I really appreciate everyone being here. And hopefully this will be a good learning experience for those that have not done a lot of court testimony, and for those that do, you know, hopefully it will be an opportunity for review and reflection and growth. So this is an overview of the session over the next hour and a half. Hopefully we're going to go over a little bit to set the frame about what the courtroom looks like in court testimony. That's going to be my section. And then Dr. Laurel is going to talk a little bit about confidentiality and privilege and how these issues really come into play when you're the treating psychiatrist often testifying in matters in court on your patients. And then Dr. Jotty is going to talk a little bit about preparation for commonly encountered court hearings and then effective courtroom testimony. And then we actually have some video involving myself acting as an expert, somewhat behaving badly, and then two attorneys doing direct and cross-examination. And the goal is for you as participants to take a look at it, think a lot about what I'm doing well, what I'm doing poorly, and then hopefully, like, answer questions that you have. Starting with courtroom 101 for the psychiatrist. This is what I'm going to go over in the next 15 minutes or so. But I want to be really clear that the focus here is not on forensic settings, so competency to stand trial and criminal responsibility. I note that those skills, I mean, these skills are pertinent there, but my real focus here is the general psychiatrist, even though everybody here is a forensic psychiatrist. And then we're really going to focus on inpatient settings, including, like, right to refuse treatment and treatment over objection and civil commitment. But it's important to realize that in some settings, particularly like outpatient commitment, if you are an outpatient doctor or you're working in emergency room settings, at times that information is relevant as well. So this hopefully pertains to you, too. So the first thing I want to point out is that the proceedings that we're testifying in, civil commitment, right to refuse treatment, outpatient civil commitment, these are civil proceedings. They are not criminal proceedings. And states handle these issues differently. So in New York State, where I practiced previously, there's the separate mental hygiene calendar I practice now in Michigan. It's a probate court matter. And so states handle these issues differently, but we're always in civil court. And by the same nature, the attorneys, like who represents the hospital, who represents the patients, also varies from state to state. So in New York State, there are law firms that handle these issues for hospitals, and they handle the paperwork and the court testimony and the preparation. But in other states, the hospitals are represented by other entities, sometimes people in the public sector. And that goes for the patients as well. So in Michigan, public defenders are often representing patients in legal matters, whereas in New York State, the Office of Court Administration has a carved out group called Mental Hygiene Legal Services that provides representation for patients on these matters. So the expertise and also the work of the attorneys providing this representation varies. Just a reminder that patients can represent themselves, and that creates its own unique issues. If you've ever had to testify and a patient is asking you questions, it's a unique experience. And obviously, often judges are presiding over these hearings. Sometimes you'll have magistrates. Sometimes you'll have hearing officers. Usually there's a judge or some sort of determining individual fact finder. But there are situations where a jury, a patient could ask for a jury, and so then there would actually be a jury handling the matter. And if you've ever sat through one of those, it's a unique experience. So this is the court diagram I use for competency to stand trial evaluations in the state of Michigan. It's pretty common. My main purpose of having this up here is just to note that this is an adversarial process, that there are people, there are two sides. There's a judge. There's a court reporter taking notes. You in the number two position acting as the witness. And that sometimes depending on what the courtroom is set up like, you may have other players. And this is, we have a, you know, our goal is to talk a little bit about Zoom testimony here and how that plays out. But sometimes on Zoom, you'll have multiple players, including people who have nothing to do with your case sitting there, depending on how the courts are handling the issue. So in terms of the timelines for these types of court hearings, they vary by jurisdiction. I always recommend that if you're moving to a different state or even when you're in training, you find the person that knows how it all works, which isn't always a psychiatrist, which is what I've learned over the years. And then figure out like the procedures that the hospital has set up. For some, in some jurisdictions, patients are automatically placed on a court calendar. And in some jurisdictions, they have to request a hearing. I always say that for the most part, these types of hearings happen within a week. I'm going to shift a little bit. So I'm going to talk about the burden of proof. So the burden of proof is the obligation of a party to prove its position. So in these types of proceedings, it's the hospital's burden to prove that the person needs to remain either involuntarily hospitalized or, you know, treated over their objection. And then there's the standard of proof. So the standard of proof is the level of certainty and degree of evidence necessary to establish proof in a criminal or civil proceeding. It's an analysis that the fact finder, either the judge or the jury in this case, does when making their decision. I put these slides together, and I've been teaching this for years, before O.J. died. So I put this together, and then O.J. died, and it was suddenly in the news again. So I'm aging myself a little bit, but this was happening when I was in high school. O.J. is accused of killing Nicole Brown Simpson and Ronald Goldman, and he goes to trial in the criminal proceeding, and the standard of proof in a criminal proceeding is beyond a reasonable doubt. And I always, like, equate that to, like, some sort of, like, 95 percent certainty for the judge or the jury to make a decision. And, of course, as you know, if the gloves don't fit, you must acquit, and so he's successful in the criminal proceeding. But what happens subsequent to that is Ronald Goldman and Nicole Brown Simpson's families, they go and they sue him in civil court, where the bar is actually lower. So the standard of proof in a criminal or in a civil proceeding is actually preponderance of the evidence, which is just a little over 50 percent. And so the families sue, and they win money, because in a civil proceeding, only money's on the table. And so they both, you know, the families win a judgment. He, of course, spends years really not paying them, which became pertinent recently in the last month, because he still owed money. And so that's a lower bar. That's also the bar in medical malpractice cases, just to remember. Here's O.J. in the criminal trial, as you might remember. So like, these are three common standards of proof that I provide as, like, teaching when I'm teaching residents or fellows. So we talked about beyond a reasonable doubt in a criminal proceeding and preponderance of the evidence in civil proceedings where money is on the line. But this idea of clear and convincing evidence is actually the standard of proof in a civil commitment proceeding. And we say it's, like, between the two. So if residents tell me, oh, 70 to 80 percent certainty for the judge or the jury, that I say, okay, that's actually a good estimate of where clear and convincing evidence is. And I'll mention this a little later, but it's really this struggle that goes on between, like, how many people do we want to civilly commit and, you know, do we want to make it hard for the hospital or do we want to make it hard on the patient? So of course, like, in our line of work, unlike any other lines of work in medicine, it makes our life harder, because we have to go to court and testify often. And that's a unique position where, like, we're the specialty where we go to court most of the time. And it really is this struggle between, like, parens patrie, or parent of the nation, like us, you know, working and saying essentially that someone needs treatment and the medical model that we work within, and then the legal model of dangerousness. So if we're, you know, if somebody is immediately dangerous to themselves or others, we're medicating them over their objection emergently. But there are these situations where it's not emergent or urgent, and we can't medicate them over their objection. So there's always this pull between, and you see the courts sort of struggling with this. So in most states, the criteria for inpatient civil commitment, number one, you need to establish mental illness. And mental illness varies by statute, depending on what state you're in, and it's important to know what the definition of mental illness is, where you live. And then some element of either dangerousness to self or others, grave disability or deterioration, someone is deteriorating clinically, and it's concerning that they need treatment. And then in some states, this idea of incompetence, this idea, like, they lack insight in their need for treatment. And then the other piece is it has to be the least restrictive alternative, which we'll talk about a little