The Psychiatric Report. Principles and Practice of Forensic Writing

May 2012

BOOK REVIEWS: The Psychiatric Report. Principles and Practice of Forensic Writing

May
2012
Vol. 24. No. 2

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.

REFERENCES

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).