What is Forensic Psychiatry? with Mark Levy

0:00 Cultural altitudes have certainly changed in my fifty year career. Homosexuality has moved from being listed as a mental disorder in the Diagnosticatistical Manual to gay marriage. That's a huge social transition. In the same period that that, thank Goodness has evolved, that our social thinking about choice of people to love has evolved, Worthy Wade has gone backwards. Welcome to the Santhra Life. We're curiosity Sparks, dialogue and dialogue sparks change. I'm your host, Adam Ganwell. Today's episode, we're diving into the fascinating intersection of psychiatry and the justice system with doctor Mark Levy, a leading forensic psychiatrist, as a trailblazer who navigates the complex pathways between how we understand mental health now it's interpreted in the courtroom.

0:56 Doctor Levy brings a perspective that's both enlightening and essential his insights into how subtle nuances and human behavior can swing the scales of justice. We'll leave you with a new view on the deep connections between our minds and the laws that govern society. This is an episode that you don't want to miss. Stay tuned. Awesome, So just want to to kick off and say, Mark, really excited to have you on the podcast today and excited to dive on in. So thank you for joining me today, thank you for inviting me. It's good to be here. Awesome. So to kick us off, there's there's kind of two you know words in terms of framing how you do your work. You know, forensic in psychiatry that oftentimes people may not think about as going together, you know, very frequently it's kind of a maybe a new area area for some folks. So can you kind of kick us off by giving us a sense of this, like what is what is forensic psychiatry as a as a as a frame and as a field, as a discipline, and then let's dive into your story about how you got into that in the first place. Sure, that's a good place to start. Forensic psychiatry actually what has been done for probably centuries, but it's not being recognized or even a trained area of medicine. But because psychiatry deals with human behavior and the law deals with human behavior, there have been instances when psychiatrists have been called into court to offer opinions, particularly in criminal matters. But today forensic psychiatry is probably one of the newest medical subspecialties. It is in fact the

2:31 only area of medicine where there is a fellowship trading and board certification. Even though doctors from all specialties can be called upon in legal matters, in particularly to testify in court when their specialty is called in the question. You know, somebody is suing about a complication of a delivery, then obstetricians are very important to educate the court. That's the judge or the trier of fact, which is usually the jury unless it's just what's called the bench trial of it just a judge. The experts necessary to educate them about the specific issues in the obstetric that come to bear on the issues that's in dispute. But in general, because psychiatry deals with human behavior, there is a much wider range where psychiatric expertise is all upon. So there's a big difference between a treating psychiatrist and a forensic psychiatric experts. And I can summarize pretty quickly what the difference is. And I wear both hats, but never both hats, never two hats with the same person. That is, I'm a treater and I'm

4:06 also a forensic psychiatric expert. But I would never be the independent expert for a patient whom I'm treating, nor would I take a plaintiff who I am the independent expert about and make them my patient, because they are all kinds of role distinctions and even ethical complications. So in a nutshell, the role distinction is this. Let me just say before I get into this. Forensic psychiatry is the interface of law and psychiatry, and in some respects it goes very easily, but in some respects it's quite different because medical terms and legal terms are not identical or even interchangeable. A good example is uh, not guilty by reason of insanity, and this is a decision that's made usually in a murder case when someone doesn't appreciate the wrongfulness of their act because of a mental illness. But insanity is not a medical term. It doesn't equate to psychosis. It's a legal term. It's defined in case law and it's defined in statute. So one of the roles of forensic psychiatry is a translation role.

5:34 And just like translating between languages, there aren't always identical words in two different languages, So you have to get clothes. That's an approximation, but it's not. It's not equivalent necessarily, and certainly on a nuanced basis not equivalent. So forensics psychiatry, like the law, is divided between criminal and civil. And if you'd like, I could talk about that later, but I wanted to make this distinction between the roles. The treating psychiatrist and the independent forensic psychiatric expert have entirely different missions, methods, and ethical duties.

