Episode 139 - Mistakes Writers Make about Forensic Psychiatry and How to Avoid Them with Susan Hatters Friedman
June 21, 2022
Susan Hatters Friedman, MD discusses MISTAKES WRITERS MAKE ABOUT FORENSIC PSYCHIATRY AND HOW TO AVOID THEM. She talks about the differences between forensic psychiatry and forensic psychology; the rules governing psychiatric confidentiality; the fact that forensic psychiatrists are not lie detectors; the depiction of competency versus sanity in fiction (and which is easier to argue in court); and lines a psychiatrist (at least a reputable one) wouldn't cross.
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Susan Hatters Friedman is a psychiatrist specializing in forensic psychiatry and maternal mental health. She currently serves as President of the American Academy of Psychiatry and the Law. Susan received the Manfred Guttmacher Award from the American Psychiatric Association for editing the book “Family Murder: Pathologies of Love and Hate.” She is pursuing a Masters in Crime Fiction at the University of Cambridge and has studied with The Second City, the world's premier comedy club, comedy theater, and school of improvisation. Her creative writing is found in “Hobart,” “Eclectica," and “Drunk Monkeys,” among others.
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"Psychiatrists in general, we want good things for our patients, but we're not there to comfort them physically. There would be very rarely any circumstance where a psychiatrist would be engaging in physical contact other than a handshake with a patient or a forensic psychiatrist with an evaluee. It's a human thing to think about wanting to pat someone on the shoulder, but that's a line we wouldn't cross." —Susan Hatters Friedman, MD
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Links
From Intro:
How to create an AI narrated audiobook with Google Play | Google Play Auto Narrated Audiobook 2022 from M.K. Williams
From the interview:
Forensic Psychiatrists and Crime Fiction: Top 10 myths corrected by Susan Hatters Friedman, MD
Susan's full biography: http://jaapl.org/content/49/4/488
Journal of the American Academy of Psychiatry and the Law
Matty's Links:
Affiliate links
Events
How to create an AI narrated audiobook with Google Play | Google Play Auto Narrated Audiobook 2022 from M.K. Williams
From the interview:
Forensic Psychiatrists and Crime Fiction: Top 10 myths corrected by Susan Hatters Friedman, MD
Susan's full biography: http://jaapl.org/content/49/4/488
Journal of the American Academy of Psychiatry and the Law
Matty's Links:
Affiliate links
Events
Transcript
[00:00:00] Matty: Hello and welcome to The Indy Author Podcast. Today my guest is Susan Hatters Friedman. Hey Susan, how are you doing?
[00:00:06] Susan: Good. How are you? Yeah, I'm happy to have you here. To give our listeners and viewers a little bit of background on you, Susan Hatters Friedman is a psychiatrist specializing in psychiatry and maternal mental health. She currently serves as the president of the American Academy of Psychiatry and the Law. Susan received the Manfred Guttmacher Award from the American Psychiatric Association for editing the book, "Family Murder: Pathologies of Love and Hate."
[00:00:30] Matty: She's pursuing a master's in Crime Fiction, which is super cool, at the University of Cambridge and has studied with The Second City, the world's premier comedy club, comedy theater, and school of improvisation. And her creative writing is found in Hobart, Eclectica, and Drunk Monkeys, among others.
And we're going to be talking about Mistakes Writers Make about Forensic Psychiatry and How to Avoid Them. And this is going to join a lineup of other Mistakes Writers Make in the crime fiction area. Just to give a quick run through of those it's PIs with Patrick Hoffman, the FBI with Jerri Williams, first responders with Ken Fritz, coroners with Jennifer Grazer Dornbush, police procedure with Bruce Robert Coffin, and firearms with Chris Grall. And you can find all of those if you go to theindieauthor.com/podcast and search for mistakes.
So, we wanted to dive into the mistakes writers make about forensic psychiatry.
Her Experience with Second City [00:01:23] Matty: But before we do that, I had to ask about your experience with Second City. Talk about that a little bit.
[00:01:29] Susan: So it's very exciting. During the pandemic in particular, people from around the country, around the world have been able to study online with The Second City. And with my interests, I studied satire writing and they have a course of different series that you take to study satire writing with them and, fabulous experience on learning from amazing satire writers.
[00:01:50] Matty: And you were saying this was an online opportunity, which is pretty nice opening that up to more people.
[00:01:57] Susan: Amazing. And yes, I'm not needing to think about how to get to class during the pandemic and, super interesting people from all around the country and the world.
Is There Overlap Between Satire and Crime Fiction?
[00:02:06] Matty: That's great. Actually, I was debating about whether to ask you about The Second City experience or getting a Master's of Crime Fiction at the University of Cambridge, but it sounds like there might actually be some overlap if you're studying satire, for example, in The Second City. Is there overlap, are you being able to apply the learnings from one to the other?
[00:02:26] Susan: Oh, I definitely think so because, with crime fiction writing and thinking about how to lay the clues and where is the appropriate place for different things and, similar to how you're needing to think about how to lay things out in satire, yes.
[00:02:40] Matty: Very cool. I have to say that as a unique CV that I got for a guest, so that was very fun to read.
So I thought what I would do, the article that I will include a link to in the show notes for this episode has a list of, I believe 10 mistakes that writers commonly make in this area. And we'll see how many we can get through. I'll feed you some of the comments, and I would love to hear your thoughts and examples pro and con in crime fiction.
Forensic Psychiatry vs Forensic Psychology
[00:03:07] Matty: And the first one, which I think is sort of foundational is, forensic psychiatry is not forensic psychology. So talk about that a little bit.
[00:03:14] Susan: Yes, absolutely. And I think before I went to medical school, I might have been unclear about the exact difference as well. So I know that a lot of people confuse psychiatry and psychology, much less than forensic psychiatry and psychology. Psychiatry is a branch of medical science. So a psychiatrist like me has gone to, in America, undergrad for four years and then medical school for four years, and then done psychiatric training, an internship or residency, which is four years more, if you're sub-specializing in something else. And then a fellowship in forensic psychiatry, which is a year in the US.
