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Forensic Psychiatry and the Perturbation of Psychiatrists' Attention and Neutrality During Psychotherapy

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Forensic Psychiatry and the Perturbation of Psychiatrists' Attention and Neutrality During Psychotherapy Forensic Psychiatry and the Perturbation of Psychiatrists' Attention and Neutrality During Psychotherapy Robert I. Simon, M.D. Most psychiatrists who practice the specialty of forensic psychiatry also conduct a general psychiatric practice. The free-floating attention necessary for the conduct of psychotherapy can be distracted by the many exigent demands a forensic practice places on the clinician. On the other hand, forensic psychiatrists are exposed to challenging cases and learn clinical skills ordinarily not obtainable from the general practice of psychiatry. The conduct of general practice is quite different from that of forensic practice. Understanding the essential differences should help maintain the equanimity of the psychiatrist and preserve the psychiatrist's attention to his or her patients. Forensic psychiatry is burgeoning. The Most forensic psychiatrists spend past decade has witnessed enormous most of their time in the practice of growth in interest in this specialty as general psychiatry and consider forensic demonstrated by the proliferation of psychiatry a subspecialty. Very few psy- journals devoted exclusively to forensic chiatrists practice forensic psychiatry ex- psychiatry, the development of forensic clusively. Therefore, it is important to psychiatry fellowship programs, and cer- tification by the American Board of Fo- examine the influence that the practice rensic Psychiatry. In addition, the Amer- of forensic psychiatry has on psycho- ican Board of Medical Specialties has therapeutic interventions. recognized forensic psychiatry as a sub- Forensic psychiatry is defined as "a specialty of psychiatry. It has authorized subspecialty of psychiatry in which sci- the American Board of Psychiatry and entific and clinical expertise is applied Neurology to conduct examinations for to legal issues in legal contexts embrac- a certificate of added qualifications in ing civil, criminal, correctional, or leg- forensic psychiatry in 1994. islative matters."' In examining litigants, no treatment agenda exists. The forensic Dr. Simon is clinical professor of psychiatry at George- town University School of Medicine, Bethesda, Md. psychiatrist usually is retained by an at- Address correspondence to Robert I. Simon, M.D., torney to provide professional services Georgetown University School of Medicine, 7921D Glenbrook Road, Bethesda, MD 208 14-244 1. in the course of litigation. The forensic 269 Simon psychiatrist must consider a number of ing. During the quiet of a psychotherapy data sources and cannot rely exclusively session, the psychiatrist's attention may on reports from the litigant. The forensic be captured by the intellectual chal- psychiatrist's role is one of active partic- lenges posed by a complex forensic case. ipation in the legal process. Countertransferential feelings of guilt, Forensic practice usually requires the annoyance, or even anger may be felt as juggling of a number of rapidly devel- a consequence of not listening to or hav- oping cases and responding to the exi- ing to listen to the patient. Moreover, gent needs of attorneys. Some cases may forensic cases may have a certain seduc- require court testimony. Phone calls are tive allure through sheer excitement and received frequently from importuning action. The raucous scene of battling attorneys operating on court-mandated lawyers and the publicity surrounding a deadlines. The constant rescheduling of sensational case may captivate the psy- depositions, examinations, and trials can chiatrist's attention as the case heats up be extremely disruptive to the stable rou- to a fever pitch. If the psychiatrist is tine required for the treatment of pa- treating a difficult, low-fee patient, a tients. Travel arrangements may need to creeping resentment can undermine the be made. Invasion of the psychiatrist's quality of the psychiatrist's listening, practice by the hurly-burly of litigation particularly when forensic cases can is a reality of forensic practice. bring substantially higher fees. A steady diet of sordid and gruesome forensic cases can harden the psychiatrist and Perturbations of Attention impair the capacity for empathy so nec- Freud' discussed the importance of essary in treating patients. evenly suspended attention in psycho- Once a case is litigated, lawyers usu- therapeutic work with patients. Psychi- ally quickly move on to their next case. atrists require quiet, relaxing surround- Immediately after the trial, however, the ings that promote unperturbed attention forensic psychiatrist may experience a when listening to patients. Although in- "morning-after syndrome" regardless of teractive, the psychiatrist's position is the case outcome. Although elation may essentially one of attentive ne~trality.