Overview | Clinical Scenarios | Additional Tips | References
By Abhishek Jain, MD and Renee Sorrentino,MD
OVERVIEW
Definitions
Overview
Forensic psychiatry is a medical subspecialty at the intersection of law and mental health. The activities of physicians in this subspecialty are varied and include the treatment of forensic patients, forensic evaluations, expert witness testimony, and scientific research. Forensic psychiatrists are also in a unique position to advocate for the mentally ill in legal and forensic systems.
The American Academy of Psychiatry and the Law (AAPL), founded in 1969, is a professional organization dedicated to excellence in the practice of forensic psychiatry through scientific and educational activities, such as annual meetings, publications (e.g., Journal of AAPL, Newsletter), and resource documents.
While all psychiatrists encounter medicolegal matters – from civil commitments to Tarasoff-type warnings – forensic psychiatrists specialize in these areas and have acquired skills through additional education and training.
Examples of forensic psychiatry roles and expertise are:
- Criminal evaluations – competency to stand trial, insanity defense
- Civil matters – fitness for duty, disability, medical malpractice
- Correctional psychiatry – treatment in jails and prison
- Academic research – violence risk assessment, sexual offender management
- Public health –policymaking, ethics/human rights considerations
Ethical considerations
Unique roles and practice settings in forensic psychiatry bring ethical considerations, such as:
- Confidentiality – e.g., limitations on an evaluee’s right to privacy in certain situations
- Consent – e.g., notifying the evaluee regarding the nature and purpose of the evaluation
- Honesty and Striving for Objectivity – e.g., regardless of the retaining party
- Qualifications – e.g., only providing opinions and testimony in areas of expertise
CLINICAL SCENARIOS
Scenario #1: A psychiatrist works in a mental health clinic. The lawyer for one of the psychiatrist’s patients calls and asks the psychiatrist to provide an opinion regarding the patient’s state of mind and ability to understand right from wrong when the patient committed a crime a year earlier.
- The psychiatrist should decline this request. This is typically outside the scope of a general psychiatrist’s skills and training. In addition, dual agency – when the psychiatrist has a forensic role in addition to a treating role with their patient – should be avoided in this scenario. The psychiatrist could suggest that the lawyer seek a forensic psychiatrist to evaluate the patient’s criminal responsibility (e.g., insanity defense). While some requests initially seem harmless and in the interest of advocating for one’s patient, conflicts such as confidentiality, objectivity, and qualifications are important to consider.
Scenario #2: A forensic psychiatrist attempts to conduct a court-ordered competency to stand trial examination, but the defendant refuses to participate.
- In these situations, consent is often not required. While efforts to notify and engage the defendant are imperative, an opinion may be possible if sufficient sources of information are available (e.g., observations of the defendant and records). The report and testimony should clearly state that an interview was not conducted, on what basis the opinion was rendered, and the limitations of the opinion.
Common myths about forensic psychiatry
With expert testimony being the one of the most visible roles of a forensic psychiatrist, misconceptions include that forensic psychiatry experts are hired guns, lie detectors, and crime solvers. In addition to expert testimony and specialized forensic work, it is important to keep in mind that many forensic psychiatrists also continue practicing in general clinical settings.
ADDITIONAL TIPS
AAPL is a valuable resource for career and training opportunities in forensic psychiatry.