bit more. But there is no other alternative in the community or in a less secure, confined setting that would be appropriate for this patient. Again, so in treatment over objection or outpatient commitment, the laws vary by state. So in the state of Michigan, you can actually go to court for civil commitment and then get what's called a treatment order as part of that. It's one hearing, you get the treatment order, and that's the end. You don't have to go for a second court hearing. And that's also true in the state of Michigan for outpatient commitment. So you can get what's called a combined order, where you can get involuntary civil commitment, and then as part of that, when the person's discharged, they're actually on assisted outpatient treatment or outpatient commitment following their hospitalization. What I will tell you is in New York State, these are three separate hearings and three separate matters. And so they're broken up in a different way. And every state's a little bit different on how that works. So of course, one of the bottom lines in this talk is to figure out how your state handles this. So I'm briefly going to talk about case law very quickly. Why are we worried about least restrictive alternatives? And most of the cases I'm going to talk about emerged from the 1960s and the 1970s, addressing these issues. And now they're being used sort of subsequently today. So this is Lake versus Cameron. This is Judge Bazelon, who is a DC Court of Appeals judge. And it's the story of a woman that essentially was in a psychiatric hospital because she wandered off because she had dementia. And the psychiatrists were testifying that she could probably live in a nursing home. And the judge in this case basically held that someone could not be held voluntarily if there was a less restrictive treatment alternative available, that the hospital then should put them in that setting. This is my favorite story. This is Ms. Lessard. She died at the age of 94 in 2015, so just remember, we never know how long folks are going to live. In the 1970s, she was involuntarily committed in the state of Wisconsin, was for an indeterminate period of time. She was upset about it and filed a class action lawsuit saying that she wasn't given notice, she wasn't given representation or due process rights through the court, and she was successful. And this, even though it was a Wisconsin Supreme Court case, formed the basis for the establishment of due process rights, including the right to counsel, the right to a hearing, a right to notice of a hearing in many states throughout the country. And there's this idea about dangerousness. So this is Mr. Donaldson. He was confined for years in a state hospital in Florida. He sued the hospital, and this wound into the courts for many years, but wound up at the Supreme Court. And the Supreme Court essentially said that if somebody wasn't dangerous, that you couldn't restrict their freedom. And in this case, he had a place to stay with friends and family, so that, you know, they shouldn't hold him if there was a less, you know, there's one, a less restrictive alternative, but also that if he wasn't dangerous. And then this idea about the standard of proof that I mentioned earlier, Addington v. Texas was a case from 1979, essentially held that clear and convincing evidence was the standard of proof that served as the constitutional minimum for civil commitment. So again, like this balancing the rights of the individual with legitimate state or hospital concerns. So let's talk a little bit about videoconferencing for court, because I do think this is important and became much more popular during the pandemic. It was first written about in the legal literature in the 1970s, mainly about telephonic testimony. So somebody would, you know, somebody would provide testimony by the phone. And then in the 1980s, we shifted to videoteleconferencing. And it's important to note that even at the federal level and at some states, this technology has been used in civil commitment proceedings for more than 20 years, and the APA first endorsed using it in a resource document over 25 years ago, and then developed a position statement nearly eight years ago about the same issue, noting that it was cost effective, it protected privacy, and protected due process rights. So the literature on its use has grown in the last 20 years, and of course, it became more popular during the pandemic. So there are some clear advantages for anyone who's ever had to, like, be involved in the transport of patients. There is a safety risk, both the elopement risk and the agitation risk. So I will forever be reminded when I trained at St. Vincent's here in Manhattan of the patient who was transferred from St. Vincent's to Bellevue for a court hearing and promptly hopped out of the hospital, or hopped out of the ambulance outside of Bellevue and ran away and, you know, was running around, he was the president of the United States. And so that was always, like, on the table if you were transporting, because, you know, they're not going to go and run after the patient. Then there's always the risk of agitation. If you've ever been in a courtroom where someone's become agitated, it's something you don't forget. Of course, it decreases hospital staffing needs for patient transport. It decreases the amount of time psychiatrists need to be taken away from their clinical duties. It also reduces the time, particularly in remote areas, for court personnel to travel to either hearing sites, either, like, different courtrooms or also to a hospital. It lowers costs to healthcare systems. And the other piece that I think is relevant is it's easier to call collateral witnesses with relevant testimony. So if you have an outpatient provider and you're trying to get some information and they need to come to court, it's unlikely they're going to be able to come to court. But if you actually have somebody saying, here's a Zoom link, hop on at this time, they're probably more likely to give testimony. And that holds true for family members. Sometimes family members don't want to come to court. But if you give them a Zoom link, they might be willing to talk and give you direct testimony or give the judge or the jury a direct testimony. So there is case law looking at these issues in civil commitment. And the case that's most often cited is this United States v. Baker case from 1995 that was a federal case involving an involuntarily committed federal prisoner who had the civil commitment proceeding happen by teleconference and he basically said his rights were violated and the courts, the Fourth Circuit, said no. And states have varied on how they handle this and some of it's, like, outlined in case law. So Virginia, this was looking at a civil commitment hearing by videoconference for somebody who was a sexually violent predator. He tried to argue that his statutory rights were violated and the Virginia Supreme Court said no. And the Florida Supreme Court said in this case that civil commitment hearings could occur remotely when the respondent, in this case the patient, approves the use of the format. So you could have a scenario where the patient doesn't approve the format, it becomes an issue. And in the Florida case they basically said he did, like, grant the, you know, approve the use of the format so therefore it could move forward. And again, state statutes vary on this issue. So in the state of Michigan, they're, you know, they've established some preferred modes for some proceedings. This is mainly in criminal cases, but, like, pretrial hearings, motion hearings, the Michigan courts have said they prefer Zoom. But what's interesting is they've left court discretion regarding whether or not it should be in person or remotely. So they basically said if everyone's given notice, then they can move forward because they have a right to object, but a patient could theoretically object and demand an in-person hearing. I have seen that happen. And also the courts themselves can say, listen, we think this matter should happen in person, therefore it's going to happen in person. So they're, they've given some latitude in terms of how they're handling the issues. So I'm going to switch and Dr. Laurel's going to talk. All right. Good morning. So I'm going to talk about confidentiality, privilege, and ethical considerations, and then we'll briefly go through some of the cases that set precedent for this. So why is testifying awkward in these proceedings? And there's many reasons why it could be awkward, right? So we'll explore some of that, and maybe there'll be some questions towards the end. Okay. So confidentiality. So confidentiality is defined as the right of the patient to have communications spoken or written in confidence, not to be disclosed to outside parties without authorization. It's both ethical, professional, and a legal obligation from the principles of medical ethics with annotations, especially applicable to psychiatry. Confidentiality is essential to psychiatric treatment. This is based in part on the special nature of psychiatric therapy, as well as on the traditional ethical relationship between physician and patients. Okay. Sure. Is that better? Hold on. A little? A little? All right. I'll talk louder. Okay. So briefly on HIPAA, so the Health Insurance Portability and Accountability Act of 1996, this is intended as a step towards the development of health information infrastructure. Privacy rule, for the first time, created national standards to protect individuals medical records and other personal health information. It applies primarily to electronic transmission of medical data including electronic billing and insurance