And so during that time we're in medical school, learning to be psychiatrists and in medical school we're taking the same courses and doing the same practical experiences in the hospital as someone going into internal medicine, as someone going into surgery. And then the residency, you're working as a resident doctor in the hospital, except you're focused on psychiatry, a bit of neurology, a bit of internal medicine and family medicine, so we have that background as well. I would think of our training as more similar to what you would see in Grey's Anatomy, as far as the residency and learning from the attending physicians prior to becoming an attending physician oneself.
And there's a very structured length of time that things take. So it's a four-year residency. Longer, if you're doing child psychiatry or adding on geriatric psychiatry or addiction psychiatry. And then a forensic psychiatry fellowship is one year after the residency as well. And so it is a bunch of time that it takes to do it.
An example that I like to give, what is psychiatry versus psychology, the background I have is Frasier Crane's apartment. Frasier Crane and his brother Niles Crane were psychiatrists in fiction and television, and they were medical doctors who became psychiatrists.
So psychologists, instead of an MD, they have a PhD, so they've pursued undergraduate, and then graduate school in psychology. And then they do additional training in the hospital as well, but they're not medical doctors. So a lot of the things that we do may be very similar, but we diverge in some areas. So in general, psychiatrists are able to prescribe medication because of going to medical school, et cetera. Psychologists are able to do therapy as are psychiatrists. Psychologists also have a wealth of different experience, but it's a different role.
And in a lot of things you read, or a lot of things you watch on TV, it may flip flop from one scene to the next, if someone's a psychiatrist or psychologist or a forensic psychiatrist or psychologist, and in real life, they're different roles with different background and training.
Inaccurate Depictions of Psychiatrists and Psychologists
[00:06:02] Matty: Is there something that is the red flag for you that someone's gotten it wrong, if they're presenting the character as one of those, and then they do something? What's something that they do that is just not accurate?
The switching back and forth is something I see a lot, but also medication. So in general, forensic psychiatry units will have a team-based approach, and so there's a forensic psychiatrist, a forensic psychologist on the hospital unit, nurses, social work, occupational therapy, rehabilitation, et cetera. And it will be the forensic psychiatrist who's prescribing the medication. And testifying about medication, prescribing medication, those are in general the province of the forensic psychiatrist.
What Does Forensic Actually Mean?
[00:06:42] Matty: So the difference between psychiatry and psychology is important, but I think that the other key word here is forensic. And I realized embarrassingly recently that I think I'd always assumed that forensic had to do with death, but then you hear about like forensic accounting and things like that. So can you explain what the term forensic actually means?
[00:07:01] Susan: Sure, the forensic and forensic psychiatry is really anywhere where psychiatry interacts, intersects with the legal system. So in crime fiction, it's a lot of thinking about evaluations of defendants or of perpetrators and, our role as forensic psychiatrist is there in the legal system in that way, in a lot of crime fiction.
But it can be anywhere where we intersect with the legal system for a forensic psychiatrist. Civil law cases, for example, a disability evaluation and malpractice evaluation. Those would be included as well.
Also included within forensic psychiatry would be correctional psychiatry. So a psychiatrist working with offenders or with defendants in the correctional system would fall under forensic psychiatry. And then also, we may help educate legislators about psychiatric issues and that would fall under the umbrella of forensic psychiatry as well.
Psychiatric Confidentiality
[00:07:57] Matty: Okay, thank you. One of the other key points you highlighted where people get things wrong was the topic of confidentiality. Confidentiality with the treating psychiatrist is similar to that with a priest or a lawyer. Can you talk about that a little bit and where you see people getting that right or wrong in crime fiction?
[00:08:15] Susan: Absolutely. I think that it's really important that readers and folks in the general population understand the role of a psychiatrist as far as confidentiality, because I don't want it to dissuade anyone from getting the help they need, the mental health help they need and feeling like we're just going to go tell somebody about what they said. And so yes, it's similar to like a priest and someone who was coming to the priest, or other sorts of doctors that we need to keep things confidential.
There are certain exceptions that are very specific within the law. Like if there's ongoing child abuse that we're concerned about, for example, or an acute threat that we need to hospitalize someone, for example. But there are various instances in crime fiction where for example, a psychiatrist sees a patient, the patient reports something to them, the psychiatrist gets suspicious and then reports it to the police. And that's not something we can just do.
If I was seeing someone for example, and they were making homicidal threats, usually the first thing we're thinking of is hospitalizing them for safety. There are very specific instances where law enforcement would be notified, but that's and in a couple of cases and in crime fiction, it's just the patient reports something to the psychiatrist or the therapist and right away the police find out.
In otherwise wonderful novels that I really enjoy reading, but it takes me out of the story, for one. And it also makes me worried, is someone who's thinking about seeing a psychiatrist for this personal issue that they're having, going to be afraid that if they do, other people are going to find out? So yeah, there are very specific exceptions to confidentiality, but in general, it’s between the adult patient and the psychiatrist.
[00:09:59] Matty: I think in that case, a writer has two choices. One is that they have a character that's a psychiatrist and they decide to be realistic about it and they don't have the character do that. But I can imagine a plot where the plot requires that someone who has perpetrated a crime confides in someone else, or someone who's thinking about committing a crime confides in someone else, and that person goes to the authorities. Is there an alternative to making that person a psychiatrist that you can think of that would legitimately result in that the person that's being confided in being able to go to the police?
[00:10:33] Susan: That's an interesting question. Legitimately versus crime fiction, because in crime fiction, I can certainly imagine someone making an anonymous call or something like that that would not be ethical in real life. Or someone overhearing someone talking to someone who they're telling confidentially. In crime fiction might be something.
I liked that because you've identified a third option, which is, the person does the bad thing, but there's some acknowledgement that it's a bad, unethical, out of norm thing to do, which may take your story in a different direction. Or someone finds something that someone wrote about, or their text messages or et cetera. Someone. Yeah. So I can imagine other ways. It worries me when it's a treating psychiatrist going to the police about their patient.
When is Hospitalization Appropriate?
[00:11:23] Matty: And you had mentioned hospitalizations. So can you talk a little bit about what that process is like, and it sounds like the police don't necessarily, maybe they necessarily do not get involved, in that kind of step, if someone has said something that the psychiatrist believes should be met with hospitalization.
