Future of Psychology

[Alemo]

Hi everyone,

Forgive the vague clickbait title.

I’m going into forensics (I’m in psychiatry residency) and recently have had a few conversations with forensic psychiatrists (AAPL leaders and program directors) who told me in no uncertain terms that “I’ll need to specialize in something [forensic] psychologists don’t do.” Soon afterwards, I was discussing the field on a different psychology forum and had some folks (identifying themselves as forensic psychologists) claiming psychiatrists simply made “clinical judgments” which were no more valid than “hot takes.” One commenter even suggested we (psychiatrists) “leave the forensics to them (psychologists).”

I didn’t realize there was such a turf war. Of course clinically, I’ve long recognized the value of neuropsychology and a good clinical psychologist practicing therapy. I studied psychology in college and cherish that experience (even as other premeds took biochem, chemistry, or neuroscience).

Of course I’d like to hear opinions from @splik and @whopper for forensic matters, but also from psychologists here and anyone else with even non forensic opinions.

I know the professions have different roles. With the potential for biomarkers/objective measures of illness (huge stretch believe me I know), will psychometric tests and other such assessments remain valid (more so than the interview methods we are taught)? Should forensic psychiatrists improve their familiarity with testing (one aforementioned commenter tried to ridicule me for mentioning the M-FAST as “it’s not specific”). Do psychologists really see us as bloviating clowns who give “hot takes” and expect people to listen because we are learned doctors? Is there a worry in the clinical psychology profession that psychiatrists are encroaching (I would guess not due to the dearth of psychiatrists and the shrinking percentage who practice therapy).

Thanks!

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[erg923]

I don’t know what a “hot take” is, but suffice to say most practicing (criminal) forensic psychologists and psychiatrists are extremely detailed, scientifically orientated clinicians and evaluators. It’s really hard to get in the field and stay in it if you’re not. There have been famous blunders and “clown” moments from both professions over the years.

You are not a forensic psychiatrist yet, so I’m not sure why somebody on a forum would be so upset with your lack of knowledge of forensic oriented testing and evaluation procedures?

I really don’t think there’s that much of a turf war. It’s the inter-webs. Got to create drama somehow.

 

[WisNeuro]

Small, sample size, so far I've only been asked to comment a couple times on opinions by psychiatrists in legal settings. In those two times, the psychiatrists offered opinions with no basis in any kind of empirical literature (mild TBI cases) and made diagnoses and statements of prognosis that did not take into account the peritraumatic details and that flew in the face of the extant literature. There was also no formal type of assessment in their evaluation, just clinical interview. Hard to generalize from those cases, as the individuals are known plaintiff shills.

As for encroachment, not a worry for me. For every legal case I accept, I have to turn down 1-2 because it doesn't fit into my schedule. I'm just planning on raising my rates every year until that evens out.

 

[dl2dp2]

There are legal reasons why psychologists (or any other non-physician practitioner) cannot ever fully encroach on a psychiatrists' turf. This phenomenon exists in not just a forensic context but also in a number of other capacities (i.e. clinical trials, commercial regulatory affairs, etc).

The gestalt here is in many clinical scenarios, there's a legal necessity for a certified physician to make a final call on a high-stakes clinical judgment. Can a forensic psychologist diagnose schizophrenia? Technically, yes: anyone can use the DSM checklists and say this person match all the criteria and that person didn't. However, in many contexts, all of the parties involved prefer that such final opinion is rendered by a physician.

This is relevant for things like not being criminally liable for reasons of insanity, civil forensic issues regarding parental capacity, etc. etc. The non-physician is thought to typically not have the expertise to render an opinion AS SOON AS a legitimate medical issue arises (i.e. any requirement of medication). And this makes sense--the best-trained forensic psychologist is still less credible about psychotropic medications than a comparable psychiatrist on these topics.

Similarly, when any commercial entity wants a rubber stamp that what they do is "following conventional medical practice standards", a psychologist or any other type of non-physician is not qualified to render this opinion. This is why medical directors at pharma (and other) companies get paid 2x a non-medical director.

That being said, in practical terms, it's always good to think about business-related issues, such as what is your real value, and how do you market yourself to be differentiated from the competition. Very often, the value is unrelated to the actual product given, but to market realities of supply and demand, and various other factors. For example, it is possible that many tasks in forensic evaluation can be done just as well by a PhD for cheaper, and in many contexts (i.e. public, most criminal) a cheaper alternative is sought. However, in some smaller segmented market (private, civil, etc) there's a client that demand MDs. Even though it's a smaller client, the number of MDs that would satisfy that market is EVEN smaller, rendering the fee structure to be more favorable to the MDs providing the services. These are issues similar to NP encroachment, etc. You just have to know the market well and be willing to make mistakes and explore.

 

[WisNeuro]

The overlap probably varies depending on what area you do the most work in. I am rarely seeing psychiatry in my personal injury TBI cases. Even when PTSD is in question it's not that common. But, will see it in some of my RTW type stuff, though we're usually asked to answer questions in different areas. As for marketing and payment, pretty variable. I know people charging as little as $200/hr, which is just poor business sense, but also people charging, and regularly getting, 4 figures an hour.

 

[Bartelby]

In high-stakes cases often a psychologist and a psychiatrist both conduct evaluations. Each can bring things the other can't to the evaluation, and it is better to think of the two professions as different in a forensic context rather than considering one simply better.

