The Summer Institute is a program that teaches the basics of behavioral, psychiatric, and mental health ethics and provides tools to deal with moral problems in clinical practice. This year the curriculum includes instruction on the basics of bioethics, behavioral health bioethics, the ethics of the recovery movement and parity, and Ethical Issues for Psychiatrists Working with the Legal System. This year we will be putting a great emphasis on a workshop on moral decision-making, and will dedicate the entire second day of the seminar for case vignettes analysis, and learning to implement principles of ethical decision-making.

The Summer Institute will be held on July 15 – 16, 2010, at the Bodek Lounge, Houston Hall, The University of Pennsylvania, 3417 Spruce Street, Philadelphia, PA, 19104.

Our instructors are experts from the University of Pennsylvania’s Center for Bioethics, Department of Psychiatry, and the School of Social Policy and Practice. The Summer Institute is intended for an audience of behavioral health practitioners from a variety of practice disciplines and venues in the greater Philadelphia area and beyond.

There is a $50 registration fee to attend this program, payable by CHECKS ONLY, Cash will NOT be accepted. Please make all checks payable to: “Trustees of the University of Pennsylvania.” Our expectation is that you will attend the full day-and-a-half program. Upon completion of the program, we will issue you a certificate of participation. Psychology and Social Work Continuing Education credits will be offered with an additional $20 processing fee (see further information attached here).

Space is limited. If you are interested, please fill out the Application Form by Monday, June 28th and return with your registration fee by mail to: The ScattergoodEthics Program, Center for Bioethics, 3401 Market Street, Suite 320, Philadelphia, PA, 19104, by fax to: 215.573.3036 or by email to: spaebh@mail.med.upenn.edu. Please note that you will be notified of your application status by Wednesday, June 30th, 2010.

Cancellation and Refund Policy
The Scattergood Program for the Applied Ethics of Behavioral Health, reserves the right to cancel or postpone any course due to any unforeseen circumstances. In the event of cancellation or postponement, The Scattergood Program for the Applied Ethics of Behavioral Health will refund any registration fee but it is not responsible for any related costs, charges, or any expenses to participants, including cancellation costs incurred by airlines/travel agencies. In order to process refunds for course withdrawals, written notification of cancellation must be received two weeks prior to the lecture (subject to a service fee). No refunds will be granted thereafter.

If you have any questions please contact the Program Coordinator Hila Rimon-Greenspan at hila@mail.med.upenn.edu or 215.573.8105.

I can imagine a television ad for the following:

Feel empty, self-destructive, overly angry, and afraid of abandonment? Do you have volatile relationships? Talk to your doctor; you may have Borderline Personality Disorder (BPD).

But it hardly needs people to come forth and suggest that this might be their diagnosis—it’s a popular diagnosis in the DSMs. And it’s especially seen as applicable to women, at least in the United States. Women are far more likely to be diagnosed with BPD than are men; in fact, the DSM-IV-TR reports that 75% of those diagnosed with BPD are women. Mary Ann Jimenez, who has analyzed the psychiatric literature for its evolving thoughts on women, argues that new diagnostic categories continue to reflect a psychiatric orthodoxy where dominant values subjugate women into gender-role conformity. In fact, the picture of the borderline patient as a manipulative, demanding, aggressive, and angry woman is a persistent theme since the diagnosis was included in the DSMs in the early 1980s.

I began taking an interest in the diagnosis and treatment of BPD when I worked as a crisis counselor and would be warned by other workers to avoid so-and-so because “she’s a borderline.” The pejorative tone was hard to miss. Since then, I have taken it upon myself to investigate BPD both in terms of its conceptual features and its bearing on psychiatric ethics.

A personality disorder is considered a structural organization of the personality that is exhibited by a dysfunctional pattern of behavior. A personality disorder is stable over time and, because it is a structural defect in internal organization, it is considered to be inflexible. The inner experience of a personality disorder, along with its outward manifestations, causes the person distress or impairment in functioning.

The borderline personality is considered a severe personality disorder. It is characterized by identity disturbance, feelings of chronic emptiness, impulsive or self-destructive behavior, and unstable intense interpersonal relationships. Other key characteristics include a loss of a sense of self, separate from others, contradictory self-images that are experienced as an inner void and an abundance of mismanaged anger. A significant percentage of the population in the Western world is diagnosed with this personality disorder: 10% of the patients seen in outpatient mental health facilities and 20% of those seen as psychiatric inpatients are diagnosed with BPD. This is a population at risk; as I noted above, patients diagnosed with BPD have a reputation for being extremely difficult to work with. Indeed, clinicians often self-report attitudes of blame, rejection, and a lack of empathy for BPD patients. John Gunderson reports that the most common countertransference feeling of clinicians toward their BPD patients is hate. These facts worry me.

