Psychiatr News June 16, 2006
Volume 41, Number 12, page 1
© 2006 American Psychiatric Association
Assembly, Board Pass Statement On Detainee Interrogations
Ken Hausman
A wide-ranging agenda finds the APA Assembly tackling issues related to
several aspects of medication prescribing, postdisaster psychiatric care, and
a controversial APA position statement on the limits of psychiatrists'
participation in detainee interrogations.
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Former APA President Paul Appelbaum, M.D., urges the Assembly to endorse
an APA position statement on psychiatric participation in detainee
interrogations, while Joseph Berger, M.D., of the Ontario District Branch
waits his turn to speak. See article below. David Hathcox
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After an extended and often impassioned debate at its May meeting in
Toronto, the Assembly passed an APA position statement dealing with
psychiatrists' participation in interrogation of detainees held in either
military or civilian detention. The Board of Trustees endorsed the position
statement at its meeting later that day, so it is now official APA policy.
The statement also reiterates APA's position that psychiatrists
"should not participate in, or otherwise assist or facilitate, the
commission of torture of any person" and should report any instances of
torture they learn have occurred or are being planned (see page 10). There was
no disagreement among Board or Assembly members about this part of the
position statement.
The Board had endorsed a statement addressing torture and interrogations at
its October 2005 meeting, but in November 2005 Assembly members approved a
statement whose wording differed on key points related to the interrogation
limits, with a majority of the Assembly favoring less-restrictive limits on
psychiatrists' involvement in interrogations. One major difference was that
the while the Board's statement said that psychiatrists should not take part
in "interrogation of persons held in custody by military or civilian
investigative or law-enforcement authorities....," the Assembly added
wording to ban participation only in "coercive"
interrogations.
The Board, however, reaffirmed its version in December 2005, prompting APA
President Steven Sharfstein, M.D., to appoint a small work group to develop
wording on which the two governing bodies were likely to agree.
The revised wording was presented to the Assembly in May. With 66.4 percent
of votes in favor, 30.2 percent opposed, and 3.4 percent abstaining, the
Assembly endorsed the statement with the following wording:
"No psychiatrist should participate directly in the interrogation of
persons held in custody by military or civilian investigative or law
enforcement authorities, whether in the United States or elsewhere. Direct
participation includes being present in the interrogation room, asking or
suggesting questions, or advising authorities on the use of specific
techniques of interrogation with particular detainees. However, psychiatrists
may provide training to military or civilian investigative or law enforcement
personnel on recognizing and responding to persons with mental illnesses, on
the possible medical and psychological effects of particular techniques and
conditions of interrogation, and on other areas within their professional
expertise."
One noncontroversial part of the statement emphasized that psychiatrists
should not disclose any part of a medical record "or any information
derived from the treatment relationship" to people conducting detainee
interrogations.
During the Assembly debate last month, several members, including Thomas
Grieger, M.D., representative of the Society of Uniformed Services
Psychiatrists (an APA district branch for members in the military), urged the
Assembly to delete part of a sentence that described what "direct
participation" in interrogations entails, including being present during
the interview and "advising authorities on the use of specific
techniques of interrogation." Grieger, who was a member of the work
group appointed by Sharfstein, was concerned that the wording provides
unnecessary restrictions on psychiatrists' ability to advise officials on
noncoercive interviewing techniques that could be effective in eliciting
information from certain detainees. Greiger told Psychiatric News
that he sees a legitimate role for psychiatrists in "suggesting
approaches to conducting interviews." Among the examples he cited were
"using a different interviewer, asking more open-ended questions, [and]
opening sessions with periods of rapport building." He likened such
activities to what forensic psychiatrists do and noted that their goal is
mainly to identify "other potentially dangerous individuals who are not
in custody...."
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Barry Perlman, M.D., who has been the Area 2 representative to the
Assembly for the last four years, is the first recipient of the Ronald A.
Shellow Award. The award is named for a former speaker and longtime member of
the Assembly who died in 2004. Perlman was honored for his contributions to
the Assembly during his 18 years as a delegate. David Hathcox
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Agreeing with Grieger was Joseph Berger, M.D., a representative of the
Ontario District Branch, who indicated that he has two daughters and six
grandchildren living in Israel, where the threat of terrorism in constant. He
insisted that he would want psychiatrists to be able "to do anything if
it prevents terrorists from killing innocent people."
Former APA President Paul Appelbaum, M.D., chair of the joint
Board-Assembly work group, pointed out that psychiatrists in forensic and
other roles often perform nonclinical tasks, but the difference between those
and interrogating detainees is that in the former instances the person being
questioned understands the psychiatrist's role, and the interaction is neither
coercive nor deceptive. The purpose of forensic evaluations is "to
assess the person's mental state."
"Interrogations, even when conducted legally, are inherently coercive
and deceptive," Appelbaum said in a memo to Assembly Speaker Joseph
Rubin. They are "coercive because a detainee who wanted to talk would
not have to be interrogated; deceptive because interrogators are trained to
mislead suspects and are supported by the law in doing so. The purpose of the
interrogation is to pressure or trick the detainee into revealing information
the detainee does not want to disclose."