If you do evaluations on your own you should become familiar with very basic testing (TOMM, M-FAST, SIRS-2, etc). You likely should not try for more complicated tests like the MMPI or PAI without the appropriate background.

 

[comp1]

It seems no matter where you go in medicine, there's a near obsession with other people coming for their jobs. Really, you'll be fine. You have your lane and they have theirs. There's plenty of work for everyone.

 

[WisNeuro]

In high-stakes cases often a psychologist and a psychiatrist both conduct evaluations. Each can bring things the other can't to the evaluation, and it is better to think of the two professions as different in a forensic context rather than considering one simply better.

If you do evaluations on your own you should become familiar with very basic testing (TOMM, M-FAST, SIRS-2, etc). You likely should not try for more complicated tests like the MMPI or PAI without the appropriate background.

Honestly, I would even leave the TOMM out of it. One of the most recognizable and coached PVTs out there, and even before all of this, very poor sensitivity. In assessing PVTs vs SVTs, fairly dynamic and nuanced part of the eval.

 

[PsyDr]

Should forensic psychiatrists improve their familiarity with testing .....

Is there a worry in the clinical psychology profession that psychiatrists are encroaching....

Uhmmm.

 

[dl2dp2]

It seems no matter where you go in medicine, there's a near obsession with other people coming for their jobs. Really, you'll be fine. You have your lane and they have theirs. There's plenty of work for everyone.

Generally, sure. More specifically, NPs have eliminated certain jobs for MD psychiatrists. So if one is one of the specifics who got eliminated, your sentiments might seem weird and patronizing. While being paranoid is dumb, being informed and prepared is not. Not engaging with the market reality is not really reassurance.

 

[splik]

unlike other fields of medicine, psychiatric expert witnesses can often be interchangeable with psychological expert witnesses. Which is to say, in some cases an expert with either background may be acceptable. In other cases, psychology or neuropsychology is definitely needed, and in other cases a psychiatric expert is needed. In complex cases a forensic psychiatrist will work in conjunction with a forensic psychologist. I've not really seen much difference in quality. I have read many reports by psychologists full of nonsense. Using testing may obfuscate the nonsense but it does not eliminate it. One case I did, the opposing expert was a neuropsychologist and stepped outside of their scope to comment (wrongly) on MRI brain findings, and also to recommend Lamictal for psychosis. One report from a forensic psychologist I read was mainly copy and pasted from a website. Frequently, the conclusions and opinions proffered are not backed up by the data.

I do have to say, on average, psychologists write better reports than psychiatrists, but I see no difference in the quality of the opinions provided. Some people are very good, and others not so much. Many of either profession are quite willing to say anything for pay. And of course the ethical standards of psychology are lower, as evidenced by the lack of a total prohibition of sexual relations with former clients, and allowing psychologists to participate in torture.

A lot of attorneys do not know the difference between a psychologist and psychiatrist. I have frequently been called, and listed in court documents as a "clinical and forensic psychologist" despite my fee schedule being higher. In the aforementioned case, the judge required the defendant to be on lamictal for psychosis on the recommendation of the psychologist.

 

[erg923]

It seems no matter where you go in medicine, there's a near obsession with other people coming for their jobs. Really, you'll be fine. You have your lane and they have theirs. There's plenty of work for everyone.

I mean, yea, sorta? I'm not sure I would say it is a about "lanes?" Psychiatrists and psychologists are often called upon to answer the same forensic question in a case though, right? Obviously, questions involving medical comorbidities and questions about medication effects or influence (or lack thereof) would fall more to a psychiatrist in a case. But typically, there is much overlap, and it is ultimately the jury's job to parse out the "credibility" of any expert witness testimony regarding the trier of fact. In some cases, a neuropsychologists clinical and forensic experience and subsequent testimony might be needed and preferred. In others, a practicing physician/psychiatrist.

 

[dl2dp2]

as evidenced by the lack of a total prohibition of sexual relations with former clients, and allowing psychologists to participate in torture.

lol ouch ... good job bud for the burn here

my experience in civil has been that as soon as meds are involved, parties start to call MDs. could be my area tho... civil lawyers have told me about bad experiences calling psychologists re: meds. in your example, the opposing council could easily cross-examine the bad answers out and destroy the witness's credibility. *typically* high-end civil want to avoid these scenarios...

 

[PsyDr]

Thematically, the response is “I’m better”. That response is the problem for forensic psychiatry.

 

[calvnandhobbs68]

A lot of attorneys do not know the difference between a psychologist and psychiatrist. I have frequently been called, and listed in court documents as a "clinical and forensic psychologist" despite my fee schedule being higher. In the aforementioned case, the judge required the defendant to be on lamictal for psychosis on the recommendation of the psychologist.

Nice, bet the defendant got way better.

 

[Alemo]

Uhmmm.

I think you were sarcastically implying to try that I've answered my own question, but as I've said I'm ignorant as to the state of the field on this question.

I'm glad to hear that the majority of both professions seem to offer good well reasoned opinions, despite the psychiatrists' reliance on clinical judgment and the variable training in neuroscience of psychologists. I wonder what psychometric tests are important for the forensic psychologist, and the degree to which they outperform the clinical interview (I presume significantly but again I don't know).

Thematically, the response is “I’m better”. That response is the problem for forensic psychiatry.

I think I missed the joke here...

 

[erg923]

and the degree to which they outperform the clinical interview (I presume significantly but again I don't know).

What does this even mean?

 

[PsyDr]

I think you were sarcastically implying to try that I've answered my own question, but as I've said I'm ignorant as to the state of the field on this question.