The criteria for diagnosis of BPD raise difficult philosophical and ethical questions. Cultural factors and social norms play a significant role in all of our behaviors and how those behaviors are interpreted, and the diagnosis and treatment of patients with symptoms of BPD are no exception. In fact, the construct of BPD arguably obscures the clinical picture of patients given this diagnosis instead of clarifying it. It is possible that some of our deeply held ideas about the self, identity, anger, and so on lead us astray when we interact with others in distress, attempt to interpret their behavior, and respond to their communications. It is also possible that some of the concepts that we rely upon (such as manipulativity, a label that is ubiquitous in clinical literature) are too vague to serve as a basis of ethically responsive and therapeutically constructive clinical work.

A central task of a philosopher of psychiatry is to press questions such as to what extent the symptoms of the classificatory disorder BPD represent pathology or, instead, cultural disapproval or social disvalue – what is often called the ‘mad or bad’ problem. This problem points to a difficulty in determining whether a given diagnosis is genuinely psychiatric in character or is indicative of embedded moral values that do not belong to psychiatric judgment. This task is crucially important because our attitudes, beliefs, perceptions, and judgments provide the conceptual schemas through which we interpret others; if our conceptual schemas are distorted or faulty, our understanding of others is also likely to be flawed. As I stated above, analysis is needed because the diagnosis and treatment of BPD rest on a number of concepts that are not clearly understood. Particularly interesting are the issues of identity disturbance, anger, interpersonal difficulties, impulsivity, self-injury, and manipulativity, all of which are under-analyzed from a philosophical perspective in relation to BPD. A rigorous examination of these issues will provide valuable insight.

In the clinical context, good theory and practice for clinicians must rest on conceptual and perceptual frameworks that conduce to patient healing – or at least managing of distress. In particular, ethical dimensions of therapy are likely to become tangled and skewed without philosophical clarity of the underlying concepts. The first part of this project, therefore, is to provide a rich and nuanced philosophical analysis of some of the central concepts underlying BPD. My ultimate aim of this exploration is to enhance clinicians’ ability to treat patients who exhibit symptoms of BPD in an ethical manner. To that end, I draw on a moral framework of virtue ethics, emphasizing three virtues that I take to be especially relevant to working with patients diagnosed with BPD: trustworthiness, what I call “the virtue of giving uptake,” and empathy.

Dr.  Potter is an Associate Professor in the Department of Philosophy at the University of Louisville.  Her book, Mapping the Edges and the In-between: A Critical Analysis of Borderline Personality Disorder, came out in September 2009 through Oxford University Press in its series on International Perspectives on Philosophy and Psychiatry.

Other relevant publications can be found in:
Current Opinion in Psychiatry
Journal of Personality Disorders
Philosophy, Psychiatry, and Psychology
Harvard Review of Psychiatry

The Department of Philosophy at King's College London and the London Institute of Psychiatry invite applicants for their joint program, a MSc in Philosophy of Mental Disorder.  This is a one-year program, or two years part-time. 

The course provides a unique opportunity to examine issues arising at the intersection of philosophy and the theory of mental disorder, and more generally to examine the philosophical and conceptual problems raised by the study of the human mind.  For more information, see the program's website.

The application deadline is February 1, 2010.  The application procedure can be found here.

In recent years, scholars have begun to consider the application of alternative constructs as a means of illuminating underlying mental disability law issues. Of special contemporaneous interest is the insight of ``therapeutic jurisprudence'' as a model by which to assess the ultimate impact of case law and legislation affecting persons with mental disabilities.

"Therapeutic jurisprudence"  --  originally conceived of by Profs. David Wexler and Bruce Winick¹ -- studies the role of the law as a therapeutic agent. This perspective recognizes that substantive rules, legal procedures and lawyers' roles may have either therapeutic or antitherapeutic consequences, and questions whether such rules, procedures, and roles can or should be reshaped so as to enhance their therapeutic potential, while not subordinating due process principles.

Thus, authors have recently considered the therapeutic jurisprudential issues inherent in such mental disability law issues as the involuntary civil commitment process, the right to treatment, the insanity acquittee conditional release hearing, juror decisionmaking in malpractice litigation, competency to consent to treatment, standards of psychotherapeutic tort liability, the impact of scientific discovery on substantive criminal law doctrine, the plea stage of sex offender cases, the substantive insanity defense, substantive tort law standards, competency to be executed, health care delivery, the right to refuse medication, the role of counsel at refusal-of-medication hearings, the duty to rescue the vulnerable, the mandated reporting of child abuse, correctional law, forensic testimonial issues, the federal sentencing guidelines, the right to voluntarily receive mental health services in community settings, competency to stand trial, court clinic systems, the interplay between mental disability and the Americans with Disabilities Act, incompetency labeling, sexual predator statutes, the psychotherapist-patient privilege, ``repressed memory'' litigation, the relationship between continued mental illness and hospital retention following an insanity acquittal, and the relationship between voluntary and involuntary commitment.