[00:11:42] Susan: Sure, and here I'm talking about like someone seeing their general psychiatrist in the community and the psychiatrist having concerns. Primarily, is the person because of their mental illness, presenting a risk to others or to themselves that really hospitalization is the appropriate option? Then either the psychiatrist would talk to them about voluntarily coming to the hospital, or in some cases, the psychiatrist would need to move toward an involuntary hospitalization, if there was serious concern about the risk and the person didn't have insight into the importance of getting treatment.
And so, every state has different rules about exactly how that works. But no, in many cases, the police wouldn't need to be involved in that. If the person came to the emergency room or if EMS was involved, et cetera, psychiatrists. And depending on the state, which one could check with the state laws of the state that someone's in or talk with the psychiatrists about how it works. There are processes and procedures for how the person would be psychiatrically hospitalized.
And they're very specific procedures to protect the person's rights. But it's also thinking about the state's power to want to protect the rest of its citizens, as well as that person themselves. So if it was a concern about suicide, et cetera. We know in the past psychiatric hospitalization, 50 years ago, 100 years ago, has a history of being misused. And that's why there are very specific safeguards and rules of what the psychiatrist, what the hospital needs to do, and the evidence that needs to be provided to a judge in a specific timeframe, depending on the state about the persons at risk and dangerousness from mental illness.
How Does Involuntary Hospitalization Work?
[00:13:28] Matty: And what would the process actually look like? I know that there would be a ton of variability from case to case, but just picking out an example, if the psychiatrist felt that hospitalization was necessary and the person they were working with wasn't willing to do it voluntarily, how does the involuntary hospitalization process work?
[00:13:49] Susan: Sure. So depending on the state, for example, in Ohio where I currently work, there's a form called a pink slip. It's called different things in different states based on how it came about and the different state laws. And so for example, Ohio, there are criteria that the psychiatrist would need to consider. Does the person have a mental illness? Is it impacting their judgment, their ability to recognize reality, et cetera? And then, is it causing them to be at an acute risk of harming themselves or others or unable to take care of themselves?
And so then that is completed, the person is hospitalized and in Ohio, we have to file more paperwork with the court within a 72-hour timeframe. So you can see it's a very short hold, and then the court becomes involved, and civil commitment proceedings may occur. The goal is to get people the help they need in the shortest amount of time though, as well. So someone may even be released before the court becomes involved, depending on how they're doing, are the medications working, et cetera.
Past Crimes vs Future Crimes
[00:15:03] Matty: And is there any difference between a person working with a psychiatrist and saying that they committed a crime in the past, versus that they're thinking about committing a crime in the future?
[00:15:16] Susan: Yes, great question, and yes. I would say most psychiatrists I know would be contacting their hospital's legal department if either thing happens, just to make sure the current state of the law and that. But yes, in general, as I was saying like with the priest as well, a past crime is different than a future crime that someone's planning to commit, et cetera, and that's related to their mental illness.
Now, an exception to that would be child abuse, elder abuse, if someone's in danger right at the present time because of ongoing criminal activity. But yeah, I think most psychiatrists would be checking with their legal office of their hospital, if any of those things happen. But yes, thinking similar to the priest.
[00:16:04] Matty: And this is a little bit of a tangential one, but that answer made me think, would there be a scenario where a psychiatrist is not affiliated with a hospital, they're an independent practitioner and in that case, would they go to their lawyer to ask?
A lawyer or every psychiatrist in America is going to have a malpractice insurer, and they have a law team with different malpractice insurers to help through legal situations like that or concerning situations like that.
Forensic Psychiatrists Are Not Lie Detectors
I'm going to move on to another one that sort of caught my fancy, which was forensic psychiatrists are not lie detectors. Talk about that a little bit.
So many things you hear colloquially or when people strike up a conversation with me at a party or something, and they'll ask like, how can you tell if someone's lying? And yeah, they're kind of old wives' tales or myths that you hear about if someone looks in a certain direction, et cetera, it means they're lying.
[00:16:58] Susan: If only it were that easy. When we are seeing people as forensic psychiatrists, usually our role is going to be, well, in crime fiction and in criminal law with forensic psychiatry, we are usually seeing someone to do an evaluation, to write a report to the court, perhaps to testify in court about a specific issue related to that person. So I'm doing an evaluation for example, about someone's competency to stand trial or their sanity at the time of the act or their future risk of violence.
In doing that evaluation, I'm getting a lot of history about their life, not just about the time of the crime. So I'm asking many questions about their life story, I'm asking many questions about their substance use history, about their psychiatric history, and then focusing in on what they're alleged to have done or what they've been found guilty of doing.
One of the things that we consider is malingering or feigning of mental illness. Is someone making up a mental illness out of whole cloth? Are they exaggerating a mental illness that they or a family member has had? Some people minimize their mental illness background because they don't want to be perceived negatively by society. So we're determining or attempting to determine if someone's malingering, if they're exaggerating, if they're completely feigning. And we use our knowledge of mental illness from having treated many patients over years, as well as our studies, et cetera, of what real mental illness looks like.
[00:18:37] Susan: And then we look at the behaviors of the person at the time. We look at many collateral records of what the police reports say, what do hospital reports say? Not just what the person sitting in front of us says.
Also, it's often the province of forensic psychologists, our colleagues, who will do testing or malingering as well. And so we use all of that information to make our best report about the person's mental illness or lack thereof, their feigning or lack thereof, and really use all of those pieces of the puzzle.
[00:19:14] Susan: And so sometimes, someone can be very convincing in person and the most convincing people, if they are telling a tall tale about a crime or trying to make it appear that they were mentally unwell at the time when they weren't, the people who were most convincing are the people who know the most about mental illness, right? So maybe they have themselves experienced mental illness or their family members have, and they've been thinking a long time about how to make it sound like they were mentally unwell. In some of those cases, it can be really difficult.
