e., human); medicine's shifting from a healing profession to an “upgrading” profession; the so-called myth of free will (as demonstrated by neuroimaging versus via speculation by theologians and philosophers) and algorithms' being able to predict our desires and behavior better than we can ourselves; and humankind's shift from conquering famine, pestilence, and war to attaining immortality and permanent happiness via neurochemical modulation.
Obviously, Harari is not the first author to write about technology's potential impact on society. Aldous Huxley, George Orwell, and others have described distant dystopian futures that thankfully have not yet been realized. However, Harari's predicted changes seem more imminent, both because of technology's exponentially increased rate of change and because aspects of his forecasts can already be seen.
Many of these changes are relevant to the field of psychiatry and the law. Functional magnetic resonance imaging (fMRI) studies have indicated that decisions may be determined up to 10 seconds prior to the decision's reaching conscious awareness.15 How does this affect our understanding of free will? Noninvasive brain stimulation has the capacity to both enhance moral reasoning16 and improve soldiers' killing efficiency.17 How effective is this technology related to those ends, and in what situations are these types of uses ethically permissible?
A 2015 study published in the Proceedings of the National Academy of Science demonstrated that computer-based personality judgments (based on analyzing Facebook “likes”) were more accurate than those made by humans.18 How applicable is this study to clinical and forensic psychiatry? If the findings are applicable and accurate, when and how can we utilize this process to augment (or, conceivably, replace) our evaluations? A 2017 German study19 demonstrated that, with the use of fMRI and “mask images,” researchers could covertly monitor individuals' sexual interests without their being able to control or manipulate their responses. How accurate is the predictive power of this technique, and in what situations is this type of monitoring permissible?
Multiple jurisdictions are beginning to utilize, with good success, predictive analytics and algorithms to determine a child's risk of being abused in the future and which families are most in need of services.20 Call screeners and supervisors are being given less discretion to override the algorithm's recommendations. For example, in September 2018, a Los Angeles County Superior Court judge refused to dismiss criminal charges against child-protective workers related to their contribution to a youth's death, in part because they had overruled an algorithm's risk assessment.21 Are there limitations or drawbacks to this algorithm? How does this algorithm affect the role of the forensic psychiatrist in termination of parental rights evaluations? How intrusive should the state be in the absence of any current harm or crime, but in the presence of a moderate to high risk of a future harm or crime?
Regardless of whether or when Harari's arguably dystopian view of humanity's future ultimately arrives, there is no doubt that science and technology are advancing at a breathtaking pace and an increasing rate in all areas of our lives. In the very near future, both current and anticipated technological advances will affect society writ large and almost all professions, including forensic psychiatry, to a remarkable degree. Legislators, administrative agencies, the courts, and the public will need forensic mental health input on multiple aspects of these advances. Organized forensic psychiatry will be crucial in assessing, implementing, and, if appropriate, utilizing these new technologies as they become available, both for society's and its own benefit.
Addressing the Challenges
So how can AAPL and its members better track and be more involved in positively influencing policy and law, and in educating the public about topics related to forensic mental health? Perhaps a good starting point is for the organization and its members to be aware of pending legislation, court cases, and topics of media and public attention. Most state psychiatric associations and the APA keep abreast of pending legislation and case law. However, these associations typically do not focus on topics specifically related to forensic mental health.
In addition, members may wish to join one or more recently created AAPL special committees dedicated to tracking these concerns and providing input to the AAPL Council related to potential involvement in legislative, judicial, or media and public relations domains. The aim of these committees is not to duplicate efforts of other organizations (e.g., APA or state psychiatric associations), but rather to augment these efforts by, among other things, focusing on forensic mental health topics, affording more junior AAPL members an opportunity to participate in these processes and interface with more senior AAPL members, and serving as an educational resource for members, policymakers, and the public.
Government Affairs Committee
The mission of the AAPL Government Affairs Committee is to assist AAPL's interface with and provision of education and organizational expertise about forensic psychiatric or mental health matters to state legislatures, the U.S. Congress, and relevant federal departments and administrative bodies; to serve as an educational resource for members via presentations, AAPL Newsletter articles, and other means; and to provide opportunities for more junior members to become involved in the government affairs process.
The committee, which is composed of 42 members representing 15 states, is expected to keep abreast of and informed about pending state and federal legislation relevant to forensic mental health topics; to offer recommendations to the AAPL Council regarding opportunities for AAPL to provide input to legislative offices (via the CFSO; described next); and to serve as an educational resource for legislative offices as well as relevant federal departments and administrative agencies. A table of relevant state and federal legislation was developed to facilitate tracking, and this is updated on a regular basis by the committee chairs.
Consortium of Forensic Science Organizations
Other critical components of the Government Affairs Committee's mission related to federal legislation are realized via AAPL's membership in the CFSO, which AAPL joined in February 2018. The CFSO is an association of six forensic science professional organizations, whose collective membership totals approximately 21,000 people. It was formed in 2000 and currently includes the following organizations: AAPL, AAFS, the National Association of Medical Examiners, the Society of Forensic Toxicologists, the American Society of Crime Lab Directors, and the International Association for Identification. Member organizations strive to “speak with a single forensic voice in matters of mutual interest to its member organizations, and to influence public policy at the national level.”22
AAPL's membership in the CFSO gives it access to an experienced, well-connected, and essentially full-time legislative advocate, Beth Lavach, in Washington, D.C. In addition, the CFSO has relationships with multiple executive agencies and departments (e.g., the USDOJ) and is in the process of developing relationships with the National Association of Attorneys General and the National Governors Association, which are important policy-influencing entities. AAPL's annual dues are lowered because costs are shared among the six members of the consortium.