verification protected health information or P.H.I. is individually identifiable health information. OK so in New York State we have mental hygiene law thirty three point thirteen and it essentially is more stringent than HIPAA. It applies to clinical records confidentiality. It reflects that although safeguards must be maintained an exchange of information between providers can assure continuity and appropriateness of care of individuals served thus confidentiality is not an insurmountable barrier to information sharing for treatment purposes when as it is frequently the case time or circumstance prevents a provider from obtaining the patient's written consent. So basically what I'm saying here is and this would apply for individual states as Dr. Grover mentioned you should know the different nuances within your state when practicing HIPAA is additive to state requirements on confidentiality. So whichever price provides more confidential confidentiality to the patient prevails. So some exceptions would be a covered entity may without consent disclose protected health information to other health care providers for the purposes of treatment necessary to lessen a serious and imminent threat to the health and safety of a person or the public or the public and the risk to human life trumps confidentiality. The required exceptions would be reports of child abuse reporting contagious diseases reporting gunshot wounds warn caretakers that a patient is assaulted report an attempt to unlawfully procure control drugs protect third parties from a planned crime and this would be more of Tarasov variation by jurisdiction which I'll get to shortly. All right. So now let's go through privilege. So privilege is also known as testimonial privilege. The right to bear another sorry the right to bar another person from testifying based on information that person has gained from contacts with them. So the basis of privilege confidentiality required to maintain the relationship communication occurs with expectation of confidentiality and the relationship serves a social value injury from disclosure greater than benefit from correct disposal of litigation. So how does information become privileged. OK. So obtained by the interview a physical exam transmitted between the patient and physician as part of a doctor patient relationship and it's generally loss of third parties are in the room so some complications that can arise. Privilege applies only to the judicial settings. This leads to conflict. Courts have a right to every person's evidence to bring about justice. The desire to protect professional communication promotes honest disclosures. So we have the attorney client privilege doctor patient priest penitent and marital privilege. In certain cases just can decide if the need for evidence outweighs the desire to maintain confidentiality exceptions here patient litigant court ordered examinations invitations to commit crime after the patient's death patients dangerous to sell for other others malpractice suits against the therapist collection of unpaid bills most criminal trials military courts child custody case cases and patient testimony about privilege relationship confidentiality versus privilege confidentiality is the clinician's obligation for silence out of court automatically arises out of a doctor patient relationship. Privilege patients right to prevent disclosure in court privilege can be considered a subset of confidentiality. OK. So briefly I'll go through some of the cases that would be relevant to confidentiality and privilege. OK. So Dr. Lifshitz this occurred in California in 1970 and it was a case where Joseph how sick a high school teacher brought damaged suit against John or even a student alleging physical pain injuries and mental and emotional stress from an alleged assault. Dr. Lifshitz was providing psychiatric care for about 10 years. Dr. Lifshitz and his records were subpoenaed. He refused to provide the medical records or give testimony claiming order infringe the order infringe on personal right to privacy privacy of the rights of his patients and his right to effectively practice his profession. He was then found in contempt and jailed for several days. The courts found need for confidentiality and psychotherapy must be balanced with society's needs for determining the truth who said had waived the privacy privilege by initiating a lawsuit by asking for damages for pain and suffering had made his emotional state an issue. The patient not the therapist had the right to privacy and therefore the exclusive ability to waive that right. In Jaffe versus Redmond in 1996 Officer Mary Lou Redmond shot and killed Ricky Allen while on patrol subsequently participated in about 50 counseling sessions with Karen Beyer a licensed clinical social worker. Jaffe was the executor of Allen's estate sued for use of excessive force wanted records of the counseling refused the records by the court to share information discussed in these sessions asserting information protected by the psychotherapist patient privilege. The district district court disagreed with the privilege Court of Appeals reversed and remanded for new trial in the Supreme Court affirmed this and what happened here was it expanded the privilege to social workers in the case of Dovey Rowe in 1977 New York Jane Doe sued her former psychiatrist Dr. Jane Rowe and Dr. Rowe's psychologist husband stating that so Dr. Jane Rowe and Dr. Rowe stated that they had oral consent from the patient so it was alleged violation of privacy. What they did was they published a book based on the sessions that were had from Jane Doe and the book contained her thoughts feelings emotions and reported that were reported verbatim throughout those therapy sessions Rowe's defense based upon the scientific value of the book for professionals with the right to publication was protected by the First Amendment. They stated that oral consent was provided and it was founded that oral consent was not enough in this situation and scientific discovery would take precedence over privacy nondisclosure. But Rowe failed to prove the book met the status rejection of punitive damages because actions were not willful malicious or wanton they were just found merely stupid. Really just don't write books about your patients even if you get consent in that situation. But oral consent was not enough here. OK. So going on to Tarasov Tarasov versus the regents of University of California October 27th 1969 was when Potter a student shot shoot and stabbed Tara soft. They met earlier for some history in 1967. He was a student as a grad student at UC Berkeley in 1968 Potter meets and befriends Tatiana Tarasov another student. They spent some time together. They I think briefly had a casual date and kiss on New Year's Eve. He pursues a romantic relationship with her but is turned down and subsequently becomes depressed and withdrawn. He sought out care at the student health clinic and put her told police that he would not harm Tatiana Tarasov and did not seem actively psychotic at that time. So 1969 Tarasov is now not at Berkeley but studying abroad in Brazil. And during this time Potter ends up seeing psychologist Dr. Lawrence Moore and reports of wanting to kill an unnamed female campus police were notified of this sent a letter of notifying danger and should be taken into custody. Potter given his statements campus police completed their own evaluation and released him. Dr. Harvey Pell said was the director of psychiatry department and supervisor to Dr. Moore and he essentially forbade further attempts to commit him meaning Potter and Potter discontinues treatment. October 27th 1969 he then kills Tarasov. He was convicted of murder in the second Tarasov parents filed a wrongful death lawsuit stating failure to detain a dangerous patient failure to warn of a dangerous patient abandonment of a dangerous patient and breach of primary duty to protect the patient and the public trial court case was dismissed. Dr. Moore cannot be held directly liable for failing to successfully hospitalized the patient. No special relationship existed between the parties. Common law stated that generally there is no duty to control the conduct of a third party to prevent harm to other to another person unless a special relationship is present. In the appeals court affirmed that so Tarasov one going on California Supreme Court reversed the appellate decision in 1974 and it stated the duty to use reasonable care to give threatened persons such warnings as are essential to avert foreseeable danger arising from the patient's condition. Protective privilege ends where public peril begins. The conflict would be duty to protect the patient confidentiality over to protect people versus people from serious violence. So the duty to protect we need to notify intended victim notify law enforcement hospitalized increase office visits other reasonable steps. And when considering the possible interventions it's always beneficial to include the patient right in the decision making process. Some takeaways from Tarasov psychiatrists and psychologists have a special relationship with patients. It's not restricted to warnings. What can we do to protect public safety outweighs confidentiality attempts to carry out the duty to protect must be done effectively. Interventions must have the intended effect and further action may be required depending on the outcome. So no legal obligation to furnish information even to law enforcement officials statutory statutory disclosure requirements due to judicial compulsion. So for example a court order unless justification of disclosure can be established breach of confidential confidentiality in