6:21 There's a huge distinction between these roles. The mission of a treating doctor under the Hippocratic is to alleviate suffering, and and that's why people come to a doctor physically or mentally their suffering and they want some help and relief from the pain. The method of a treating psychiatrist is to rely almost entirely on their patient's subjective self report. There are exceptions to that, but generally, if a patient comes in and TELP me. Patient comes to me, and as part of my taking their history, they tell me that their father beats them.

7:05 I accept that. I don't go and interview family members to determine is this objectively true or is this sort of slightly off based, is this completely wrong? I accept that with the exception that if someone comes in who's psychotic and tells me that the television talking to them that is so far out of our consensual reality that I know this isn't necessarily objectively accurate, although this is their subjective experience, and the ethical duty of a treating doctor, also under the Hippocratic oath, is to do what the doctor feels is in their patient's best interest. In the Hippocratic oath, it comes from a Latin phrase, but it translates into first dudento harm. But the application of that is you do what you think is going to be helpful to this person. In contrast, the mission of the forensic expert is to determine what is objectively true as best as possible. The gold bully On standard is the ballistics expert who says the shell came from the gun or it didn't. It's much more difficult in behavioral medicine than it is in ballistics. Not to understate how difficult it may be in ballistics, but that's the gold bully On standard, and the method

8:39 is entirely different because, particularly in outpatients psychiatry, a treating doctor, as I said, relies on their patients subjective self report in they don't even it's very rare for a treating a treating psychiatrist to get medical records on their patient, let alone request outside psychological testing to help determine their diagnose. It happens, but it's rare. It's not the rule at all. In forensic psychiatry, you want to see all available data, so that's years of medical records on the person you are examining. We always get a forensic psychologist or forensic neuropsychologist if there are clear brain issues like a traumatic brain injury or someone has dementia, and that's very objective data. We get all depositions that Those are transcriptions of under oath interviews that are taken as part of a legal process, usually in civil matters, and in a sense they are elaborate witness interviews or interviews of the plaintiff under oath by usually opposing counsel with their own council present, and we read those and other legal documents. You know, there may

10:11 be a police report in a criminal matter. There may be employment records in a civil employment issue where somebody's alleging they've been discriminated against or harassed or wrongfully terminated and then we do a multi hour interview of the plaintiff in the civil matter or the defendant in a criminal matter. And although that is by definition their subjective self report, it's very important to see not only what they say, but the way that they say it. And that's a big difference between the deposition, which is a formal interview with all kinds of rules of how what can be asked and how it can be asked, and a psychiatric interview, which often goes although we cover many areas that we need to cover, you know, let's say the person's history, their childhood, their relationship history, their employment history, et cetera. Our method is more of an associative method. So somebody you ask, somebody you know, tell me about yourself, open ended questions, and then you take it from there and see what they pick up and tell you about and ask questions about that and circle back and fill in blanks. And the ethical duty of the forensic psychiatrist is not

11:41 to the plaintiff, even if they are retained by the plaintiff's council. It is to the trier of fact, and that's the person or the people who decide who weigh the facts and decide what is true and what is not. A jury and a jury trial, there are bench trials where there's just a judge doing it. That's to whom we owe a duty. We have a fiduciary duty to the attorney who has retained us. But our job is to be is to call balls and strikes as we see them, and to support it with evidence, not just the authority that I've done this for so many decades, therefore it's true. But here's the evidence that I have found that supports this. So those are the distinctions, and frequently I might say one another thing. There are fewer than two thousand board certified forensic psychiatrists. To become board certified, you have to, after a psychiatrist, do a full time one year fellowship in law on psychiatry. There are seventy thousand board certified psychiatrists. Many psychiatrists who are not trained in forensic psychiatry, UH put themselves out there to be retained as forensic experts, and they don't understand their role distinctions. They end up being advocate, which is the lawyer's job. You

