Forensic Psychiatry: An Essential Major Subspecialty

October 30, 2015
James L. Knoll IV, MD
Volume 32, Issue 10

With a consistent and evolving presence in the US, forensic psychiatry has grown increasingly complex, with many specialty areas under its subspecialty umbrella.

SPECIAL REPORT INTRODUCTION

If psychiatrists cannot adequately communicate their knowledge and its basis to juries, how can we enlist the necessary aid of the public or the legislatures in drafting laws more just and more helpful to our patients?1

I am pleased and honored to introduce this Psychiatric Times Special Report on Psychiatry and the Law. Forensic psychiatry now occupies a place as an essential, major subspecialty of psychiatry. The field has become a necessity since “without information from well trained and competent forensic psychiatrists in certain cases, there is an increased likelihood of miscarriage of justice.”2 Forensic psychiatry has been a consistent and evolving presence in the US.

[[{"type":"media","view_mode":"media_crop","fid":"42448","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9352132905146","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4596","media_crop_rotate":"0","media_crop_scale_h":"131","media_crop_scale_w":"125","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]American forensic psychiatry’s founder, Isaac Ray, had already begun to influence courts and judges after publishing his “Treatise on the Medical Jurisprudence of Insanity” in 1838. Another major milestone in American forensic psychiatry was the formation of the American Academy of Psychiatry and the Law (AAPL) in 1969 by Dr Jonas Rappeport and colleagues. Over the next 45 years, AAPL would become “an organization of psychiatrists dedicated to excellence in practice, teaching, and research in forensic psychiatry,” with more than 1500 members in North America and around the world.

The efforts of AAPL and its leaders have played a fundamental role in the evolution of the field into its current status as a “multidisciplinary science.”3 The profession now “demands high ethical standards and sophisticated knowledge of many aspects of psychiatry, law, ethics, and public policy.”4 Forensic psychiatry includes research and clinical practice in the many areas in which psychiatry is applied to legal issues. It utilizes scientific and clinical expertise in a wide variety of legal contexts involving civil, criminal, correctional, administrative, and legislative matters.

Despite the rising importance of the field since the inception of AAPL, it could be argued that psychiatry itself was “born forensic” in the sense that even before it began to pursue the moral care of persons in the 1700s who suffered from severe mental illness in jails or almshouses, psychiatry was also attempting to assist courts in the task of understanding the relationship between psychopathology, capacity, and offending. Early forensic psychiatrists were known as alienists from about the mid-1800s to the early 1900s. The term is believed to be derived from the Latin “alius” (other) and the French “aliene” (insane). Those who suffered from mental illness were viewed as being estranged from their normal faculties.5 Thus, those who studied and cared for them were called alienists.

Today, forensic psychiatry has grown increasingly complex, with many specialty areas under its subspecialty umbrella. To name just a few, the past several decades have seen sophisticated progress in areas such as child forensic psychiatry, correctional psychiatry, forensic gero-psychiatry, and forensic psychiatric research.6 The forensic psychiatrist must meet the challenge of functioning “within a social context that is influenced by time and place.”7 Forensic psychiatry’s evolution is therefore constant, and its practice daunting, albeit highly rewarding. It could be said that to practice forensic psychiatry is to walk the psychiatric razor’s edge of sociolegal culture.

In this Special Report, the authors cover a number of fascinating forensic issues, including the emotionally disturbing subject of filicide (Drs Hatters Friedman and Resnick) and forensic evaluations of the geriatric population (Dr Holzer). Forensic psychiatric evaluations in geriatric psychiatry have become increasingly advanced and valued by the courts. Some of the more prominent forensic gero-psychiatry issues include testamentary capacity (competence to make a will), guardianship, end-of-life decision making, and elder abuse. Dr Blum shares his knowledge of competency hearings and what all psychiatrists need to know in order to best assist the court and triers of fact.

Dr Bernet addresses the highly controversial subject of parental alienation syndrome. Legal scholars and students of forensic psychiatry know that the courts have a tradition of being highly skeptical of “syndromes” and syndromal evidence. The DSM-5 Task Force considered but rejected adopting parental alienation disorder (PAD) as a mental illness. Just prior to the DSM-5 Task Force’s decision, PAD was the subject of vigorous debate in the Journal of the American Academy of Psychiatry and the Law.8,9 Regardless of its exclusion from DSM-5, PAD will continue to surface in volatile child custody cases and in family courts.

Finally, Drs Martin and Schroeder address the complex challenge of distinguishing factitious disorder from malingering. This is a common diagnostic challenge in general psychiatry-particularly in emergency settings. The distinction may become further complicated when both genuine and malingered symptoms are present-a scenario that demands abandoning rigid, dichotomous thinking.

Isaac Ray was not just the founder of American forensic psychiatry. He was arguably one of the most prominent reformers, writers, and thinkers in psychiatry in the 19th century. Clear, rational, critical analysis and self-examination were some of his strong suits. He corresponded with Dorothea Dix, as they both shared a passionate belief in treating persons with severe mental illness with dignity and protecting them from abuse. His writing was studied and revered by the court in the famous Daniel M’Naughten insanity case in England, and used by a New Hampshire Supreme Court judge to clarify that state’s law on the insanity defense.10 Ray understood that for the field of psychiatry, it was crucial to have a foot in both worlds-psychiatry and law-so that lawyers’ and doctors’ “different style of mental training” did not leave them “remaining wide as poles asunder.”1

Disclosures:

Dr Knoll is Editor in Chief Emeritus of Psychiatric Times. He is Professor of Psychiatry at the SUNY Upstate Medical Center in Syracuse, where he is Director of Forensic Psychiatry, and Director of the Forensic Psychiatry Fellowship at Central New York Psychiatric Center. He reports no conflicts of interest concerning the subject matter of this Special Report.

References:

1. Quen J. Isaac Ray: have we learned his lessons? J Am Acad Psychiatry Law. 1974;2:137-147.

2. Dike C. Commentary: is ethical forensic psychiatry an oxymoron? J Am Acad Psychiatry Law. 2006; 19:544-546.

3. Sadoff R. The Evolution of Forensic Psychiatry: History, Current Developments, Future Directions. New York: Oxford University Press; 2015.

4. Pinals D. Forensic psychiatry fellowship training: developmental stages as an educational framework. J Am Acad Psychiatry Law. 2005;33:317-323.

5. Medical Dictionary. Alienist. http://medicine.academic.ru/280/Alienist. Accessed September 9, 2015.

6. American Academy of Psychiatry and the Law. The AAPL Institute for Education and Research. http://www.aapl.org/aier.htm. Accessed September 9, 2015.

7. Grubin D. Commentary: mapping a changing landscape in the ethics of forensic psychiatry. J Am Acad Psychiatry Law. 2008;36:185-190.

8. Houchin T, Ranseen J, Hash P, Bartnicki D. The parental alienation debate belongs in the courtroom, not in DSM-5. J Am Acad Psychiatry Law. 2013; 41:127-131.

9. Bernet W, Baker A. Parental alienation, DSM-5, and ICD-11: response to critics. J Am Acad Psychiatry Law. 2013;41:98-104.

10. Reik L. The Doe-Ray correspondence: a pioneer collaboration in the jurisprudence of mental disease. Yale Law J. 1953;63:183-196.