To date, AAPL's brief membership in the CFSO has proved fruitful, as evidenced by its facilitating several activities. A “Capitol Hill Briefing,” which described multiple aspects of AAPL, was distributed to legislative offices, the USDOJ, and other administrative bodies to introduce them to our organization and apprise them of our availability to provide input and expertise on forensic mental health topics. AAPL member Andrew Levin, MD, Chair of the Trauma and Stress Committee, has been working with the American Society of Crime Lab Directors to provide training to their members about vicarious trauma (i.e., from working in a crime lab) and may develop a funded research project around this topic. During my visit to Washington, D.C., in June 2018 to meet with multiple U.S. Senate offices, the USDOJ, and U.S. House of Representatives staff to introduce them to AAPL and describe our organization, they seemed very interested in consulting with us about initiatives related to forensic mental health.
Judicial Action Committee
The mission of the AAPL Judicial Action Committee (JAC) is to assist AAPL in liaising with and providing education about forensic mental health topics to appellate levels of the judiciary; to serve as an educational resource for members and a repository of information about ongoing state and federal appellate cases for AAPL Council; and to provide an opportunity for more junior AAPL members to become involved in the judicial action process.
This committee is composed of 35 members from 14 different states; it monitors state and federal appellate cases relevant to forensic mental health topics; offers recommendations to the AAPL Council regarding AAPL's potentially joining pending amicus briefs for which the organization's support is sought; and provides education and training to state and federal courts as relevant and requested via interface with the Conference of Chief Justices, National Center for State Courts, Conference of State Court Administrators, and the Federal Judicial Center. The Co-Chairs of the JAC committee have been engaged in discussions with several of these groups about developing resources of mutual interest to state court leaders and AAPL; identifying educational opportunities and AAPL speakers for state court programs, whether national, regional, or state-specific; and collaborating in tracking appellate decisions involving mental illness.
Members of the JAC will become aware of and track cases relevant to their home states, federal districts, or federal circuits. A table has been developed to assist the tracking of pending state and federal appellate cases relevant to forensic mental health concerns. These cases will be of interest to AAPL's general membership, as well as to JAC members and the AAPL Council.
Media and Public Relations Committee
The goal of the Media and Public Relations Committee, which consists of 31 members representing 16 states, is to help establish AAPL as the premier and primary forensic mental health organization that the media and the public can approach for objective, expert information about forensic mental health matters. The committee's activities include promoting AAPL's provision of education and organizational expertise to the media and the public; outreach to various media sources to apprise them of AAPL's availability to provide forensic mental health expertise; responding to media inquiries related to forensic mental health concerns; and developing AAPL's social media presence, in collaboration with the AAPL Technology Committee. The committee chairs, with input from committee members, have developed a list of members' areas of expertise to direct relevant media inquiries to them. These individuals' opinions will not necessarily represent AAPL as an organization.
AAPL's Next 50 Years
Organized psychiatry has a long tradition of governmental advocacy and public engagement, based in ethics, altruism, and pragmatism. These processes educate policymakers (thought of broadly) and the public (including the media) to the subsequent benefit of patients, evaluees, the profession, and society at large.
Since its founding 50 years ago, AAPL has engaged in some activities in these fields, although its involvement has been much less robust than other similarly situated professional organizations. For approximately the first 30 years of its existence, AAPL was understandably focused on the establishment of the discipline of forensic psychiatry and, subsequently, on increasing this field's profile, quality, and legitimacy by guiding it through various accreditation and certification processes. In addition to these endeavors, AAPL has also excelled in educating its members and other forensic mental health professionals.
Over the past 20 years, it has become clear that AAPL has accomplished some of its initial objectives. Its membership has continued to grow, as has its collective expertise. AAPL is now capable of devoting some of its organizational attention, energy, and resources to expand its educational mission, related to current and future forensic mental health topics, to a broader audience. This audience should include policymakers and the public.
In addition, the range of activities included in the field of psychiatry and the law has expanded, and an increasing number and type of professional activities related to our discipline are affected by governmental regulation (e.g., legislation, regulations, case law, etc.) and, indirectly, by public opinion. Therefore, it is crucial that AAPL become involved in shaping policy. This is particularly true because several other forensic mental health organizations already are actively involved in governmental advocacy and have been for decades.
Revolutionary technological advances and significant regulatory and standard-of-care changes (e.g., imposition of standards and certification) related to forensic psychiatry are already beginning to be realized, and others loom large on the horizon. AAPL and its members are uniquely qualified to meet these challenges and have a responsibility to help make sure that these advances are implemented and utilized as appropriately as possible. As an organization and as individual members, AAPL has a vested interest in crafting emerging standards related to the practice of forensic mental health in general and forensic psychiatry in particular; therefore, we must be central participants by having a seat at the table.
Put more simply, going forward as an organization, we must decide whether we want to be inward-looking or outward-looking, insular or involved, proactive or reactive. I know our thoughtful, involved members will help leadership consider and determine the answers to these questions as AAPL moves into its next 50 years.
- © 2019 American Academy of Psychiatry and the Law