~ be experienced briefly if his or her "side" This may be less a requirement, how- wins, the forensic psychiatrist may feel ever, for psychiatrists who use cognitive- depleted, let down, or even depressed by behavioral techniques or who primarily the sudden absence of excitement. Un- use psychopharmacologic treatments. der these circumstances, the prospect of Perturbations of free-floating atten- going back to work with patients may tion and the position of neutrality may appear to be a paltry substitute. These arise from a number of directions when feelings are hardly conducive to main- the psychiatrist takes forensic cases. For taining undisturbed attention in psycho- example, most forensic cases are inter- therapy. esting; some of these cases are fascinat- The adversarial process tends to pro- 270 Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 Attention and Neutrality During Psychotherapy duce polarization of expert witnesses on the conduct of psychotherapy. Anxi- and overidentification with the side that ety may disturb the psychiatrist's posi- has retained the forensic psychiatrist. tion of neutrality, precipitating inappro- Some psychiatrists may say "our side" priate activity in therapy. Boundary vi- or "their side" when involved in litiga- olations such as talking too much, tion. As the case heads toward deposi- making self revelations, looking to the tion or trial, the polarization process can patient for reassurance, or attempting to mesmerize the psychiatrist and distract quell personal doubts engendered in lit- attention from treatment. An expected igation by impressing the patient may full-fledged, "hammer-and-tong" attack take place in an effort to discharge anx- on the forensic psychiatrist by opposing iety. The unfamiliar terrain inhabited by counsel also can be a source of consid- attorneys and judges is an unfriendly erable anxiety and can prove to be ex- landscape that can strike fear in even the tremely distracting to the psychiatrist's most seasoned forensic psychiatrist. ability to listen empathetically. Rarely returning to his or her general Complex cases require extensive prep- practice as a conquering hero, most fo- aration before deposition or trial. Di- rensic psychiatrists who have endured gesting a large amount of complex infor- litigation frequently experience a very mation is both energy consuming and comforting feeling of being "back extremely demanding of attention and home." In the haven of the ofice and concentration. At such times, the foren- amidst appreciative, sometimes even sic psychiatrist may resent the distract- adoring, patients, the psychiatrist finds ing demands of a general psychiatric comfort and refreshment. This, after all, practice. On the other hand, the psychi- is the psychiatrist's appropriate metier. atric practitioner with a small forensic To be sure, the psychiatrist has dis- practice may chafe at the demands cre- tractions arising from his or her own ated by a complex forensic case and practice quite apart from forensic pres- become irritated by the disruptive intru- sures, but the pressures feel different. For sion of litigation on patient care. Coun- example, most psychiatrists have dealt tertransferential feelings engendered by with tough clinical emergencies such as the litigation process may lead to bound- a suicidal or homicidal patient on the ary breaches with patients. If the psychi- verge of hospitalization. The anxiety and atrist must leave patients to travel fre- distraction experienced by the psychia- quently on forensic cases, finding trist usually are not of the same magni- adequate coverage can become burden- tude as that experienced before going to some. Upon the psychiatrist's return, he deposition or trial. Because of extensive or she will invariably find that some training and experience, the psychiatrist patients feel abandoned and angry and managing a clinical emergency experi- are clinically regressed. ences the locus of control within himself Anxiety created by participation in or herself. Once venturing into the un- litigation can have other adverse effects familiar legal arena, however, the locus Bull Am Acad Psychiatry Law, Vol. 22, No. 2, 1994 271 Simon of control passes onto attorneys, judges, taining a forensic psychiatric practice. and juries. Thus, perturbations of atten- Understanding the difference between tion are much more likely to be driven medicine and law is critical to the main- by forensic anxieties than by clinical tenance of professional equanimity. It is exigencies. essential to recognize that the lawyer, One of the dangers confronting a fo- who is ethically bound to represent the rensic psychiatrist is the gradual, imper- client to the fullest, is an advocate rather ceptible erosion of professional identity. than a scientist.
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