One of the most important controversies that has emerged from the first generation of therapeutic jurisprudence scholarship is the question of whether, as a result of therapeutic jurisprudence, mental disability law will be more "therapeutic" or more "jurisprudential." Some of the most important criticism of therapeutic jurisprudence flows from what is perceived as its willingness to subordinate civil libertarian concerns to therapeutic interests; indeed, some of the enthusiasm that therapeutic jurisprudence has engendered may flow implicitly from the same assumption. On the other hand, Wexler and Winick recognize explicitly that therapeutic jurisprudence cannot and must not trump civil libertarian interests. Other therapeutic jurisprudence "fellow travelers" write from what is clearly a civil rights-expanding perspective.

A therapeutic jurisprudence perspective on the rights of institutionalized mentally disabled persons (and persons subject to the civil commitment process) may help determine both whether therapeutic jurisprudence truly is compatible with a civil rights perspective, and whether, if it is, the courts should look more closely to therapeutic jurisprudence as a source for legal rights. By way of example, Lessard v. Schmidt² was the forerunner of a generation of involuntary civil commitment cases, all making some sort of finding that there must be a ``real and present danger of doing significant harm'' to show dangerousness sufficient to support such a commitment. The cases were not unanimous, e.g., as to the need for an actual overt act. Yet, they nevertheless reflected a clear "[break] with a century-old tradition that 'civil' commitment of the mentally ill, whether for their own good or that of society, demands fewer procedural protections than does incarceration for punishment."³  Nearly thirty years after the case was decided, Lessard remains the high-water mark in 'dangerousness' law.

Much of the Lessard court's opinion appears to have been based on a therapeutic jurisprudence perspective. In evaluating Wisconsin's commitment statutes, the court chose to look at the effects of civil commitment upon those committed. The court considered evidence that lengthy hospitalization, particularly involuntary hospitalization, may greatly increase the symptoms of mental illness and make adjustment to society more difficult.

Additionally, the court considered the substantial loss of substantive civil rights suffered by persons adjudicated mentally ill and unable to care for themselves or in need of hospitalization. On the other hand, the court gave little credence to the state's contention that notice and an evidentiary hearing within the first few days of confinement may be psychologically harmful to the patient. In fact, the Lessard court contains at least one explanatory passage that seems to qualify as one of the true judicial forerunners of therapeutic jurisprudence:

Although Penn has long been a leader in neuroethics research and scholarship, the recent launch of the Center for Neuroscience and Society is an exciting and important development for the field.  The Center brings together faculty and researchers from departments across the University of Pennsylvania, including the Schools of Medicine; Law; Engineering and Applied Science; and Arts and Sciences, and partners with equally interdisciplinary academic organizations, including the ScattergoodEthics Program.  Under the stewardship of Academic Director Martha Farah, PhD; Executive Director Joe Powers, PhD; and Associate Directors Anjan Chatterjee, MD and Stephen Morse, JD, PhD, the Center is poised to expand Penn's neuroethics program significantly.

The Center for Neuroscience and Society will focus on bringing together scholars to advance the field of neuroethics through lecture series, visiting scholars and educational programming.  Neuroscience and neuro-technologies will continue to advance, impacting virtually every sphere of our personal, professional and social lives.  The Center for Neuroscience and Society and its partners, including ScattergoodEthics, look forward to advancing awareness of neuroethical issues and encouraging the development of sound practices surrounding the implementation of neuroscientific technology.

It was in the spring of my freshman year at the University of Pennsylvania that I was reluctantly and unexpectedly introduced to the field of college mental health.  My older brother, Brian - an accomplished and popular student at another Ivy League university - had just shattered my world and taken his own life.

From that experience was born Active Minds.  First started as a student group on my campus at the University of Pennsylvania, Active Minds, Inc. is now a 501(c)3 organization headquartered in Washington, DC with campus-based chapters across North America.  To date, we have helped develop and support over 190 chapters on campuses (primarily college, but a few high schools as well), in 39 states plus Washington, DC and Canada.  The mission of each Active Minds chapter is to utilize peer advocacy – the student voice – to raise awareness about issues of mental health, signs and symptoms of mental illnesses, and available resources for seeking help on college campuses.  By increasing the dialogue around mental health issues, Active Minds is breaking the silence that surrounds such issues to encourage early help seeking and prevent tragedies.

Across the board, college counseling centers in recent years have reported an increased number of students seeking their services.  And the majority of those centers are reporting that students are presenting with more serious concerns than ever before.  What was once a place that helped students navigate the woes of broken relationships or answer questions about potential career paths, has in recent years become intensive mental health clinics with social workers, clinical psychologists, and psychiatrists on staff.  What is causing this increase?  Should we be concerned?  How should campuses respond?

I would argue that this increase is actually a sign of positive change, and campuses need to adapt their policies to match the changing needs of their students.  Access to mental health care, while still not perfect, has significantly improved in recent history.  With the passage of the Mental Health Parity Act in 2008, insurance companies are now required to cover mental health care at the same level as they cover physical health care, helping alleviate the financial barriers that would often prevent individuals from getting the care they need.  As well, there has also been a recent increase in the number of stigma-reduction campaigns, like Active Minds, that help encourage those individuals in need of help to seek it.  