But then sometimes you get the police reports and the witness statements and the hospital reports, and they're maybe very different from what the person tells you. Whereas you may have been really drawn in as a human being to the story that they told you, the more objective evidence says differently. And it's never a snap judgment about someone lying or someone malingering. It's really looking at all of these different pieces of evidence to make those determinations.
Competency vs Sanity in Fiction
[00:20:49] Matty: We had touched on the next topic that I wanted to cover a little bit already, but it's the idea that competency to stand trial and sanity at the time of the act are two different concepts. Anything you'd like to add to that?
[00:21:02] Susan: Sure. I'm keen to explain both of them because yeah, I see them mixed up in fiction and real life. Competency, which depending on the location might also be referred to as fitness to stand trial, this is in the here and now, someone's mental state, versus sanity, is something at the time of the act. So competency or fitness to stand trial, an idea that we wouldn't want to, as a society, try someone who's unable to help themselves in court for whatever, usually mental health related reason.
So if someone has a severe intellectual disability and they don't understand what's going on in court, we would in general think they're unable to participate at present. They're not competent. If someone is unable to help their lawyer, to provide information to their lawyer, about the offending or about the situation, or is unable to pay attention to what's going on in court, for example, maybe they have a delusion and fixed false belief about someone in the courtroom. They believe the judge is related to them and will always release them or any other delusion like that, then it's possible that the person would be incompetent to stand trial.
And then that's not the final answer. Then what we want to do is try and restore them to competency to stand trial. And I'm speaking in generalities here because there's different laws with everything. But in general, then that person would be forensically hospitalized in a forensic hospital. They're often also referred to us as state forensic hospitals. And our goal would be to restore them to competency. So they in general would be treated with medication to help treat whatever disorder they had, if it was something that you could treat with medication. And teaching, and groups learning about the court process, so that then hopefully they could be restored to competency to stand trial. It's a here and now thing, depending on the person's mental illness that can certainly change over time.
[00:23:11] Susan: That's different than sanity at the time of the act, and the bulk of the states have sanity laws. They're slightly different in different states, but in general, sanity is about at the time of the act, the person's mental illness. And did they understand what they were doing, et cetera at the time?
And so you can then imagine that there are many times where you're seeing someone right now for an evaluation. They're not competent. They may well have been saying, when they did the crime, but right now they're not able to assist in their defense or able to understand what's going on in court. The opposite can also be true, that the person was insane at the time or has qualities that would suggest that, but right now, they're getting treated and they understand and they're able to go to trial. So there are different concepts and if say, someone goes to trial, they're found insane, then in general, the next thing is they would be hospitalized for treatment rather than punishment, because the idea behind it in sanity is that really, if someone was so mentally unwell at the time, what are we doing punishing them, shouldn't we be treating them?
Which Is Easier to Argue: Competency or Sanity?
[00:24:21] Matty: Someone was trying to make some decisions about their plot. And I'm assuming that in general, it is the defense attorney who is more likely to be arguing that their client is either not competent to stand trial or was not sane at the time of the act. Is there one of those that's easier or harder to disprove? If the lawyer is trying to make that plug about competency or sanity, they have a better chance arguing one or the other?
They should get an objective evaluation for either one. Competency is more something that's changeable, right? Because it's a here and now thing, versus sanity was at the time of the act. And a finding of insanity is pretty rare, despite what we might believe from the media and trials that are in the media.
[00:25:13] Susan: But so competency as a here and now, it's in general, not a permanent disposition, whereas the insanity would be the end outcome of some court cases.
As far as the evaluations, there may be a psychiatrist who works for the courts and who is court-appointed, but the defense and prosecution can also have a forensic psychiatrist that they ask to evaluate the client.
[00:25:41] Susan: And you're right, that in general it's the defense attorney who's going to bring up their concerns, because it's the defense attorney who's talking to the defendant trying to understand their side of the story, for example, and then the things their client is saying just aren’t making sense to the defense attorney, et cetera. And so oftentimes, that's why we would get a referral for a competency evaluation.
But anyone in the process, whether it's the judge or the prosecutor or the defense attorney who has a concern about competency, could be bringing it up.
Lines a Psychiatrist Wouldn't Cross
[00:26:12] Matty: There was one word that I wanted to hit in the time we have available to us, and that is forensic psychiatrists don't pat our evaluees on the shoulder or give them hugs when they are sad or talking about their trauma or offending, which I've got to believe is maybe one of the most gotten wrong parts of this in crime fiction. Do you want to talk about that a little bit?
[00:26:32] Susan: Yeah, so psychiatrists in general, we want good things for our patients for example, or we want good things in the interest of justice for our forensic evaluees, but we're not there to comfort them physically. There would be very rarely any circumstance where a psychiatrist would be engaging in physical contact other than a handshake with a patient or a forensic psychiatrist with an evaluee. And yes, so often I'm in a good book and I'm reading it and then all of a sudden there's a hug or a pat, and certainly like, I'm human, you hear a sad story, it's a human thing to think about wanting to pat someone on the shoulder or something like that, but that's a line we wouldn't cross in general.
There are other movies where psychiatrists end up in romantic relationships with their patients and those are yeah, completely across any line that psychiatrists should be.
[00:27:29] Matty: So I would think that in the sense that a movie or a book about a completely standard psychiatric interaction might leave something to be desired. I can imagine that's a legitimate choice, as long as the writer is clear that a line has been crossed and that this is a problem. It's not just oh, and by the way, they had this kind of professional relationship before they had the personal relationship. Do you agree with that?
[00:27:53] Susan: So I think that as a reader who is a psychiatrist and a forensic psychiatrist, when a line needs to be crossed in fiction, I would love to see at least the person reflecting on this, like ethically and what would be, that's not what I would normally do in that situation, or that's not the normal ethical line. At least that would tell the reader, oh, there's something going on here that's different than it should be.
[00:28:15] Matty: Yeah, I think that would need to be a whole, like that's maybe the plot where you're exploring what that means. And then I think that there's the extreme example where they become romantically involved, but then there's just lots and lots of hugging going on, I think in fiction. Platonic hugging going on, comforting hugging going on, which I think people should be aware that it's not intrinsic to the plot and it is going to be taking eligible people out of the story.