and out of courtroom scenario can result in tort action for defamation or invasion of privacy includes disclosure that an individual is a patient. Subpoena does not necessarily mean that information must be disclosed and requires appearance in court. So this is my portion and I'm going to hand it over to Dr. Jodi. Good morning everyone. Thank you for being here. Just a couple of points. Dr. Haley gets in who was the fourth member of our panel was unfortunately able to make it this morning so I will do my best to give her portion of the presentation justice. My name is Miriam Jodi I'm the associate program director for the Albert Einstein School of Medicine forensic fellowship program. Just a little shout out if there are any medical students residents fellows who are interested please feel free to come up and introduce yourself in the interest of fairness. I guess I should also mention that Dr. Grover is the program director at University of Michigan. So if you want to you can talk to him too but come to me first. So now we're really getting kind of into the meat of the presentation. The next two sections really kind of overlap but that was done intentionally. You know it's always better to hear important things more than once. So in this first section we're going to be talking about preparation for your courtroom testimony. So as has been mentioned before it's really really important to know the definitions within the state that you practice. So definitions such as mental illness dangerousness to self or others need for treatment. All of these can be defined differently depending on where you're located. You also really want to know your technology. So as we all know once COVID hit most of our courts if not all of our courts switched over to virtual testimony. It's become pretty commonplace now. And even though we do have the ability to go back to in-person hearings a lot of courtrooms have continued to have their hearings done virtually. Despite this I have been surprised at how often I see physicians struggling with the technology that we've been using for the past couple of years. So some basic points just to make the day go as smoothly as possible. You always want to make sure that you have the invitation available to you ahead of time so you're not scrambling to reach your attorney or reach the courtroom to be able to access it right before your hearing the court hearings may be done on different platforms so Webex Microsoft Teams Zoom they all look a little bit different. The buttons for them are all located in different areas. So if you're not used to using these programs it's very helpful to just practice using them know where the video button is where the volume button is how to adjust your screen so that you can see who's talking who's not talking. Be familiar with muting and unmuting yourself. So I have observed multiple court hearings where we've been delayed by several minutes simply because someone couldn't find the mute or unmute button. And again it's one of the most basic things of a virtual courtroom. So be familiar with that. And we don't always think about it but particularly if you wear glasses it's helpful to double check the glares of other screens. So one of our panelists this came up because someone who was testifying was actually watching TV on another screen and it was reflected in their glasses. So point number one you shouldn't be watching TV when you're testifying. But if you must make sure that it can't be seen in your in your eyeglasses. For those of you who may need to go in person to a courtroom and especially if you've never done this before these days can can drag on and you may need to wait for a while. So it's helpful to make sure that you arrive to the courtroom well in advance. Make sure that you can find the room bring work with you if you can to pass the time while you're waiting for your hearing. And if you're unable to bring work bring a book bring your cell phone something so that the day doesn't feel like a complete waste. You also really want to know yourself. Again this seems kind of self-evident. But I think a lot of us as we continue forward in our careers kind of forget things like dates that we've graduated medical school or residency fellowship whatever it might be. This type of information is all included in what's called the voir dire which can be translated as to speak the truth. You may have heard of it more commonly in popular culture as a way to find a jury. In this context it is a series of questions that are asked. So when you are called into court to testify as part of the qualification of you as an expert you will be asked where you work where you did your training where you graduated what might be part of your role in in that position. So again just think about it ahead of time so that you can make sure that you're in that position. So again just think about it ahead of time. So these questions don't catch you off guard when you are asked them on the stand. Another common question that's often asked is how many patients you've treated either over the past year or over your career. And again it's not necessary to have an exact number but it's really really helpful to have an idea of estimates. So whether it's 500 patients a thousand patients you know if you have a particular specialization how many patients you've seen within that because again that goes to your credibility and that goes to the establishment of you as a witness. And then the other thing to just keep in mind is you may not necessarily be the treating psychiatrist for the patient that you are testifying on. So particularly in cases as an example in New York I commonly do second evaluations for patients who are moving forward for treatment over objection or forced medication hearings. So I'm not the treating psychiatrist for this patient. And so when I testify it's important for me to be able to tell the court when I met them how much time I spent with them what the purpose of my meetings with this patient was to again kind of establish the context of that relationship different types of court cases will require different types of information that you should know about the patient. Again I know probably many of you have many many patients on your caseload. So you always want to make sure that you're going back and reviewing ahead of time to refresh your memory. You are able to bring the medical chart into you or into court with you. But again the more familiar you are with the history the easier your testimony will go. So refreshing your memory as to the age and gender of your patient when they were first hospitalized how long they've been in the hospital. What were the circumstances that brought them into the hospital. In addition to what you're able to find in the medical record it's always really really helpful to get the patient's own words. So we'll talk about this a little bit more moving forward. But any time you're able to confirm psychiatric history patient history story narrative within the patient's own words that carries a lot of weight within the courtroom. When you're reviewing the record looking for circumstances that do support the idea of past grave disability dangerousness to sell for others lack of insight into the need for treatment. Again all of this is important to be able to present to the courtroom and also the level of participation of that patient within the current confines of where they are. So for a civil commitment if they've been participating on the unit how they've done when they've been discharged and then come back to the unit, have they bounced back within 2 days, do they bounce back within a month or 2 months? This is all really important information. For other cases such as a treatment over-objection or forced medication hearing, again, since this is essentially a capacity hearing, how are you going to demonstrate their lack of capacity? And again, using their own words if possible. Any sort of documentation or history you have about their behaviors or their symptoms, any instances of dangerousness towards self or others, how their behaviors and their mental illness are interconnected. For those of you who are involved in outpatient commitment, it's really important to have as many records as you can to make sure that you're meeting the specific criteria and being able to demonstrate to the court that you do meet the criteria for outpatient commitment. Again, asking the patient directly about any prior hospitalizations or acts of violence, how they've done in less restrictive settings. So that phrase has come up before. That's very important to all of these cases. So really a strong foundation of knowledge of their past history. And then knowing your role within the court. So in the court, you may be called upon to provide either facts or opinions. So when we're talking about facts, we're talking about specific actions, incidents, or events. Whereas with opinions, you're talking about diagnoses or symptom descriptions. So the example here, patient states she is the Queen of Switzerland and insists on being called Your Highness. So this would be a fact versus the patient is grandiose and delusional. So that would be your psychiatric opinion, your medical opinion. As has been mentioned before, it's important to remember that court is adversarial. So you may be working with an opposing attorney who is somewhat antagonistic and trying to throw you off your game. You may be working with an opposing attorney who is kind and sweet and seems like she wants to be your friend. And your job is just to remember that you can't be taken in or take any of that personally. And you just have to move forward with being as calm and objective as possible