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).