I'm glad to hear that the majority of both professions seem to offer good well reasoned opinions, despite the psychiatrists' reliance on clinical judgment and the variable training in neuroscience of psychologists. I wonder what psychometric tests are important for the forensic psychologist, and the degree to which they outperform the clinical interview (I presume significantly but again I don't know).



I think I missed the joke here...

1) It's an internal consistency thing. You asked if psychologists were worried about psychiatry trying to encroach on their area of expertise. Then you asked if you should start using psychology's tools. That answers that question. In all friendliness, it's a pretty funny set of questions. We've all been there.

2) The boundaries between psychiatry and psychology, to me, look more like a continuum than a hard line. That continuum offers some "space for us to argue. Without that space to argue, there would be less need for forensics. The problem arises when one uses the other's tools, and gets questioned as if they have the same degree of skill. That's why Splik's narrative is liked. That's why I like Bartleby's opinion. We could argue about the merits of clinical interviews for hours, and make a ton of money while doing that. But I wouldn't want to debate the merits of the CATIE study with him in court. And I doubt he would want to argue about the merits of t scores in court with me. Same for radiologists and medical physicists.

3) It's not a joke, but it is funny. Look at the responses, and their structure. Now compare that to Daubert. Imagine how that reasoning plays out in court.

 

[romanticscience]

Honestly, I would even leave the TOMM out of it. One of the most recognizable and coached PVTs out there, and even before all of this, very poor sensitivity. In assessing PVTs vs SVTs, fialry dynamic and nuanced part of the eval.

I believe it's partially psychiatry's, as a field, fault for not embracing evidence-based diagnosis earlier. Psychology is rooted in standardized measurements with statistical norms and distributions, which work very well in the legal context. Despite being a "statistical manual," the DSM has very little available statistical data to base the diagnosis. I've had to personally look into kappa values/reliability numbers just to be prepared on the stand.

So, when an opinion has to be rendered, the tools available to psychologists are much better suited than what psychiatrists have. It may have something to do with psychiatry developing as a primary treatment-focused or phenomenology-oriented specialty (e.g., interview/case/clinical data) versus a psychometric basis.

My question for the group. I am ceding that my primary expertise is not in testing. How can I practically guard myself against the vulnerability of making an invalid diagnosis? I know about but would defer MMPI or PAI testing. Any suggestions for opinions related to symptom and performance validity? I use the M-FAST, SIRS-2, and TOMM to inform my opinions. I suppose I'd rather be vulnerable to cross-examination on NOT being a psychologist and using them rather than having no evidence for the validity of my database.

Thoughts?

 

[Alemo]

What does this even mean?

Well as I stated in my first post, a psychologist told me that for some questions, psychometric tests offer more valid/reliable answers than a clinical interview would.

To tie this in with @romanticscience question (as well as my own interest in nosology and diagnostic validity), how do psychometric tests outperform (I.e to a legal standard) the clinical interview?

For cognition, it seems psychometric tests are a clear winner. Just as neurology deals with gross neuronal injury that can be clinically seen, we (psychiatry) deal with cognitive problems that are clinically obvious. We don’t spend time in med school or residency arguing if someone does or doesn’t have MCI. I did some reading on SVTs (for the uninitiated like me no that’s not super ventricular tachycardia) and it makes sense to me how these would be useful in assessing the degree of symptom impairment or detecting malingering in a lot of civil case matters. I once had a patient with delusions about having dementia, and I remember the clinical interview/MoCA was a pretty bad proxy in answering the question “How do these cognitive symptoms affect your life?” Objective performance on a test could have shown presence or absence of that problem.

(Regarding ADHD however, I know that in the strict sense the diagnosis is made clinically and neuropsych testing is *technically* superfluous. Is that view shared by psychologists?)

But for making sense of phenomenology, I guess I don’t see the clear utility of psychometric tests over interview. Eliciting symptoms and organizing them into a coherent pattern (“this sounds like a known syndrome” vs “this sounds more atypical” vs “this suggests malingering”) seems to be a much more suited to psychiatric diagnosticians than psychologists. I guess in the majority of cases a neuropsychologist would be well aware of common presentations of psychiatric illness and could sort accordingly, but the most complete perspective on symptoms likely comes from psychiatrists. I would include here in psychiatry’s tools the use of a standardized interview schedule so as to review as many phenomena as possible.

Maybe it has something to do with the idea that cognition is something we can all agree on a definition of (relatively) and the extent to which it can be tested is relatively high….when compared to mental illness which we are still struggling to explain on an etiological basis and for which we have no highly durable, valid classification schemes for all these varied presentations (e.g. were they manic, were they psychotic, did they have schizoaffectove disorder, are these delusions or overvalued ideas, etc).

Final question: should psychiatrists even be diagnosing personality disorders?

 

[WisNeuro]

Well as I stated in my first post, a psychologist told me that for some questions, psychometric tests offer more valid/reliable answers than a clinical interview would.

To tie this in with @romanticscience question (as well as my own interest in nosology and diagnostic validity), how do psychometric tests outperform (I.e to a legal standard) the clinical interview?

For cognition, it seems psychometric tests are a clear winner. Just as neurology deals with gross neuronal injury that can be clinically seen, we (psychiatry) deal with cognitive problems that are clinically obvious. We don’t spend time in med school or residency arguing if someone does or doesn’t have MCI. I did some reading on SVTs (for the uninitiated like me no that’s not super ventricular tachycardia) and it makes sense to me how these would be useful in assessing the degree of symptom impairment or detecting malingering in a lot of civil case matters. I once had a patient with delusions about having dementia, and I remember the clinical interview/MoCA was a pretty bad proxy in answering the question “How do these cognitive symptoms affect your life?” Objective performance on a test could have shown presence or absence of that problem.