In addition, with the increased understanding of the breadth of mental health issues individuals can face has come the realization of the impact that these issues can have on children and young adults.  Such issues are not limited to affecting adults, as was once believed.  As a result, children and young adults in need are getting help and treatment while still in grade and high school.  This is allowing them to live more fulfilling and productive childhoods and, for many, giving them the chance to even go to college whereas they wouldn’t have been able to ‘cut it’ before.  

It is clear that social factors including increased education, decreased stigma, and mental health parity are helping to remove the barriers to help-seeking in mental health.  This is allowing more students with mental health care needs to come on to college campuses than ever before.  As a result, campuses need to be thinking more strategically and seriously about how they can better support students in need.  Given most universities’ funding structures, it is nearly impossible for most counseling centers to keep up with the reported constant increase in demand.  However, by taking a public health approach to mental health and shifting the onus of responsibility from counseling centers to the whole campus, students’ mental health can be more adequately supported.  Faculty and coaches can be educated to spot symptoms in their students and better understand how to approach students about whom they’re worried; staff and mentors can run wellness-focused programming for all students.  And most importantly, students can and should be brought into the conversation as advocates and liaisons for the student body.  As often the first possible responder, and certainly the main line of defense, students can play an integral role in furthering their own mental health and that of their friends.  

As the mental health needs of students continue to evolve, campuses need to embrace the changes and think outside of the box to ensure that all students can thrive.

Alison K. Malmon is founder and Executive Director of Active Minds, Inc., the only national organization dedicated to utilizing the student voice to raise mental health awareness on college campuses.  In 2000, while a freshman at the University of Pennsylvania, Alison suffered the loss of her only sibling, brother Brian, to suicide.  Just a year later, Alison started what has become an award-winning student-run mental health awareness group on her campus.  Since graduating with honors in psychology and sociology in 2003, Alison has grown that student group into a nonprofit organization with nearly 200 chapters on college campuses throughout North America, with anticipated growth to 300 chapters by 2010.  Each group’s goal is to promote the student voice in educating young adults about mental health and available resources for seeking help.

For her efforts Alison has been named 2007 Washingtonian of the Year by Washingtonian Magazine, Citizen of the Year by the Potomac, Maryland Rotary Club, a Woman of Distinction from American Association of University Women, and received the Tipper Gore Remember the Children Award from Mental Health America.  She has been profiled in the New York Times, CNN, Glamour magazine, and Washington Post.  Alison sits on a number of planning committees and Boards of Directors and, in her spare time, teaches the flying trapeze in Baltimore.

You have 20 years of clinical experience under your belt. You feel that you know your strengths, weaknesses, and limits.  You've come to believe that the therapeutic relationship is the key "medically active ingredient" in treatment.  So, you start to think that  it is the most important thing to  develop, enhance and preserve in your work with patients.  You are treating a new patient who believes that much can be learned from you; not just your knowledge but the way you live your life.  You respond. You share stories about your life:  your marriage, your struggles parenting your child, your experiences in college.  The patient really resonantes.  This encourages you to start sharing more vulnerable stories--episodes that have much in common with the patient's experience.  You find yourself sharing how a professor in college crossed some lines with you, got too close, actually seduced you.  The patient feels your pain, because its similar.  Next session, you get a gift form the patient. It's food. The patient invites you to share the food.   You need no further reflection, after 20 years, than to check in with your own feelings.  It feels right.  Develop the relationship, don't allow the pateint to feel rejection.  You prepare your coffee table to share the repast.   The next session, is a beautful day, you move out to the balcony together and share food again.  Feels right. Next session, another gorgeous day, and the park across the street seems like an inviting therapeutic environment.  So you move the session out there, its like having a class outdoors on a beautiful day in college--no harm done.   The following session, you get up in the morning, see the weather is fine again, know that its a hot day, so that morning you dress in something more comfortable and casual for outdoors. It's slightly  more revealing, but it feels comfortable, and that's important.  Towards the end of that  session, after eating, coffee feels right, so you and the patient swing by the cafe for a cup.   The therapeutic relationship is deepening, the patient is trusting you more and more. You're getting to material than has never been reached before.   You are feeling very effective, the sensation of a senior therapist, at ease in your complex art.  You find yourself looking forward to these sessions.  In fact, you start to make sure that there is nobody else scheduled immediately after this patient's hour, so you can linger a bit longer over coffee.  It helps to move the session to the last one of the day.   You are increasingly aware that you are treating a truly remarkable person, and feel fortunate for the serendipity of being matched up by referral and chance.  Indeed, you feel that your years of experience permit you to try stretching, taking slight extensions of conventional technique--bending technical rules that are really designed more for beginners, to help structure their introductory years in the ill-defined and elusively broad art of therapy.  LIke training wheels, you sense there is a point where typical conventions are oversimplified and even unecessary.  This isn't something you can or even need to talk  about with any colleague.  They probably wouldn't understand.  They have to be here, in this particular   therapeutic relationship, to really get it.  Only you can get it.  It took 20 years, but you're really feeling you are starting to get it. 

