Psychiatric Annals

CME Article 

Forensic Psychiatry and Consultation-Liaison Psychiatry: Exciting Subspecialties with Bright Futures

Britta Ostermeyer, MD, MBA, FAPA; Jedidiah Perdue, MD, MPH; Johanna Keller, BS; Charles H. Dukes, MD, FAPA

Abstract

Additional training in psychiatric subspecialties has been increasingly recognized as a way to prepare psychiatrists to successfully manage more difficult and complex patient circumstances. This article describes the practice activities and scope of training for forensic psychiatry and consultation-liaison (CL) psychiatry. Forensic psychiatry fellowship training prepares psychiatrists to manage medical/psychiatric legal scenarios, ranging from patient-care legal issues to performing legal expert witness consultations for third parties, including courts and attorneys, as well as correctional mental health. CL psychiatry training prepares psychiatrists to master the care of patients with complex medical and psychiatric illnesses as well as to work effectively in multidisciplinary medical teams and integrated medical psychiatric care settings. [Psychiatr Ann. 2018;48(11):509–515.]

Abstract

Additional training in psychiatric subspecialties has been increasingly recognized as a way to prepare psychiatrists to successfully manage more difficult and complex patient circumstances. This article describes the practice activities and scope of training for forensic psychiatry and consultation-liaison (CL) psychiatry. Forensic psychiatry fellowship training prepares psychiatrists to manage medical/psychiatric legal scenarios, ranging from patient-care legal issues to performing legal expert witness consultations for third parties, including courts and attorneys, as well as correctional mental health. CL psychiatry training prepares psychiatrists to master the care of patients with complex medical and psychiatric illnesses as well as to work effectively in multidisciplinary medical teams and integrated medical psychiatric care settings. [Psychiatr Ann. 2018;48(11):509–515.]

Subspecialty training in psychiatry has been increasingly recognized by a variety of entities, including universities, insurance companies, patients, and diverse medical entities. Given the grave shortage of psychiatrists and the increasing number of mid-level, nonphysician mental health specialists, psychiatrists are increasingly used for more difficult patient care situations and for supervision of other mental health specialists. Additional fellowship subspecialty training will prepare psychiatrists to deal successfully with the most challenging patient scenarios for which they are more likely to be consulted. Forensic psychiatry and consultation-liaison (CL) psychiatry are both well-established psychiatry subspecialties with distinguished evolutional histories and recognized Accredited Council for Graduate Medical Education (ACGME)-approved fellowship training programs. Both subspecialties train psychiatrists for the most difficult patient scenarios: forensic psychiatry prepares for the navigation of medical/psychiatric legal issues, and CL psychiatry prepares for successfully managing patients with complex medical and psychiatric conditions. This article presents the “nuts and bolts” of forensic psychiatry and CL psychiatry fellowship training.

Forensic Psychiatry

Description of Forensic Psychiatry and the Role of Psychiatrists

Forensic psychiatry, also known as psychiatry and the law, is a subspecialty of psychiatry focusing on the interface of law and mental health.1–4 Forensic psychiatrists apply scientific and clinical expertise in a legal context, involving civil, criminal, correctional, regulatory, or legislative matters.2,4,5 Major areas of forensic psychiatry are (1) expert forensic psychiatric evaluations,2,4 (2) correctional psychiatry,5 (3) legal regulation of psychiatry,6 and (4) public policy making.7 In the forensic role, psychiatrists must strive to perform objective and honest evaluations and also respectfully balance competing duties to individual people and to society.2,4

Expert forensic evaluations are needed in civil, criminal legal, or administrative processes whenever a person's mental state or mental illness is of interest.2 Forensic psychiatrists may then be asked to perform a medical-legal evaluation (referred to as “independent” evaluation by insurance companies) to answer specific questions posed by judges, attorneys, or administrators related to a person's mental health. In such cases, forensic psychiatrists commonly furnish a written report to the retaining entity (typically judges, attorneys, administrators, insurance companies, or employers) and may also participate in depositions (in civil cases) and/or provide courtroom expert testimony (in either civil or criminal cases).1,2

