Forensics, forensics fellowship, and life in the legal system

[luckrules]

Anyone on here do any forensic work? Are you forensically trained? If so this post is for you. Also, please PM me so I can ask you more!

I am currently a resident, and, as always, mulling what I'd like to do with my life after finishing training. We have a couple of faculty who are involved in the forensics world, but our exposure to their work is rather limited. Recently I've come to think that I might enjoy work at some intersection of the legal system, but I realized I probably have a pretty poor understanding of what that looks like and what these faculty do. I intend to approach them at some point to ask about their experience, but I thought I might mine the collective hive mind of nameless, faceless posters here on SDN to try and collect my thoughts before then.

If you are in forensics, what do you like about it? What does your day look like? How much of your time is spent doing "forensic" work vs general psychiatry?

What makes someone successful in forensics? What kind of a person is suited for this kind of work? What got you interested?

My impression is that there are two kinds of forensic psychiatrists, those that spend the majority of their "forensic" time providing care for those who are involved with the criminal justice system and suffer from a mental illness, and those who spend their "forensic" time conducting evaluations and "expert witness" testimony. Is this accurate? If not, what am I missing??

I've heard it said that forensics pays the big bucks because "lawyers are used to paying a lot of money." Is this true?

I apologize for my lack of knowledge. Please feel free to PM me, I'd like to have a more informal discussion if you're involved in this world. Thank you in advance.

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[splik]

Th

If you are in forensics, what do you like about it? What does your day look like? How much of your time is spent doing "forensic" work vs general psychiatry?

I have always been more interested in the philosophical aspects of psychiatry - .e.g the nature of mental disorder, personal responsibility in the context of mental illness, the concept of psychiatric diagnosis, free will vs determinism etc. These questions are on the periphery of clinical practice but are necessarily wedded to the practice of forensic psychiatry. I am also very interested in the evaluation part of psychiatry and of formulation - trying to make sense of why people do what they do. Forensic evaluations are really the only time (except maybe more dynamically informed psychotherapy) where you get to spend hours trying to understand how someone became who they did and did what they did. I also like you get paid to do things you don't in clinical practice (e.g. gathering collateral, reading through records etc) and you have a lot more information (e.g. work records, school transcripts, medical records, police reports, performance evaluations etc) to have a more complete picture. The work can be very intellectually stimulating and rewarding.

Like many forensic psychiatrists, I do clinical work that is non-forensically related. For me that includes C-L and neuropsychiatry. However legal questions come up in clinical practice so I am drawing from that all the time in complex capacity evaluations, violence and suicide risk assessment, malingering, confidentiality, right to refuse treatment, civil commitment, guardianship/conservatorship issues, ethical dilemmas at the end of life. I also do ethics committee work. teach students and residents etc (which is important for forensic psychiatrists), mentor residents in forensic psychiatry, write papers and books, serve on forensic related committees etc. I mainly do criminal forensic evaluations (chiefly mitigation and NGRI evaluations, some competency and risk assessment or other affirmative defense stuff), and consult in some civil matters (e.g. malpractice). I also do standard of care reviews and consult to professional boards.

What makes someone successful in forensics? What kind of a person is suited for this kind of work? What got you interested?

You need to be able to read through thousands of pages worth of documentation and have an eye for detail. This can sometimes make or break a case. You need to be able to write clearly and concisely. Reports can sometimes be 25-30 pages, in some cases even longer. You need to enjoy teaching others as that is what we are doing - breaking down complex psychological and psychiatric concepts for attorneys, judges, and juries etc. Most forensic psychiatrists have some role teaching (e.g. med students, residents, fellows, law students etc).

My impression is that there are two kinds of forensic psychiatrists, those that spend the majority of their "forensic" time providing care for those who are involved with the criminal justice system and suffer from a mental illness, and those who spend their "forensic" time conducting evaluations and "expert witness" testimony. Is this accurate? If not, what am I missing??

