Forensic opinion becomes authoritative when its epistemic (knowledge-based) content achieves a certain quality and credence. This is the point at which information qualifies as expert testimony. It is epistemology that traditionally unites the factual state of things (truth) with a level of surety (belief) to become knowledge. The following description of an epistemology, or way of knowing, for forensic psychiatry draws on traditional and contemporary scholarship to propose an alliance of logic and probability for moving from inquiry to knowledge. Using probabilistic reasoning to accrue evidence toward a conclusion, this approach acknowledges the uncertainties of science and human behavior, the biases of observation and research, and the misinformation and doubt of a political era typified by skepticism and distrust.
Solitary confinement continues to be a widespread practice among jails and prisons in the United States, despite extensive evidence of its negative effects on mental health, particularly for individuals with serious mental illness (SMI). Given this, it is imperative for forensic mental health clinicians, especially those working in correctional settings, to be aware of the laws and policies that govern who can be placed in solitary confinement, for what reasons, and for how long. This article summarizes each state's statutes, administrative codes, and department policies on solitary confinement regarding people with SMI, highlighting the wide variation in the treatment of individuals with SMI in the correctional system across states and the need for uniform legislation that restricts the use of solitary confinement for people with SMI. This knowledge can help clinicians to better understand the ways in which their patients may be affected by the practice of solitary confinement and, ultimately, how to advocate for incarcerated individuals placed in solitary confinement to help minimize adverse outcomes.
Correctional facilities in the United States house many individuals with mental illness requiring psychiatric care. This study investigates didactic and clinical experiences and attitudes related to correctional psychiatry among psychiatry residency program directors and medical student clerkship directors. An online survey was distributed to assess the current landscape of learner exposure to correctional psychiatry, topics related to criminal legal involvement among people with mental illness, and attitudes toward correctional psychiatry. A total of 96 individuals responded to the survey (overall response rate of 16%). About half of clerkship director (45.2%) and program director (51.1%) respondents report affiliations with correctional institutions. Few residency programs have a mandatory rotation (24.4%) whereas a higher proportion offer elective rotations (57.8%). Although medical student clerkship directors identify teaching correctional health as important, medical students have limited exposure and education on core topics of correctional psychiatry, perhaps related to reported heightened safety concerns. Correctional settings offer an opportunity to expose future psychiatrists to the care of people with criminal legal involvement as well as individuals with serious mental illness needing care. We found variable experiences in the exposure, education, and availability of rotations related to correctional psychiatry. Educators should advocate for learners to have further opportunities in these needed areas.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) defines obsessions in obsessive-compulsive disorder (OCD) as recurrent thoughts, urges, or images that are intrusive, unwanted, and distressing. Because the manual does not include an explicit ego-dystonicity requirement, its definition risks conflating anxiety-driven intrusions with gratification-driven impulses. This ambiguity carries significant forensic implications. When violent ideation is emotionally gratifying, it may still be described as distressing or unwanted, in a practical sense. In such cases, it may be misclassified as obsessional, potentially mitigating culpability or distorting assessments of intent and risk. Using the cases of William Heirens and Robert Cameron Houston, this article illustrates how DSM language can blur the boundary between true obsessional phenomena, experienced as alien, morally incongruent, and resisted, and ego-syntonic violent ideation that is volitional, reinforcing, and aligned with behavior. Tracing this vulnerability to the DSM's historical shift from psychodynamic to descriptive nosology, the paper argues that diagnostic precision must be grounded in phenomenological meaning rather than in surface description. In forensic contexts, this distinction safeguards determinations of intent, volition, and responsibility. Clarifying that obsessions are, by definition, ego-dystonic would preserve the conceptual integrity of OCD, prevent its misuse in court, and support the ethical and evidentiary coherence of psychiatric testimony.
The mental health effects of segregation remain contested, with limited longitudinal evidence using clinical data. We conducted a retrospective longitudinal observational study of individuals placed in segregation in British Columbia correctional facilities between 2019 and 2022. Global mental health severity was assessed using serial Clinical Global Impression for Corrections (CGI-C) ratings. Mixed-effects regression models were used to examine change in CGI-C scores over time, accounting for repeated observations nested within segregation encounters and individuals. The sample included 2,288 individuals across 3,273 segregation encounters (9,282 CGI-C observations). The median segregation duration was 10 days. At the encounter level, 24.6 percent showed at least a one-point improvement in CGI-C, 60.3 percent showed no change, and 15.1 percent worsened. In adjusted models, identified mental health needs (MHNs) were associated with higher overall severity (higher CGI-C scores) and a small deterioration (increase in CGI-C scores) over time. Baseline mental health severity strongly differentiated the trajectories: individuals with high initial CGI-C ratings showed a marked early reduction in severity, whereas those with low initial severity exhibited a gradual increase. Despite improvement, high-severity individuals remained more symptomatic overall. Individuals with MHNs at baseline experienced a less favorable trajectory, although persons with a higher severity at baseline modestly improved over time, perhaps because of available support services.