within that setting. And I think a lot of physicians, psychiatrists get really nervous about the idea of testifying in court because we feel like that's not our wheelhouse. But I think a helpful way to ground yourself is to remember that your wheelhouse is as an educator. So basically, since you started medical school, residency, if you did a fellowship, certainly as an attending, you have been learning and practicing how to be an educator. And the only difference in this case is that you're taking yourself out of the hospital or your clinic and you're educating within the courtroom. So you are the expert. You do have the knowledge. And your job is to educate either the judge or the jury about a particular type of information. So I think remembering that can be helpful in making court seem a little bit less scary. I love this picture of Dr. Grover. So within the court, you may be called to act as either a fact witness or an expert witness. So a fact witness is somebody who is called to testify because they have knowledge due to direct observation. So maybe it's a random person off the street who was called to testify that they saw that the light was red when the car ran the red light. In this case, you may be a psychiatrist who was called to testify as to an observation you've had about your patient. However, in most of these hearings, we are qualified as expert witnesses. So the difference between an expert witness and a fact witness is the expert witness has facts and information specific to a science, a topic that are beyond the scope of the average lay person. So certainly as psychiatrists, you are experts in the field of psychiatry. Your scope of knowledge is beyond that of the average lay person. And as an expert witness, you are called to court both to educate and to provide an opinion to the court. So fact witnesses do not provide opinions. They simply state the fact and what they have observed, while expert witnesses are those who are called to provide opinions to the court. In the court, you will also be asked to provide your opinion to a reasonable degree of medical or psychiatric certainty. So what exactly does that mean? Again, it can vary depending on the jurisdiction that you're in. So important to know the rules where you practice. However, it's generally thought to be the equivalent of the preponderance of the evidence, or over 50%. Others would argue, and other courts have argued that it's higher than that. Jonas Rappaport defined it as more likely than not with the modification, that level of certainty which a physician would use in making a similar clinical judgment. But ultimately what this means is you don't have to be 100% certain in most jurisdictions about your thoughts on diagnoses, treatment, and need for hospitalization. You may feel like you're 100% certain, but it is not kind of a statutory requirement. Okay, so we've spent the past couple minutes talking about preparation for court. Now you're on the court, you're on the stand, how are you going to make it go as calmly and quickly as possible? So we've just spent the past couple minutes talking about preparation. Certainly preparation is the key to remaining calm, to review, you know, make sure you've reviewed the chart, pay attention to specific dates, dates of admission, any emergency medication administration, any behavioral codes. Certainly if you're doing something like a treatment over objection, you want to know the frequency of medication refusals, the general history of your patient. And here I say, take the hearsay out of hearsay. So what I mean by this is, within court you are going to be limited as to the information that you're able to provide. It's generally restricted to information that you have specifically received during the time of that patient's hospitalization. So as an example, if someone presents to another emergency room and that patient's mother tells the emergency room psychiatrist that the patient was trying to commit suicide and he was holding a knife. That emergency room psychiatrist communicates that information to me as the inpatient psychiatrist. That information is really relevant and important for me to know as a clinician, as a treating psychiatrist, but I would not be allowed to testify as to that in court because mom did not tell that to me, patient did not tell that to me. It wasn't information that was given to me during the course of that hospitalization. So the way I can get around that is if I knew that this event happened, before I go into court I'm going to ask the patient about it specifically. So then I can get in their own words confirmation either that it did happen or maybe it happened but they didn't feel it was important or it was just meant to be a cry for attention or whatever it might be. So then I can bring that piece of information into the courtroom with me, otherwise a hearsay objection could potentially be given and then I wouldn't be able to testify as to that piece of information. Prepping with your attorney, again, is hugely important. I have been surprised as to the number of times that psychiatrists have told me that they don't think it's important to talk to their attorney before going into court. Even if you've done a hearing, a certain type of hearing, 50, 100 times, touching base with your attorney helps build trust on both sides. And again, you have to remember that while the attorney is the expert within the courtroom regarding legal proceedings, you are the expert with regards to the psychiatric issue. So you're still educating your attorney as to what's important, as to what information needs to be brought out into court, as to what they need to help you get out onto the record. And it's difficult to do that if you haven't spoken with your attorney in advance. So it depends on where you're practicing. So within a hospital, as an example, the hospital that I've worked at, we have a legal department and so in the past, the hospital has provided it to me. If you're in an outpatient setting, I'm not sure, I think you would probably need to check with your ... It gets awkward. You have to figure out who's representing your interests. If it's like an outside matter, which is usually outside the scope of this, in a civil commitment hearing, you're probably testifying for your hospital, so your hospital would be the person of interest. But if you're being subpoenaed from the outside, you have to figure out who the legal department is at the clinic you work at. Most outpatient clinics have some type of legal representation or other hospital systems have legal representation. It can be tricky, I admit that. So yes, so making sure that you're reviewing with your attorney so that both parties really understand what needs to be brought into court. Consider making notes and bringing them with you to the stand. So just keep in mind that any paperwork you bring with you into the court, and this is more relevant if you're there in person. If you physically have something with you, that may become part of the record, but again, using a treatment over objection as an example, in New York, it's important for me to be able to testify as to how frequently a patient has refused to take medication, what the dates were, and that's not something that I just want to rely on my memory on. I want to have those dates in front of me. So what I'll typically do is just write those dates on a piece of paper so that I can easily reference them, and also so I don't need to spend time kind of flipping through a chart trying to find a single piece of information within, you know, hundreds of pages of information. So again, consider making notes and bringing them in with you, and then just a reminder to know the applicable criteria and statutes within the area that you're working in, and certainly again, for any medical students or residents who might be in the audience, I think it's hugely important to observe court cases if you can while you're in training. Depending on where you're in training, you may have a lot of exposure to court cases. I did my training in Ohio, and I think I saw one court case, and then when I became an attending, I had to testify on a case within a month. So I was lucky enough that I had done fellowship training, so I was more comfortable with it, but I know that a lot of psychiatrists don't get that opportunity. So if the opportunity arises, you know, please take it. If you are in a position to help your residents get that opportunity, I think it's really great. I teach residents, our psych residents, and recently asked a group if they wanted a lecture on treatment over objection or courtroom testimony, and kind of unanimously, they said TOOs because they didn't feel that courtroom testimony was relevant to them in any way, and I think that's so unfortunate because it might not be relevant to them at that particular time because they don't get to testify on cases as residents, but as soon as they're attendings, it's going to be something that they're going to need in their toolbox, that skill set. So again, just keep that in mind. The importance of thoughtful and effective testimony. So why are we talking about this? Why is it important? A patient's attorney may genuinely contest their commitment. A patient has the right to request a jury trial who will carefully weigh all the evidence presented to them, and psychiatrists provide much more than evidence just about the patient. When you're testifying, you're speaking to your own competence. You're speaking to the credibility of our profession. You're speaking to the virtues of our profession and the services we provide to our patients. It might seem counterintuitive, but it can also be a therapeutic effect