May 2012  << Back  

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The Psychiatric Report. Principles and Practice of Forensic Writing

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Alec Buchanan and Michael A. Norko. New York, NY: Cambridge University Press; 2011; ISBN 987-0-521-131184-1; pp 300; $55 (paperback).

Good, understandable, cogent, and clear report writing is important in all medicine and in psychiatry. However, it seems to me that the quality of writing and wordsmithing of reports is nowhere as important as at the borderland of psychiatry and law—forensic psychiatry. As the editors of The Psychiatric Report. Principles and Practice of Forensic Writing, Drs. Norko and Buchanan emphasize, “…it is the skill at report writing that largely defines forensic practice; it demarcates evaluators’ abilities and demonstrates their usefulness to those who enlist their efforts” (p 1). Furthermore, as Paul Appelbaum writes in the Foreword to this book, “The prototypical image of the forensic psychiatrist is the expert in the witness box…” Forensic psychiatrists are well aware, however, that only a small percentage of cases, whether civil or criminal, ever get to trial, and many “expert witnesses” stay quite busy while occasionally setting foot in a courtroom. That is because a written report of a psychiatric evaluation of a party to the case or of relevant documentation serves as the basis for settlement, plea bargaining, or other disposition far more frequently than testimony is required. “….the sine qua non of a forensic expert is the production of a written report embodying his or her findings” (p xiii). Drs. Norko and Buchanan further point out that, “The development of skill at forensic report writing requires knowledge, experience, and guidance” (p 1) and they note that there is very little in the literature on the “precise subject of report writing” (p 1). Thus, they put together a team of mostly American forensic psychiatry experts to write a comprehensive volume on 1 of the core competencies in forensic practice—the principles and practice of forensic writing.

The book consists of the Foreword, Introduction, 19 chapters, and Conclusion. In the Introduction, the editors explain the context of the forensic report (effect upon evaluees; professional identity and its implications; expectations of the legal system; and principles, guidelines, and standards) and the purpose of this textbook. The core of the book, 19 chapters, are organized in 3 conceptual sections, principles of writing, structure and content, and special issues.

The 6 chapters of the first section discuss “History and function of the psychiatric report” (a bit boring), “Preparation,” “Confidentiality and record keeping,” “Ethics,” “Writing a narrative,” and “Draftsmanship.” The chapter on preparation describes the process report preparation in 3 stages, “deciding whether or not to accept the case; procuring, examining, and categorizing forensic data that will serve as the body of the psychiatric report; and formulating forensic opinions for the report” (p 22). It also outlines the initial contact, obtaining and examining the data, marshaling the evidence, and communicating the opinion. The chapter on confidentiality brings out the multiple confidentiality obligations an expert has that relate to the agency commissioning the report (eg, prosecution, defense, court) as well as their own role in the legal proceeding (fact witness, expert witness, etc.). It also explains the Health Insurance Portability and Accountability Act in the context of forensic psychiatry, duty to third parties (Tarasoff), prosecutorial use of defense experts, work product rule, and psychotherapist-patient privilege (different in military law) confidentiality within a training program or group practice. Finally, this chapter discusses record keeping of forensic files. The chapter on ethics emphasizes that the forensic practice should incorporate an understanding of how culture and context shape claims of “objective” and “scientific” knowledge (p 57). This chapter also outlines some ethical principles for guiding forensic reports, such as respect for persons; respect for privacy and confidentiality; respect for consent processes; and commitment to honesty and striving for objectivity. The chapter on draftsmanship is the most entertaining part of this volume. It emphasizes that it is essential for forensic psychiatrists to express ideas clearly and succinctly in written reports (p 81). The text here provides extensive advice on simplicity (“Multi-syllable words reduce readability, tax the reader, and decrease comprehension. Sentences of 20 to 25 words have the greatest readability. Use common words. Rather than writing ‘remuneration,’ use ‘salary.’” When medical terms cannot be avoided, they should be clearly defined. Avoid acronyms unless they are widely known. Don’t use periods for acronyms. Avoid embellishments such as italics, underlining, or bold [pp 84-85]) and brevity (omit needless words [p 85]). The authors provide further practical suggestions, such as dictating or typing one’s record the day of the evaluation while the material is still fresh in one’s mind, using only DSM diagnoses, avoiding pregnant negatives (statements about what symptoms are not present rather than what symptoms are present), or that one’s signature should not include many titles; “The signature block should not be an ego trip” (p 89). Another useful part of this chapter is the listing of 10 pitfalls (eg, raising the bar unnecessarily; using language that appears haughty or pompous; using absolute language; using hedge words such as “apparently,” “supposedly,” etc.; using emphasis when expressing your opinion; or using language that makes your report appear to be the product of a “mill”). Finally, the authors advise proofreading a report out loud or backwards as it allows some overlooked errors to be discovered. Many of these suggestions apply to any report writing, not just the forensic one.

The 7 chapters of the second section deal with issues such as report structure, criminal litigation, civil litigation, civil and sex-offender commitment, competency to practice and licensing, child custody, and employment: disability and fitness. All chapters of this part are well written, interesting, informative, important, and fairly brief. The chapter on civil litigation warns us of the potential biases when conducting an evaluation (eg, advocacy bias, retrospective bias in medical malpractice, and hindsight bias in retrospective assessment for personal injury). The chapter on employment disability and fitness contains useful information even for the non-forensic reader—eg, did you know that “the financial criteria to qualify for Social Security Disability require that the individual has paid into Social Security Administration at least 40 quarters of payments from employment income”? Some chapters include a section on frequently asked questions in cross-examination, copies of forms used in various forensic psychiatry institutions, and good summary tables.

Finally, the chapters of the third section focus on issues such as writing for the US federal courts, incorporating psychological testing, reasonable medical certainty, violence risk assessment, malingering, and psychiatry and ethics in the United Kingdom criminal sentencing. I found the chapter on psychological testing especially useful; it discusses not only the advantages of psychological testing (diagnostic clarification, assessment for feigning and malingering) but also those questions that psychological testing cannot answer (the etiology of the deficit, the veracity of the client account, and the cause of a specific behavior in the past). It also provides advice on how to incorporate psychological assessment into one’s report; what to do when results conflict and on psychiatrist-administered psychological tests. The chapter on malingering points out that malingering psychiatric symptoms is not a rare event; it discusses informed consent in the malingering assessment, malingering assessment methods, and assessment of malingering of specific disorders (psychosis, posttraumatic stress disorder, depression).

The Conclusion briefly summarizes the main themes of the book such as narrative, respect for the person, ethics, and the role of clinical guidelines.

Although I do not practice forensic psychiatry, I really enjoyed reading this book. It is well put together, practical, and full of useful advice. There are some overlaps, but no major ones and they are not always avoidable. One may not even notice them much, unless one reads the book cover to cover, rather than reading individual chapters as needed. The book will be a welcome addition to the library of all those who practice forensic psychiatry and of teachers and students of forensic psychiatry for whom this should be a seminal text. Many of the remaining practicing clinical psychiatrists, including myself, could learn a lot from this volume, if only about the simplicity and brevity of any report writing.