And so it goes:   the slow procession of feelings, ratonalizations, and instincts which propel you down a self-determined, well meaning, and increasingly self-deluded path.  You drfit  further and further "off-the-reservation," a satisfying journey which, one day, ends in surprise, when you are being interviewed by the Maryland Board of Physicians about this case.  Where did you go wrong?  Did you ever know you had?

For the last few years, as Chairman of the Clinical Ethics Committee  for Sheppard Pratt Health Systems,  I have been called upon widely to give lectures on topics in Medical Ethics, with a specific focus on ethical issues in mental healthcare. The audiences are almost always social workers and psychologists; rarely, if ever, is there a psychiatrist in the audience.  Why is this?  It turns out that for some years, both of these professions have required not just continuing education credits to renew their licenses to practice, but specifically, 3 credits yearly in ethics.   In contrast to our fellow mental health professionals, though we are required to have yearly credits to renew our licenses as physicians, there are no specific requirements for psychiatrists to take courses in any particular area, let alone ethics.

I want to argue that a requirement in ethics training for physicians in general, psychiatrists in particular, should be implemented, in parallel with the already established requirements of social workers and psychologists.    Historically, physicians were long resistant to the idea of medical ethics as an important clinical discipline.  There was a sense that it belonged as a course in philosophy departments or at special “think tanks” like the Hastings Center for Bioethics in New York, but not in hospitals, on rounds, or in grand rounds.  However, that recalcitrance was gradually eroded, partly with the help of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) which, over the last decade, has started to require that hospitals have an Ethics Committee, which could be consulted by staff or patients.  Even prior to this, the federal government instituted the requirement of an Institutional Review Board (IRB) to review any protocol for human experimentation for ethical soundness.

One need not look past the headlines to observe that we live in times of great ethical confusion and misbehavior in many professions.  My own work with ethics consultations in health care systems and on the MPS Peer Review committee has revealed to me that there is indeed considerable ethical confusion and misadventure (both knowingly and unknowingly) among psychiatrists. 

Systematic ways of thinking through moral conundrums do exist and have been developed in the formal field of Medical Ethics.  These processes are not necessarily merely a matter of following one’s intuition.   Indeed, I have seen “clinical intuition” lead many a psychiatrist astray in this domain.  The ever increasing pressure to make decisions quickly, to spend less time with patients and less time in consultation with colleagues, have all combined to increase the chance of clinical behavior that is not just substandard, but frankly, unethical.  

It turns out that considerable thought, writing, and discussion has been taking place in  the field of Medical Ethics over the last few decades, which is keeping up with developments.  Issues that have challenged ethical thinking are evolving. Such issues as the ethics of relating to managed care organizations, doctor/patient boundaries,  and patients refusing treatment  are just examples of issues about which  thinking has been rapidly evolving in systematic ethical analysis.  Critical thinking about these areas is advancing, much as neuroscience and pharmacology are advancing.    Yet there is little opportunity to avail oneself of training in these matters. Indeed, the demands of more concrete and procedural knowledge, such as psychopharmacology, can be seductive and can lead one away from the “softer” topics when considering how to spend precious CME hours.   

Moreover, there are not many CME hours out there for ethical training of psychiatrists.  I recently had an opportunity to give an hour lecture on a CME closed-circuit TV  and webcast program.   Though asked for more , it was impossible for the producers to find underwriters for more ethics broadcasts.  In contrast, underwriters (read: pharmaceutical companies) were standing in line to sponsor programs on treatments of illnesses with pharmacotherapy.

The fact is that mandating continuing education in ethics for  social work and psychology produced a market for such courses, and suddenly, they were commonly available.   In my experience, they are eagerly attended, not simply because they are mandated.   Attendees seem to find this training  of immediate value to common practice conundrums.  These seminars actually  help to raise basic awareness of when one is actually on ethically controversial ground-- a basic awareness that, though fundamental, is often lacking.  It is one thing to know how to skate on thin ice;  it is another thing entirely to learn how to recognize that the ice is getting thin.

More than any other kinds of healing professionals, therapists and psychiatrists are often soloists.  What we do is, by necessity, very private.  Typically, we are utterly alone with our patients.  This makes us vulnerable to creating a hermetically sealed zone in which our clinical judgement is deployed, without being readily accessible to feedback from other  authoritative colleagues or sources.  My work on the MPS Peer Review Committee demonstrates to me the kind of “judgement trance” that can be fostered, in which progressive rationalizations can lead to a subtle, gradual drift away from standard ethical practice.  Unfortunately, it is often left to the patient or family member to ring the alarm bell, signaling that the psychiatrist is “off-the-reservation.”  One need only read the report of sanctions by  the Maryland Board of Physicians to see that psychiatrists are overly-represented in that roll call of dishonor. 

