Residency training in psychiatry, as in other medical specialties previously based on an apprenticeship model, is undergoing dynamic change. This change is necessary to meet societal expectations and community’s changing clinical needs (1–3). Modernization in medical practice and the role of polity in vocational training were instrumental in the development of current competency-based outcomes (4). These competencies inform the various educational methods, evaluation, and accreditation standards in training. Methods of training, when sufficiently developed, introduced early and effectively evaluated, can provide additional benefits in competencies as well as better care for patients (2).
There are different ways to expose psychiatric residents to law-related materials, including didactic training (5), problem-based training (6), mock trial experience for residents, taking a law course during the psychiatric residency, and residents’ involvement in a law curriculum (7). Reported benefits are improved comfort and knowledge (7). It is unlikely that long-lasting attitudinal change and interprofessional learning can thrive in such brief encounters between two professions known to have different origin and pedagogical orientation (8, 9). A change in approach to instruction and a protracted period of in-vivo collaborative learning (6, 10) are highly desirable. Collaborative methods of education should contribute to enhancing the core competencies of the trainee.
Changes in mental health care delivery, especially deinstitutionalization, over the last five to six decades have brought law and psychiatry closer together. The practices of the legal and psychiatric professions are different in conceptualization, procedures, and execution. This difference may be rooted in historical trajectories or differential methods of instruction. The former can inform our understanding of the differences between law and psychiatry. However, to unify the goals of the two professions, changes in the method of instruction are required. Such changes can produce attitudinal adjustment toward each other, from which will flow benefits including understanding, respect, communication, and collaboration. These attributes are essential competencies, along with professionalism, advocacy, and managerial skills that a psychiatrist, resident, or expert, is expected to have (3). They parallel the competencies of the Canadian Medical Education Directives for Specialists (CANMEDS).
Successful educational outcomes arising from interprofessional education (IPE) competencies such as collaboration and communication (11) form the basis for the seminar series involving Law and Psychiatry trainees. In IPE, these enhanced competencies lead to better understanding of each other’s professions (12, 13). Consequently, we note improved communication and increased trust among the various professionals involved. For example, collaboration, advocacy, and communication among surgical trainees were identified as essential competencies for positive outcomes (4). If similar competencies are enhanced by the change in knowledge, attitudes, trust, and communication between lawyers and psychiatrists, similar benefits should be expected. Such benefits are invaluable to the court system and other interfaces of law and psychiatry. An even better approach may be introducing such IPE practices early enough among protégées of the professions of law and psychiatry.
In this article, we seek to describe an innovative interprofessional law and psychiatry seminar reintroduced in 2005 at the University of Saskatchewan, Canada, as the embodiment of the pedagogical principles of communication and collaboration. We outline here the principles of the teaching methods, experiential involvement, and applicability in enhancing the competencies subscribed to by CANMEDS guidelines.
Rationale for the Seminar
The conceptualization of the law and psychiatry seminar is based on the principles of IPE involving psychiatric residents and law students as interprofessional participants. It seeks to build on the benefits of the interaction between the two, using case-based learning, modeling, and pedagogical perspective-change to promote CANMEDS competencies (6, 14–16), foster social responsibility, and quash preconceived boundaries (17, 18). Using relevant topics to both law and psychiatry, the seminar is based on combining various teaching methods to facilitate critical reasoning and decision-making within a system-based educational approach (19). The outcomes of patient-centered psycho-legal services, comfortably accommodating each other’s perspective and improved cognitive and attitudinal perception featured strongly in the development of the seminar.
The topics included in the seminar were chosen with the perspective of previous instructors, who first introduced the seminar to the University of Saskatchewan in 1976. The seminar ran for 15 years and was followed by a 10-year hiatus. The current version of the seminar came about after completing an independent, comprehensive search of contentious and contemporary topics, and consultation with North American psychiatric educators offering similar joint-education models (7). The topics are divided into three categories, including criminal (e.g., fitness to stand trial, criminal responsibility, and risk assessments of dangerousness), civil (testamentary capacity, contractual capacity, and involuntary hospitalization) and others (intersection of fetal alcohol spectrum disorder [FASD] and the law, tribunal function and composition, expert-testimony skills, and specific landmark cases). We have tried to keep the categories at a ratio of 5:3:2, notwithstanding minor modifications. The relevance and authenticity of the topics are supported by seven years of feedback comments from seminar participants and professionals and published analysis of the topics (8), as well as local importance of a topic like medico-legal implications of FASD and research interests of the instructors (MM and GL) (8, 20).