It is important to know that forensic psychiatrists performing an evaluation do not have a physician-patient relationship with evaluees, do not treat them, and must inform the evaluee prior to the evaluation that the forensic examination only has limited confidentiality and for whom and for what purpose the examination is being conducted.1,2,4 Because the report is usually released to the retaining entity, its content may appear in courtroom or legal documents. Unlike physicians in physician-patient relationships, forensic psychiatrists do not serve their evaluees' interests.1,4 Forensic psychiatrist serve the truth-finding process.1,2 Their opinions may not help or may actually hurt their evaluees' interests. In the forensic expert role, forensic psychiatrists are not to perform examinations on persons they have seen for treatment. Obtaining information and treating patients under confidential, HIPAA (Health Insurance Portability and Accountability Act)-protected physician-patient circumstances with an oath to pursue patients' best interests is not compatible with the neutral, truth-seeking expert role.1

Because forensic psychiatry experts do not treat evaluees, the evaluees' medical insurance cannot be billed for these expert services as no medical treatment services are rendered.1 Forensic experts are not part of treatment teams. Therefore, to view evaluees' medical or psychiatric records, forensic experts require evaluees' signed medical releases. Forensic experts typically have set fee schedules for services that are shared upfront with retaining entities. Such fee schedules usually list hourly rates for forensic services rendered, including the interview/examination of the evaluee, record review, collateral interviews, conference discussion time with the retaining entity, report preparation time, and preparing and appearing for depositions or courtroom testimony.

Given that in civil, criminal legal, or administrative settings all involved parties have something to lose or gain and malingering is often a concern, forensic psychiatrists must spend rather significant amounts of time reviewing collateral sources of information.2,4 Such collateral sources usually include review of medical, psychiatric, school, and police records and multiple interviews of other informants, including witnesses and family members. Table 1 summarizes the differences between forensic evaluations and psychiatric treatment services.

Differences Between Forensic Evaluations and Psychiatric Treatment Services

Table 1.

Differences Between Forensic Evaluations and Psychiatric Treatment Services

Civil examinations are commonly performed for psychiatric disability, conservatorships and guardianships, child custody determinations, child abuse and neglect, psychiatric malpractice, fitness for job duty, psychiatric disability, testimonial capacity, or psychic damages/personal injury.4,8,9 The most common criminal forensic examination in the United States is evaluation of defendants' competency to stand trial.7 Other common criminal examinations include evaluation for competency to enter a plea, voluntariness of confessions, insanity defense (criminal responsibility), diminished capacity, sentencing considerations, and state hospital release of persons acquitted by a verdict of not guilty by reason of insanity.4,8

In jail and other prison settings, however, forensic psychiatrists provide correctional psychiatric treatment services to inmates.5 Although correctional forensic psychiatrists do have a physician-patient relationship with inmates, they also have a dual reporting line, similar to military psychiatrists, making them answerable not only to their inmate patients but also to correctional authorities.1 Forensic psychiatrists may have to discuss inmate patients' cases with correctional authorities if inmates pose a safety treat to others at correctional facilities.5 Correctional psychiatry has inherent differences from regular general psychiatry that affect treatment planning, including medication choices, facility housing, inmates' privileges and movement levels, and more.5

Additionally, forensic psychiatrists have expertise on the legal regulation of psychiatry, which encompasses the important areas of voluntary and involuntary civil commitment to an inpatient psychiatry unit, confidentiality and privilege, informed consent, right to treatment and right to refuse treatment, professional liability and psychiatric malpractice, as well as medical ethical guidelines.6 Forensic psychiatrists may apply this expertise as part of forensic evaluations or as an advisor in policy-making processes. Forensic psychiatrists are also asked to advise on legislative policy efforts by institutions, states, or the federal government and help shape policies and procedures because of their psychiatric legal expertise.7

History and Background of Forensic Psychiatry

The history of forensic psychiatry, which originated in the 18th century, is the history of the interception of enduring legal and social challenges of establishing competency and criminal responsibility as well as the professional development of medicine and psychiatry.10 As medical theories evolved, legal ones did as well. Mental illness, once defined in moral and religious terms, changed to an understanding of a treatable illness.11 With the establishment of asylums for psychiatric disorders, accountability changed from family guardianship to the state.