(Regarding ADHD however, I know that in the strict sense the diagnosis is made clinically and neuropsych testing is *technically* superfluous. Is that view shared by psychologists?)

But for making sense of phenomenology, I guess I don’t see the clear utility of psychometric tests over interview. Eliciting symptoms and organizing them into a coherent pattern (“this sounds like a known syndrome” vs “this sounds more atypical” vs “this suggests malingering”) seems to be a much more suited to psychiatric diagnosticians than psychologists. I guess in the majority of cases a neuropsychologist would be well aware of common presentations of psychiatric illness and could sort accordingly, but the most complete perspective on symptoms likely comes from psychiatrists. I would include here in psychiatry’s tools the use of a standardized interview schedule so as to review as many phenomena as possible.

Maybe it has something to do with the idea that cognition is something we can all agree on a definition of (relatively) and the extent to which it can be tested is relatively high….when compared to mental illness which we are still struggling to explain on an etiological basis and for which we have no highly durable, valid classification schemes for all these varied presentations (e.g. were they manic, were they psychotic, did they have schizoaffectove disorder, are these delusions or overvalued ideas, etc).

Final question: should psychiatrists even be diagnosing personality disorders?

Couple of things. Psychologists are trained very well in diagnostics, including standardized interviews, so I think that is a false dichotomy. They are also trained very well in integrating the clinical interview with actuarial methods in diagnosis, which research has shown consistently over time that actuarial methods outperform clinical judgment. Another thing, you can't conflate making a psychiatric diagnosis in a clinical context, with making a diagnosis in a legal context in which there are clear secondary gain issues. These are vastly different beasts.

 

[romanticscience]

I know some interesting relationships between hypnosis and the courts, particularly regarding false memory. Another question to pose to the forensic types: Would hypnotic susceptibility testing (e.g., HIP) pass Daubert, or will it look bad to use in my forensic evaluations as another tool for differentiating diagnosis (psychosis 2/2 schizophrenia v. psychosis 2/2 BPD/trauma/etc.)?

I am just looking for more tools to compare with the psychologists' stuff (negative impression scales and inconsistency sales).

 

[erg923]

Well as I stated in my first post, a psychologist told me that for some questions, psychometric tests offer more valid/reliable answers than a clinical interview would.

To tie this in with @romanticscience question (as well as my own interest in nosology and diagnostic validity), how do psychometric tests outperform (I.e to a legal standard) the clinical interview?

For cognition, it seems psychometric tests are a clear winner. Just as neurology deals with gross neuronal injury that can be clinically seen, we (psychiatry) deal with cognitive problems that are clinically obvious. We don’t spend time in med school or residency arguing if someone does or doesn’t have MCI. I did some reading on SVTs (for the uninitiated like me no that’s not super ventricular tachycardia) and it makes sense to me how these would be useful in assessing the degree of symptom impairment or detecting malingering in a lot of civil case matters. I once had a patient with delusions about having dementia, and I remember the clinical interview/MoCA was a pretty bad proxy in answering the question “How do these cognitive symptoms affect your life?” Objective performance on a test could have shown presence or absence of that problem.

(Regarding ADHD however, I know that in the strict sense the diagnosis is made clinically and neuropsych testing is *technically* superfluous. Is that view shared by psychologists?)

But for making sense of phenomenology, I guess I don’t see the clear utility of psychometric tests over interview. Eliciting symptoms and organizing them into a coherent pattern (“this sounds like a known syndrome” vs “this sounds more atypical” vs “this suggests malingering”) seems to be a much more suited to psychiatric diagnosticians than psychologists. I guess in the majority of cases a neuropsychologist would be well aware of common presentations of psychiatric illness and could sort accordingly, but the most complete perspective on symptoms likely comes from psychiatrists. I would include here in psychiatry’s tools the use of a standardized interview schedule so as to review as many phenomena as possible.

Maybe it has something to do with the idea that cognition is something we can all agree on a definition of (relatively) and the extent to which it can be tested is relatively high….when compared to mental illness which we are still struggling to explain on an etiological basis and for which we have no highly durable, valid classification schemes for all these varied presentations (e.g. were they manic, were they psychotic, did they have schizoaffectove disorder, are these delusions or overvalued ideas, etc).

Final question: should psychiatrists even be diagnosing personality disorders?

I guess it’s “outperform” that is throwing me. That’s not really what this is and how this works. Psychologist do talk to their patients to, you know? Using tests, especially for psychiatric concerns and diagnoses is meant to add additional information to information gathered from talking with patient and collateral sources.

 

[WisNeuro]

I know some interesting relationships between hypnosis and the courts, particularly regarding false memory. Another question to pose to the forensic types: Would hypnotic susceptibility testing (e.g., HIP) pass Daubert, or will it look bad to use in my forensic evaluations as another tool for differentiating diagnosis (psychosis 2/2 schizophrenia v. psychosis 2/2 BPD/trauma/etc.)?

I am just looking for more tools to compare with the psychologists' stuff (negative impression scales and inconsistency sales).

Haven't seen anything like this in my realm, but I stay largely within the civil litigation side of things. Maybe those on the criminal side of things would have a better idea, but I'd be skeptical of HIP, and I'd think it'd be easy to sway a judge/jury against it as the lay public views hypnosis as a parlor trick.