for the patient. We do want our patients to feel as though they've gone through a fair legal proceeding. More often than not, they do not feel that that is the case, but as much as we are able to demonstrate for them that we are following the rules, that we are doing what we feel is in their best interest, even if they disagree, and explaining to them why we're moving forward with this, because it is, you know, a pretty serious, a very serious situation to be talking about taking away someone's freedom and their liberties and their right to choose. So being thoughtful about how you approach testimony is hugely important, and just a point about if you are the treating psychiatrist who does have to testify against your patient, so to speak, you always want to make sure that you are giving them advance notice. Testifying against your patient can certainly lead to a fracturing of any sort of therapeutic alliance or therapeutic rapport. If you're at least able to have a discussion with your patient ahead of time so they're not caught off guard about the things that you might be saying in court, again, they don't have to agree, but you never want your day in court to be the first time that your patient is aware that you are there and testifying against them. Your appearance matters, certainly. This applies both virtually and in person, and I'm emphasizing that because virtual hearings tend to lend themselves to a certain type of casualness, but you should still be wearing conservative clothing, muted colors if possible, appropriate grooming, try to minimize any sort of flashy jewelry or accessories. Again, this speaks to your professionalism. It speaks to your credibility. We have all seen people in court with button-down shirts that haven't been buttoned or in t-shirts or fedoras or caps. Even if you're on video, you're still in a courtroom. You're still in a legal proceeding, and you need to remember that. With virtual hearings, in particular, again, making sure that you have a professional background, so either a blank wall behind you or an appropriate kind of filtered background. You want to be in a private, quiet room. I recognize this can be challenging for some people, especially if you practice in a hospital where maybe you're in a cubicle instead of a private office. But if that's the case, you want to make sure that you're locating a meeting room or something that you can reserve so you can have that quiet space. When you're testifying, you want to make sure that you're looking directly at the screen. When you're testifying, again, don't take phone calls, don't watch TV, listen to the radio, drive, talk to people off-camera. And again, I know that this seems really self-evident, but every single one of these examples is on this slide because one or all of us have observed this happening. So, you know, muting your phone, passing off your pager to somebody else when you will be in court, closing your email program so the little Outlook dings aren't going off when you're testifying. These things are easy to forget about, but they can be very distracting within a courtroom, so just turning everything off. Make sure, as we talked about previously, that you've tested your equipment ahead of time. And if you're testifying from home, make sure you're securing any animals, but I would add secure any babies or toddlers to this as well. I don't know if anybody remembers the guy who was giving an interview on the news and then his toddler waddles into the room and then his wife kind of crashes in and pulls them all out. It's really funny to see, but again, within the context of professional testimony, not the best, so you want to try to, you know, prevent anything like that from happening. So again, just some reminders that it is an inherently adversarial process. The opposing attorney may try to make you feel nervous or upset. You should never feel like you need to be arguing or kind of meeting their attitude with your own attitude. You have the information, you have the knowledge, you are the expert, and you should feel confident in the knowledge that you have. If someone is attacking you, more often than not, it's probably because you aren't responding to them in the way that they want you to, or that maybe their case isn't as strong as they would hope it would be, and their strategy has now become trying to attack you. So just remaining calm. Your job is to speak the truth. So you never want to exaggerate or attempt to mislead or make false statements. You want to make sure that you understand the question that's being asked and that you answer the question that's being asked. And never guess. So there's a difference between I don't know versus know versus I don't recall. So if you need to take a moment to pause, think about your answer. Saying I don't know or know is always better than guessing and then being asked about it in a couple minutes and giving a response that doesn't match up with your first. Also if you can't recall but you do feel like you have it documented in the notes of the chart, you should feel empowered to ask for a moment to review the chart, to locate it, to find it. You should feel empowered to ask for a question to be repeated or clarified if you don't understand it. This is also somewhat related to pacing of questions. So you may find that an attorney kind of rapid fire asks you questions to get you into the habit of responding yes or responding no. And you know, if you're anxious on the stand, if you're inexperienced, that can be kind of a really easy trap to fall into. And the way you kind of just take back control over that situation is to just take a beat, take a breath, take a sip of water, adjust your position in your seat, ask for a question to be repeated. Just be thoughtful about your responses. You know, in court, you're not being timed. You don't have to give a response within 30 seconds. So if you need to take a moment to think about something, take that moment. And then I also just wanted to remind everyone that when an objection is raised in court, you should not continue speaking. So if an objection is raised, you need to wait until the judge rules on the objection. If they sustain the objection, you won't be allowed to continue responding to that particular question. Your attorney would have to re-ask or rephrase the question. But if it's overruled, then they would give you the permission to continue with whatever you were saying. So we see a lot that when an objection is raised, maybe a newer psychiatrist isn't familiar with what they do at that point, and they keep talking, but you should just pause and wait for the judge to make his ruling or her ruling. On the stand, you want to make sure that you're speaking clearly with an appropriate volume and tone. You know, we spend years learning about nonverbal communication. This also applies within the courtroom, you know, crossing your arms, rolling your eyes. If you have a particular expressive face, trying to keep that under control. You want to avoid humor, sarcasm, vagueness, condescension, argumentativeness, disrespect. These may be things that you are approached with, but again, if you respond in kind, that makes you look less credible and makes you look less professional. So you know, trying to keep emotions in check. And we don't always think about it, but trying to avoid statements such as to tell you the truth or to be honest. Because when you make statements like that, it implies that you haven't been telling the truth or you haven't been being honest. So try to avoid language like that. Again, remember your role as an educator within the courtroom. So avoid medical jargon as much as possible. Never assume that the judge or jury knows what you mean when you say something like schizoaffective disorder or delusions or disorganized behavior. You won't be able to entirely avoid that type of language. But providing examples to offset the jargon of it all can be very helpful. So instead of just saying, you know, the patient had disorganized behavior, follow that up with because he was opening up the fruit cups, dumping them over his head, and then walking into the corner and chanting at every mealtime. So that helps your audience kind of visualize and understand what you mean by that particular statement. You also want to try to be as concise in your answers as possible. You know, I know a lot of us can have the tendency to kind of ramble and talk on and on and on, kind of as I'm doing now. But if you can be more concise when you're responding to a question, this makes it easier for your audience to follow what you're saying, for the judge to follow or the jury. And this also goes back to having that relationship of trust with your attorney. Because if you have prepped with your attorney, if you trust your attorney, if they know what you find important in that court case, they are going to know to follow up with you. So they are going to know to ask you a follow-up question to get a certain piece of information out in the courtroom. So instead of feeling like you need to get everything out all at once, you want to have that trust that your attorney will know to take you where you need to go. And then within the courtroom, you want to avoid, obviously, eating or drinking water, except for water if it's needed. I'll make the little caveat for that, that carbonated water tends to make people burp on the stand, so try to avoid any liqueur, stuff like that. And avoidance of chewing gum, chewing tobacco, again, none of that should be happening, certainly not in person or virtual courtroom, but we've seen it before. And then we've covered this earlier in the presentation, but common questions you might be asked