The ancient Greek philosopher Plato saw the human mind divided between the rational and irrational and stated that those who choose to commit a crime “with some degree of calculation” should receive more severe punishment.10 Plato's famous disciple, Aristotle, recognized the importance of knowledge in the imputation of criminal responsibility and stated, “A person is morally responsible if, with knowledge of the circumstances and in the absence of external compulsion, he deliberately chooses to commit a specific act.”10 English law defined that the following two components had to be present to constitute a crime: (1) a forbidden act (actus reus) and (2) a guilty mind (mens rea). In the 18th century, different legal tests began to emerge through English criminal courts to determine insanity in criminal defendants.10 A rule that has been maintained by most American jurisdictions until today, is derived from the M'Naghten's case of 1843, in which the English appellate court established that for an insanity defense “It must be clearly proved that, at the time of committing of the act, the party accused was [laboring] under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing, or, if he did know it, that he did not know what he was doing was wrong.”10 In the beginning of the history of forensic psychiatry, there was no psychiatric courtroom testimony. The first recorded psychiatric testimony was in 1760.10 Legal authorities have since recognized that forensic psychiatric expertise is indispensable. Today, forensic psychiatry experts render opinions and aid legal processes in a large variety of civil and criminal legal scenarios.

Forensic Psychiatry Fellowship and Advantages of Training in Forensic Psychiatry

Forensic psychiatry was first officially recognized as a subspecialty by the American Board of Psychiatry and Neurology (a member of the American Board of Medical Specialties) in 1992 under the designation of “Added Qualification in Forensic Psychiatry.”12 The first examination for “Added Qualifications in Forensic Psychiatry” was given in 1994.13 In 1997, the certification name was changed to “certification in the subspecialty of forensic psychiatry.” The 1999 examination was the last one that did not require that the applicant had completed a forensic psychiatry fellowship. Since 2001, the completion of a fellowship has been required.13 Psychiatrists can apply to forensic fellowships after completion of a 4-year psychiatry residency program. After completion of a fellowship and passing general psychiatry boards, psychiatrists can then apply to take the forensic board examination and become board-certified forensic psychiatrists (Figure 1).

Requirements to become a board-certified forensic psychiatrist. ACGME, Accredited Council for Graduate Medical Education.

Figure 1.

Requirements to become a board-certified forensic psychiatrist. ACGME, Accredited Council for Graduate Medical Education.

The subspecialty recognition and fellowship formation came about due to the recognition of the need for special education and training experiences in forensic psychiatry. In 1992, there were 38 forensic training programs with 50 positions. Today, there are 46 US programs with 107 positions, and 8 Canadian programs with 12 positions.14 Fellowships require fellows to fulfil an array of forensic learning assignments related to inter-relationships among psychiatry and civil, criminal, and administrative law, including evaluation of people involved with the legal system, specialized psychiatric treatment of people incarcerated in jails, prisons, or forensic hospitals, and active involvement in the area of legal regulation of general psychiatric practice.15

There are significant advantages of training in forensic psychiatry because it has applicability to general psychiatry and other medical disciplines. In day-to-day psychiatric practice, forensically trained psychiatrists benefit from more expertise and experience with legal psychiatric matters, such as involuntary commitment, guardianship, right to refuse treatment, and more. Forensic psychiatrists also possess additional training and skills in risk assessments, such as for violence. From experience in correctional settings, they also learn how to handle the most difficult and often the most advanced psychiatric patient care scenarios. In addition, psychiatrists in forensic training acquire an additional skill set in performing medical-legal expert work, which is usually not learned otherwise in psychiatry training. Expert fees from psychiatric-legal work can be quite lucrative, typically ranging from $250 to $500 per hour, with fees up to $800 to $1,000 per hour charged by some experts. In addition, work as an expert witness allows for flexible work hours, and most of the work effort can be completed from home. Forensic psychiatrists are more competitive in the job market due to their possession of additional professional skills and additional income-earning capacity for their employers.

Future of Forensic Psychiatry

Forensic psychiatry has experienced enormous growth in recent years. Although the competency to stand trial evaluation still remains the most commonly performed type of forensic evaluation, forensic evaluations have evolved and differentiated into a rather expanded list of different evaluation types. Much like in forensic psychiatry's past history, this development occurred in response to today's different legal scenarios with new questions posed by the legal community to forensic psychiatrists, who have risen to the challenge and advanced their examination skills.

Today's forensic psychiatrist must be able to perform a greater variety of examinations, ranging from common types such as competency and sanity evaluations to evaluations opining on microaggression, cyberbullying, or “sexting.” As legal questions continue to evolve and change, forensic psychiatry must continue to evolve alongside the legal system.