 

[Alemo]

I guess it’s “outperform” that is throwing me. That’s not really what this is and how this works. Psychologist do talk to their patients to, you know? Using tests, especially for psychiatric concerns and diagnoses is meant to add additional information to information gathered from talking with patient and collateral sources.

I mean, I know I’m uninitiated, but to answer a question accurately (“carving nature at the joints”), that is how it works.

Jesus Christ, of course I know psychologists talk to evaluees and patients. Both professions employ humans with brains and biases and human intelligence. What I mean is, when we consider the sum total of information gathered in an evaluation, and seek to answer a question put before us by the court, which methods are better?

I’m interested in gold standard, state of the art practice.

[this would probably involve both a psychiatrist and psychologist evaluating and forming an opinion]

But what are the elements of each evaluation that get to the heart of the matter?

I think “psychiatrists are MDs and have more credibility with juries” or “I met X psychiatrist who did a ****ty job” are immaterial right now. My question is academic and theoretical.

 

[calvnandhobbs68]

But for making sense of phenomenology, I guess I don’t see the clear utility of psychometric tests over interview. Eliciting symptoms and organizing them into a coherent pattern (“this sounds like a known syndrome” vs “this sounds more atypical” vs “this suggests malingering”) seems to be a much more suited to psychiatric diagnosticians than psychologists. I guess in the majority of cases a neuropsychologist would be well aware of common presentations of psychiatric illness and could sort accordingly, but the most complete perspective on symptoms likely comes from psychiatrists. I would include here in psychiatry’s tools the use of a standardized interview schedule so as to review as many phenomena as possible.

Maybe it has something to do with the idea that cognition is something we can all agree on a definition of (relatively) and the extent to which it can be tested is relatively high….when compared to mental illness which we are still struggling to explain on an etiological basis and for which we have no highly durable, valid classification schemes for all these varied presentations (e.g. were they manic, were they psychotic, did they have schizoaffectove disorder, are these delusions or overvalued ideas, etc).

Final question: should psychiatrists even be diagnosing personality disorders?

I mean, this statement is probably where the blowback came from. Plenty of psychologists are very able to elicit symptoms and organize them into a coherent pattern as well...

Part of what these statements are getting at are also what does it mean for someone to "really" have a certain psychiatric disorder or not (so a true positive). This is actually a pretty hard thing to get at because the basis of diagnosis for most DSM disorders is, drumrolls, clinical impression. Like most things in medicine where we don't have objective testing/imaging to give us a good yes/no answer. What does it even mean for someone to be "more accurate" at diagnosing patients or have the "correct" diagnosis? I think that's what you're getting at with the second paragraph there and the reason why inter-rater reliability is so terrible in psychiatry in general.

 

[Alemo]

Couple of things. Psychologists are trained very well in diagnostics, including standardized interviews, so I think that is a false dichotomy. They are also trained very well in integrating the clinical interview with actuarial methods in diagnosis, which research has shown consistently over time that actuarial methods outperform clinical judgment. Another thing, you can't conflate making a psychiatric diagnosis in a clinical context, with making a diagnosis in a legal context in which there are clear secondary gain issues. These are vastly different beasts.

Good answer, thanks. I am aware of the last part of what you said (definitely always bears repeating). And based on these premises (which I’m inclined to accept as true), just how useful are forensic psychiatrists [or should I say THE TRAINING/METHODS of, because all people are unique and special haha].

How do forensic psychiatrists add value outside of answering medication-related questions?

 

[Alemo]

I mean, this statement is probably where the blowback came from. Plenty of psychologists are very able to elicit symptoms and organize them into a coherent pattern as well...

Part of what these statements are getting at are also what does it mean for someone to "really" have a certain psychiatric disorder or not (so a true positive). This is actually a pretty hard thing to get at because the basis of diagnosis for most DSM disorders is, drumrolls, clinical impression. Like most things in medicine where we don't have objective testing/imaging to give us a good yes/no answer. What does it even mean for someone to be "more accurate" at diagnosing patients or have the "correct" diagnosis? I think that's what you're getting at with the second paragraph there and the reason why inter-rater reliability is so terrible in psychiatry in general.

If there was ruffling of feathers from what I said (even though I made clear in the following sentence that a psychologist can and in fact do make diagnoses and understand mental illnesses), I apologize.

I’ve interacted with a lot of forensic psychologists in Cincinnati and Michigan (some nationally renowned) and many have seemed highly intelligent. If I’m really giving off the impression that I think psychologists are dumb**** *****s (or even the impression that I am underestimating their training), I should give up online forums as discussion venues.

I am well aware psychiatric diagnosis is muddy (see my recent other thread on nosology). That being duly noted, what methods (those employed by psychiatry, psychology, or a mix of such) provide “state of the art” answers to the court (imprecise as they may be today)?

 

[erg923]

I mean, I know I’m uninitiated, but to answer a question accurately (“carving nature at the joints”), that is how it works.

Jesus Christ, of course I know psychologists talk to evaluees and patients. Both professions employ humans with brains and biases and human intelligence. What I mean is, when we consider the sum total of information gathered in an evaluation, and seek to answer a question put before us by the court, which methods are better?

I’m interested in gold standard, state of the art practice.

[this would probably involve both a psychiatrist and psychologist evaluating and forming an opinion]

But what are the elements of each evaluation that get to the heart of the matter?