So we only hit half of the 10 myths corrected that are covered in the article you wrote, "Forensic Psychiatrist and Crime Fiction, 10 Myths Corrected" by Susan Hatters Friedman MD. And I'm going to include a link to that in the show notes.
But Susan, this has been so interesting. Is there anywhere else you would like to send people, either your own sites or resources or others to learn more about this?
[00:29:05] Susan: Absolutely. So I do think talking to a forensic psychiatrist, if you have questions could be a really helpful thing. And I've spoken to different authors about procedures in forensic hospitals, for example or all sorts of other topics.
The other thing is, I would send people to our field journal. The Journal of the American Academy of Psychiatry and the Law is currently available free online to anyone. And it's at jaapl.org. And there's an advanced search, and you can look up all sorts of forensic topics. You might find yourself reading for hours down a rabbit hole. But you know what, my career is such a wonderful field and so many interesting things, and I think for crime writers as well.
[00:29:49] Matty: Well, Susan, thank you so much for sharing some of those. It was great to talk to you.
[00:29:53] Susan: Great to talk to you too. Thank you.
[00:00:06] Susan: Good. How are you? Yeah, I'm happy to have you here. To give our listeners and viewers a little bit of background on you, Susan Hatters Friedman is a psychiatrist specializing in psychiatry and maternal mental health. She currently serves as the president of the American Academy of Psychiatry and the Law. Susan received the Manfred Guttmacher Award from the American Psychiatric Association for editing the book, "Family Murder: Pathologies of Love and Hate."
[00:00:30] Matty: She's pursuing a master's in Crime Fiction, which is super cool, at the University of Cambridge and has studied with The Second City, the world's premier comedy club, comedy theater, and school of improvisation. And her creative writing is found in Hobart, Eclectica, and Drunk Monkeys, among others.
And we're going to be talking about Mistakes Writers Make about Forensic Psychiatry and How to Avoid Them. And this is going to join a lineup of other Mistakes Writers Make in the crime fiction area. Just to give a quick run through of those it's PIs with Patrick Hoffman, the FBI with Jerri Williams, first responders with Ken Fritz, coroners with Jennifer Grazer Dornbush, police procedure with Bruce Robert Coffin, and firearms with Chris Grall. And you can find all of those if you go to theindieauthor.com/podcast and search for mistakes.
So, we wanted to dive into the mistakes writers make about forensic psychiatry.
Her Experience with Second City [00:01:23] Matty: But before we do that, I had to ask about your experience with Second City. Talk about that a little bit.
[00:01:29] Susan: So it's very exciting. During the pandemic in particular, people from around the country, around the world have been able to study online with The Second City. And with my interests, I studied satire writing and they have a course of different series that you take to study satire writing with them and, fabulous experience on learning from amazing satire writers.
[00:01:50] Matty: And you were saying this was an online opportunity, which is pretty nice opening that up to more people.
[00:01:57] Susan: Amazing. And yes, I'm not needing to think about how to get to class during the pandemic and, super interesting people from all around the country and the world.
Is There Overlap Between Satire and Crime Fiction?
[00:02:06] Matty: That's great. Actually, I was debating about whether to ask you about The Second City experience or getting a Master's of Crime Fiction at the University of Cambridge, but it sounds like there might actually be some overlap if you're studying satire, for example, in The Second City. Is there overlap, are you being able to apply the learnings from one to the other?
[00:02:26] Susan: Oh, I definitely think so because, with crime fiction writing and thinking about how to lay the clues and where is the appropriate place for different things and, similar to how you're needing to think about how to lay things out in satire, yes.
[00:02:40] Matty: Very cool. I have to say that as a unique CV that I got for a guest, so that was very fun to read.
So I thought what I would do, the article that I will include a link to in the show notes for this episode has a list of, I believe 10 mistakes that writers commonly make in this area. And we'll see how many we can get through. I'll feed you some of the comments, and I would love to hear your thoughts and examples pro and con in crime fiction.
Forensic Psychiatry vs Forensic Psychology
[00:03:07] Matty: And the first one, which I think is sort of foundational is, forensic psychiatry is not forensic psychology. So talk about that a little bit.
[00:03:14] Susan: Yes, absolutely. And I think before I went to medical school, I might have been unclear about the exact difference as well. So I know that a lot of people confuse psychiatry and psychology, much less than forensic psychiatry and psychology. Psychiatry is a branch of medical science. So a psychiatrist like me has gone to, in America, undergrad for four years and then medical school for four years, and then done psychiatric training, an internship or residency, which is four years more, if you're sub-specializing in something else. And then a fellowship in forensic psychiatry, which is a year in the US.
And so during that time we're in medical school, learning to be psychiatrists and in medical school we're taking the same courses and doing the same practical experiences in the hospital as someone going into internal medicine, as someone going into surgery. And then the residency, you're working as a resident doctor in the hospital, except you're focused on psychiatry, a bit of neurology, a bit of internal medicine and family medicine, so we have that background as well. I would think of our training as more similar to what you would see in Grey's Anatomy, as far as the residency and learning from the attending physicians prior to becoming an attending physician oneself.
And there's a very structured length of time that things take. So it's a four-year residency. Longer, if you're doing child psychiatry or adding on geriatric psychiatry or addiction psychiatry. And then a forensic psychiatry fellowship is one year after the residency as well. And so it is a bunch of time that it takes to do it.
An example that I like to give, what is psychiatry versus psychology, the background I have is Frasier Crane's apartment. Frasier Crane and his brother Niles Crane were psychiatrists in fiction and television, and they were medical doctors who became psychiatrists.
So psychologists, instead of an MD, they have a PhD, so they've pursued undergraduate, and then graduate school in psychology. And then they do additional training in the hospital as well, but they're not medical doctors. So a lot of the things that we do may be very similar, but we diverge in some areas. So in general, psychiatrists are able to prescribe medication because of going to medical school, et cetera. Psychologists are able to do therapy as are psychiatrists. Psychologists also have a wealth of different experience, but it's a different role.
And in a lot of things you read, or a lot of things you watch on TV, it may flip flop from one scene to the next, if someone's a psychiatrist or psychologist or a forensic psychiatrist or psychologist, and in real life, they're different roles with different background and training.