13:11 know, they their advocate or abused children or their advocates were you know, worthy causes, but it's a real corruption and misunderstanding and unfortunately for many of them, well of potholes that they step into because they don't really understand the landscape. That's that's an interesting challenge point though, because oftentimes on the to your point, like when you think about the distinction of the roles they're on the kind of treating psychiatrists doctor role, you have some kind of feeling of advocacy right for you your patient. You want to kind of get their subjective, real view and help them kind of work through those problems. But interestingly, like on the forensic law side here you're saying, it's that we're not here to advocate, where we're here to sort of determine what are the what are the facts at play, and let them let those then pass on to the adjudicating body. That's an interesting, interesting kind of thing to know, because I think something else that's interesting there. We said there's this kind of seventy thousand certified psychiatrists out there, right, but I think there's many fewer certified forensic psychiatrists, right. It's a much much like what's what's the different the different number there? We have seventy thousand certified psychiatrists. Yeah, fewer than two thousand. But let me just pick up what you said, because you're correct. A treating doctor is an advocate for their patient, rightly so, and sometimes a treating doctor needs to be called into a legal process.

14:37 Most treating doctors hate it, and they they regard being deposed as an opportunity to be humiliated. And it's really doctors in general avoid litigation like the plague because it's scary and they don't know, they don't understand it. But it's okay to testify as the treating doctor. But you are what in the legal terminology is a precipient witness. You're a witness. Your point of view is defined as subjective, and within that context you can advocate for what you think is in your patient's best interest. But you're not an independent expert. You may be an expert in your field, but you're not an independent expert.

15:22 And that's the important distinction. And when the doctors say the psychiatrists who don't have training in forensic psychiatry all for themselves as independent experts, invariably they're doing it from the mindset of being a treating doctor. And therefore it seems quite natural to them to advocate. But in a stude attorney, certainly a cross examining attorney who's been down this road or who is being coached by a forensic psychiatrist who he or she has retained, can really destroy their credibility when they do that. Which is the problem in testimony is if you get caught in one instance of finessing your answer, not to mention lying, but just finessing it. In litigation attorneys, that's like blood in the water and a pool of sharks. You get devoured because of that lack that one answer that was shady, and everything that you said loses its credibility. So that's when you practice in this area. It's very important to stay within the guardrails. This is my area of expertise. This I know is I have the evidence at the court and sometimes attorneys will try to pull you out of that. But

16:52 doctor, you know you you're a psychiatrist, but you're an MD, aren't you? What do you think about this hysterectomy that was done? Never answer that I'm not an ob gyn. I'm a psychiatrist. Yes, I'm a physician. You need a ob guyn to answer that question. That's interesting. So it even seems that in a student lawyer thinking about both how can they either poke holes in a defendant's case, right or a plaintiff's case, to your point, can try to go through a forensic psychiatrist and try to ask questions that are sort of outside that they're in the independent expert category. That's not what you're there to even do in terms of just presenting, you know, evidence that that's interesting and it does kind of show also you can see where it's like the especially if you get called, you know, you get proposed to go act as a as a percipient witness, but on an independent expert. That can be that challenge there of not wanting to say too much, right, but then kind of say, well, I'm an expert in this field. But you know that's not really what you're being You're being asked in that regard that that's a really interesting thing. I mean, you know this is I'll sound like a super amateur here because I've served on jury duty a number of times and that's you know, my experience in the courtroom.

17:59 But you always interested in this notion too of uh, the you know, the kind of process, you know it is it's it's set up in a very specific way, right when you know, you can have your different opposing sides, you know, make their arguments that you can. Then you'll see them, you know, talk to to the witnesses and ask different questions, and that interesting process of like when they have to bring in an expert or you know, in a forensic psychiatrist to to kind of pay attention to what kind of language is used, right in Like it's it's not almost as this pure kind of On the one hand, I guess it's like, you know, as a friendly psychiatrist, you're there to provide expert testimony in the sense of saying, here's the facts that we see, like determining kind of objective truth. Yet a lawyer might ask you questions that pull you into subjectivity yourself, right, so you're gonna have to have to walk that fine line, as it were, to make sure that you don't accidentally do that. What I find so interesting about this field, this sub specialty field, is how nuanced it is. It's nuanced in what do you know and what is your subjective opinion? And most importantly, what are your biases? Because we all have biases and the more you can be aware of them, the better you are at limiting your opinion to things that you objectively can support and not just drifting into areas of bias. And attorneys are very good at trying to find