I think “psychiatrists are MDs and have more credibility with juries” or “I met X psychiatrist who did a ****ty job” are immaterial right now. My question is academic and theoretical.

First, easy with the blasphemy.

A multimethod approach to assessment of a patient allows for multiple data points that can then be examined for discrepancies or additional information of revelations not told directly too you verbally by patients or collaterals. This is often what you are looking for in a forensic question and case. Multiple data points and sources for those data points is a good thing. The fact that one is backed up by large N normative and/or clinical groups is extremely helpful. But that does not make tests a superior method and "outperform" is not a accurate way to look at this. Tests do not make a diagnosis.

Again, I have to come back to the false dichotomy you seem to have regarding psychiatric interview and psychological tests/testing. I am well aware of and well trained in psychiatric interviewing, the SCID, and CAPS, etc. Not all psychologists are, but the ones doing forensic work are by necessity. I am actually no t involved in forensic work, but just so happened to have been well-trained in the area doing to my grad school research lab's work/focus.

 

[PsyDr]

@Alemo

1) Keep in mind that erg has some discordant views. So do I.
2) The issue with diagnosis, in a legal setting, is about Daubert criteria (e.g., reproducibility, known error rate, etc.) Psychologists have tests, which help meet these criteria. We also have base rate data on malingering, which help. Psychiatric methods can do this quite well, too, using their own tools. Each scenario has its own strengths and its own weaknesses. For example:

a. Let's say the litigated issue was Alcohol Use Disorder. Both professions would do an interview. Psychologists would use some testing. That has some validity. But psychiatry can use superior lab tests like GGT, AST, ALT, etc. Which one would do better?

3) IMO, the "strength" in psychiatry, is that you guys are trained to speak definitively. That can work out very well, assuming you stick to your areas. I was listening to Goldberg the other day. In narrative form, he cites the literature, its limitations, the stats, and how he formed his opinion. That is a deeply convincing way to speak in legal settings. Resnick does it well. So does Dietz. However, it can go bad. The most famous example of this is the trial of the guy who killed Harvey Milk. The psychiatrist was trying to explain the correlation between carbohydrate intake and serotonin turnover. It's not a bad point. But the expert assumed his opinion would be accepted, so he didn't explain the backing of his opinion, and there are no firm stats on it. So the media called it the "twinkie defense", and laughed at him. He would have been better off not speaking so definitively.

 

[splik]

@Alemo

However, it can go bad. The most famous example of this is the trial of the guy who killed Harvey Milk. The psychiatrist was trying to explain the correlation between carbohydrate intake and serotonin turnover. It's not a bad point. But the expert assumed his opinion would be accepted, so he didn't explain the backing of his opinion, and there are no firm stats on it. So the media called it the "twinkie defense", and laughed at him. He would have been better off not speaking so definitively.

This guy is 85 and he is still going. It is true that his opinions were misrepresented as the Twinkie Defense and what he was saying was not as ridiculous as he it sounds. However, having read many of his reports, he is definitely example of someone who offers embarrassing opinions that make psychiatrists look bad. In a competency report, he opined the sex offender was definitely insane and needed lithium for bipolar (I did the NGI eval and the guy was malingering). In my favorite one, he claimed a domestic abuser was not in control of his behavior, because he was a victim of projective identification and the victim unconsciously wanted him to act out in this way.

Two of his wives committed suicide and one tried to kill him. I bet he didnt regard her as a victim of projective identification.

 

[PsyDr]

This guy is 85 and he is still going. It is true that his opinions were misrepresented as the Twinkie Defense and what he was saying was not as ridiculous as he it sounds. However, having read many of his reports, he is definitely example of someone who offers embarrassing opinions that make psychiatrists look bad. In a competency report, he opined the sex offender was definitely insane and needed lithium for bipolar (I did the NGI eval and the guy was malingering). In my favorite one, he claimed a domestic abuser was not in control of his behavior, because he was a victim of projective identification and the victim unconsciously wanted him to act out in this way.

Two of his wives committed suicide and one tried to kill him. I bet he didnt regard her as a victim of projective identification.

Holy hell!

 

[Alemo]

@Alemo

1) Keep in mind that erg has some discordant views. So do I.
2) The issue with diagnosis, in a legal setting, is about Daubert criteria (e.g., reproducibility, known error rate, etc.) Psychologists have tests, which help meet these criteria. We also have base rate data on malingering, which help. Psychiatric methods can do this quite well, too, using their own tools. Each scenario has its own strengths and its own weaknesses. For example:

a. Let's say the litigated issue was Alcohol Use Disorder. Both professions would do an interview. Psychologists would use some testing. That has some validity. But psychiatry can use superior lab tests like GGT, AST, ALT, etc. Which one would do better?

3) IMO, the "strength" in psychiatry, is that you guys are trained to speak definitively. That can work out very well, assuming you stick to your areas. I was listening to Goldberg the other day. In narrative form, he cites the literature, its limitations, the stats, and how he formed his opinion. That is a deeply convincing way to speak in legal settings. Resnick does it well. So does Dietz. However, it can go bad. The most famous example of this is the trial of the guy who killed Harvey Milk. The psychiatrist was trying to explain the correlation between carbohydrate intake and serotonin turnover. It's not a bad point. But the expert assumed his opinion would be accepted, so he didn't explain the backing of his opinion, and there are no firm stats on it. So the media called it the "twinkie defense", and laughed at him. He would have been better off not speaking so definitively.

Thanks for this response; this is exactly what I was looking for.