Inaccurate Depictions of Psychiatrists and Psychologists
[00:06:02] Matty: Is there something that is the red flag for you that someone's gotten it wrong, if they're presenting the character as one of those, and then they do something? What's something that they do that is just not accurate?
The switching back and forth is something I see a lot, but also medication. So in general, forensic psychiatry units will have a team-based approach, and so there's a forensic psychiatrist, a forensic psychologist on the hospital unit, nurses, social work, occupational therapy, rehabilitation, et cetera. And it will be the forensic psychiatrist who's prescribing the medication. And testifying about medication, prescribing medication, those are in general the province of the forensic psychiatrist.
What Does Forensic Actually Mean?
[00:06:42] Matty: So the difference between psychiatry and psychology is important, but I think that the other key word here is forensic. And I realized embarrassingly recently that I think I'd always assumed that forensic had to do with death, but then you hear about like forensic accounting and things like that. So can you explain what the term forensic actually means?
[00:07:01] Susan: Sure, the forensic and forensic psychiatry is really anywhere where psychiatry interacts, intersects with the legal system. So in crime fiction, it's a lot of thinking about evaluations of defendants or of perpetrators and, our role as forensic psychiatrist is there in the legal system in that way, in a lot of crime fiction.
But it can be anywhere where we intersect with the legal system for a forensic psychiatrist. Civil law cases, for example, a disability evaluation and malpractice evaluation. Those would be included as well.
Also included within forensic psychiatry would be correctional psychiatry. So a psychiatrist working with offenders or with defendants in the correctional system would fall under forensic psychiatry. And then also, we may help educate legislators about psychiatric issues and that would fall under the umbrella of forensic psychiatry as well.
Psychiatric Confidentiality
[00:07:57] Matty: Okay, thank you. One of the other key points you highlighted where people get things wrong was the topic of confidentiality. Confidentiality with the treating psychiatrist is similar to that with a priest or a lawyer. Can you talk about that a little bit and where you see people getting that right or wrong in crime fiction?
[00:08:15] Susan: Absolutely. I think that it's really important that readers and folks in the general population understand the role of a psychiatrist as far as confidentiality, because I don't want it to dissuade anyone from getting the help they need, the mental health help they need and feeling like we're just going to go tell somebody about what they said. And so yes, it's similar to like a priest and someone who was coming to the priest, or other sorts of doctors that we need to keep things confidential.
There are certain exceptions that are very specific within the law. Like if there's ongoing child abuse that we're concerned about, for example, or an acute threat that we need to hospitalize someone, for example. But there are various instances in crime fiction where for example, a psychiatrist sees a patient, the patient reports something to them, the psychiatrist gets suspicious and then reports it to the police. And that's not something we can just do.
If I was seeing someone for example, and they were making homicidal threats, usually the first thing we're thinking of is hospitalizing them for safety. There are very specific instances where law enforcement would be notified, but that's and in a couple of cases and in crime fiction, it's just the patient reports something to the psychiatrist or the therapist and right away the police find out.
In otherwise wonderful novels that I really enjoy reading, but it takes me out of the story, for one. And it also makes me worried, is someone who's thinking about seeing a psychiatrist for this personal issue that they're having, going to be afraid that if they do, other people are going to find out? So yeah, there are very specific exceptions to confidentiality, but in general, it’s between the adult patient and the psychiatrist.
[00:09:59] Matty: I think in that case, a writer has two choices. One is that they have a character that's a psychiatrist and they decide to be realistic about it and they don't have the character do that. But I can imagine a plot where the plot requires that someone who has perpetrated a crime confides in someone else, or someone who's thinking about committing a crime confides in someone else, and that person goes to the authorities. Is there an alternative to making that person a psychiatrist that you can think of that would legitimately result in that the person that's being confided in being able to go to the police?
[00:10:33] Susan: That's an interesting question. Legitimately versus crime fiction, because in crime fiction, I can certainly imagine someone making an anonymous call or something like that that would not be ethical in real life. Or someone overhearing someone talking to someone who they're telling confidentially. In crime fiction might be something.
I liked that because you've identified a third option, which is, the person does the bad thing, but there's some acknowledgement that it's a bad, unethical, out of norm thing to do, which may take your story in a different direction. Or someone finds something that someone wrote about, or their text messages or et cetera. Someone. Yeah. So I can imagine other ways. It worries me when it's a treating psychiatrist going to the police about their patient.
When is Hospitalization Appropriate?
[00:11:23] Matty: And you had mentioned hospitalizations. So can you talk a little bit about what that process is like, and it sounds like the police don't necessarily, maybe they necessarily do not get involved, in that kind of step, if someone has said something that the psychiatrist believes should be met with hospitalization.
[00:11:42] Susan: Sure, and here I'm talking about like someone seeing their general psychiatrist in the community and the psychiatrist having concerns. Primarily, is the person because of their mental illness, presenting a risk to others or to themselves that really hospitalization is the appropriate option? Then either the psychiatrist would talk to them about voluntarily coming to the hospital, or in some cases, the psychiatrist would need to move toward an involuntary hospitalization, if there was serious concern about the risk and the person didn't have insight into the importance of getting treatment.
And so, every state has different rules about exactly how that works. But no, in many cases, the police wouldn't need to be involved in that. If the person came to the emergency room or if EMS was involved, et cetera, psychiatrists. And depending on the state, which one could check with the state laws of the state that someone's in or talk with the psychiatrists about how it works. There are processes and procedures for how the person would be psychiatrically hospitalized.
And they're very specific procedures to protect the person's rights. But it's also thinking about the state's power to want to protect the rest of its citizens, as well as that person themselves. So if it was a concern about suicide, et cetera. We know in the past psychiatric hospitalization, 50 years ago, 100 years ago, has a history of being misused. And that's why there are very specific safeguards and rules of what the psychiatrist, what the hospital needs to do, and the evidence that needs to be provided to a judge in a specific timeframe, depending on the state about the persons at risk and dangerousness from mental illness.
How Does Involuntary Hospitalization Work?
