Forensic psychiatry is a relatively new field in which formal specialty training did not exist until around 1960 (1). Definitions of forensic psychiatry have varied. Pollack described forensic psychiatry as limited to psychiatric evaluations for legal purposes and law and psychiatry as a "broad general field in which psychiatric theories, concepts, principles, and practices are applied to any and all legal issues" (2). Other authors have defined forensic psychiatry in a broader context as related to "sociolegal issues" (3, 4). The creation of the American Academy of Psychiatry and the Law in 1960, the American Board of Forensic Psychiatry in 1976, and sub-specialty certification examinations sponsored by the American Board of Psychiatry and Neurology in 1994 contributed to the recognition of "forensic psychiatry" or "law and psychiatry" as fields worthy of formal recognition in residency and fellowship programs.
The Accreditation Council on Graduate Medical Education (ACGME) lists the curriculum requirement for forensic psychiatry as "experience under the supervision of a psychiatrist in evaluation of patients with forensic problems" (5). The strength of the requirement is that it allows individuals to tailor their exposure to forensic psychiatry based on the interests and expertise of the teacher. Its weakness is that, by adopting too narrow a focus, programs may fail to train residents in aspects of forensic psychiatry most relevant to the practitioner of general psychiatry. Components of a core curriculum of forensic topics for general psychiatry residents have received limited attention in the literature (1, 2, 3, 6—10). The objectives of this paper are to outline topics in forensic psychiatry relevant to general psychiatry residents and discuss materials and settings useful for teaching forensic psychiatry to general residents.
A resident whose only exposure to forensic psychiatry is a 6-month 2-day-a-week rotation at a forensic hospital or a 1-month rotation at a correctional facility is unlikely to gain and retain a broad knowledge base of forensic issues that are critical to the general psychiatrist. A better model might be one in which residents are exposed to forensic topics on an ongoing basis as the topics relate to the various settings of rotations (t1). The exposure would optimally take place during all 4 years of residency, with a main goal of progressive exposure to forensic concepts most relevant to general psychiatry residents. t2 outlines strongly recommended, recommended, and advanced topics for the residency forensic curriculum. It also outlines topics suited for a "crash course" format early in the first year.
Topics Related to Basic Law and the Legal System
General psychiatric residents need a solid grounding in legal issues related to the practice of psychiatry (3, 6—10) in order to understand the origins and rationale of legal requirements. Study of the evolution of issues such as involuntary commitment, duty to warn/protect, or right to refuse psychiatric treatment gives perspective on psychiatrists’ role in the legal process as advocates, activists, and educators. Faculty can use primary materials such as statutes and case law from within and outside of their state, readings from basic legal texts, and ethics codes from organizations such as the American Medical Association and American Psychiatric Association to teach basic law.
Psychiatric trainees commonly experience anxiety when called upon by the legal system to provide documentation or opinions about their patients. A central issue involved in such requests is the blurring of treating and potential expert witness roles. Residents need to understand the concept of conflict of interest and to recognize that involvement by a treating psychiatrist in a legal case can disrupt the treatment process. They may lack the ability and competence to address complex forensic issues and need close supervision when involved in legal issues. Residents should review their cases to ensure they are qualified and are comfortable providing the information requested. Understanding the legal standards to be applied to questions in each case, what collateral information is necessary before rendering an opinion, the appropriateness of the question being posed, and the potential need to refer the question to a more qualified or neutral evaluator is crucial. Subpoenas can be particularly stressful to residents, who often do not understand what they need to do when they receive a subpoena, or fear looking foolish if they do end up needing to testify or to provide records.
Topics Related to Patients and Patient Care
Involuntary commitment, right to treatment, and right to refuse treatment are of crucial importance and should be introduced in the first year. The two bases for involuntary commitment, parens patriae and police power, can be explained and illustrated with relevant case examples. The societal tension between the need to forcibly treat the mentally ill and the need to honor individual autonomy should be highlighted and placed in historical context. Concepts such as the right to treatment in the least restrictive environment and right to due process when undergoing the involuntary commitment process are important for junior residents. New concepts, such as involuntary outpatient commitment, offer a good opportunity to involve residents in debate about what is optimal care for the mentally ill. Nuances of the right to treatment debate, such as whether or not individuals with mental disorders which are not easily treatable or may not rise to the level of serious mental illness can be confined against their will, are fruitful areas of debate for more advanced residents.
