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.
The job is to give advice and lend expertise in a neutral way, not to put weight on the scales in one direction or another.
Because psychiatry is so fuzzy, forensic and general psychiatrists need to know exactly what is based in science, what in clinical experience, and what in neither.
Any clinical conclusion should rest on a basis you can explain to a neutral audience, and be intelligible to the average reasonable person, who may be your patient or an independent observer.
There are not that many outright hired guns who knowingly give the attorney the opinion they want. There are more and less talented evaluators.
The first function of the judicial system is to resolve disputes, not necessarily to get to the truth.
The defense traditionally excludes antisocial personality disorder. Anyone trained in why it exists knows it cannot apply there.
The traditional framework: not understanding the nature or wrongfulness of the act, because of a mental illness. A psychopath who does not know right from wrong because they do not care does not qualify.
Standards vary by state. Using moral wrongfulness is more permissive and lets more people plead insanity; legal wrongfulness alone admits a very small minority. California separated the two, so not understanding the moral wrong qualified even if the legal wrong was understood.
It is rare: only about 1 percent of felony cases raise it at all. With long commitments and long hearings, most people would rather take a deal, and the outcome is often not favorable.
As a society we have an obligation to detect early when someone's illness leaves them unable to make a rational decision about treatment, and then to intervene, but we do not.
The most common criminal forensic evaluation is competency to stand trial: whether, because of mental illness, the person cannot rationally assist their attorney or understand what is going on in the courtroom.
There is a whole section of people who are just ill enough to get by in society without a clinic or hospital, yet ill enough to land in trouble with the law. Moderate-grade psychosis often goes unnoticed, but it can shape decisions, thinking and beliefs.
Dissimulation is the reverse: patients with subtle mood and psychotic disorders and low insight who present as healthy because they do not want to be found mentally ill.
To detect dissimulation, hold a prolonged conversation that has little to do with evaluating specific symptoms. Talk about things that seem unrelated, and rely on your mental status exam rather than on what the patient says.
Questions plainly looking for particular answers anchor patients into certain ways of responding. Prompting them to keep going on one line of narrative often gets you richer information than specific questions would.
In any intake, or whenever you are assessing for a specific diagnosis, hold off on structured questions and DSM criteria for at least the first 20 percent of the interview.
A favorite question: what was that like for you? That is what we are trying to get at.
Walking up and opening with any thoughts of hurting yourself or others puts patients on the defensive. Coming at it less directly lets you see how they think, unguided by their defenses.
Go for the primary source: the patient's own recollection of their experiences, not their summary of it filtered through your specific questions.
If they cannot give a timeline of the illness, skip to the social history: school, work, gaps, longest job, relationships. Overall functioning over time becomes your timeline and shows more about course of illness and personality than structured DSM questions can.
Stay in the interview until you have a story that makes some sort of sense.
Gather enough information together with the patient to string it into a story they are going to accept.
When you feel angry at a patient, do not tell yourself you cannot be angry. Be curious and say: I wonder why that is.
Even if your own emotional response is unique or outsized, the countertransference in acute psychosis is being provoked by something objectively identifiable.
Carefully observe different types of patients and compare them to each other.
Even within depression, a melancholic, more biological episode looks very different from depression that comes from trauma or personality.
With patients clearly in the psychotic range who are not hiding it, the countertransference tends to be almost maternal.
The proper psychotic disorders are not psychological in origin. They are brain disorders, a disruption in the reasoning and perceptive networks, even though the way symptoms manifest is still psychologically rooted.
Do not dismiss a patient as "just malingering." If you think so, put into words a full assessment of why.
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.