[00:13:28] Matty: And what would the process actually look like? I know that there would be a ton of variability from case to case, but just picking out an example, if the psychiatrist felt that hospitalization was necessary and the person they were working with wasn't willing to do it voluntarily, how does the involuntary hospitalization process work?
[00:13:49] Susan: Sure. So depending on the state, for example, in Ohio where I currently work, there's a form called a pink slip. It's called different things in different states based on how it came about and the different state laws. And so for example, Ohio, there are criteria that the psychiatrist would need to consider. Does the person have a mental illness? Is it impacting their judgment, their ability to recognize reality, et cetera? And then, is it causing them to be at an acute risk of harming themselves or others or unable to take care of themselves?
And so then that is completed, the person is hospitalized and in Ohio, we have to file more paperwork with the court within a 72-hour timeframe. So you can see it's a very short hold, and then the court becomes involved, and civil commitment proceedings may occur. The goal is to get people the help they need in the shortest amount of time though, as well. So someone may even be released before the court becomes involved, depending on how they're doing, are the medications working, et cetera.
Past Crimes vs Future Crimes
[00:15:03] Matty: And is there any difference between a person working with a psychiatrist and saying that they committed a crime in the past, versus that they're thinking about committing a crime in the future?
[00:15:16] Susan: Yes, great question, and yes. I would say most psychiatrists I know would be contacting their hospital's legal department if either thing happens, just to make sure the current state of the law and that. But yes, in general, as I was saying like with the priest as well, a past crime is different than a future crime that someone's planning to commit, et cetera, and that's related to their mental illness.
Now, an exception to that would be child abuse, elder abuse, if someone's in danger right at the present time because of ongoing criminal activity. But yeah, I think most psychiatrists would be checking with their legal office of their hospital, if any of those things happen. But yes, thinking similar to the priest.
[00:16:04] Matty: And this is a little bit of a tangential one, but that answer made me think, would there be a scenario where a psychiatrist is not affiliated with a hospital, they're an independent practitioner and in that case, would they go to their lawyer to ask?
A lawyer or every psychiatrist in America is going to have a malpractice insurer, and they have a law team with different malpractice insurers to help through legal situations like that or concerning situations like that.
Forensic Psychiatrists Are Not Lie Detectors
I'm going to move on to another one that sort of caught my fancy, which was forensic psychiatrists are not lie detectors. Talk about that a little bit.
So many things you hear colloquially or when people strike up a conversation with me at a party or something, and they'll ask like, how can you tell if someone's lying? And yeah, they're kind of old wives' tales or myths that you hear about if someone looks in a certain direction, et cetera, it means they're lying.
[00:16:58] Susan: If only it were that easy. When we are seeing people as forensic psychiatrists, usually our role is going to be, well, in crime fiction and in criminal law with forensic psychiatry, we are usually seeing someone to do an evaluation, to write a report to the court, perhaps to testify in court about a specific issue related to that person. So I'm doing an evaluation for example, about someone's competency to stand trial or their sanity at the time of the act or their future risk of violence.
In doing that evaluation, I'm getting a lot of history about their life, not just about the time of the crime. So I'm asking many questions about their life story, I'm asking many questions about their substance use history, about their psychiatric history, and then focusing in on what they're alleged to have done or what they've been found guilty of doing.
One of the things that we consider is malingering or feigning of mental illness. Is someone making up a mental illness out of whole cloth? Are they exaggerating a mental illness that they or a family member has had? Some people minimize their mental illness background because they don't want to be perceived negatively by society. So we're determining or attempting to determine if someone's malingering, if they're exaggerating, if they're completely feigning. And we use our knowledge of mental illness from having treated many patients over years, as well as our studies, et cetera, of what real mental illness looks like.
[00:18:37] Susan: And then we look at the behaviors of the person at the time. We look at many collateral records of what the police reports say, what do hospital reports say? Not just what the person sitting in front of us says.
Also, it's often the province of forensic psychologists, our colleagues, who will do testing or malingering as well. And so we use all of that information to make our best report about the person's mental illness or lack thereof, their feigning or lack thereof, and really use all of those pieces of the puzzle.
[00:19:14] Susan: And so sometimes, someone can be very convincing in person and the most convincing people, if they are telling a tall tale about a crime or trying to make it appear that they were mentally unwell at the time when they weren't, the people who were most convincing are the people who know the most about mental illness, right? So maybe they have themselves experienced mental illness or their family members have, and they've been thinking a long time about how to make it sound like they were mentally unwell. In some of those cases, it can be really difficult.
But then sometimes you get the police reports and the witness statements and the hospital reports, and they're maybe very different from what the person tells you. Whereas you may have been really drawn in as a human being to the story that they told you, the more objective evidence says differently. And it's never a snap judgment about someone lying or someone malingering. It's really looking at all of these different pieces of evidence to make those determinations.
Competency vs Sanity in Fiction
[00:20:49] Matty: We had touched on the next topic that I wanted to cover a little bit already, but it's the idea that competency to stand trial and sanity at the time of the act are two different concepts. Anything you'd like to add to that?
[00:21:02] Susan: Sure. I'm keen to explain both of them because yeah, I see them mixed up in fiction and real life. Competency, which depending on the location might also be referred to as fitness to stand trial, this is in the here and now, someone's mental state, versus sanity, is something at the time of the act. So competency or fitness to stand trial, an idea that we wouldn't want to, as a society, try someone who's unable to help themselves in court for whatever, usually mental health related reason.
So if someone has a severe intellectual disability and they don't understand what's going on in court, we would in general think they're unable to participate at present. They're not competent. If someone is unable to help their lawyer, to provide information to their lawyer, about the offending or about the situation, or is unable to pay attention to what's going on in court, for example, maybe they have a delusion and fixed false belief about someone in the courtroom. They believe the judge is related to them and will always release them or any other delusion like that, then it's possible that the person would be incompetent to stand trial.
And then that's not the final answer. Then what we want to do is try and restore them to competency to stand trial. And I'm speaking in generalities here because there's different laws with everything. But in general, then that person would be forensically hospitalized in a forensic hospital. They're often also referred to us as state forensic hospitals. And our goal would be to restore them to competency. So they in general would be treated with medication to help treat whatever disorder they had, if it was something that you could treat with medication. And teaching, and groups learning about the court process, so that then hopefully they could be restored to competency to stand trial. It's a here and now thing, depending on the person's mental illness that can certainly change over time.
