Being an Effective Psychiatric Expert Witness

Many psychiatrists feel intimidated by or frightened about courtroom testimony. However, with the proper preparation, the psychiatrist need not have a difficult experience. It is the role of an expert witness to educate the court on matters that are beyond a layperson's understanding. In about 80% of civil cases and 50% of felony prosecutions, litigants call on expert witness testimony.¹ The court or attorneys may ask psychiatrists to conduct a psychiatric examination and render opinions on criminal issues such as competency to stand trial, insanity, or mitigation of penalty. In fact, the United States Supreme Court has commented on the "pivotal role that psychiatry has come to play in criminal proceedings."² In addition, civil issues may be addressed, including malpractice, disability, and psychological damage.

A psychiatrist may be requested to testify as either a "fact witness," or an "expert witness." A fact witness simply testifies about direct observations. A common example would be a treating psychiatrist who is asked to testify about his or her patient's symptoms and course of treatment. In this situation, the psychiatrist is not ordinarily asked to give opinions. An expert witnesshas "special knowledge" that the average person may not possess. The psychiatric expert witness may testify in the form of an opinion about facts directly related to the profession of psychiatry.

In the role of expert witness, the psychiatrist's task is to "shine the light" of psychiatric science and clinical knowledge on the legal question. Put another way, the role of the forensic psychiatrist is to "assist the trier of fact to understand the evidence or to determine a fact in issue."³ The "trier of fact" may be a jury, or in the case of a bench trial, a judge. When serving as an expert witness, the psychiatrist should have an understanding of certain guiding principles (Table 1).

These principles include the psychiatrist's duty to educate the court, clarify relevant psychiatric issues, remain honest and objective, offer well-reasoned opinions, and readily acknowledge the limitations of his opinion. Beyond these fundamental principles, other expert qualities have been described as playing an important role in effective testimony. These qualities include proper qualifications, good communication skills, and familiarity with legal standards and procedures.⁴

In the United States and the United Kingdom, trials are based on an adversarial model in which attorneys are "zealous advocates" of the causes they represent. This may present a confusing paradigm shift for the novice psychiatric witness. To maintain ethical standards, the psychiatric expert witness must resist the temptation to accept an advocate's role.⁵ Two general models of ethical expert testimony have been described.⁶ In the "advocate for truth" model, the expert becomes a completely neutral observer and adheres to absolute truth during testimony. In contrast, the "honest advocate" model holds that it is acceptable to be a persuasive advocate for one's honest opinion. In actual practice, most experts adopt a combination of these 2 models.

It is unrealistic to assume that the psychiatric expert witness can be completely impartial, but the psychiatrist should strive to initially approach a case with an impartial attitude. Once a comprehensive analysis has produced a well-reasoned opinion, it is only human to identify with one's opinion. On taking the witness stand, the expert must strive to impartially preserve the truth. Relevant information may not be kept secret.⁷ The expert must guard against a sense of "loyalty" to the retaining attorney, which might cause a temptation to go from objective expert to advocate. Blatant advocacy is easily recognized by the trier of fact and reduces the credibility of the expert. The psychiatrist should not go beyond the available data or the scholarly foundations of his testimony.⁸ An ethical psychiatric expert can enhance credibility by appropriately acknowledging the facts of the case that are unfavorable to his opinion, the limitations of his opinion, and hypothetical situations under which his opinion would be different.³

Some degree of skepticism already exists in US courts about diagnostic boundaries and evidence of mental disorders.⁹ For this reason, psychiatric experts must strive not only for accuracy in diagnosis but also for honesty about limitations in the field. Commonly observed reasons that psychiatrists intentionally or unintentionally claim greater certainty in ill-defined areas include a desire for a just outcome and having an agenda of bringing public attention to a particular mental condition.

When approached by an attorney, the psychiatrist should first seek to clarify the specific legal question that is being asked. Before beginning an evaluation, the psychiatrist should determine whether he has the proper "knowledge, skill, experience, training, or education" required.³ Table 2 lists questions that can assist psychiatrists in determining whether they are qualified for a particular case.

Once the qualification issue has been resolved, the psychiatrist should obtain the precise legal standard for the referral question, which may vary from one legal jurisdiction to another. For example, in a professional malpractice case, it is critical that the expert apply the proper standard of care for that jurisdiction.¹⁰ An opposing attorney may seek to have the expert's report declared inadmissible if it uses the wrong legal standard.