The example about AUD is interesting because the clinical interview is sufficient for diagnosis. A transaminiitis (changes in AST and ALT) is pretty non-specific, and short of a liver biopsy and being a hepatologist, a psychiatrist isn't definitively qualified to say this person's liver condition is due to AUD. Those lab tests you mentioned are similar to seeing someone with a shopping cart full of Jim Beam. They probably have an alcohol problem, but there are other explanations.

In diagnoses then (almost all DSM diagnoses are clinical) it seems the forensic psychology methods would be superior to those of psychiatrists. After all, it doesn’t help if one “speaks definitively” but hasn’t gone through the trouble of testing which bolsters their claim. I know what the Daubert standard is, and I know simply meeting it settles the question practically, but I’m interested in what is a better way to get at the truth of the matter (or conversely, are psychiatric methods adequate).

I’ve also seen criminal responsibility and competency evals/reports by psychologists where testing was not used, so I understand it’s not a sure thing.

Also curious about the cryptic reference to “discordant views” ….

 

[WisNeuro]

Thanks for this response; this is exactly what I was looking for.

The example about AUD is interesting because the clinical interview is sufficient for diagnosis. A transaminiitis (changes in AST and ALT) is pretty non-specific, and short of a liver biopsy and being a hepatologist, a psychiatrist isn't definitively qualified to say this person's liver condition is due to AUD. Those lab tests you mentioned are similar to seeing someone with a shopping cart full of Jim Beam. They probably have an alcohol problem, but there are other explanations.

In diagnoses then (almost all DSM diagnoses are clinical) it seems the forensic psychology methods would be superior to those of psychiatrists. After all, it doesn’t help if one “speaks definitively” but hasn’t gone through the trouble of testing which bolsters their claim. I know what the Daubert standard is, and I know simply meeting it settles the question practically, but I’m interested in what is a better way to get at the truth of the matter (or conversely, are psychiatric methods adequate).

I’ve also seen criminal responsibility and competency evals/reports by psychologists where testing was not used, so I understand it’s not a sure thing.

Also curious about the cryptic reference to “discordant views” ….

The clinical interview is sufficient as long as the evaluee is being honest. Which, in many cases of AUD, is not as often as we'd like. Throw in legal repercussions of the AUD, and good luck getting anything reliable.

 

[PsyDr]

The example about AUD is interesting because the clinical interview is sufficient for diagnosis. A transaminiitis (changes in AST and ALT) is pretty non-specific, and short of a liver biopsy and being a hepatologist, a psychiatrist isn't definitively qualified to say this person's liver condition is due to AUD.

Somewhat true. But, I find your opinion interesting in light of the DSM-5 section that states , "Individuals whose heavier drinking places them at elevated risk for alcohol use disorder can be identified both through standardized questionnaires and by elevations in blood test results likely to be seen with regular heavier drinking". And that the tests I mentioned are in the "Diagnostic Markers" section for AUD.

Just something to think about. Your opinion is consistent with the majority. But, I've made my living arguing about this kind of thing.

 

[Alemo]

Of course. Urine EtG and PEth are the sensitive biomarkers to detect presence of alcohol in the body ("Has this person imbibed recently?"). My point is though, the clinical interview (and/or record or collateral review in the case the evaluee completely lies or denies everything) is sufficient in the vast majority of cases and those lab tests don't add much value. Use disorders are outliers too; most mental illnesses have no biomarkers.

 

[PsyDr]

Of course. Urine EtG and PEth are the sensitive biomarkers to detect presence of alcohol in the body ("Has this person imbibed recently?"). My point is though, the clinical interview (and/or record or collateral review in the case the evaluee completely lies or denies everything) is sufficient in the vast majority of cases and those lab tests don't add much value. Use disorders are outliers too; most mental illnesses have no biomarkers.

I didn't disagree with your point. My point is that psychiatry has tools that are unavailable to psychology. AUD is an example, not some separate debate.

 

[Alemo]

I gotcha. It would be interesting to hear perspectives from psychiatry about what those tools are (aside from “speaking definitively” which I understand but see as an intangible).

 

[Bartelby]

"Speaking definitively" sounds more like arrogance than a special tool if we're being honest . Every expert speaks to a "reasonable degree of [medical/scientific/etc.] certainty," which pretty much translates to more likely than not.

One of the biggest things you bring to the table as a physician is *medical* expertise. A person is claiming PTSD after a car crash, but they also have an alcohol problem, sleep apnea, and congestive heart failure with a cocktail of drugs. Oh, and they also struck their head during the crash and are alleging permanent brain injury. You can help explain how each contributes (or does not contribute) to their distress. Or another person has a somatic symptom disorder combined with several chronic health issues, and you help parse out what portion appears to be psychiatric in nature. Or part of the opinion involves evaluating a medication regimen that goes beyond simple first-line drugs, or assessing whether a drug side effect contributed to the commission of a criminal offense. Your background as a psychiatrist brings obvious value in each case. Beyond that, you likely have experience seeing a very broad range of pathology in every setting. Some psychologists may have similar experience with a range of pathology and settings, but you should not sell yourself short when it comes to the thousands of hours you have spent in and around hospitals seeing real-world examples of just about every type of pathology out there. So, broadly speaking, your extensive training and experience are the "tools" that will bring value to your forensic work.