I submit that this is not surprising, considering the nature of our work.  That means that our specialty has a particular  need for ethical education to cultivate a more robust and effective ethical self-monitoring.  

This is the reason that I think it is time for us to join the good sense of our colleagues, the social workers and psychologists, and require of ourselves mandatory continuing education in one particular area-- ethics.  The zeitgeist   of our increasingly ethically confused society calls for it, the virtue of humility in the face of a complex clinical art calls for it, and last (and least)-- our malpractice attorneys call for it.

Mark S. Komrad, M.D., is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, and Clinical Assistant Professor of Psychiatry at the University of Maryland.  He was an attending psychiatrist on the Treatment Resistant Psychotic Disorders Unit at Sheppard Pratt Hospital for 15 years, where he continues to train residents in psychotherapy and psychopharmacology and runs the Ethics Consultation Service and Hospital Ethics Committee for the Sheppard Pratt Health System throughout Maryland.  He has lectured throughout the country on a variety of topics in psychiatry.  Dr. Komrad also appears widely on TV and radio to discuss topics in psychiatry and teaches psychiatry to residents and primary care physicians.  Dr. Komrad was the keynote speaker at the 2009 Scattergood Summer Institute for the Applied Ethics of Behavioral Health and is a member of ScattergoodEthics' Academic Advisory Board.

 A version of this essay originally appeared in The Maryland Psychiatrist.  It has been reprinted here by permission of the author.

This year the annual Scattergood Summer Institute for the Applied Ethics of Behavioral Health took place at the University of Pennsylvania Center for Bioethics over July 23-24th, 2009.

The goals of the ScattergoodEthics Summer Institute are to raise awareness of the special ethical considerations in behavioral health care, to teach clinicians the basics of behavioral health ethics and to provide them with tools to deal with moral problems that arise in their daily work and clinical practice.  

Directed by Angelique M. Reitsma, MD, MA, and Arthur Caplan, Ph.D., this year’s Summer Institute was open to behavioral health practitioners from a variety of disciplines and venues in the greater Philadelphia area and Northeast. The response to and interest in the workshop were overwhelming and well beyond double the quota for this year’s workshop. With over 45 participants and 10 instructors, the room was packed with people, ideas, experience and expertise.

The curriculum was compiled to provide an introduction to the most salient ethical issues prevalent in behavioral, psychiatric, and mental health care. The lectures included instruction on the basics of bioethics, and bioethics in the setting of behavioral health. We presented special topics of interest to behavioral health providers, such as: decision-making capacity and autonomy; coercion and compliance to treatment; civil commitment with an emphasis on Pennsylvania law; stigma and the ethics of the recovery approach to behavioral health; issues of confidentiality, especially in light of public safety considerations; the portrayal of psychiatric treatment ethics in the entertainment industry; and a workshop on moral decision-making.  

Our instructors were experts from the University of Pennsylvania (Center for Bioethics, Departments of Psychology and Psychiatry, the School of Social Policy and Practice, and Penn Law School), the Institute of Living, Sheppard Pratt Hospital & Johns Hopkins School of Medicine, and the University of Virginia.

Lectures:

Introduction to Bioethics, Art Caplan, PhD

Behavioral Health Ethics, Angelique Reitsma, MD, MA

Coercion and Compliance, Harold Schwartz, MD

Civil Commitment in PA, Anita Allen, JD, PhD

Capacity and Competency, Donna Chen, MD, MPH

Confidentiality in Behavioral Healthcare, Angelique Reitsma, MD, MA

Access to Appropriate and Effective Services, Cordula Holzer, MD

Recovery, Stigma and Ethics, Phyllis Solomon, PhD

Lessons in Doing it Wrong: How Hollywood Depicts Psychiatric Treatment in Movies, Mark Komrad, MD

This year we offered Social Work Continuing Education Credits to those interested, for which more than a third of the participants applied.

In the post-workshop evaluation, participants showed a strong satisfaction with the Summer Institute overall, and with its breadth and depth. Participants felt that all of the topics presented were important and relevant to their work and practice. They overwhelmingly agreed that the presentations were informative, enriching, helpful and provided them with both better understandings and skills to approach ethical issues in their work and practice.

To the question of whether they think it will help them in their clinical practice, participants who are clinicians all agreed that it would be helpful. Some also commented:

“Yes - I am more aware of these issues and feel I can bring this to my co-workers.”

“Enhanced it. Ethics and ethical decision-making is ALWAYS front-and-center.”

To the question of whether they think it will help them in their work, participants who are non-clinicians all agreed that it would be helpful. Some also commented:

 “This experience will enhance my ethical decision-making as it relates to personal and consumers' safety, future, emotional management.”

“Exposure to broad range of MH professionals was very illuminating.”