on cross-examination. These are questions that you can prep with your attorney in advance. It's helpful to be able to anticipate what weaknesses you might have in your case or what questions you might be asked by the opposing side, so then you have an answer prepared and you're not caught off guard. So again, preparation for these court cases, it doesn't take very long, but kind of the payoff in the end is huge, because you'll just be that much more comfortable when you're on the stand. Okay, so we're coming up to the vignette part of the presentation. We've got two. The first one is a little longer, so we'll apologize in advance. We did try to cut it down for time. We're going to be showing an example of a civil commitment hearing, the language, the process. All of it is consistent and accurate with court cases that we have in New York. And then the second case will be a treatment over objection hearing. Again, we've cut things out to try to cut it down for time. But while you're watching, we'd like you to be asking yourself what you think went well, what didn't go well, what maybe you would have done differently, and at the end, what similar or different challenges you might have faced in your own testimony. So we'll watch the first vignette, I think it's about 18 minutes. We'll try to take some time for discussion, and then we'll move on to the next. And I recognize we might not have time for both, so . . . Okay, just so everyone knows, I'm going to play the second one, which is a right to refuse treatment, treatment over objection case, because it's shorter in the interest of time. Because I would like some time for feedback. I'd like to call Dr. Freeman Jeffries to the witness stand. Doctor, please raise your right hand. Do you swear or affirm to tell the truth, the whole truth, and nothing but the truth? He's muted. I do. Dr. Jeffries, if you can also please remove your video background, it's distracting. Oh, I'm sorry about that, Your Honor. I guess I can do that. Counsel, you may proceed. Okay. Thank you, Your Honor. Dr. Jeffries, have you previously testified in court? I have not. Dr. Jeffries, can you please tell the court your educational history? Yes, I can. I completed my undergraduate studies at South Carolina College in 2014, my medical school training at the University of some state College of Medicine in 2018, then I completed my psychiatry residency training at St. Vincent's Hospital in Manhattan and a consultation liaison psychiatry fellowship at University Hospital in Boston, Massachusetts. I am currently a forensic psychiatry fellow at the New York School of Medicine. Thank you, doctor. Are you licensed to practice medicine in the state of New York? Yes, I am licensed to practice medicine in the state of New York. Are you board certified in the field of psychiatry? Yes, I am board certified in the field of psychiatry. And approximately how many patients have you assessed and treated in your career? I have assessed and treated over a thousand patients at this point in my career. Thank you, doctor. Your Honor, I move to qualify Dr. Jeffries as an expert in the field of psychiatry. Dr. Jeffries, how are you familiar with Ms. Ortiz? I'm currently Ms. Ortiz's treating psychiatrist on our inpatient unit. She has been admitted since April 22nd. I've met with her daily, discussed her care on treatment team rounds with other staff members, reviewed her prior and current medical records, and spoke with the nursing home where she resided prior to her arrival at the hospital. I also informed Ms. Ortiz that I will be testifying on this matter today in court. Thank you, Dr. Jeffries. Are there records that you have brought with you to court today? Yes, I have. Dr. Jeffries, what were the circumstances of Ms. Ortiz's admission to your hospital? Ms. Ortiz was initially brought in by EMS, activated by her nursing home, because they were concerned that she stopped taking her medications and assaulted a peer. Objection. Hearsay. Sustained. Doctor, I would ask that you delimit your testimony to information from your hospital. Thank you, Your Honor. I will do that. Ms. Ortiz was transferred to N-A-Town Hospital Center from Othertown Hospital on April 22nd. She had been living in a nursing home prior to her arrival at Othertown Hospital. In our triage area, Ms. Ortiz was known to be psychotic. She was paranoid, internally preoccupied, irritable, and religiously preoccupied. She was also known to have psychotic anxiety. Thank you. Doctor, do you have an opinion based on a reasonable degree of medical certainty as to whether the patient is suffering from a mental illness? Yes, I do. Doctor, what's your diagnosis? Schizoaffective disorder, depressed type. And what are the symptoms of schizoaffective disorder that Ms. Ortiz is currently displaying? Ms. Ortiz is displaying many symptoms consistent with schizoaffective disorder. She has a psychiatric history that started in her 20s with both psychotic and manic symptoms. She told me that she has been hospitalized many times before, including at Riverside Hospital and Rotter Hospital. She also told me that she assaulted someone at the nursing home before she was put in the hospital. Can you talk a bit more about the symptoms that Ms. Ortiz has been displaying while in the hospital? If you were listening, you would remember that I said she displayed psychotic and manic symptoms, such as psychotic anxiety, internal preoccupation, irritability, hypergraphia, pressured speech, delusional thoughts, paranoia, disorganized thoughts, no sleep, and religious preoccupation. Okay. Doctor, can you explain to the courts, though, what you mean by psychotic anxiety, internal preoccupation, hypergraphia, and delusional thoughts? I thought I explained myself, but okay, for those that don't understand. Ms. Ortiz has been very agitated since her arrival and stopped taking medications on the second day. She punched someone three days ago in the unit and said the unit social worker was part of the Church of Satan that's trying to kill her. So that's what I mean by psychotic anxiety. Ms. Ortiz says that she is not hearing voices. What I mean by that is she says she's not experiencing auditory phenomena that others cannot hear, but we observe her on the unit talking to herself and mumbling. Sometimes we can't even get her attention. She also talks fast, is difficult to interrupt, is taking notes on all unit activity. She's also hoarding those little juice jugs we give patients on the room. Is that enough? Yes, I think that suffices for now. What is Ms. Ortiz's current treatment plan? Ms. Ortiz is currently prescribed Haldol, Zyprexa, and Depakote, but she is not taking them consistently. Her symptoms have increased in their severity because she is not taking them consistently. She is also meeting with myself, the unit social worker, and the unit psychologist regularly. She's also scheduled to attend groups and may interact with other patients. According to the team, the notes, and my observation, she is not consistently attending groups. You mentioned that Ms. Ortiz is not taking her medications consistently, correct? Ms. Ortiz has not taken Haldol or Depakote since arriving at our hospital two weeks ago. I think that she has only taken Zyprexa three times. Okay. And how does the treatment plan benefit the patient? When Ms. Ortiz is compliant with her medications, her symptoms improve. She is less agitated. The voices that she experiences are less intense. Her speech is slower and more organized, and she is better able to engage with others, including the treatment team. Our goal is to work with Ms. Ortiz so she can take her medications consistently and work toward being safely discharged from the hospital. Has the hospital prepared a treatment plan for the patient? Yes, we have prepared a treatment plan for Ms. Ortiz. And what is your medical opinion as to Ms. Ortiz's capacity to refuse treatment at this time? I believe that Ms. Ortiz does not have the capacity to refuse treatment at this time. I have approached Ms. Ortiz about this issue. She gets very agitated, tells me that medication is poison. The hospital is part of a larger conspiracy against her to have her killed and sent to hell. These symptoms have increased in severity since she arrived because she was taking medications consistently before arrival, but then stopped them soon after arriving. Attempts by several staff members, as well as Dr. White, who provided the second opinion to my report, have been unsuccessful in terms of engaging her in this conversation. We would consider other medications at this point, including Clozeril, but her level of non-adherence with treatment prohibits or really makes it difficult to make that an option for her. So our present plan is to go back with the medication regimen that she was taking prior to her arrival in the hospital, adjust that dose of medication, and continue to work with her. And in your medical opinion, what is Ms. Ortiz's prognosis without the treatment? Ms. Ortiz's prognosis is poor. She will continue to present with psychotic symptoms and irritability. We may need to continue to provide intramuscular injections to her on an urgent basis due to her agitated behavior. She will continue to deny that she has a mental illness, and she will remain unable to be discharged into the community given her ongoing inability to care for herself. And in your medical opinion, is Ms. Ortiz a danger to herself or others at the present time? I believe that she is a danger to herself and others at the present time. She's had multiple episodes of agitation, it appears, and continues to be found yelling on the unit. There is a risk that she may hurt others with her behavior. If she