Although forensic psychiatric assessments of fitness to stand trial are well established in criminal law, the analogous question of civil litigation capacity, particularly the ability to commence or continue legal proceedings, receives far less attention. In this article, we examine the statutory frameworks and case law governing litigation capacity in Canada and the United States. Focusing on decisions such as Carmichael v. GlaxoSmithKline Inc. and In re Mirapex Products Liability Litigation, we analyze the legal criteria used to toll limitation periods, evaluate how courts distinguish functional incapacity from psychiatric diagnosis, and highlight the presumption of capacity as a core principle. We also consider comparative standards, emerging rights-based approaches under the United Nations Convention on the Rights of Persons with Disabilities (CRPD), and the implications for forensic psychiatric practice. Emphasis is placed on the importance of functional assessment and supported decision-making models, offering forensic clinicians practical guidance aligned with contemporary legal values.
Over time, U.S. civil commitment laws have evolved from broad, paternalistic statutes to more narrowly defined legal standards that emphasize individual liberty, least-restrictive treatment, and due process. This shift contributed to deinstitutionalization as state hospital beds decreased and the number of those meeting the new involuntary commitment standards diminished. Subsequent analyses found that, as states narrowed their criteria for involuntary commitment and as community mental health systems strained to absorb the gap, homelessness and criminal justice involvement among people with mental illness increased. Recently, some states and localities have begun to examine their civil commitment frameworks, aiming to broaden eligibility to address complex social and public safety concerns. This article examines these nationwide occurrences and trends through the lens of New York, California, and Minnesota, analyzing their legal reforms and exploring the ethics tensions they raise. These developments reflect a recurring tension between respect for individual autonomy and society's obligations to provide care and ensure public safety, a dynamic that continues to shape modern civil commitment frameworks.
Medical schools and residency programs vary widely in the depth and breadth of training offered within their social justice curricula, creating an uneven knowledge base for incoming forensic psychiatry fellows. To address this disparity, a core faculty group in a forensic psychiatry fellowship designed a novel social justice curriculum to ensure that all fellows possess the knowledge needed for competent forensic evaluation and treatment. The course begins with an introduction to the ethics of practicing within an unjust system and utilizes a three-tiered model that explores the social determinants of outcomes within the legal system, bias in forensic evaluation, and special population considerations. The curriculum is designed to provide a space for fellows to discuss the influence of identity on legal and forensic mental health outcomes, enhance their knowledge of social justice, recognize and reduce their biases, and understand the lived experiences of those whom they evaluate and treat. This course provides a potential solution for training inequities and offers a national model to ensure that all fellows, regardless of previous educational experiences, receive training that is vital to competent practice in forensic psychiatry.
Burnout and well being in forensic psychiatrists have been insufficiently examined, with most research focusing on vicarious trauma, compassion fatigue, or posttraumatic stress disorder among forensic mental health professionals. Previous research in Canada from 2023 highlighted a high prevalence of burnout among forensic psychiatrists, particularly among early-career psychiatrists, those whose values were misaligned with their institution, and those who had a low perceived control over their workload. Building upon this, the current study provides an assessment of the U.S. workforce in forensic psychiatry, identifying aspects of practice that contribute to, or mitigate, burnout and enhance professional fulfillment. Survey results of American Academy of Psychiatry and the Law (AAPL) members (response rate 11%) indicated that those experiencing burnout were younger, female, perceived to have had less control over their workload, spent more time on the electronic medical record (EMR), and felt their values were misaligned with leadership and colleagues. Factors predicting professional fulfillment were overall job satisfaction, value alignment with colleagues, and mentoring others. The findings of this survey will help to identify interventions at institutional and systems levels to address contributors to burnout, promote professional fulfillment and well being, and enhance recruitment and retention in the field of forensic psychiatry.
