You're a Whore

A reader recently sent me this comment:

"Frankly, I have little respect for Forensic Psychiatry these days. It is a whore subspecialty until proven otherwise, as it is doing what is financially convenient for the MD and just making general psychiatrists pick up the messes."

The accusation that forensic psychiatrist are 'hired guns' is not a new one. When I was a medical student I did a neurosurgery rotation. Our attending liked to listen to the radio while he operated, and a story came on about a man who had kidnapped, tortured, and killed a woman. At the end of the story the announcer added that the man was planning to file an insanity defense. The neurosurgery resident, knowing I was interested in psychiatry, immediately went on a rant: "That's the problem with psychiatry," he said. "Somebody does something criminal and there's always a psychiatrist somewhere saying he was crazy and shouldn't go to prison. This guy should be locked up for the rest of his life. They should do the same thing to him that he did to that woman."

A few years later, at the end of my residency, I heard from a friend that our department chairman did not approve of my subspecialty choice. "It's too bad she's going into forensics," he had told my friend. Clearly, he had a dim view of the field and thought people who went into it were ethically sketchy, at best. (Ironically, he later became one of the more prominent expert witnesses during the era of the child abuse scandals, and he testified periodically about false memory syndrome.)

Shortly after I began my fellowship, Dr. Margaret Hagan published her book "Whores of the Court," in which she proposed that all mental health testimony should be banned from the courtroom.

And so today, almost thirty years later, we return to this comment. My first thought was: "I've heard it all before, it's old stuff, and it's not true but people won't stop believing it." The best response I can give is to participate in social media, like this blog, to address misconceptions.

Here are the common misconceptions about forensic psychiatry:

1. Forensic psychiatrists 'get people off' from their crimes.

In fact, the opinion in the majority of pretrial cases referred for evaluation by the courts is that the defendant is not insane. Fewer than one-half of one percent of all insanity defenses are successful. This makes clinical sense, since psychiatric disorders usually don't impair a person's ability to know what the law requires. And it's not the psychiatrist making the decision about guilt or innocence: that decision is made by a group of average citizens–the jury–or by a judge. Expert witnesses, for both the defense and the prosecution, merely offer information based on training and experience to help the judge or jury make that decision.

2. Forensic psychiatrists will say what they're paid to say.

A good attorney will not hire a 'hired gun.' They are paying a lot of money for a witness who is credible, and a forensic psychiatrist with a reputation for being a 'whore' is not going to go very far with a judge or jury. Being a 'hired gun' is bad for business for the forensic psychiatrist, too, since a bad reputation cuts pretty far into your referral base.

Also, remember that in many cases the forensic psychiatrist is not retained by a private attorney. Many forensic psychiatrists are employed by state health departments. They are salaried employees, not private practitioners. As such, their income is independent of the opinions they form.

3. Forensic psychiatrists aren't doing 'real' psychiatry.

In other words, they're not clinicians. Ah, so untrue. Most forensic psychiatrists will tell you that it's important to retain at least a part time private practice because it's too demanding to have a 100% evaluation-oriented practice. Some forensic psychiatrists don't do evaluations at all, but devote all their time to providing clinical care to patients in correctional facilities or secure hospitals. Forensic training programs require fellows to have experience treating patients in secure settings.

Misconceptions about forensic psychiatry may not go away, but hopefully they can be moderated a bit by talking about the reality of the field.