19:32 your bias. For example, it's a deposition one oh one question every law student must learn in some you know, in some course that has to do with the practice of law. Doctor, what percentage of your cases have been defense and what percentage have been plaintiff? And that's an effort to presumably show your bias eight percent or plaintiff cases. You know, what is what I sometimes say, But you have to be careful not to be a smart alec in a deposition. Is it is? What it is? In my case, it's usually two thirds to seventy percent defense in civil matters and the rest is plaintiff. But that's how the phone rings, and I don't control who calls me. If you're asking about bias, then the question really is, doctor, how often do you come to an opinion that you know it doesn't support the inquiring attorney's theory of the case. That's the integrity question, you know, and that's you know, for me, around ten percent, But that's the question that they're never taught to ask, and that's really you know, the meaningful question about bias. Mm hmm. That's interesting too, just to to give us that question, right, because we often see in in

21:04 a broader business context too. Right, there is this there's been engaging in ongoing conversations of understanding things like unconscious bias, right in terms of what are you bringing to the table, whether it could be you know, tells in a in a you know, poker context of like, you know, my my left eyes twitching when i'm you know, when I get a when I get a you know, ace of spades or something. But then also this idea of like how I discuss topics, right, and so I understand this this idea in terms of if I'm being asked a question, it's it's kind of like the philosopher Kwame Apia has said that it's, you know, a lot of life is not figuring out necessarily had to play the game, but understand what game you're playing in the first place, you know, And so this kind of question exactly. Yeah, yeah, And that's I mean, that's really interesting in this in this context too, because also obviously, like the I want to get into some of the subjects matter areas that we'll we'll kind of see in a case in some of the cases that you've worked on as part of that, because it seems like there obviously because if you're working in in cases around you know, sexual abuse or domestic violence, uh, you know, and areas are around dementia, right, there can be some challenge like there's they're emotionally charged spaces, right, there's there's there's people that have been wrong, you know, the people have been hurt and so uh, even that, I think it's an interesting kind of pasway to think about how you how you can go go into these spaces and like sit with the you know, the ethics, the methods and the and the mission of the work in order to not get pulled. And if if if a lawyer is kind of trying to pull you into an emotional argument or something that takes you outside of that that space, does that happen? You know, I don't know frequently, but just like what's the percentage of times that you know, if you might get pulled or that that's kind of like you you'll see,

22:37 I guess is that a thing is do do you find that attorneys respect the space or do they do you do you find that you often will get asked questions that sort of try to pull folks into an emotional argument away from a more of like a I can support with evidence kind of answer. It was such a very good question, and like the variation among people, it has a lot to do with the different with the variation among lawyers, I mean the cross examining attorney and we the prob The our litigation system is an adversarial one, you know, It's it's each side pulling for what they want and then the trier of fact trying to decide who has authentic, capable, genuine facts on their side and who doesn't, and therefore who wins the argument.

23:30 That's different from just if I can divert direct grass for a minute. It's different from the European that it's called the Napoleonic system, where the judge is the person who weighs the balance, and the expert, the forensic psychiatrist in a French court is employed by the court. Yeah, so in a sense it's a much fairer and more balanced since except there are other problems with that when you have people from a particular class and walk of life and biases, et cetera, being the sole arbiters rather than our concept of a jury of one's peers. But you know, it's a very difference. Isn't much less adversarial. So in our adversarial it doesn't to answer your question. Even gentlemanly attorneys need to try and find the holes in your argument, even if you're honestly saying, well, I'm not sure about that. So in other words, it could be the attorney will say. In other words, it could be the opposite as much as it could be what you're saying it is.