Before the trial, the psychiatric expert must engage in considerable preparation and planning. One authority has described guidelines known as the "6 P's of trial preparation." These include preparation, planning, practice, pretrial conference, pitfalls, and presentation.⁶ Preparation refers to thoroughly reviewing the entire casefile as well as analyzing the opposing expert's opinions. In this way, the expert develops mastery of the case and is well pre-pared for rebuttal of the opposing expert's testimony.

The underlying basis for the expert's opinion must be clearly explained and supported. The importance of having a logical rationale underlying the opinion cannot be overestimated. Jurors and judges often determine the credibility of an expert based on the soundness of the reasoning for the expert's opinion. Psychiatrists should refrain from giving an opinion using "ultimate issue" language, such as the "defendant was sane/insane."

Sometimes, the expert's testimony will not occur on the day that was originally scheduled. The expert should engage in planning that allows for the possibility that the trial will extend into the next day. The expert should practice how he will convey his opinion to the jury. If visual aids are to be used or blackboard drawing is to be done, this should be practiced as well. A pretrial conference with the retaining attorney is recommended to clarify how the expert's testimony will fit into the attorney's theory of the case. In considering potential pitfalls, the expert should review the weaknesses of his opinion, and anticipate what can be attacked on cross-examination. Finally, in polishing the presentation, the expert should be clear on how he will communicate his opinion to the trier of fact. Simple analogies and metaphors are helpful in conveying complex material to juries.

The psychiatric expert witness first undergoes direct examination by the retaining attorney. The direct testimony consists of nonleading questions, which allow the witness to express opinions and reasoning without interference. If there has been sufficient pretrial preparation with the attorney, this process should unfold in an organized manner. The expert witness should direct his remarks to the trier of fact in a clear and understandable fashion. Cross-examination is conducted by the opposing attorney to test the credibility of the testimony. Next, redirect examination allows the retaining attorney to repair damage done during cross-examination and to further clarify points. Finally, recross-examination must be limited to issues raised in the redirect examination.

At the beginning of the direct examination, the qualifications of the expert are elicited. Ordinarily, any licensed physician will be recognized as an expert witness who has the right to give opinions. Qualifications include the schools attended, internship, residency training, academic titles, hospital affiliations, board certifications, and honors. Journal publications that are relevant to the case should be mentioned. It is preferable to have the attorney elicit these qualifications through several questions to avoid the appearance of immodesty.¹¹ Next, the witness will be asked whether he has formed an opinion with reasonable medical certainty regarding the contested issue. The precise definition of "reasonable medical certainty" varies from one jurisdiction to another.¹² In many states in the United States, it simply means "more probable than not."

The psychiatric expert witness should come across as likeable and possess a credible presentation style. Because the expert is under constant observation while on the witness stand, attention should be paid to nonverbal communication. The expert should make eye contact with the jury to see whether they understand his testimony. A critical goal of the expert witness is to establish his credibility through expertise, dynamism, and trustworthiness. Expertise involves credentials, training, and experience. Dynamism relates to the style of delivery during testimony.¹³ Trustworthiness refers to the appearance of objectivity and sincerity; it is often more important than credentials in achieving credibility.¹⁴

The expert's style of speech can significantly influence credibility. Research has shown that powerful speech is more convincing and credible than powerless speech.¹⁵ Characteristics of powerful speakers include a straightforward style and greater use of 1-word answers. Thus, the expert should avoid language that hedges or qualifies his opinion.¹⁶ Answers to specific questions during direct testimony should be kept brief and clear. Testimony should be kept free of jargon. Professional jargon in the courtroom is likely to be misunderstood at best, and may even be made to look ridiculous. It is preferable to use equivalent words, such as "mood" for"affect," even if they are not perfect synonyms. Instead of saying, "The patient showed marked psychomotor retardation," a better approach would be to say, "His movements and speech were unusually slow."

The expert should avoid speaking in a condescending manner. If the jury feels patronized, they will be less likely to accept what the expert is saying. Nothing alienates a jury more quickly than a psychiatric expert witness who appears arrogant. When testifying, the expert should attempt to display dignity, confidence, and humility. Jurors are adept at spotting insincerity and condescension. The average juror's attention span has been estimated to be about 20 minutes.¹⁷ Time should not be squandered. The jury should be told what they need to know, not all that you know. Table 3 gives a list of what jurors want most from an expert.