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
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Bursztajn HJ, Brodsky A: A new resource for
managing malpractice risks in managed care. Arch Intern Med 1996;
156:2057–2063
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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.