looks at someone else on the unit or engages in other behavior that could agitate a peer, there is a risk that she could be harmed as well. And in your medical opinion, is this treatment plan the least restrictive alternative to treat the patient at the present time? Yes, it is my opinion that it is the least restrictive alternative at the present time. Thank you, Doctor. Your Honor, I have nothing further. Ms. Brown, do you wish to inquire? Yes, Your Honor. Please proceed. Dr. Jeffries, was it your testimony that Ms. Ortiz had punched someone on the unit three days ago? Yes, it was. I'm going to ask you to look in the Anytown Hospital Center's records on page 53. Can you take a look at that with me? Yes. Can you read the nursing note from May 5th at 2.30 p.m. at the top of the page? Start with where it says patient. Yes. Patient was noted to be talking to herself on the unit about how everyone wants her dead. Social worker approached Ms. Ortiz to offer support. Ms. Ortiz raised her fist, yelled that the social worker was, quote, just wanted her dead, unquote, took a swing at her and missed. Staff responded and Ms. Ortiz was walked back to her room and de-escalated by other staff. No medications were needed and no injuries were sustained. Dr. Jeffries, I do not hear in your reading of that note any evidence that the social worker was hit by Ms. Ortiz. Is that correct? That's correct. And Dr. Jeffries, would it be fair to say that Ms. Ortiz threw a punch but no one was injured? Yes, that would be fair. And would it be fair to say that Ms. Ortiz was able to be calmed down without the use of any medications at that time? Yes, it would be. Is it true that Ms. Ortiz has not had any other incidents on the unit where she has tried to punch another patient or staff member? Yes, that would be true. And would it be fair to say that she has not required any intramuscular injections for violence on the unit? Yes, it would be fair to say that too. Isn't it true that she has not expressed any suicidal ideation or made attempts to harm herself while she's been hospitalized? Yes, that would also be fair to say. And Ms. Ortiz is maintaining her personal hygiene on the unit, correct? She's a little disheveled from day to day and by that I mean she doesn't always comb her hair but she always wears clean clothes on the unit. I've observed her washing her clothes with the unit washing machines. So, it would be fair to say that she's maintaining her activities of daily living or ADLs? Yes, it would be fair to say that. Now, Doctor, I want to review Ms. Ortiz's reasons for refusing her medications. You mentioned that she has said that the medications are poison. Has there been anything else that she has mentioned to you as a reason for why she's refusing medications? Yes, she informed me that she was worried about weight gain on the medications, which I think is a reasonable concern because these medications can cause weight gain. Doctor, why did you not offer this explanation earlier in your testimony? I've reviewed prior records. Those records support that these medications have not caused more than a five-pound weight gain over the last three years in Ms. Ortiz. Her weight has generally been stable during that time, which coincides with her being most compliant with treatment. I acknowledge she's worried about it, but we would monitor this carefully as a potential side effect. Thank you, Doctor. Thank you, Doctor. Can you explain to the court what would happen if Ms. Ortiz refused medication? If Ms. Ortiz refused medication, we would then inform her that we plan to offer an injectable form of the medication. If she refused the injectable form of the medication, staff would hold her for the purposes of giving her the medication. She would be restrained. Let's just call it that, right? Yes, she would be restrained. Doctor, would it be fair to say that you would restrain her for labs, too? We would only restrain her for labs if only absolutely necessary. The hope would be that the court order would be adequate enough to encourage her to have lab work completed. We would also hope that as she took medications more consistently, her symptoms would improve. She would recognize our need to monitor her doproic acid or doplicate level and monitor any potential side effects from the medications. And to clarify the proposed court order, is it your understanding that you could use Ativan to calm her down before drawing her labs, and if that didn't work, you would manually restrain her to obtain the labs? Yes, we would be asking for the ability to do that. The use of both intramuscular medications and manual restraints to obtain lab work would be the last resort and something we would carefully consider and have several conversations with Ms. Ortiz before moving forward. I have nothing further, Your Honor. I was glad to hear the laughter at some of the more ridiculous parts of the testimony. But again, just a reminder, anything that was included in this video is something that we have observed. So going back, thinking what went well, what didn't go well, what would you do differently? If anybody wants to shout out with what they thought went well or could have been done better. That's true. You'd be surprised. I have seen lots of eating. It's true, and I've seen it, and the other example that I have is somebody that doesn't do that, and it does come off as really impacting your credibility if you can't keep those things straight in your head, and I do think preparing matters. One thing I'll also, because we didn't get a chance to do the first one, a good hearing after a cross will have a redirect, where your attorney will come back around to issues. This is why court preparation is really important, because if something comes out on cross-examination that's concerning, or it didn't sound like there was a full explanation, they can come back around for you and give you that opportunity. So I always say preparation is helpful, but also redirect is really an opportunity for you to get a chance to speak again. No, no. And I think that's important. I think one of the things we wanted to take away is you have to balance using jargon and explaining yourself and also doing that in a respectful way. So you don't want to come off as arrogant or flip. And I think there's, again, I think you've said it nicely. You have to be confident, but there has to be some element of humility in how you're conveying yourself. True, but you have to balance it a little bit because, you know, you're dealing with personalities in the courts too. So you can say, this is what I think. This is how I'm thinking about this. This is my opinion. Someone could come to a different opinion, but you still have to manage to do that sort of professionally. I've definitely seen people just get agitated and irritable with a judge or an attorney and that just doesn't go over very well. So, we actually talked about that when we were preparing this as well. So, in our discussion in Michigan where Dr. Grover is, that is more how they expect it to be. In New York, I would just respond as yes or no. Yeah. So, you kind of adjust to the courtroom in which you're at. Yeah. So, I mean, you didn't rise to the bait about the, and you're going to restrain her to do this and you're going to restrain her. I always had trouble with that. Yeah. It gets into this game about how you handle it. I think you always do your best to explain what might happen. I've been asked if I've known the procedures of how that works before. At some juncture in my career, I said no. I mean, I have a basic sense of how they work. I'm not involved in the direct restraint and I would have to refer to the policies and procedures of the hospital. I think it's important. I mean, we didn't really talk about this, but if you don't know something, I know Dr. Jotty had this slide, just say you don't know. It's okay. If you don't know it, it's like outside the scope of what you do, or you don't know the exact procedure, so you don't know. Was the monotone delivery deliberate? What? Was the monotone delivery deliberate? Yeah. I mean, to a certain degree. Yes. I don't think you should be totally monotone. I think you have to be a little more interactive with the courts. I mean, the people that do this work the best are the people that also have a background in acting. But there is a balance. So I would say monotone isn't great, but you don't want to be Ben Stein. That's how I always think about it. But you want to be somewhat interactive, but it's fair. Yes. Well, I know Matt well. He's a much nicer guy. Well, that's good. Yeah. Again, you would be surprised. Of course, at the beginning, the muting issue was actually just something naturally occurred in the filming, but it was just so common. Most people are forgiving about it, but knowing when to mute and not mute, at some juncture, it didn't get picked up by the audio. I had Taylor Swift playing in the background, but fortunately or unfortunately, it wasn't picked up. I mean, I think we've kind of picked up on some of the important pieces, and I know time is of the essence, so I just wanted to point out that, special thanks, there was involvement. The attorneys are folks in the New York Attorney General's Office of Mental Hygiene Legal Services, and were kind enough to offer their time. I'm also happy to share references, and I appreciate your time and attention. If you have other questions, feel free to come up and talk to us afterwards, so thank you. Thank you.

court testimony

psychiatrists

civil settings

confidentiality

privilege

civil commitment

right to refuse treatment

preparation

jurisdiction-specific

mock testimony

professionalism

attorney relationships