24:48 Isn't that correct? Doctor? That's an easy style of cross examining. But there are also attorneys who are works, in my opinion, and who want to play Perry Mason with gotcha, and which is sometimes dramatic and theatrical and effective with a jury. Sometimes it's off putting to a jury if they like the expert and the attorney who's crossed examining the expert is trying to crucify them. That doesn't necessarily win points for the crucifier. So it depends, you know, if the expert is pompous and aloof and you know, talks like an academic and jargon, and there's a feeling of the jury that they're being condescended to. Then the gotcha cross examiner, you know, may be very effective in in poking holes in the credibility of the expert, but in general, one of them when you what one learns to do when you're trained in this, which most doctors are not and therefore feel great anxiety about being cross examined is listen to the question and take as much time as you need before answering, and control the pace because across examining, attorney may try to fire

26:22 stuff at you like this, you know, and get you off balance, and you just take it down a notch and say, well, let me think about that, counselor, and that gives you time to think about just what you're saying, but also to listen because the attorney who has retained you may stand up and say objection your honor. This goes to blah blah blah, and that is a signal to what you should be considering or not saying in respond. So there's a lot of theatrics to this, you know.

27:06 It's not unfortunately or just understandably because it's a human activity, and it's adversterial. It's not all about justice. A great deal of it is about procedure. A whole watch of litigation is about procedure. You could have a great case, but you file it too late and it is out of time and so procedurally you don't have a chance it'll be dismissed. But even in when you're in litigation, the procedures that go on in the courtroom are important to understand if you're a witness, so that you can so it can to the extent appropriate guide how you respond. And also if just want to think, but you know, if the attorney who has retained you stands up and objects to the question you've just been asked, and the court sustained the objection, you don't have to answer. It gets you off the book easier that way, right, Yeah, yeah, yeah, it's it's interesting to think about that too, where because it's oftentimes and for the most part, right, it's one person talking at a time, right, it could be the cross examining attorney, right, But then often say objection and it'll it'll stop it, you know. Or that's the interesting point too, when you see when it becomes a team sport. Then it also tells you, all right, I either have to continue or I have to stop now, you know, right, which is what could be helpful. I think that, right, I think this is this is super fascinating, and I think that you know, part of it I'm curious about, like maybe we can we dive into

28:36 because something you set up top two that that I want to spend some time with, is this idea that right human behavior is is can be difficult to you know, map out objectively, right, I mean, obviously we all have subjective experiences, right, and you set a good example of of the if I either having a bad day or I think my television is talking to me, there's there's also an objective kind of standard that we've all agreed upon that televisions typically don't talk to you. I mean besides when they're on, but you know the tea it selfie doesn't talk to you, right, And so that can that can kind of say, okay, well, there may be something objective that we can talk about even though your subjective experiences is x y Z. So let's talk about like that, like the kind of complexities of how do we evaluate mental health in legal context? When when we're looking at scenarios like this, or maybe you can pick if there's a case that has jumped out to you. I mean you mentioned before that I think it is really interesting to the insanity is a legal term, not a medical term, and that's something that we know who's using that wear can have some important implications, right, But yeah, walk me through that a little bit like these complexities. Well, a case that I was involved in quite a few years ago, which was a civil case, that is, people were suiting other people or damages which results only in money being paid to if they win or not paid if they lose by the defendant. Did it plane to it?

29:56 It touched on a murder and a criminal matter, and it was a man who was diagnosed in his teens. When in his late teens when psychotic disorders like schizophrenia usually present themselves. That is, people start becoming symptomatic with illusions and illucinations if they have schizophrenia, which is probably a group of diseases, but it is a labeled mental illness in their late teens or very early twenties. You don't develop schizophrenia, you know, at forty nine too much?

30:38 Would it had to have happened before to stignal that you may have the psychosis which is deviating from consensual reality, having problems with the term of art. In psychiatry or psychology, it's called reality testing. But it's of a different It could be from drugs, it could be from brain disease, it could be from some other mental illness. So this was a man who became was diagnosed with schizophrenia after he was violent at home. He was punching hole he was his parents were Asian immigrants and said they were kind of old world from Asia, and he would punch holes in the wall and then he assaulted his father on a couple occasions. I don't even know what the disputes were, but the police were involved and as a result of that, he was diagnosed and treated for schizophrenia, and he did very well when he took his medications, and then he was in a different state where he As many people who have severe mental illness like schizophrenia, he was economically marginal as an adult.