Given the ever-increasing need for subspecialty knowledge and tools, tomorrow's forensic psychiatrist is required to train in an ACGME-approved fellowship and has to participate thereafter in ongoing forensic continuing medical education. Recognizing the tremendous need for forensic psychiatrists to exchange and develop ideas, the American Academy of Psychiatry and the Law (AAPL) was founded in 1969 under the leadership of Dr. Jonas Rappeport.16 Today, the AAPL is the leading organization of forensic psychiatrists promoting scientific and educational forensic activities through publications and regularly scheduled national and regional meetings.16

Over recent decades, neuroscience and neuropsychology have made significant progress as well. Neuroscience advances pertaining to the connection of brain and behavior will continue to shape not only psychiatry, but forensic psychiatry as well. Today's forensic psychiatrist employs psychological testing and works hand-in-hand with neuropsychologists who perform detailed test batteries to shed additional light on cognitive brain processes as they may pertain to legal questions posed by legal entities. Tomorrow's forensic psychiatrist will likely be required to apply more advanced neuroscience knowledge, including brain scans and other laboratory tests.17

Consultation-Liaison Psychiatry

Description of CL Psychiatry and the Role of Psychiatrists

CL psychiatry is a psychiatric subspecialty that serves as an important interface between psychiatry and medicine.18,19 The terms “CL psychiatry,” “psychosomatic medicine,” and “psychiatry for the medically ill” have been used to describe the practice and philosophical premise of the area of psychiatry that interfaces with general medical conditions from theories about etiology, prevention, course, and outcome.18 Patients are seen in consultation only at the request of another physician.18,19 In the consulting role, psychiatrists are expected to review patient records and evaluate patients to render a diagnosis and treatment plan.18,19 The CL psychiatrist plays a critical role in bridging the gap between psychiatry and medicine as well as keeps a keen eye on the importance of the psychosocial context. The CL psychiatrist plays an important and vital role in integrated health care with an overall positive impact toward reduced morbidity and mortality.

In addition to serving in the consultant role, the liaison role of the CL psychiatrist is of paramount importance. The psychiatric liaison plays a valuable role in the application of psychiatric knowledge and communication with other caregivers to better understand their patients and their dispositions, whether psychiatric or medical.19 To reduce psychiatric stigma, the CL psychiatrist serves as both an advocate and educator about mental illness and also has to be keenly aware of organizational systems in place to ensure patient safety. Indeed, there are times when mental illness is overlooked or lost in complex medical conditions. The contrary is also true—namely, that medical conditions can be lost in the wake of neuropsychiatric sequelae that are common in many illnesses, such as delirium, dementia, and traumatic brain injury. The CL psychiatrist's challenge is to be able to inform and educate other medical specialties about the presence or absence of mental illness and its degree of manifestation and advise accordingly.

History and Background of CL Psychiatry

CL psychiatry can trace its origins back to Dr. Benjamin Rush, the father of American psychiatry. Rush had a great interest in the integration of medicine with the soul.20 The first designated liaison service was at Albany Hospital (New York), and the forerunner for medicine-psychiatry units was designated in 1902.20 From the 1920s through the 1950s various hospitals developed models for the delivery of CL services, initially focusing on specific psychodynamic concepts that were thought to affect medical illness. The early psychodynamic/medical model eventually evolved into a broader biopsychosocial medical model. From just a few hospitals in the 1920s, more hospitals established services with teaching physicians, culminating with the expansion of CL services with special opportunities for medical students in the 1970s.20 At this point in history, formal CL fellowship programs were established.

CL Psychiatry Fellowship and Advantages of Training in CL Psychiatry

In 2003, subspecialty certification in psychosomatic medicine was approved, and the first certification examination was administered in 2005.18 Since 2009, it has been mandatory to complete an ACGME-approved fellowship to sit for the CL board examination.18

Psychiatry residents who have completed 4 years of psychiatry residency training can apply to undergo an ACGME-accredited 1-year fellowship program in psychosomatic medicine. Presently, there are 61 ACGME-accredited CL fellowship programs across the US.21,22 After completion of a CL fellowship and after passing general psychiatry boards, the psychiatrist can then apply to take the CL board examination to become a board-certified CL psychiatrist (Figure 2). The American Board of Psychiatry and Neurology officially changed the name of the subspecialty from psychosomatic medicine to consultation-liaison psychiatry in January 2018.23

Requirements to become a board-certified consutlation-liaison psychiatrist. ACGME, Accredited Council for Graduate Medical Education; CL, consultation-liaison.

Figure 2.

Requirements to become a board-certified consutlation-liaison psychiatrist. ACGME, Accredited Council for Graduate Medical Education; CL, consultation-liaison.

