As physicians, we strive to heal suffering; as psychiatry trainees, we are taught to relieve that suffering through careful assessment, development of rapport, and empathic care. What then of the forensic expert, whose role is to provide the courts with objective assessment of the “defendant,” free of a therapeutic alliance1,2? Learning to navigate between these different roles is a necessary part of forensic training.2
In my journey to become a forensic psychiatrist equipped to treat adults and youth, I’ve had the good fortune to learn from those who appear to have mastered this balancing act. In this article, I present some of those lessons, with the hope that they will resonate with others—both those who are forensically inclined and those who wish to ease the jolt of being subpoenaed to appear before the court.
A day spent in the system
One of my earliest forensic experiences occurred during my training at Johns Hopkins, when I worked in the municipal court. I learned several lessons when I was assigned to pre-screen a defendant for competency to stand trial3 and criminal responsibility,4 both determined by the court but often informed by forensic evaluation.
Lesson #1: Answer only the question that you have been asked. En route to call for the defendant, I scanned my “how-to” guides and was relieved to learn that I was not to serve as decision-maker or treating clinician.5 I realized that I was not being asked to determine guilt or even give treatment recommendations; having a circumscribed task made that first evaluation less overwhelming. Learning to answer only the question you are being asked is a valuable lesson—one that ought to be remembered by those preparing for forensic evaluations and court testimony.
Lesson #2: There is a place for role induction. Entering a nearly empty office at municipal court, I sat behind a large metal desk and waited for the defendant. When he arrived, dressed in orange and escorted by the armed court officer, I rose to my feet awkwardly. I thought that I should shake hands with him, but stopped my hand in mid-air when I saw his handcuffed wrists.
As the guard knelt to chain the defendant’s ankle shackle to the floor, I waited patiently. Once the guard was outside, I introduced myself and read from my script. I explained the purpose of the evaluation and informed him that, unlike a
physician-patient relationship, this evaluation would not be confidential and would be shared with the court in a written report. Although the content of this introductory segment was in stark contrast to my usual patient encounters, this role induction6 was not. The purpose of role induction in a forensic setting is not to affect prognosis, yet such explanation is necessary to maintain ethical boundaries.1
Lesson #3: Know your phenomenology. Proceeding with the evaluation, I inquired about aspects of the defendant’s life. I attempted to assess his knowledge of the charges against him and how the court works,3 and obtained his account of the reported criminal events.4 Having an interest in psychotic illness and an appreciation for Jaspers’ descriptions of psychiatric phenomenology,7 I confidently delved into questions about the source, number, quality, and content of the voices he reported hearing.
Although not fail-proof, knowledge of phenomenology is necessary to discern whether reported symptoms should be trusted.8,9 In his writings10 and during my brief mentorship by him, Phillip Resnick, MD, stressed the importance of being able to detect malingering through knowledge of classic phenomenology and by maintaining a healthy level of suspicion.
Lesson #4: Impartiality is difficult but necessary. I concluded the interview, thanked the defendant, and asked if he had any questions. He declined. I motioned for the court officer to enter the room, unshackle the defendant from the floor, and escort him out. Exiting the room, I turned off the lights and shut the heavy door. The coldness of the physical environment seemed a metaphor for how I felt during the evaluation: In seeking the “truth,”11 had I lost a vital humanistic element?
Performing that early assessment, I felt as if such work challenged the reason I had decided to enter the medical profession. I struggled to see how such objective work contributed to relieving human suffering.
Now, only slightly more seasoned in this trade, I have a better appreciation for this necessarily impartial work. Although the role of the treating provider and the role of the forensic evaluator are distinct,12 both can be rewarding and both provide a valuable service.