Clinical Reasoning in Forensic Psychiatry: Concepts, Processes, and Pitfalls

Abstract

Forensic psychiatrists are often sought by the court of law to provide professional opinion on specific legal matters that have a major impact on the evaluee and possibly society at large. The quality of that opinion and recommendations rely on the quality of the analysis from the assessment results conducted by the psychiatrist. However, the definition and scope of a forensic psychiatric analysis is not clear. While existing literature on forensic psychiatric analysis generally includes organizing information, identifying relevant details, and formulating a set of forensic psychiatric opinions as components, there is no explicit and unified definition of these terms and process. This lack of clarity and guidelines may hinder forensic psychiatry from achieving its goal of providing objective information to the court or other relevant parties. Forensic psychiatric analysis exhibits numerous parallels to clinical reasoning in other fields of medicine. Therefore, this review aims to elaborate forensic psychiatric analysis through the lens of clinical reasoning, which has been developed by incorporating advances in cognitive sciences. We describe forensic psychiatric analysis through three prominent clinical reasoning theories: hypothetico-deductive model, illness script theory, and dual process theory. We expand those theories to elucidate how forensic psychiatrists use clinical reasoning not only to diagnose mental disorders, but also to determine mental capacities as requested by law. Cognitive biases are also described as potential threat to the accuracy of the assessment and analysis. Additionally, situated cognition theory helps elucidate how contextual factors influence risk of errors. Understanding the processes involved in forensic psychiatric analysis and their pitfalls can assist forensic psychiatrists to be aware of and try to mitigate their bias. Debiasing strategies that have been implemented in other fields of medicine to mitigate errors in clinical reasoning can be adapted for forensic psychiatry. This may also shape the training program of general psychiatrists and forensic psychiatrists alike.

Translation, validity and reliability of decision style scale in forensic psychiatric setting in Indonesia

“…Type 1 processing reaches a decision through intuition, while Type 2 processing utilizes higher-order cognitive functions to reach a decision by logically analyzing information. Thus Type 1 processing is deemed prone to bias, neglecting ambiguity, focusing mainly on existing evidence, and ignoring absent evidence [ 1 , 2 ].…”

Decision-Making Within Forensic Psychiatric Investigations: The Use of Various Information Sources by Different Expert Groups to Reach Conclusions on Legal Insanity

“…Nevertheless, since SMD is a dichotomous concept in Sweden, such differences between professionals could create problems in the team’s general decision-making process if the different perspectives are not clearly described in such discussions and in reports. Since the lack of consistency in conclusions between FPI experts is considered to be generally negative ( 1 , 42 ), different SMD conclusions from different professional groups could also be complicated for the court when a decision must be taken in a specific case.…”

“…An open and non-judgmental atmosphere, something that decreases with stress, could therefore be considered a cornerstone for teamwork to increase the chance of evidence-based decision-making within FPIs. Although teamwork could be considered an advantage, it must be noted the experts regardless are exposed to other kinds of HEP model types of bias, due to human nature (e.g., fatigue, antipathy/sympathy toward a client), that could influence the forensic expert when conducting a FPI ( 1 , 2 ), and also due to processes such as group think (e.g., inflated sense of certainty when ideas are endorsed by the group). These processes therefore need further investigation.…”

“…The decision-making processes within forensic psychiatric investigations (FPI) are highly complex and vary between cases, and experts may even disagree on its conclusion ( 1 ). In order for the conclusions reached to be valid, FPIs need to be performed according to the best available current evidence on complex decision-making ( 2 , 3 ).…”

“…In the United States, forensic mental health experts (including psychiatrists and psychologists) conduct assessments (and can be retained by one side or another in a case to testify in court) ( 4 , 29 ), while in Norway two general specialists in psychiatry or one specialist in clinical psychology and one psychiatrist are appointed to make the assessment ( 30 ). In other parts of the world, such as Indonesia, it is also physicians/psychiatrists who conduct this kind of forensic assessments ( 1 ). Although Holland requires the participation of more than one professional group apart from psychiatrists [most often psychologists; see Messina et al ( 31 )] within assessments, Sweden’s routine inclusion of four different expert groups in FPIs is unique in the European Union ( 28 ) and, to the best of our knowledge, in the world.…”