CL fellowship training conveys numerous advantages. It provides a breadth of experience through exposure to a variety of medical settings, both inpatient and outpatient, and allows the psychiatrist to build expertise through training with leaders in the field. Fellowship training also allows the psychiatrist to become increasingly capable in performing CL-related specialized assessments, such as decision-making capacity, candidacy for transplantation, suicide risk assessments in medical settings, and atypical psychiatric presentations of medical illness.18 Finally, fellowship training also allows for important, often lifelong mentorship relationships and an opportunity to develop and hone academic interests and expand skills in teaching and research.

CL fellowship-trained psychiatrists are best prepared to work with the most medically and psychiatrically ill patients in inpatient and outpatient settings. This translates to significant job market advantages, particularly as health systems are now shifting from fee for service to bundled payment models and as physicians are seeking more hospital-based employment. CL psychiatrists add value to health systems through effectively treating comorbid psychiatric illness, which improves medical outcomes and lowers overall health care costs. Thus, medical teams are better able to recognize psychiatric treatment contributions by psychiatrists trained in CL.

Future of CL Psychiatry

Backed by a strong base of research demonstrating the efficacy and cost-effectiveness of collaborative or integrated interventions in improving outcomes in primary and specialty medical care settings, the future of CL psychiatry remains bright.24–27 Integrated care will likely see broader implementation, presenting significant opportunities for CL psychiatrists to influence system design and benefit individual patients and populations. Psychosocial care co-located in medical settings is becoming increasingly common, and CL psychiatrists have the specialized training to treat psychiatric illness in the setting of significant medical comorbidity. Cancer care provides an excellent example of this trend, in which assessing and addressing psychosocial needs is considered standard of care.28 CL psychiatrists are a natural fit to provide integrated services, with opportunities likely increasing over time due to an aging population and increased burden of chronic disease. In hospital settings, where untreated psychiatric illness leads to higher costs and greater morbidity,29 CL services are cost-effective and reduce length of stay.30 The demand for CL psychiatrists will likely increase across inpatient settings as health systems shift away from fee for service toward value-based and bundled payment models. Likewise, increased case identification through broader systematic screening of medical inpatients for depression, delirium, and substance abuse will likely lead to an increase in referrals to CL services. In his 2017 address to the American Psychosomatic Society (now the Academy of Consult-Liaison Psychiatry), Dr. Christoph Herrmann-Lingen expressed a vision that the Society “can become a hub linking psychological affect science and neuroscience with behavioral and biologic medicine and health care.”31 CL psychiatrists are well-positioned to be leaders in these efforts, shaping research, system design, and patient care.

Conclusion

Forensic psychiatry and CL psychiatry fellowship training programs allow psychiatrists to acquire additional skills and additional job market value in medical/psychiatric legal scenarios and complex patient care scenarios with psychiatric and medical illnesses, respectively. Both ACGME-approved fellowship programs require the completion of a 4-year psychiatry residency training program, have a duration of 1 year, and offer subspecialty board-certification on successful completion.

References

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Differences Between Forensic Evaluations and Psychiatric Treatment Services

Issue Forensic Evaluation Psychiatric Treatment Service
Role Forensic examiner Treating physician
Services rendered Forensic only Medical only
Person to be evaluated Evaluee/subject Patient
Purpose to help patients Truth finding, help legal processes Medical treatment
Physician-patient relationship No Yes
Confidentiality Limited HIPAA
Malingering Always suspect Less likely
Collateral sources Must seek May seek
Able to review medical records Only with evaluee's release Yes
Report part of medical records No Yes
Payment Fee agreements Medical insurance
Covered under medical practice Should be covered under forensic malpractice Yes
Authors

Britta Ostermeyer, MD, MBA, FAPA, is a Professor, and the Chairman and the Paul and Ruth Jonas Chair in Mental Health, Department of Psychiatry and Behavioral Sciences. Jedidiah Perdue, MD, MPH, is an Assistant Professor, Department of Psychiatry and Behavioral Sciences, and the Director, Mental Health, Stevenson Cancer Center. Johanna Keller, BS, is a third-year Medical Student. Charles H. Dukes, MD, FAPA, is a Clinical Assistant Professor, the Director of Psychiatry Residency Training Program, and the Director of Consultation Liaison Service, Department of Psychiatry and Behavioral Sciences. All authors are affiliated with the University of Oklahoma Health Sciences Center.

Address correspondence to Britta Ostermeyer, MD, MBA, FAPA, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center, P.O. Box 26901, WP3470, 920 Stanton L. Young Boulevard, Oklahoma City, OK 73126-0901; email: Britta-Ostermeyer@ouhsc.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20181008-03

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