In the US, the former was what all of psychiatry was at one point- working with the insane in asylums. The latter role became what forensic psychiatry was in the US because of the importance of psychiatrists to assessment of civil competencies (e.g. testamentary capacity) and in determinations of cause of death, as suicide invalidated life insurance in the early part of the 20th century (and in some cases does early in the plan). Typically when we are talking about forensic psychiatry in the US we are talking about the psychiatrist as expert witness although most psychiatrists serving as experts are not forensically trained. Recently there has been a trend to include correctional psychiatry (i.e. working with mentally disordered offenders in correctional settings) in forensic psychiatry but most psychiatrists in correctional settings are general psychiatrists. Many state hospitals have forensic populations. Typically people treating those patients are not forensic psychiatrists thought may well be, and most institutions will try to have those with such experience do the competency and criminal responsibiltiy evaluations and testify in court for those patients.

In contrast in other countries (e.g. US, Australia) forensic psychiatry typically refers to those psychiatrists who specialize in treating mentally disordered offenders.

I've heard it said that forensics pays the big bucks because "lawyers are used to paying a lot of money." Is this true?

There is a huge variation in what pays what. Some of this is geographically determined and some of it depends on who is paying. Also psychiatrist payment compared to other specialities doing medicolegal work is depressed by psychologists who is many cases can serve as an expert instead of a psychiatrist. If you are working for the local public defenders office then the pay is similar or less to what you would get for clinical work ($150-250 is typically). District Attorney's office pay similarly but better. Misdemeanor cases will have much less budget than felony cases. You are also likely to be capped on the total number of hours you get paid for, even if the case requires more hours than you get paid for. Private criminal attorneys may pay better but often their clients don't necessarily have much money and depending on the case you are still looking at the lower end. High profile cases may pay better if there is special dispensation and typically those cases will go to very experienced forensic psychiatrists.

Courts tend to pay poorly. Our local courts pay such garbage I do pro bono work for them for a few interesting high profile cases a yr. The federal courts pay better but again things are capped. In my area (the most expensive in the country), the federal courts cap at $350/hr for non-capital cases for psychiatrists. There are exceptions for special cases.

Civil cases (e.g. personal injury, malpractice, workplace discrimination etc) tend to pay better. Plaintiff attorneys tend to have solo practices and work on a contingency basis (i.e. no win no fee). So they don't want to spend much money, will often not be reliable about paying, and they are using their own money. Typically they have only a 20% chance of winning a case, so they try to keep expenses as a minimum. However it is not unusual for for psychiatrists to charge $400-800 for this. In some locales e.g. NYC, it is not unheard of for senior psychiatrists to charge $900/hr.

Defense attorneys often work for big firms and often have clients with deep pockets (I have consulted on cases where the defendant is a bank for example). So they usually do pay reliably. Similar rates as above. Some people do charge >$1000/hr but that is unusual in psychiatry.

Legal aid firms and charitable organizations that provide immigration services will often want you to work for free or for such low amounts its better just to do it free for "public service" or for the experience.

Disabiltiy and worker's compensation cases tend to pay a fixed amount. Worker's comp pays better than social security disabilty cases (very poorly for the latter). Private insurance companies pay more in the realm of what was discussed above (e..g $350-550/hr)

Professional boards might have a cap. Our local ones only pay $150-200/hr. It is considered service and also does give experience that makes you attractive for higher paying cases.

In short, there is a wide variation in how much one can make doing forensic work depending on the cases, geography, and your experience. Varies from $0/hr to >1000/hr. Criminal cases tend to pay much lower, public/governmental agencies tend to pay much lower for criminal cases, and civil cases can often pay very well due to the high financial stakes. Many people charge the same or more in cash only private practice in coastal cities than in forensic work.

I actually make more for my clinical consulting work than I do for forensic work. However I can do most forensic work from my bed and find it intellectually stimulating. So much so I do about 80hrs a yr for forensic work pro bono.

 

[watto]

Psyguru will hopefully chime in with his perspective as well. Splik did a nice overview.

I really enjoy doing Independent Medical Examinations, which require a forensic evaluation. As Splik noted, the work can be intellectually stimulating (especially if you are an analytical thinker).