The teaching method of the seminar incorporates the principles of interdisciplinary work, case-based experiential learning, and socratic and a protracted interaction. Enhancing perspective-taking, communication, understanding, and correction of myths are critical components of the seminars (11, 13). Through case-based learning on real-life patients interviewed in the joint sessions, participants respect and learn from each other’s perspectives (21). Incorporating these tenets into the interprofessional context of the seminar is thought to enhance the concept of looking beyond each other’s borders (6, 15). Evaluations of similar principles have been reported as providing the cornerstone of appropriate legal and medical education (10, 15).
The psychiatric residents undertake 3 to 4 didactic sessions alone, facilitated by a forensic psychiatrist (MM). Similar sessions are held with the law students, facilitated by the law professor (GL), usually assisted by the forensic psychiatrist (MM). These separate preparatory sessions are differently aimed at improving the knowledge base and providing basic understanding of law to psychiatrists and vice versa.
Interactive joint sessions held with an average of 15 senior law students and 3 to 9 psychiatric residents provide experiential learning. After interviewing a patient, instructors introduce the relevant case laws in light of psychiatric opinion and lead discussions using socratic questioning in a nonjudgmental atmosphere, which fosters understanding and makes for lively discussion. Such cross-pollination of ideas is at the core of knowledge-acquisition.
The law students choose a topic of interest on which to write a major paper. Some of these papers have subsequently been published in peer-reviewed journals (22, 23). The topics, commonly on issues raised in the seminars, are as varied as are students’ interests.
Additional experiential learning opportunities include visits to the secure forensic hospitals, interactions with post-licensure practitioners, and invited guests to the seminars. In Canada, each province has a multidisciplinary Not-Criminally-Responsible Review Board (NCRRB). The board supervises the disposition and care of those adjudicated as not criminally responsible on account of a mental disorder. Seminar participants are encouraged to attend the NCRRB hearing. The students are accorded easy and unrestricted access to the instructors and scholarly materials to help solidify the experience.
In the law school, the seminar has proved very popular among law students, with an annual waiting list being maintained. The law students have a choice to “ballot” for the course, which, as noted, is limited to 15 students. This may select very interested students. The residents are not accorded the same choice, as the seminars are embedded into the rotational yearly schedules for the weekly academic program in psychiatry, in the college of medicine.
The psychiatric residents run a busy clinical load, along with the seminar participation. Although this helps to incorporate the daily clinical experience into the clinical/academic setting of the seminars, it does lead to some absences from the seminar. Attendance is not recorded for the residents, and any resident on overnight clinical duty is contractually excused from seminar sessions the following day. As such, full participation at extra-seminar experiential activities can be hampered by the schedules fixed beyond the seminars. Differential evaluations, predetermined by the two colleges, create a layer of unclear knowledge-acquisition, as no immediate examinations are conducted.
Obtaining consenting patients whose cases align with the seminar topic, sudden change in consent to participate, unanticipated and laborious institution-specific obstacles relating to clearance requirement all add a practical layer of challenge.
To resolve the patient-access issue, we propose to develop audiovisual recordings of volunteer patients representing selected criminal, civil, and other topics. When edited appropriately, less vicarious traumatization will be expected. No doubt, we will lose the advantage of the fortuitous, unexpected, and in-vivo life issues or the direct questioning by the other seminar participants, when using video recording. However these are useful, especially when no patient fits the topic for discussion or when a patient declines consent to participate a few minutes before the start of the seminar.
Anecdotally, instructors assert that both individual advancement and scholarly activities have been enhanced through the seminars. This is evidenced by ongoing joint publications and other collaborative scholarly activities, which recently culminated in securing a university scholarly award (Merlis Belsher Family Endowment Fund in Forensic Education) of $2,000 offered to the participants of the seminar for joint law and psychiatry educational project (8, 24). Such collaborative initiatives between a lawyer and a psychiatrist have been applauded by other authors (12, 14, 25). Formal evaluations completed by the participants show that they find the seminars invaluable to their professional careers (26). Compared with a non-interprofessional seminar, participants’ cognitive and attitudinal perceptions were more significantly and positively affected in the law-and-psychiatry participants (26). The psychiatric residents indicate on feedback forms that the CANMEDs guidelines achieve fulfillment through the processes and practices of the seminar (26).
Publications on various topics similar to those of the law-and-psychiatry seminars affect the law and practice of medico-legal psychiatry (15). The community treatment order (CTO) in Saskatchewan and in general has been criticized on a number of fronts (18). The post-seminar paper authored by the seminar participant A.D. Wandzura (22) gives a balanced approach to the efficient application of the CTO. The paper could potentially influence changes in mental health legislation. A similarly influential article on PTSD in the military is also a result of the seminars (23).