[00:23:11] Susan: That's different than sanity at the time of the act, and the bulk of the states have sanity laws. They're slightly different in different states, but in general, sanity is about at the time of the act, the person's mental illness. And did they understand what they were doing, et cetera at the time?
And so you can then imagine that there are many times where you're seeing someone right now for an evaluation. They're not competent. They may well have been saying, when they did the crime, but right now they're not able to assist in their defense or able to understand what's going on in court. The opposite can also be true, that the person was insane at the time or has qualities that would suggest that, but right now, they're getting treated and they understand and they're able to go to trial. So there are different concepts and if say, someone goes to trial, they're found insane, then in general, the next thing is they would be hospitalized for treatment rather than punishment, because the idea behind it in sanity is that really, if someone was so mentally unwell at the time, what are we doing punishing them, shouldn't we be treating them?
Which Is Easier to Argue: Competency or Sanity?
[00:24:21] Matty: Someone was trying to make some decisions about their plot. And I'm assuming that in general, it is the defense attorney who is more likely to be arguing that their client is either not competent to stand trial or was not sane at the time of the act. Is there one of those that's easier or harder to disprove? If the lawyer is trying to make that plug about competency or sanity, they have a better chance arguing one or the other?
They should get an objective evaluation for either one. Competency is more something that's changeable, right? Because it's a here and now thing, versus sanity was at the time of the act. And a finding of insanity is pretty rare, despite what we might believe from the media and trials that are in the media.
[00:25:13] Susan: But so competency as a here and now, it's in general, not a permanent disposition, whereas the insanity would be the end outcome of some court cases.
As far as the evaluations, there may be a psychiatrist who works for the courts and who is court-appointed, but the defense and prosecution can also have a forensic psychiatrist that they ask to evaluate the client.
[00:25:41] Susan: And you're right, that in general it's the defense attorney who's going to bring up their concerns, because it's the defense attorney who's talking to the defendant trying to understand their side of the story, for example, and then the things their client is saying just aren’t making sense to the defense attorney, et cetera. And so oftentimes, that's why we would get a referral for a competency evaluation.
But anyone in the process, whether it's the judge or the prosecutor or the defense attorney who has a concern about competency, could be bringing it up.
Lines a Psychiatrist Wouldn't Cross
[00:26:12] Matty: There was one word that I wanted to hit in the time we have available to us, and that is forensic psychiatrists don't pat our evaluees on the shoulder or give them hugs when they are sad or talking about their trauma or offending, which I've got to believe is maybe one of the most gotten wrong parts of this in crime fiction. Do you want to talk about that a little bit?
[00:26:32] Susan: Yeah, so psychiatrists in general, we want good things for our patients for example, or we want good things in the interest of justice for our forensic evaluees, but we're not there to comfort them physically. There would be very rarely any circumstance where a psychiatrist would be engaging in physical contact other than a handshake with a patient or a forensic psychiatrist with an evaluee. And yes, so often I'm in a good book and I'm reading it and then all of a sudden there's a hug or a pat, and certainly like, I'm human, you hear a sad story, it's a human thing to think about wanting to pat someone on the shoulder or something like that, but that's a line we wouldn't cross in general.
There are other movies where psychiatrists end up in romantic relationships with their patients and those are yeah, completely across any line that psychiatrists should be.
[00:27:29] Matty: So I would think that in the sense that a movie or a book about a completely standard psychiatric interaction might leave something to be desired. I can imagine that's a legitimate choice, as long as the writer is clear that a line has been crossed and that this is a problem. It's not just oh, and by the way, they had this kind of professional relationship before they had the personal relationship. Do you agree with that?
[00:27:53] Susan: So I think that as a reader who is a psychiatrist and a forensic psychiatrist, when a line needs to be crossed in fiction, I would love to see at least the person reflecting on this, like ethically and what would be, that's not what I would normally do in that situation, or that's not the normal ethical line. At least that would tell the reader, oh, there's something going on here that's different than it should be.
[00:28:15] Matty: Yeah, I think that would need to be a whole, like that's maybe the plot where you're exploring what that means. And then I think that there's the extreme example where they become romantically involved, but then there's just lots and lots of hugging going on, I think in fiction. Platonic hugging going on, comforting hugging going on, which I think people should be aware that it's not intrinsic to the plot and it is going to be taking eligible people out of the story.
So we only hit half of the 10 myths corrected that are covered in the article you wrote, "Forensic Psychiatrist and Crime Fiction, 10 Myths Corrected" by Susan Hatters Friedman MD. And I'm going to include a link to that in the show notes.
But Susan, this has been so interesting. Is there anywhere else you would like to send people, either your own sites or resources or others to learn more about this?
[00:29:05] Susan: Absolutely. So I do think talking to a forensic psychiatrist, if you have questions could be a really helpful thing. And I've spoken to different authors about procedures in forensic hospitals, for example or all sorts of other topics.
The other thing is, I would send people to our field journal. The Journal of the American Academy of Psychiatry and the Law is currently available free online to anyone. And it's at jaapl.org. And there's an advanced search, and you can look up all sorts of forensic topics. You might find yourself reading for hours down a rabbit hole. But you know what, my career is such a wonderful field and so many interesting things, and I think for crime writers as well.
[00:29:49] Matty: Well, Susan, thank you so much for sharing some of those. It was great to talk to you.
[00:29:53] Susan: Great to talk to you too. Thank you.
A question for you ...
I hope you enjoyed my conversation with Susan! Does your work involve forensic psychiatry and, if yes, have you falled into any of the traps Susan mentioned? Can you think of others that your fellow crime fiction authors should watch out for?
I’d love to hear your thoughts!
However, I don’t get notifications of comments posted here, which means I may miss some, and my website builder doesn’t enable commenters to respond to a specific comment, which makes it hard to engage in any kind of dialogue. So I’m recommending that you post any comments on YouTube.