Psychiatrists are routinely asked to assess patients’ risk of danger to self or others. Such assessments form the cornerstone for commitment to inpatient units. While some cases may be straightforward, others may be fraught with complexity. Although psychiatrists are not able to consistently offer accurate predictions of long-term dangerousness, they are able to assess risk factors that could make a patient dangerous to self or others short term. Residents need to understand the differences inherent in identifying risk factors and protective factors versus adopting black and white definitions of dangerous versus not dangerous. There is inherent tension between the psychiatric focus on near term risk and the legal profession’s emphasis on the distant future (3). The literature on prediction of dangerousness for both mentally ill and non-mentally ill individuals should be presented with a review of potentially serious punitive consequences of an erroneous label of "dangerousness." Ethical considerations of offering prediction of dangerousness, particularly in death penalty cases, could be explored with more senior residents.
Topics Related to the Physician-Patient Relationship
Even the most junior residents should be firmly grounded in the basic concepts related to competency, informed consent, and the right to refuse treatment. Although patients have the right to refuse treatment based on the constitutional right to privacy, their refusal may be invalidated if they are not competent to weigh the risks and benefits of their refusal. Residents should be familiar with statutes in their state related to involuntary medication, including documentation and due process, before force medicating a patient. They should also learn that if a patient gives a voluntary and informed consent for a procedure but is incompetent to do so, the consent is not valid.
Competency, the mental capacity to carry out a particular task, is a critical concept in forensic psychiatry. Situations in which a patient may be incompetent to make treatment decisions or informed consent may not be possible (e.g. emergency), or even not in the patient’s best interest (e.g. therapeutic privilege) can be explored with vignettes or case examples. The right to refuse treatment is a particularly relevant issue for residents rotating on consultation liaison, where calls are frequently made to psychiatry asking for assistance managing a patient who is refusing a potentially life-saving procedure, or threatening to leave against medical advice. Evaluation of such a patient can be done in an organized, structured, clinically, and legally sound manner. Gaining a basic knowledge of how to assess such volatile situations is helpful for trainees new to the often charged atmosphere of consultation liaison.
All residents should enter their programs with some knowledge of the concept of doctor-patient confidentiality because of their exposure to the Hippocratic Oath. Even first-year residents must be aware of what types of communications are confidential, and in what situations confidentiality may or must be breached. A review of the Tarasoff decisions (i.e. duty to warn, followed by duty to protect), and examination of relevant case law and statutes of the state in which the training is taking place, is critical. Training in how to work with patients when confidentiality must be breached (i.e. what effect reporting a patient to child protective services might have on therapy and how to negotiate it) is useful. The concept of privileged communication and patients’ general right to keep treatment privileged must be balanced with education about situations where there is exception to this privilege (e.g. patient-litigant exception, court-ordered examinations). Education about institutional and federal policies (e.g. Health Insurance Portability and Accountability Act) concerning confidentiality of electronic and written records is also important. Other more advanced topics of interest include confidentiality and HIV, nuances of confidentiality in child psychiatry, and confidentiality and third party insurance providers.
Malpractice is a topic likely to cause residents considerable anxiety. Despite the anxiety the topic produces, frank discussion about what malpractice is and how to avoid it is important. Residents should learn what the components of a successful malpractice case include (i.e. damages that are directly related to a failure to perform a duty owed to the patient by the doctor), what the most common claims against psychiatrists are in inpatient and outpatient settings, risk factors for having malpractice suits filed, and strategies to minimize liability through appropriate and thorough documentation. Training should also include differentiating between errors of judgment and errors of fact, and should emphasize that a bad outcome, in and of itself, does not necessarily indicate malpractice occurred. Residents working in correctional and state settings need to learn about differing standards for liability (e.g. deliberate indifference; gross negligence versus mere negligence) and the standards used to assess medical practitioners’ treatment by expert witnesses in a malpractice case.