After the positive evaluations of the participants (26), we hope to examine the real-life impact of participants. We plan to examine the influence of the seminar in the choice of career. Whether seminar participants work collaboratively and communicate more efficiently ‘in the field’ is of value to the civil and criminal justice systems (CJS). This is an outcome we are interested in studying, to add more than anecdotal evidence (25). Applying a specific CANMED evaluation tool will add to the goal realization of the seminar. Finding out how the seminar has contributed to understanding and competence in professional and interprofessional context could serve as a rationale to advance this unique method of instruction at this time of subspecialization in psychiatry. Improved competencies of communication, collaboration, and understanding stand to improve the legal and psychiatric outcomes of the accused or the offender.
Similar to IPE principles, the law-and-psychiatry seminar is patient-centered, but expands the role of law in healthcare (27). The subspecialization of forensic psychiatry recognizes an increasing number of patients in the CJS (28). Competencies required for post-licensure practice inform training models for general as well as specialty psychiatry. The Accreditation Council for Graduate Medical Education (ACGME) and the Royal College of Physicians and Surgeons of Canada (RCPSC) combine the current pedagogical theories and the expected competence to direct accreditation of training programs. The ACGME competencies, communication skills, collaboration or systems-based learning, practice-based learning, and improvement, are examples of these (29). It requires training programs to demonstrate how these competencies will be achieved by their trainees.
In line with CANMEDS roles, the didactic aspect of the seminars lays the foundation for knowledge-acquisition where law and psychiatry interface. Medical expertise and knowledge are augmented as residents hear of new situations, are confronted by the “lay” inquiries of the law students, and respond by researching topics not regularly broached in psychiatry-only seminars. Mastery of the CANMEDS roles is said to occur through vicarious learning, as psychiatric residents think through cases, observe instructors’ expertise, and interact with others (1, 16).
In the communication role, experts need to adjust their style of conversing to fit the audience. Residents using technical terms are “literarily” forced to learn the art of modulating their language in the interactive phase of the seminars. Such adaptation is not only important in listening to patients and families, it is also advisable for communication competence acquisition (16). This skill is improved as residents relay technical information about risk-assessment, diagnosis, and investigations in response to semantic inquiry of regularly-used psychiatric terms and jargons by the law students. Networking is encouraged, and, through such interactions, residents become more familiar with the roles of lawyers. Expected outcomes and evaluations of the seminar suggest that those role-definitions are strong anchor-points for respect and understanding. Collaboration flows out of this new partnership and teamwork.
Most law students approach the detention of vulnerable persons, for instance mentally-disordered offenders, with a liberal stance. This prompts a challenge to the psychiatric residents, who cautiously tend toward restriction of liberty. The interchange of reasons and ideas on a real clinical case and the cross-pollination of ideas in joint sessions amplify the residents’ role as health advocates for the vulnerable. Residents become knowledgeable about the resources in the CJS and how the court diversion schemes strive to manage resources better. Proficiency in the CANMEDS roles of health advocate and manager can be enhanced.
Truth-seeking and the guiding principles of expert evidence promote scholarly investigation, scrutiny, and rigor. Lay and inquisitive law students learn in this mode and thus promote the residents’ use of research principles and results to answer questions. Doing these in the inter-professional setting, with well-defined, patient-oriented goals is fertile ground for both collaborative and scholarly endeavors. Confidentiality, inequality, and ethical conduct are discussed in relation to the Canadian Charter of Rights and Freedoms (Part I of the Constitution Act, 1982, being Schedule B to the Canada Act 1982 [U.K.], 1982, c. 11) (30). These serve to increase residents’ acumen in the sphere of professionalism. The seminars on litigation of psychiatrists and the right to refuse treatment are the most animated ones. Thus, ethics and practice principles, such as duty to warn, autonomy, and privacy, assist psychiatric residents in incorporating the essentials of professionalism, even if the prevention of litigation is the precursor.
There is sufficient justification to include the legal profession in IPE as well as being part of the healthcare team. More relevantly, the interaction between law and psychiatry serves to foster stronger collaboration and acquisition of CANMEDs competencies. Conceptualizing psychiatric practice as essentially interprofessional should inform the interprofessional educational methods used for instruction. The law-and-psychiatry seminar provides that interaction. Interaction is a key IPE feature in knowledge-acquisition, and in dismantling myths and misunderstanding. By crafting appropriate communication and developing collaborative respect in a positive learning environment, each profession’s attitude toward the other undergoes change and helps each develop greater competencies. Scheduling between the two colleges poses a major challenge, but the results of deconstructing the stereotypes projected in the two professions is worth the effort. Acquisition of competencies and improvement of interprofessional relationships may not only be evident in this pre-licensure setting; they should translate into post-licensure practice for the benefit of the patient and society at large.
The authors thank Associate Professor Harold Bursztajn, Co-Director, Program in Psychiatry and the Law of Harvard Medical School, at the Massachusetts Mental Health Center, Boston, for the insights and review of this article.