Mental illness and criminality are evaluated by different sorts of professionals doing very different things. Here are some of the points of distinction:
Mental Health Evaluation
In the State of Florida, all the five major classes of psychotherapist—Marriage and Family Therapist, Social Worker, Mental Health Counselor, Psychologist, and Psychiatrist—are required to know how to give “ordinary” mental health evaluations. Such an evaluation is used to create a diagnosis of the person coming in for treatment. The diagnosis, in turn, is used to bill insurance companies, or to determine if a person needs admission to a hospital.
The diagnosis is selected from a book called The Diagnostic and Statistical Manual of Mental Disorders written by a large committee of the American Psychiatric Association. There have been several overhauls over the past half-century.
Of interest, is the fact that in Europe, there are not so many categories as here, and of even greater interest is that there can be large disagreements among professionals in deciding the diagnosis. That lack of reliability notwithstanding, any time your therapist bills a third party, this diagnosis is required.
Theoretically, the diagnosis should guide treatment much the same way as a medical diagnosis determines whether a person needs an antibiotic (for a bacterial infection) or not (for a viral infection). In actual practice, statistically, the diagnosis has very little bearing on the treatment of emotional issues. One reason, as I just said, is that different clinicians observing a person, reading the history in the file, asking good questions, and checking with family will still come up with a variety of different diagnoses; diagnosing is more an art than a science. Another reason is that various different diagnoses will still require the same or similar treatment.
Many other clinicians, myself included, prefer not to use the diagnosis manual because they feel it is too negative and unbalanced. Unlike medical problems, emotional problems usually arose for a very sound and good reason. The person with the “problem” actually displayed good coping skills under the circumstances in which the symptom arose. Thus, we tend to see diagnoses as counterproductive and prefer to examine a person’s strengths instead; it’s a different way of looking at people.
In contrast to the above relatively simple evaluation process, forensic evaluation leads to information that is used in court. The word “forensic” refers to the legal system. Such evaluation may need to be made for a variety of reasons such as:
- Competence to stand trial
- Sanity at the time of the crime
- Determining whether a crime occurred
For example, a forensic examination would be used to determine whether a sexual molestation occurred. Doing this type of evaluation goes way beyond what an ordinary mental health professional, such as a psychiatrist, can do. Psychiatrists are medical doctors and have expertise in the biochemistry and physics of the human body and the interplay of that with medication and other treatments. Their medical training normally does not include forensic evaluation.
Training for forensic evaluation entails both book learning and practical experience under the supervision of an expert. The training entails knowing precisely how to ask questions such that the interviewer does not inadvertently (a) give away information to the interviewee that he or she should not have, and (b) suggest to the interviewee what answer he is looking for, or (c) miss lying by the interviewee, or what is technically called Malingering.
In 2002, a psychiatrist, Richard Gardner, who is an expert in the area of child abuse investigation, wrote a book, Sex Abuse Trauma Or Trauma from Other Sources? that I reviewed for the Annals of the American Psychotherapy Association. In that book, he advanced the proposition that well-meaning but poorly trained mental health practitioners can actually cause trauma to children through poor interviewing techniques. Gardiner created a test battery and, interestingly, one of his scores was “LPTT” for Legal Process/Test Trauma, that is, trauma created by the legal process.
Although in my review, I pointed out that Gardner’s position itself is not bolstered by sufficient empirical evidence to be sure that such trauma can actually occur just from the legal process, I did—and do—give Gardner credit for alerting professionals to a potentially serious problem. The way that this problem is avoided is through:
- Only having experts who are trained in doing forensic evaluation do it.
- Have the least number of adults—professional or not—talk to the child.
Forensic evaluation is also required in divorce situations where there is a custody dispute; in personal injury cases to determine if the “injured” person is lying; in guardianship cases where there is a question of competence to manage affairs; in therapist malpractice cases; and workers compensation cases.
Psychologists specializing in forensic evaluations would have membership in the American Psychological Association’s Division 41, American Psychology-Law Society and be board certified by the American Board of Forensic Psychology, a specialty of the American Board of Professional Psychology. In addition to the general qualifications to pass this board, a psychologist must take specialized coursework in forensic psychology and work 1000 hours in the field under supervision to specialize in this area.
Psychiatrists interested in specializing in Forensic Psychiatry must spend a year of specialty training after their regular four-year medical residency in psychiatry.
Professionals in other clinical fields such as Marriage and Family Therapy or Social Work may testify in court as expert witnesses and may receive specialized training in forensic work but do not receive board certification for that training.
Mental health evaluations, then, are meant (for the most part) for billing purposes while forensic evaluations are used in a court of law and require specialization well beyond the training that psychotherapists ordinarily get