The issue of competency to manage one’s healthcare decisions, finances, and personal care often arises with chronically or severely mentally ill patients, head injured patients, and elderly patients with dementia. The concept of presumed competency and the need for legal intervention to declare a patient incompetent is an important one. A second important issue is that competency is task specific; for example, standards for competency to make out a will differ from competence to consent to medical care which will differ from competence to manage personal affairs. Although residents might offer opinions on patients’ competencies to do certain tasks, the ultimate decision about whether a patient is legally competent or not to perform a given task is left to the court to decide. Residents should also understand what happens when a patient is declared incompetent. The role of guardians, and the difference between guardian of estate (i.e. conservator), guardian of the person, and powers of attorney, should be explored. These concepts optimally should be introduced early in training so trainees know to inquire about whether or not patients have a guardian and if so what the guardian has power to decide.
Topics Related to Criminal Process
Trainees with little experience may equate forensic psychiatry with psychiatry related to criminal law. Ironically, they are much more likely to be exposed to other issues in forensic psychiatry in their own general practice. Despite this, learning about criminal aspects of forensic psychiatry is valuable and often enjoyable for the general psychiatry resident. Topics might include competence to stand trial, criminal responsibility, issues related to the death penalty, and correctional psychiatry. Rotations in correctional facilities, court clinics, or forensic hospitals are all valuable to the general psychiatry resident. Patients involved with the legal system are often minority, disenfranchised, young, male, and dually diagnosed with drug and alcohol problems. These patients offer an excellent opportunity to learn about general psychopathology, as well as forensic issues. Some residents may look with trepidation at the possibility of working with people charged with crimes or venturing into a prison. They require support during the experience, as well as education about the prison system, its mission, its various mandates, and issues related to dual agency.
Topics Related to Child Psychiatry
Rotations in child psychiatry should cover basic forensic issues related to children. These could include children’s competency to consent to treatment, right to special education services, right to treatment in the face of parents’ refusal to grant permission for treatment, child custody, and termination of parental rights. Child psychiatry, although a subspecialty of general psychiatry, is a complex field, which requires additional years of training to attain expertise (6, 7, 11, 12). Forensic issues related to children are inherently complex because they intertwine two subspecialties to which the general psychiatry resident has not been deeply exposed. Residents should learn the limitations of expertise and that it is completely acceptable to decline to answer questions beyond the range of their knowledge and expertise. For example, a resident treating a patient may be asked by an attorney to prepare a report about who should get custody of children. Custody evaluations optimally involve interviewing both parties involved in the dispute and are best performed by psychiatrists with expertise in child psychiatry and no treatment relationship with any of the parties involved. General psychiatry residents are unlikely to be able to do these evaluations adequately. In contrast, residents must be fully conversant with the duty to report suspected child abuse or neglect. Statutory requirements for such reporting need to be reviewed, and residents must be apprised of the consequences of failure to report suspected abuse. Equally important is the understanding of the scope of the duty to report. Some residents may erroneously believe that once a report has been filed, confidentiality no longer exists with respect to Child Protective Services. Residents should also learn basic risk factors for juvenile violence and child abuse, and have some exposure to the juvenile justice system.
Forensic psychiatry, by nature a heterogeneous field, can be taught in a variety of settings. These include the main teaching hospital on inpatient units, outpatient clinics, consultation-liaison, child psychiatry, and electives such as geropsychiatry. Additional teaching can be provided at affiliated sites such as correctional facilities for adults and juveniles, community mental health centers, forensic hospitals, nursing homes, or hospice facilities. For more advanced residents, rotations in more specialized legal settings such as court clinics (used in some states to assess competence to stand trial and/or criminal responsibility in criminal defendants), legal aid clinics, public defenders or state’s attorneys’ offices, private attorney’s offices, law schools, or legislative offices may be of benefit.
