Psychotherapist Versus Expert Witness
TO THE EDITOR: In their summary of the forensic psychiatry community’s
position on keeping forensic psychiatric evaluation separate from
clinical treatment [1], Larry H. Strasburger, M.D.,
and colleagues generously acknowledge my contribution and my own
work [2]. However, while for a variety of reasons
I agree with the guidelines of the American Academy of Psychiatry
and the Law on this question, I do not share the authors’ characterization
that “direct probing necessary for forensic evaluation is inconsistent
with the ‘evenly hovering attention’ . . . of the dynamic psychiatrist.”
Maintaining evenly hovering attention [3], even
when directly probing, is important to avoid contamination by countertransference-driven
suggestion or avoidance, both in the course of confrontation in dynamic
psychotherapy and in the unstructured as well as the structured portions
of the forensic psychiatric examination [4].
Other differences aside, it is perhaps most important to note that while
role conflict is and has been ubiquitous historically, physicians
today are becoming increasingly aware of the variety of role conflicts
and dual agencies inherent in the reorganization of individual health
care into third-party-administered managed care. While multiplicity
of roles is unavoidable, consultation with a forensic psychiatrist
by the treating clinician can have a variety of ethical, clinical,
and risk-management benefits in contexts such as disability determination
[5]. When the potential for unavoidable role conflict
exists, a clinician’s first duty is to engage in an informed consent
process. In such a process, how the individual patient wants to use
the relationship can be explored and analyzed, and the patient is
informed as to foreseeable conflicts. Thus, potential conflicts need
to be addressed by dialogue rather than by unilateral fiat, or, as
clinicians refer to them, standard third-party excuses such as institutional
policies, geography, less than ideal circumstances, or other scapegoats
[6].
REFERENCES
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Strasburger LH, Gutheil TG, Brodsky A: On
wearing two hats: role conflict in serving as both psychotherapist
and expert witness. Am J Psychiatry 1997; 154:448–456
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Bursztajn HJ, Scherr AE, Brodsky A: The rebirth
of forensic psychiatry in light of recent historical trends in criminal
responsibility. Psychiatr Clin North Am 1994; 17:611–635
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Freud S: Recommendations to physicians practising
psychoanalysis (1912), in Complete Psychological Works, standard
ed, vol 12. London, Hogarth Press, 1958, pp 109–120
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Bursztajn HJ, Brodsky A: Competence and insanity,
in Psychiatric Secrets. Edited by Jacobson JL, Jacobson AM. Philadelphia,
Hanley & Belfus, 1996, pp 501–515
-
Bursztajn HJ, Brodsky A: A new resource for
managing malpractice risks in managed care. Arch Intern Med 1996;
156:2057–2063
-
Bursztajn HJ: Reflections on my father’s experience
with doctors during the Shoah (1939–1945). J Clin Ethics 1996; 7:311–314
HAROLD J. BURSZTAJN, M.D.
Cambridge, Mass.