All participants (clinicians and non-clinicians alike) stated that they would recommend it to colleagues.

For future workshops, participants stated that the following topics are some that should be included or expanded on: focus on child, youth, and family; more emphasis on recovery; and substance abuse and addictions. Some participants also suggested having a panel discussion and including mental health care consumers as presenters. Many participants would have liked to discuss case studies from their or others’ professional experience.

Participants also expressed an interest to continue such discussions about ethical issues special for behavioral and mental health practice with each other and with their fellow colleagues. Some suggested that the ScattergoodEthics Program should establish a listserv for this purpose, and lead such discussions in the future.

If you are interested in attending similar educational and professional workshops in the future, please contact Hila Rimon-Greenspan at hila@mail.med.upenn.edu.

For more information about this and similar events in the future, please see our Events page

Thomas Scattergood was born January 23, 1748 in Burlington, New Jersey.  While trained as a tanner, he was drawn to Quaker ministry where he rose to prominence at his local meeting.  He had several personal tragedies in his life.  His father died when he was only six years old.  His first wife died after eight years of marriage.  Perhaps his own experiences made him more sensitive to others’ tribulations. 

Scattergood himself was prone to sadness and withdrawal and was referred to as the “mournful prophet.”  However, he was extremely dedicated to his work as a Quaker minister, and would persevere through God’s presence.  In 1794 Scattergood set sail to England, where he would remain for six years.  During the voyage, he writes in his diary:

I have been sitting since dinner, pensively musing and thinking of my family and North meeting.  My was broken into tenderness… Oh how desolate has been the state of my mind since I parted from my dear wife and family.  I could say in humble acknowledgment to the God of my life, that He was my light and my song, my shepherd, and I should not want… Lord, I believe, help Thou my unbelief.

During Scattergood’s lengthy sojourn in English, he would preach, meet with fellow Quakers, visit schools, prisons and orphanages.  “His sympathy with the afflicted was often manifest…claiming his tender regard and bringing to his brethren an account of their suffering, hoping to alleviate their suffering.”

Individuals afflicted with mental illness have a long history of being treated with contempt and isolation.  Many considered them to be possessed by demons, and deserving of punishment and even death.  As late as 1777, London asylums charged visitors to observe patients with mental illness for their amusement or curiosity.  By contrast, Quakers view all people as enlightened by the divine, and entitled to respect and consideration.  This view of humanity may have sensitized Quakers to the plight of those with mental illness.

In 1791, Hannah Mills, a young Quaker woman, became acutely ill, and displayed mental changes.  She was sent to the York Asylum, and her family, who lived some distance from York, asked Quaker friends to visit her at the Asylum.  Unfortunately, when they tried to visit, they were turned away, being told she was unfit to receive visitors.  Tragically, she died within weeks and several local Quakers from York decried this situation.  William Tuke proposed that Quakers create their own institution for those afflicted with mental illness.  “The situation caused some Quakers to reflect on the situation of the insane.  It was felt that there might be some advantage if the Society of Friends created their own institution which could provide milder, more appropriate treatment.  It was hoped that if patients enjoyed a lucid interval, they could experience companionship with others of similar beliefs and habits.”

Within four years, the York meeting had a plan, had raised funds, and began admitting patients in 1796 to the York Retreat.  Three aspects of the Retreat’s early experience deserve mention.  First, the retreat promoted the concept of “moral treatment.”  Moreover, this emphasized a positive, nurturing, sympathetic attitude towards patients, and a safe, attractive, respectful environment.  Second, they found that a surprisingly high number of their patients improved dramatically.  This was particularly true if the mental illness was of recent onset.  Thirdly, they kept meticulous financial records, and discovered that they could provide kind, compassionate care, and be financially solvent.  The Quakers had acquired considerable experience in establishing schools, and obtaining financial support from their members.  This fund raising was all the more successful as their cause was embraced and relevant information distributed.  So it was that within several years of opening, the York Retreat was regarded locally as a great success.  Interested parties came to visit the Retreat and began creating similar institutions.

In 1799, Scattergood traveled to York where he dined with William Tuke, the founder of the York Retreat.  He also stayed at the home of Lindley Murray, one of the original supporters of the York Retreat.  The following day, Scattergood visited the Retreat where he met with 30 Quaker patients with mental illness.  Scattergood writes in his diary: “We sat in quiet, and I had vented a few tears, and was engaged in supplication.”

Scattergood’s visit to the York Retreat occurred near the end of his time in England.  While it was to be a seminal event, Scattergood yearned to return to his family in Philadelphia.  He writes:

When I view my situation, when I consider the distance I am from my home, how long I have been absent, the afflictions I have passed through…my hear has been sometimes overwhelmed.  I hastened to be ready to go home, but here I am yet, as a prisoner in bonds.