Childhood lead toxicity remains a nationwide problem, despite significant progress in reducing exposure sources in the United States since the 1970s. Neurodevelopmental sequelae of lead exposures often persist into adulthood, with limited reversibility. These include long-lasting deficits in intelligence, impulse control, and emotional and behavioral regulation, which can increase one's propensity for aggression and criminality. Yet, despite the strong association between lead poisoning and criminality, there is little agreement thus far among U.S. jurisdictions about how to apply such knowledge to criminal legal proceedings. Here, we explore forensic considerations of childhood lead toxicity for evaluation, sentencing, and staff support in the criminal justice system. We cite both clinical science and case law in navigating this complex intersection of forensic psychiatry, public health, and the environment. We aim to provide preliminary guidance on how forensic psychiatrists can approach and refer to lead toxicity in their medicolegal work. This article may hopefully inspire further forensic research on the topic and the eventual creation of standardized, lead-related guidelines for criminal legal proceedings.
Structured risk assessment tools are essential in forensic psychiatry to evaluate the likelihood of recidivism. The Violence Risk Appraisal Guide-Revised (VRAG-R) was developed as an update to the VRAG, but its predictive validity across offender populations remains underexamined. Our study aimed to examine the predictive validity of the VRAG-R for general, violent (including and excluding sexual offenses), and sexual recidivism. We conducted a systematic review and meta-analysis, searching 10 databases and gray literature sources for studies reporting psychometric outcomes for the VRAG-R published since 2013. Risk of bias was assessed using Prediction Model Risk of Bias Assessment (PROBAST) and data extraction followed the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies (CHARMS) checklist. Area under the curve (AUC) values were pooled using random-effects meta-analysis. In total, 15 studies comprising 3,932 participants were included. The VRAG-R showed acceptable predictive validity for general recidivism (pooled AUC = .71, 95% CI: .67 to .75) and violent recidivism (AUC = .72, 95% CI: .69 to .75). Predictive validity for sexual recidivism was modest (AUC = .65, 95% CI: .61 to .68). In conclusion, the VRAG-R demonstrates acceptable predictive validity for general and violent recidivism, comparable with other tools. Its performance in predicting sexual recidivism, however, is limited and concerns about generalizability remain. Future research should prioritize diverse samples, reporting of calibration, and continued evaluation of performance.
Professional, political, and public debates are ongoing regarding the best way to assess risk and monitor individuals who have been found not guilty by reason of insanity (NGRI). Political and public impressions are often confounded by few, often dramatic and highly publicized cases of NGRI acquittees reoffending, rather than by an accurate understanding of the process and actual rearrest rates. States have implemented their own policies and practices for NGRI pleas (if allowed) and the subsequent evaluations, monitoring, and care for acquitted individuals, resulting in significant variation across jurisdictions. In the last five years, Arizona dissolved its Psychiatric Security Review Board (PSRB) and there were calls for ending the Connecticut PSRB. We review some of the past and current practices and evidence from PSRBs in Oregon, Arizona, Connecticut, and Washington. We discuss the challenges of comparing state practices because of variation in the connections between policy and practice and competing stakeholders' interests.
In Canada, the insanity defense is outlined in both legislation and judicial case law and finds original basis in M'Naughten's case. Federal jurisprudence in Canada has addressed the second and more complicated branch of the not criminally responsible on account of mental disorder (NCRMD) test on wrongfulness, yet legal ambiguity persists in provincial courts. A recent Supreme Court of Canada decision, R v. Bharwani, adds clarity. Finding agreement on the primary matter of fitness, the Court's dissenting opinion, delivered by two of its esteemed jurists and joined by a third, casts aside the obiter dictum of the court of appeal on NCRMD and was unrefuted by the majority. Thus, Bharwani resists easy classification as to its jurisprudential authority. We review the relevant case law and consider application of hybrid authority to the NCRMD portion of the Bharwani dissent.
The quack expert pretends to have some peculiar knowledge or skill that the expert does not possess or that may not even exist at all. Within forensic psychiatry, the response to quack experts has been varied and largely ineffective in mitigating their effect. Previous efforts to address quack experts have primarily relied on the courts, sanctions from professional organizations, or state board intervention. A shift to more globally addressing the misinformation itself and creating education of what appropriate testimony entails is likely far more helpful than trying to identify and punish each quack expert. At the individual level, new avenues of intervention include forensic psychiatrists taking advantage of educational opportunities and engaging in self-reflection. At the regional and national level, potential interventions include the American Academy of Psychiatry and the Law's educating courts and attorneys, developing resource documents conveying basic principles of appropriate practice, and expanding peer review.
Borderline personality disorder is unique in many ways from other diagnoses contained in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Most salient, however, are the negative connotations often associated with the label itself and the resulting bias of providers. The ways in which these biases manifest are especially problematic in violence risk assessment, wherein evaluators are tasked with systematic consideration of data, with most data coming from available records. In this article, we describe some of the ways in which bias and objectivity are encountered in risk assessment with this population, describe a relevant case example, and offer practical recommendations for evaluators.
