Though Hannibal Lecter most readily jumps to mind, other forensic psychiatrists also feature in crime fiction. Yet, as an ardent mystery reader and a forensic psychiatrist, I am often yanked out of the story because of simple things about my field that authors get wrong. Of course there are times when the author needs to manipulate the role in service of the story. But I’m referring to errors that rather indicate a lack of research—in otherwise amazing books.
People are much more likely to read crime fiction than to have encountered a forensic psychiatrist in real life. Thus, for example, when forensic psychiatrists go to court to testify, jurors are likely to have misconceptions from fiction about what forensic psychiatrists do—and don’t do. As much as I love suspension of disbelief, my concern is this real-life misperception. Here are my top 10 myths from crime fiction, corrected:
1. Forensic psychiatry is not forensic psychology.
Psychiatry (think of Frasier and Niles Crane) is a branch of medicine. Psychiatrists have gone to medical school (dissected cadavers just like the rest of the medical doctors), obtained their MD (or MBBS, or DO), and then completed residency (registrar) training in psychiatry. In the US, psychiatry residency is four years, and forensic psychiatry fellowships are one year. In psychiatry residency, residents evaluate and treat patients with mental illness, under supervision by their attendings (consultants). They work overnight call. Forensic psychiatry fellowships exist in most major cities, and have specific core competencies that forensic psychiatrists must demonstrate. Research may be a part of it, but fellowships primarily involve performing evaluations of evaluees to answer specific legal questions and learning to write court reports, with some court testimony. Fellowships also have portions devoted to treatment of criminal justice-involved individuals. Psychiatrists prescribe medications (just like the rest of the MDs), as well as doing therapy.
(In distinction, psychologists have studied psychology at the doctoral level (PhD or PsyD). Forensic psychology is a sub-specialty area within psychology. Psychologists then complete internships, and post-doc training. Forensic psychologists complete psychological assessments and treatment, write court reports, provide court testimony, and perform psychological testing—whereas forensic psychiatrists generally do not perform testing.)
A character should either be a forensic psychiatrist or a forensic psychiatrist, not switch jobs and background during a narrative. These are different, though intersecting, fields. If the character is completing forensic evaluations, writing reports, and testifying, they might be either. If the forensic evaluation is related to medication (e.g. did the antidepressant medication make her sexually offend?; did the sleep-aid make him kill his mother-in-law in his sleep?), the character would be better served with a medical (psychiatry) background. If a character is prescribing medication, then they should absolutely be a psychiatrist. (If they are performing psychological testing, the character would often be a forensic psychologist.)
2. Forensic psychiatrists work in various capacities, since forensic psychiatry involves the intersection of psychiatry and the law. We work in forensic hospitals where people who are found incompetent to stand trial or insane at the time of the act are sent. (Note: they are not called ‘inmates’ in the forensic hospital, but are ‘forensic patients’ or ‘patients’.) We work in correctional facilities. We work in court clinics (where evaluations for court reports and testimony are completed, rather than treatment) and private offices. Forensic psychiatrists are also called upon for civil (rather than criminal) evaluations—for example fitness for a police officer to return to duty, or psychological damages in tort cases.
3. In general, confidentiality with a treating psychiatrist is similar to that with a priest or lawyer. Sacrosanct, unless the patient is reporting plans to commit suicide or kill someone, or cases of child or elder abuse, for example. A general psychiatrist cannot, for example, call the police because a patient had a dream about something—this would completely erode trust in the profession and cause people not to seek out the mental health help that they need.
But the whole point of a forensic evaluation is to gather information to help the court in its determinations—there is not confidentiality with the person being evaluated, and the evaluee is warned about that. The forensic psychiatrist cannot agree with an evaluee that something is ‘just between us’.
4. Forensic psychiatrists are meant to avoid dual agency where possible—meaning not testifying about one’s own patients due to conflicts of interest. See #3. This drives me batty in crime fiction. In rare instances, in real life, the attorney will request that the treating psychiatrist testify, and their patient will agree. However, it is impossible for this to be unbiased due to the pre-existing relationship, and may lead to loss of trust in the psychiatrist in the future. As well, the psychiatrist could be accused of saying that the patient is mentally unwell to help fill the psychiatrist’s coffers.
5. Forensic psychiatrists are not part of police interrogations with deception, and definitely not a part of torture. We are usually consulted, rather, after a defendant has been arrested.
6. Forensic psychiatrists are not lie detectors. We do not check if a person looks to the left (or any other direction) to see if they’re lying. If it were that easy to tell if someone was lying, we would be out of work, and all the people we evaluate would know to just switch the direction they look in. This has actually been debunked—but was never even something that we did. Forensic psychiatrists are general psychiatrists first, and need a lot of experience with real mental illness prior to beginning to evaluate people for malingering (feigning symptoms). Psychological testing by our psychologist colleagues helps in some cases of malingering, as does knowledge about true vs. false mental illness.
7. Forensic psychiatrists are not on one side or the other, getting paid on commission. Forensic psychiatrists, rather, strive for objectivity no matter whether hired by the prosecution, the defense, or the court itself. The evaluation outcome should be the same no matter who has hired the forensic psychiatrist. It is considered wholly unethical to work for commission, because that would bias the forensic psychiatrist.
8. Competency to stand trial and Sanity at the time of the act are two different concepts. We do many other sorts of evaluations as well, but these are the two that I often see confused in fiction.
Competency (or fitness) to stand trial is concerned with whether the defendant is mentally unwell at the time of the trial, which is often many months after the alleged offense. For example, if a defendant is acutely psychotic or severely depressed, manic or delirious, they may not be competent to stand trial—and need to be treated in a forensic hospital prior to standing trial. The trial is halted while they are getting treatment. In a civilized society, ensuring that a defendant is competent to stand trial helps ensure the fundamental fairness of the justice system.
Sanity at the time of the act, in distinction, examines the defendant’s mental state around the time of the offending. Did god’s voice tell her to kill her partner, or did she do it because she was angry? Was he hearing voices telling him to steal, or did he do it to feed his family? Not as simple as this, of course, but this is the essence. And yes, based on our extensive general psychiatry backgrounds and knowledge of true mental illness, we work to ferret out malingering. Otherwise, virtually every defendant could be saying they heard god’s voice telling them to offend.
9. 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. In general, any psychiatrist is not meant to touch patients. And definitely not to have sex with them. In forensic psychiatry, we are especially careful to maintain the appropriate boundaries.
10. Unfortunately, we do not get flown around in private jets for cases. When we travel to perform evaluations, it is not in the midst of the crime being committed, but after the arrest when attorneys and courts are considering the defendant’s mental state. We fly on commercial airlines, sometimes in the middle seat of economy class—although there may be many more Zoom evaluations rather than flights in the future, in light of the pandemic.
Forensic psychiatry is an exhilarating profession for fictional characters and real people alike—especially with these common misconceptions corrected. Although I wouldn’t mind a private jet.
Susan Hatters Friedman, MD, editor of Family Murder: Pathologies of Love and Hate, was awarded the 2020 Manfred Guttmacher Award for the outstanding contribution to the literature of the field of forensic psychiatry. She has previously served as Vice President of the American Academy of Psychiatry and the Law.