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By: Douglas Page  
Issue: June/July 2008

One realm of forensics has nothing to do with crime scene evidence like blood, bones, or ballistics, but its intangible contributions are no less important to the flow of criminal and civil justice.

Forensic psychiatry deals with matters of mental health. Its own health is robust.

“Forensic psychiatry is booming,” said Timothy Allen, MD, director, Forensic Services, Department of Psychiatry, University of Kentucky.

Over 40 forensic psychiatry training programs currently exist at U.S. universities. The work of forensic psychiatrists ranges from evaluating competency to stand trial, sentencing recommendations, and providing expert opinions on mental health questions via written report, deposition, or courtroom testimony.

Of all the activities conducted by forensic psychiatrists, the most frequent pertain to a person’s mental competency. Court ordered competency evaluations in some areas have doubled in the past five years.

In criminal cases, forensic psychiatrists evaluate a defendant’s competency to waive Miranda rights, competency to stand trial, and competency to waive legal representation. They also contribute to the jury’s decision as to whether the defendant is sent to prison or to a mental hospital. Once convicted, the forensic psychiatrist might assess the defendant’s competency to waive appeal or be executed.

“Forensic psychiatrists play an important role because neither interrogations, nor trials, nor executions can proceed if the person is not mentally competent,” said William Bernet, MD, director of Forensic Services in the Vanderbilt University School of Medicine.

One of the biggest challenges in the field of forensic psychiatry is what to do with mentally ill individuals who are repeatedly found incompetent to stand trial and are released, but continue to reoffend. “

Often, these individuals do not meet commitment criteria of being a danger to themselves or others,” Allen said.

Some states have opened new forensic psychiatric hospital beds to accommodate non-violent, mentally ill defendants, but in others there is no such facility.

One perceived weakness in forensic psychiatry is that mental health professionals often diametrically disagree, sometimes over the same interview. Two experts, for instance, can view a videotaped interview of a child disclosing sexual abuse and one will conclude the statement is spontaneous and authentic while the other will see the disclosure as simply the product of coercive questioning.

“Blatant disagreement over the same set of facts are embarrassing to the profession of forensic psychiatry,” Bernet said. While no professional evaluation standards yet exist, that may be changing.

Bernet predicts within the next five to ten years, professional organizations will publish standardized protocols for conducting forensic evaluations, as well as standardized methods for interpreting the data.

“We will also see more interdisciplinary cooperation among psychiatrists, other physicians, psychologists, basic scientists, and attorneys, including more interdisciplinary research, dayto- day evaluations, and policy statements,” Bernet said.

Other aspects of forensic psychiatry have progressed more rapidly. Charles L. Scott, MD, chief of the Division of Psychiatry and the Law, University of California Davis Medical Center, believes the way psychiatrists assess a defendant’s propensity toward violence has improved markedly.

“Compared to 30 or 40 years ago, when interview evaluations relied more on clinician judgment without much research to back it up, risk evaluations now are based much more on objective measurements and known factors,” Scott said.

Scott said these advances are the direct result of improved training and board certification. Board certified forensic psychiatrists receive a minimum of nine years of higher education and training, including medical school (4 years), general psychiatric residency (4), and forensic psychiatry fellowship (1 to 3).

“The goal of these programs is for forensic psychiatrists to be more consistent so that the evidence presented in court is based more on objective evaluations, rather than personal opinion,” Scott said.

Since the challenge is to understand the complex interplay between mind, brain, and behavior, it is not surprising that forensic psychiatry is attracted to recent advances in neuroscience, especially in the areas of behavioral genomics and brain imaging.

“Our current knowledge regarding the causes of criminal behavior, such as violence, psychopathy, and sexual offending, is rudimentary compared to discoveries that will be made in the next five to 10 years,” Bernet said.

The task then will be to determine the relationships among genetic variations, changes in neurons and neural networks, changes in cognitive and affective functioning, changes in behaviors, and, ultimately, diagnoses. Then, forensic psychiatric evaluations will become more precise and reliable, and therefore, more helpful to attorneys, judges, and juries.

One issue not particularly helpful in the current pursuit of justice is the increased psychiatric interest in the concept of ‘ evil,’ particularly in defining and testifying about evil, according to James Knoll, MD, head of the forensic psychiatry program at Dartmouth. Knoll argued in a recent paper (J Am Acad Psychiatry Law. 2008;36(1):10516) that evil can never be scientifically defined because it is an illusory moral concept, it does not exist in nature, and its origins and connotations are inextricably linked to religion and mythology.

“Any attempt to study violent or deviant behavior under the rubric of this term will be fraught with bias and moralistic judgments,” Knoll concluded. “Embracing the term ‘evil’ into the lexicon and practice of psychiatry will contribute to the stigmatization of mental illness, diminish the credibility of forensic psychiatry, and corrupt forensic treatment efforts.”

Douglas Page writes about forensic science and medicine from Pine Mountain, California. He can be reached at douglaspage@earthlink.net.