Key moments, in order
Forensic psychiatry is not correctional psychiatry. It is the application of psychiatric expertise and knowledge to legal questions that overlap with psychiatry.
Treatment has multiple agents, and the agent is not always the patient. It can be the state, for safety or for someone who lacks insight, or a parent on behalf of a child.
Be clear in your mind who all the agents of treatment are and whether they should be. If not, attention splits among them and forging an alliance with the patient becomes extremely hard.
When a patient says you are keeping them in the hospital, it helps to understand that the law is: a system of rules society has agreed on for good reasons.
Even one patient is not one agent. Part of them wants to get better and change; part wants to stay the same, feel safe and avoid new and scary things. Ally yourself with the part that wants to change.
In most developed countries, psychiatry is part of the executive branch of the state, like prosecutors and police: in a small or sometimes bigger way, part of social control and protection.
Think of the three branches: the legislature writes the law, the judiciary interprets it, and the psychiatrist, as part of the executive branch, argues that someone is dangerous.
In most places you need a mental illness, not a personality disorder that is the person's normal functioning, and you need to connect its symptoms and impairments to a likelihood of harm without commitment.
Excluding personality disorders from "mental illness" for commitment is a legal reality, not a clinical one; you could even call it a legal fiction in some places.
Instead of debating what counts as mental illness, ask two things: is this a change from the person's baseline, and if so why? And is it treatable by psychiatry as it exists today?
Violence and dangerousness during intoxication and for a week or two after is treatable: monitor, keep them in a safe place and give temporary antipsychotics. That makes it a legitimate use of involuntary treatment.
Any good forensic determination requires being a good psychiatrist: real experience trying to evaluate and tell these conditions apart in many people, and seeing how well you did.
Even when the patient, the parents and you yourself have all said it is the meth, do not automatically assume that is that.
Drug use is the number one thing that makes people dangerous from a mental health standpoint. Before discharging, ask whether the person has really had enough time sober to reflect on what happened and what treatment they need.
People think psychiatrists can predict the future, have special insight into people and can save them from suicide or keep them from harming others. It is not true.
When there are more patients than beds, triage by medical need, and if need is equal, consider dangerousness, such as a patient who owns guns and has threatened people. Document facts and enough to show medical decision making; longer notes are not better.
Be both harder and easier on yourself. Easier, because you are not necessarily there to please the person in front of you.
An assessment rests on all the medical data you can gather for the case. If the patient will not cooperate, you cannot simply make no decision; you can wait and reassess later.
Review the records of all your patients, outpatients included, from other hospitalizations and clinicians. Relying only on what a person tells you is incomplete because there is always some conscious or unconscious editing.
Ask how a theoretically healthy person would act in this situation, then how this patient is acting. If there is a significant divergence, look for the medical explanations.
Never take a patient's statements out of context, especially if they may be uncooperative or hiding things. Gather the whole life course and what brought them in; effort and investigation get closer to the truth.
Gather more information the higher the stakes and symptoms. When a patient refuses collateral, in many places you can still call someone and listen while saying you can neither confirm nor deny anything about a patient.
Some places have an imminent-harm exemption that allows calling collateral and disclosing protected health information, but it is very state-dependent.
Be comfortable being the whiny five-year-old who will not stop asking why. Do not take the first answer for granted.
Be transparent about how you are thinking about the case, so the patient understands why you want the information and does not hear it as a threat.
Name your role plainly: if you do not do your due diligence, you could lose your license and they could be in danger. Then ask for their help: you are not perfect, so help me out here.
Once threats are confirmed, the top of the differential is usually substances, personality and mood disorders. With high dangerousness you cannot assess responsibly from one look at a patient.
At discharge, your job is not to predict the future. It is to practice within the standard of care: assess short-term and long-term dangerousness and recommend treatment.
Do not catch a whiff of borderline and explain everything else away. Patients with BPD are at elevated risk of completed suicide.
What you are ultimately liable for is a process, not an outcome. Do your assessment within the standard of care and document it. You are not expected to be right every time, because no one can be, but you do need to follow the standard of assessment and treatment planning.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.