I take pride in doing thorough evaluations, which give me the confidence to opine on sometimes complex cases. I admit that I enjoy having access to large files of treatment records, with a 360 degree view of a case, such that I can make treatment recommendations. When I see egregious care (psychopharm-wise or therapy-wise), I can make an informed opinion about it and hopefully direct someone into something more effective. I also enjoy the gamesmanship that can be involved in detecting malingering. It keeps me on my toes.

 

[icysky]

Hello. I’m an incoming resident also interested in forensics. Are there any tips you can give getting involved in these cases as a resident? I would like to help an attending on a few cases with the actual work to see if I want to pursue this career path or not. Since my program has a forensics fellowship, should I just ask the attending if I could do some of the work or what is the best way to get my feet wet a bit before deciding? Thanks!

 

[psych_0]

I also enjoy the gamesmanship that can be involved in detecting malingering

Any good books or papers to help with this? I've read the classic Phil Resnick article "The detection of malingered psychosis" but was wondering if you had any recommendations for something newer or more in depth?

 

[romanticscience]

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[watto]

I do a lot of PTSD rule-out so have found the following article to be helpful. I also purchased and learned to administer the M-FAST, which has been very useful.

Multimodal Approach to Identifying Malingered Posttraumatic Stress Disorder: A Review - Innovations in Clinical Neuroscience

Peer-reviewed evidence-based information in neuroscience research and practice, including psychiatry, neurology, psychology

innovationscns.com

 

[psyguru]

Yes, I can chime in. I do part-time clinical work and part-time expert witness work. I did the fellowship. There is a wide variety of cases from the stress of pre-imminent death, asylum cases, NGRI, Defense Base Act (contractors injured in Irani missile attack on US base), Capital Sentence Mitigation, Testmementory Capacity, Personal Injury, Malpractice, correctional, Occupational IME (they can be very interesting...I had two back to back psychosomatic cases). I believe I see far more variety of diagnoses as an expert witness than I do at two of my clinical jobs combined.

The hourly does vary. I think the rates splik mentioned were the base rate (reviewing records, evaluations, phone calls with an attorney, etc). Usually testifying is $150 to $200 more an hour. For travel, I charge less than half my base rate to encourage out-of-state work. Some experts charge the same rate for travel time. Although I do pro-bono work, I will stick with my fee schedule and have no shortage of work. If an attorney can't afford it, I will suggest they contact a forensic psychologist. Occasionally I may lower my rate for an interesting or very large case.

You may want to take a look at my other posts and PM me. There is an FB group for physician expert witnesses.

 

[psyguru]

I do a lot of PTSD rule-out so have found the following article to be helpful. I also purchased and learned to administer the M-FAST, which has been very useful.

Multimodal Approach to Identifying Malingered Posttraumatic Stress Disorder: A Review - Innovations in Clinical Neuroscience

Peer-reviewed evidence-based information in neuroscience research and practice, including psychiatry, neurology, psychology

innovationscns.com

I was just reading A Systematic Approach to the Detection of False PTSD . There was an excellent seminar on the topic at the Austin AAPL meeting.

 

[splik]

The hourly does vary. I think the rates splik mentioned were the base rate (reviewing records, evaluations, phone calls with an attorney, etc). Usually testifying is $150 to $200 more an hour. For travel, I charge less than half my base rate to encourage out-of-state work. Some experts charge the same rate for travel time. Although I do pro-bono work, I will stick with my fee schedule and have no shortage of work. If an attorney can't afford it, I will suggest they contact a forensic psychologist. Occasionally I may lower my rate for an interesting or very large case.

I charge the same rate for record review, report writing, travel, testimony and deposition which is pretty standard in forensic psychiatry though non-forensic psychiatric experts typically do charge more for testimony/deposition. My rationale is you are paying for me time regardless of what I am doing.

 

[watto]

I was just reading A Systematic Approach to the Detection of False PTSD . There was an excellent seminar on the topic at the Austin AAPL meeting.

This is a good article. I am going to use some of the references for my arguments against "checklist-style" diagnosis of PTSD in non-forensic practice.