Approaches to teaching forensic psychiatry should be balanced. Basic didactics can be taught in seminar format. Self-assessment questions and tests can help residents learn and retain key material. Case conferences on forensic topics are easily related to outpatient, inpatient, or consultation work. Residents can also participate in preparing case conferences on forensic topics for grand rounds with the mentorship of faculty. More advanced residents may benefit from taking classes of interest (e.g. criminal law, disability law) at an affiliated law school. Observation of forensic clinicians conducting evaluations and testifying also benefits trainees.
Residents participating in a forensic elective may review case materials, prepare a "shadow" report, attend and observe the deposition or testimony, or discuss the process with their mentor. Faculty participating in such training must be mindful of the substantial time commitment involved, and of any potential conflicts of interest they may have, related to cases the resident presents. Such experience helps put didactic knowledge into a practical and accessible light. Residents also benefit from observing videotaped forensic interviews and reviewing the cases with mentors. Videotaping mock testimony of residents helps them learn what they need to do to be effective witnesses. Participation in a mock trial with law school students may provide further experience in a situation approximating the real life scenario of testifying in a courtroom. Most residents participate in probate court commitment hearings before they have received any training in how to testify. These probate court hearings are an excellent opportunity to give residents hands-on supervision related to their own testimony. Journal clubs for advanced residents and forensic fellows are also a useful forum to introduce controversial topics, recent legal decisions, or late breaking research.
Because forensic psychiatry is a broad field with areas of specialization, interdisciplinary teaching is beneficial (6, 11, 12). Courses taught by both medical and legal personnel (e.g., lawyers, judges) offer useful perspectives. Other personnel confronting complex medico-legal issues (e.g., chaplains, ethicists, legislators, nurses, patients) also offer valuable perspectives. Issues related to children are specialized and complex areas within forensic psychiatry, and child psychiatrists and child forensic psychiatrists are important to a balanced forensic curriculum. Often, forensic cases and issues may be nuanced or controversial. Having more than one teacher, or using a debate format for some seminars, can benefit residents by demonstrating different approaches to the same case material or different views on the same issue. The ultimate structure of the forensic teaching team at a particular program will be determined by resources, available personnel, affiliated facilities, and residents’ abilities and interests. In a setting with limited resources (e.g., no law school, no forensic hospital), readings from a forensic psychiatry textbook, or material from the American Academy of Psychiatry and the Law Review Course, could provide structure for didactics.
A variety of materials are useful for teaching resident forensic psychiatry. Readings from textbooks on specific topics, and outlines of the topics, form a base for further learning. Reading actual statutes and case law relevant to the state in which the residency is located helps residents understand the origin of the rules they apply to their practice. More advanced residents may enjoy reading landmark cases in forensic psychiatry (t3). Retention is best if these didactics are coupled with case conferences in which residents apply their new knowledge to actual clinical dilemmas, under supervision. Advanced residents may enjoy reviewing controversial areas of forensic psychiatry (e.g. sexually violent predator laws, death penalty issues, mandatory treatment for drug offenders). These topics could include amicus briefs from organizations (e.g. American Psychiatric Association) and task force reports on the issue, recent legislation and judicial decisions, and materials generated by the media. A crucial part of training for more advanced residents involves developing the ability to review material in a critical, reasoned, and informed fashion. Residents with a particular interest in forensic psychiatry can gain opportunities for mentorship through membership in the American Academy of Psychiatry and the Law and attendance at its annual October meeting.
Ensuring adequate, well-balanced basic training in forensic psychiatry to general psychiatry residents will be ultimately beneficial to the field of general psychiatry. For some residents, the exposure may lead to a pursuit of employment in the public sector where they can then further foster relationships to their teaching institution. This academic-public sector collaboration expands teaching, clinical, and research efforts in both sectors. Other residents may become interested in advocacy for the mentally ill and use their training to be more effective outside of strictly medical settings. Some trainees may become interested in research related to forensic issues. A minority of residents will actually pursue forensic psychiatry as a career choice. A solid, balanced, interesting, and rich curriculum serves all of these residents in effectively pursuing their career paths and encourages critical evaluation of key issues in general psychiatry.