Forensic Corner; Therapeutic Neutrality
Lee H. Haller, M.D.
Knowing one's role is important in all contexts of
our profession. This is one of the central points of
consultation/liaison, as well as psychotherapy. Once
the psychiatrist enters a case in a particular role,
that role should not change without the express and
informed consent of all parties and considerable thought
on the part of the psychiatrist as to what the ramifications
of such an action might be. Sometimes this change of
role is not a problem. For example, when a psychiatrist
is called by the attending pediatrician for consultation
on a 13-year-old hospitalized for abdominal pain of
unknown etiology, he will perform a consultative evaluation
which may lead to a conclusion that psychotropic medication
and/or psychotherapy would likely be beneficial. As
a consultant, he writes these recommendations in the
appropriate place in the chart, but does not write any
orders. After discussing the plan with the attending
physician, with the patient, and with the patient's
guardian, if he obtains consent from all of them, then
he may change roles to become a treating physician,
providing the needed therapy and/or medication.
Having made this switch, the psychiatrist now works
with the patient to identify, explore, and work through
issues. Parents or siblings may be involved, as indicated
to assist in this process, either through family therapy
or parent guidance. In all these sessions the therapist
maintains a stance of therapeutic neutrality and avoids
contact with any of the family members outside the therapeutic
setting.
This is all basic psychiatry. It is surprising, therefore,
that the same clinician who would readily decline other
involvement with the family outside of therapy, will
allow himself to be seduced into contaminating the therapy
by the patient's attorney. This, however, is exactly
what is being asked of a therapist when he is requested
to be an expert witness in litigation involving his
patient. By acceding to the attorney's request, the
clinician is drawn into a dual role of therapist and
expert witness. Not only does this contaminate the therapy,
but it also leads to potential conflict for the clinician,
since the expert witness' job is to help the attorney
(to the degree possible) win the case. Accepting this
role will be perceived as an advocacy stance by the
attorney, patient, and family. Clearly, such is not
consonant with the concept of therapeutic neutrality
and should therefore be avoided.
So how does one react when approached to be an expert
witness for a current patient? First, do not discuss
anything with an attorney until you have obtained informed
consent from your patient and the legal guardian. Here,
the word "informed" is key because the parties need
to know, among other issues, that you cannot limit your
disclosure to selected issues or data. Assuming that
the patient and parents do want you to proceed and they
document these wishes via written consent, then you
are free to speak with the attorney and it is appropriate
that you do so. You have pertinent information that
the attorney needs, including your analysis of the problem
(s) and why you've undertaken a particular mode of treatment.
If the attorney finds your input helpful to his client's
care, he will want your testimony. The therapist should
decline giving testimony, explaining to the attorney
that being forced into such a role will have an adverse
impact on the patient's treatment. Suggest that an independent
medical examination is preferable. This should be performed
by another qualified child psychiatrist who will use
the data obtained by the therapist, but who will also
do an independent assessment. He can then communicate
openly with the attorney regarding the strengths and
weaknesses of the case in a way that does not interfere
with the therapist's ongoing relationship with the patient,
presenting the case forcefully in the various legal
settings.
Use of an independent expert in such a manner allows
the therapeutic work to go on simultaneously with the
legal proceedings. The therapist remains unencumbered
by the legal proceedings and is available to the patient
for ongoing therapeutic work and support during the
legal process.
Dr. Haller is in the private practice of forensic psychiatry
in Potomac, Maryland
AACAP
News/July-August 1995 |