I think where psychology holds an edge is really in the standardized testing tools they use. Being able to say "Mr. X's performance on memory test Y was below 99.996% of test-takers with genuine pathology, suggest an attempt to exaggerate or feign memory issues" is more powerful than simply pointing out that Mr. X's memory does not seem to be as bad as he alleges. Similarly, showing that a person frequently endorses items that are almost never endorsed by people with genuine pathology (but are frequently endorsed by individuals paid to try to feign that same pathology) is also more powerful than simply saying "these symptoms do not appear consistent with [condition X] and are instead more consistent with an effort to feign illness." That is part of why, in my opinion, a good forensic psychiatrist respects what a psychologist brings to the table and is glad to work in tandem with them. You can, though, of course engage in evaluations on your own using a careful examination of multiple lines of evidence (collateral information, careful observation, a full exam assessing for many different forms of inconsistency etc.) to reach accurate opinions.

 

[romanticscience]

I gotcha. It would be interesting to hear perspectives from psychiatry about what those tools are (aside from “speaking definitively” which I understand but see as an intangible).

Given what others have mentioned about both fields' different tools (medicine v. testing) and how they related to each's forensic consultation, remember that the quality of your evaluation, report writing, and testimony will be most relevant to your success as an expert witness.

In clinical medicine, we often protect ourselves by restricting "access" to certain procedures and privileges (e.g., radiologists read the films, not the neurologist). This may be why we have "turf wars." Things work differently in medico-legal work.

I'm an early career forensic psychiatrist who does not have a fellowship, so take my opinion with caution: Worry less about your exclusive tools and more about your relevant specialized clinical experience, quality of writing/opinion formation, and testifying skills.

 

[Alemo]

"Speaking definitively" sounds more like arrogance than a special tool if we're being honest . Every expert speaks to a "reasonable degree of [medical/scientific/etc.] certainty," which pretty much translates to more likely than not.

One of the biggest things you bring to the table as a physician is *medical* expertise. A person is claiming PTSD after a car crash, but they also have an alcohol problem, sleep apnea, and congestive heart failure with a cocktail of drugs. Oh, and they also struck their head during the crash and are alleging permanent brain injury. You can help explain how each contributes (or does not contribute) to their distress. Or another person has a somatic symptom disorder combined with several chronic health issues, and you help parse out what portion appears to be psychiatric in nature. Or part of the opinion involves evaluating a medication regimen that goes beyond simple first-line drugs, or assessing whether a drug side effect contributed to the commission of a criminal offense. Your background as a psychiatrist brings obvious value in each case. Beyond that, you likely have experience seeing a very broad range of pathology in every setting. Some psychologists may have similar experience with a range of pathology and settings, but you should not sell yourself short when it comes to the thousands of hours you have spent in and around hospitals seeing real-world examples of just about every type of pathology out there. So, broadly speaking, your extensive training and experience are the "tools" that will bring value to your forensic work.

I think where psychology holds an edge is really in the standardized testing tools they use. Being able to say "Mr. X's performance on memory test Y was below 99.996% of test-takers with genuine pathology, suggest an attempt to exaggerate or feign memory issues" is more powerful than simply pointing out that Mr. X's memory does not seem to be as bad as he alleges. Similarly, showing that a person frequently endorses items that are almost never endorsed by people with genuine pathology (but are frequently endorsed by individuals paid to try to feign that same pathology) is also more powerful than simply saying "these symptoms do not appear consistent with [condition X] and are instead more consistent with an effort to feign illness." That is part of why, in my opinion, a good forensic psychiatrist respects what a psychologist brings to the table and is glad to work in tandem with them. You can, though, of course engage in evaluations on your own using a careful examination of multiple lines of evidence (collateral information, careful observation, a full exam assessing for many different forms of inconsistency etc.) to reach accurate opinions.

Thanks for this answer. I agree that “speaking definitively” is a little hand wavy. I do think there is an element of generalism that I’ll need to be wary of (Such as relying on “broad experience” and “clinical judgment”). Not that other evaluators like psychologists don’t use that, but like you said multiple lines of evidence and methods need to be pursued.

 

[Alemo]

In clinical medicine, we often protect ourselves by restricting "access" to certain procedures and privileges (e.g., radiologists read the films, not the neurologist). This may be why we have "turf wars." Things work differently in medico-legal work.

I'm an early career forensic psychiatrist who does not have a fellowship, so take my opinion with caution: Worry less about your exclusive tools and more about your relevant specialized clinical experience, quality of writing/opinion formation, and testifying skills.

So style over substance?

Just kidding, thanks for this!

 

[nexus73]

Of course. Urine EtG and PEth are the sensitive biomarkers to detect presence of alcohol in the body ("Has this person imbibed recently?"). My point is though, the clinical interview (and/or record or collateral review in the case the evaluee completely lies or denies everything) is sufficient in the vast majority of cases and those lab tests don't add much value. Use disorders are outliers too; most mental illnesses have no biomarkers.

I think the point is psychiatrists are physicians. And in some forensic cases there’s usually lots of records with ED visits, and labs, imaging, vital signs, physical exam records, EEGs, etc. If the question is about AUD, a physician can do an interview and ask all the right questions like a psychologist, AND the physician has the training and expertise to review all the medical records (is BAC elevated each time the person visits the ED the last 49 times? Was BAC high like 0.09 or high like .523? is there history of transaminitis, pancreatitis, fatty liver on ultrasound, signs/symptoms of alcohol withdrawal: tremors tachy sweaty, withdrawal seizures, delirium treatments?) to support or refute AUD as a probable diagnosis. Interpreting that data is where being a physician is helpful.