Once Scattergood returned to Philadelphia, he became involved with teaching and financial support for a newly created Quaker school in Westtown.  Scattergood had a number of anecdotal encounters with troubled souls, including people with severe depression and chronic alcoholism.  After meeting such individuals, he would abandon his intended plans and devote hours to counseling them and praying with them.  “A friend had tears running from her eyes, and after a time and some conversation, she took courage and told me what sympathy she had felt with me.”

One deeply ingrained tenet of the Quaker faith was strenuous objection to war.  This view was articulated by George Fox, the founder of the Quaker movement, as early as 1650.  As a result, Quakers were objectors to serving as soldiers in times of war.  This held true during the American Revolutionary War.  One repercussion of this was resentment of Quakers after the war when they tried to participate in politics or other activities.  Some observers have suggested that this exclusion from mainstream trends drove them to innovate internally.

Meanwhile, Samuel Tuke, the grandson of William Tuke, was researching the history and progress of the York Retreat.  His Description of the York Retreat would be published in 1813, but Samuel acknowledges sharing much of the information in 1810 with his “American friends.”  In February 1811, Scattergood proposed to the Philadelphia Yearly meeting that “means should be devised for the care of such members of our society as may be deprived of the use of their reason.”

Scattergood had been speaking to fellow Quakers about mental illness.  These conversations “awaked a tender, sympathetic feeling for the welfare of this afflicted class.”

The meeting designated seven individuals to pursue this proposal.  Thomas Scattergood was the first to be named, and the list also included Isaac Bonsall, a local farmer who would serve as the first superintendent of Friends Hospital (1817 – 1823).  The influence of the York Retreat’s experience is undeniable.  The plans for acquiring land, architecture, staff, and financial support are almost identical to that described in Tuke’s account.  In April 1812, the Philadelphia Yearly meeting recorded their plan to:

Create an Asylum, as at the York Retreat, for their insane brethren, which would furnish besides the requisite medical aid, such tender and sympathetic attention, and religious oversight as may sooth their agitated minds and thereby under the divine blessing, facilitate their restoration to the inestimable gift of reason.

Sadly, Thomas Scattergood died of Typhus fever in 1814, three years before Friends Hospital would open.  Fellow Quakers were at Scattergood’s death bed and noted:

His vital powers now appear to be fast sinking, and his speedy departure was looked for: but reviving a little he said “I do not expect I am going now”… After some time of silence, and when very near his close, he said with emphasis, “I will lead them, and who will stand?”

In retrospect, the personal disposition of Thomas Scattergood combined with the timing of his visit to the York Retreat were profoundly fortuitous in the founding of Friends Hospital.  “To Thomas Scattergood, a minister in the Society of Friends, it is generally believed that we are indebted for the inception of the institution.”

And so it was that his son, Joseph Scattergood, was appointed to be one of the original Managers of Friends Hospital.  The main building of Friends Hospital is named after Thomas Scattergood.  More recently, the Thomas Scattergood Behavioral Health Foundation was created in 2005 with the mission to advance awareness of behavioral health issues.  Lastly, the Scattergood Program for the Applied Ethics of Behavioral Health was created in 2007.  This program seeks to promote awareness of ethical dilemmas encountered in clinical practice.

References

Journal of the life and religious labors of Thomas Scattergood, a minister of the gospel in the Society of Friends.  Stereotype edition, Philadelphia, 1874, Page 157, 404, 487

Description of the Retreat, an institution near York, for insane persons
Of the Society of Friends.  Containing an account of its origin and progress,
the modes of treatment, and a statement of cases.  Samuel Tuke. York, England, 1813.  pages 22-23.

Philadelphia Yearly Meeting Minutes, 1811.

Friends Asylum 1813-1913, John C. Winston Company Press, Philadelphia,
1913: page 14.

Philadelphia Yearly Meeting Minutes, April 1812.

Acknowledgment:  I wish to recognize the kindness, patience and resourcefulness of the library staff at Haverford College, in the Quaker section.  They seem to embrace my mission to understand the background and contributions of Thomas Scattergood.

David Roby, MD, is Associate Professor of neurology at the Temple University School of Medicine in Philadelphia.  He worked at Friends Hospital during the Vietnam War as a conscientious objector, and authored a booklet describing the early experiences of Isaac Bonsall, Friends Hospital's first superintendent.  He served on the Board of Managers at Friends Hospital from 1985 to 2006, and is a board member of the Thomas Scattergood Behavioral Health Foundation.  Dr. Roby is currently working on a biography of Thomas Scattergood.

As we noted in February, legislators in Minnesota proposed a bill earlier this year to restrict research practices in psychopharmacology.  Namely, the bill intended to prohibit researchers from enrolling people that have been committed for a mental illness by a court order in clinical trials.  The measure was prompted by instances of reported abuse, particularly the story of Dan Markingson.  The legislation, referred to as “Dan’s Law,” was recently signed into law and will go into effect August 1.

For more information about Dan’s Law, please see Christopher Lane's blog entry, When Drug Trials Go Terribly Wrong: Lessons From a Bereaved Mother, in Psychology Today.