Evan Eyler, M.D., the Area 1 ECP representative, urged her colleagues to
support the revised wording, saying that while the wording may not seem ideal
to some members of the Assembly, APA should not delay even further in adopting
an official position on this critical topic. "I am most proud of APA
when it tackles difficult issues," Eyler stated.
In his address to the Assembly's opening session, Sharfstein stressed that
"our ethics as physicians require us to obtain consent" before
meeting with someone in a professional capacity. He added that "policing
functions belong to the state, not to physicians."
In other actions the Assembly voted to
- Urge the editors of the American Journal of Psychiatry and
other APA journals and books "to publish full disclosure information re
potential conflicts of interest of contributors of manuscripts" as
is already done in such journals as JAMA and New England Journal
of Medicine.
- Support a proposal calling on psychiatrists and others to stop using an
anti-social personality disorder diagnosis as grounds to recommend involuntary
commitment of someone to a psychiatric hospital. This was a response to
the growing trend in the United States to apply this diagnosis to violent
sexual offenders as a way to keep them confined after they complete their
prison sentence.
- Ask APA councils that deal with education and child psychiatry issues to
explore a model that would open a new route into child and adolescent
psychiatry training. This proposal attempts to address the critical
shortage in the number of child and adolescent psychiatrists by developing a
training program that requires 18 months of general psychiatry training with
an additional 18 months of training in child and adolescent psychiatry. The
Assembly wanted the program to be open to board-eligible or board-certified
pediatricians.
- Have APA examine diagnostic and therapeutic factors that arise after
large-scale disasters. The paper's intent was to "facilitate
development and implementation of treatment interventions" targeted to
the psychiatric sequelae of the trauma that can follow a major disaster.
"Therapeutic interventions need to be developed that are appropriate for
use after large-scale [traumatic] events, in environments that cannot easily
or rapidly return to normal," the paper explains.
- Urge APA to discuss with the Federal Emergency Management Agency and the
Substance Abuse and Mental Health Services Administration a proposal to have
the agencies "provide financial support for
short-term/crisis-intervention and long-term psychiatric treatment"
following natural and man-made disasters. While a federal law earmarks
funds for short-term postdisaster psychiatric interventions, the paper's
authors noted that disaster victims who develop PTSD, anxiety disorders, or
major depression may require mental health care for months or years after the
disaster.
- Have APA compile and disseminate information "on the practices of
nonlicensed personnel who administer medication" and on the
standards each state requires for those who administer prescription drugs.
- Develop a strategy to address Food and Drug Administration approval of
psychiatric drugs according to DSM criteria only rather than also
approving new drugs "for signs and symptoms of
psychopathology" as direct indications for use of the particular
drug. "In clinical practice," the paper pointed out,
"prescribing often targets signs or symptoms, not a diagnostic entity
per se.... Psychiatrists often prescribe `off-label' for a variety of signs
and symptoms that are not necessarily associated with a specific diagnosis for
which medications may be indicated."
- Approve an APA position statement on racism and racial discrimination
and their impact on mental health. The statement, developed by Committee
of Black Psychiatrists, says that "America's ever-increasing
multiculturalism requires that traditional definitions of racism be expanded
to include not only discriminatory attitudes and actions that take place
between systemically advantaged groups against their targets, but also
interactions between and among victimized groups that buttress the
perpetuation of racist ideology." The statement requires Board approval
before it can become official APA policy.
- Endorse less-frequent use of executive sessions by the Board of
Trustees. The purpose of the proposal was to "affirm the principle
that every meeting of every component of APA is open to any member of
APA." Among the suggestions in the paper were that the Board hold closed
sessions only after a notice to do so is posted on the APA Web site, disclose
the rationale for holding a closed session, ban closed sessions that discuss
APA governance issues, and limit such sessions "to the minimum time
necessary to discuss the specific confidential issues."
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Assembly member and SAMHSA senior medical advisor Anita Everett, M.D.
(center), stands with the four Iraqi psychiatrists she invited to attend the
Assembly and annual meeting in Toronto. They are (from left) Muhamed Lafta,
M.D., Maiia Abas, M.D., Ali Obeed, M.D., and Waeel Hikmit, M.D. David
Hathcox
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The Assembly also heard a discussion by AMA Trustee Ronald Davis, M.D., of
issues on that organization's health care advocacy agenda, most of which
parallel those of APA. The AMA's top legislative priority, he said, is medical
liability reform. Also high on the agenda are reforming the Medicare physician
payment system so it reflects practice costs and inflation, expanding health
care coverage for the uninsured and increasing access to care, and
improvements in patient safety and quality of care. Davis is a candidate for
president-elect of the AMA.
A summary of actions from the May Assembly meeting is posted in the
Members Corner section of APA's Web site at
<www.psych.org/members.index.cfm>
under "Assembly." 
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