32:00 He couldn't hold he couldn't really have a career or hold high paid jobs. So he worked intermittently and he was on you know, benefits, public benefits. Intimately and this date we had outsourt to a corporation the treatment of the indigence severe mentally ill. The highest training level expert in the treader in the system that this company had in this state was a nurse practitioner psychiatric nurse practitioners. And he stopped appearing for his regular monthly of check in appointment, I think when his meds would be renewed, et cetera. He lived on his own the time, he was probably in his early forties, was a solitary guy. And she was alarmed about this, and they had like a home visiting team. So they sent out the home visiting team and they knocked on the door and they heard dog barking. All the blinds were closed, and they did nothing. He didn't answer. They did nothing. They did this a couple of times, and then he sort of drifted from really any active coverage. Over six months, he became he had stopped taking his meds,

33:35 and he had stopped getting them refilled, and became increasingly psychotic. He did believe that the TV was sending him messages. He believed that license plates were coded messages to him from the Chinese embassy. And one day and he had another social problem in our society. He had a gun and one day, at one in the afternoon he went to a Walmart parking lot and shot repeatedly two strangers dead in the parking lot. I was an expert for the plaintiff, which was the widow of one of the murdered victims and her three young children. And the issue in this case that was interesting was the failure of the outside corporation that hired the people who were supposedly providing care for the indigen severely mentally ill failure to follow up on this because in that state, it was very easy to compel the police to pick up the person. Even a neighbor could say, I'm very worried about this person. You can call

35:06 the police. Would you please do a wellness check and if you can't, you know, get evidence that things are fine. Bring him to a mental health like an emergency room, a crisis center where trained professionals can evaluate and take appropriate action, meaning provide care if he needs it, you know, if he were if someone had, if the police had come not he not responded and they broke down the door and found that he was delusional, etcetera. They'd bring him to such an ability, he would have been hospitalized and medicated and treated. They hadn't done that. So the defense in this case position was the lack of foreseeability. How could we know this guy was going to go kill people? And the plaintiff's case was that's not the issue, the excellence on the wrong styll abl The issue is you didn't take appropriate action to get this person evaluated. You knocked on the door, there was no answer, and you left. Basically, Hey, an interesting analogy would be if he were a woman with a suspicious papsmere. Most hospitals or insurance systems like in the West Coast Kaiser have elaborate checklist procedures to go through. You

36:37 know, now that's not a potentially violent situation, but not just to call to send letters and certified letters. They'll send out a nurse practice, They'll go to great lengths to follow up and get that person back in for the follow up evaluation of their suspicious papsmere. But in this case, and I've been involved in other cases, it's kind of like too much effort, and so they dropped the ball. And the consequence it's not that it wasn't foreseeable that this man would kill people rather than uh, you know, running in the street naked or something that was not violent, but it or the issue was that they hadn't provided the appropriate follow up. So I've kind of lott my my plot here and talking to you. But I think that that was in response to, you know, a real case where which no, well it was yeah, and and the kind of question there was also thinking about this idea of the I mean, you illustrated it perfectly. It's just the complexities of when we're evaluating mental health and a legal context, like what does it mean? You know, and you brought it. I think you brought a number of really really relevant examples and in points there were just in terms of when we're we have a case around somebody that has a mental illness and then especially with something like schizophrenia, and then there's a challenge around their lifestyle.

38:10 You know, you canotically marginal marginalized like they're not quote unquote used to you know, living a quote normal life, or like the norms and standards of maybe answering your door when you when you someone knocks right or obviously having delusions or things where we are hallucinating that a license plate is sending us signals uh, and then how that translates to the kinds of actions or in this case, like the kinds of help they do or do not get in a social work medical context. And then how that might translate over into into a legal case. To me, I mean, I've seen like there's like three steps there that are quite challenging to kind of work with. Right, so you can both determine did a murder take place? Yes, and then what happened as part of that right? And then the synderty argument where you said that the defense was saying that there's a lack of foreseeable action we did we couldn't. How could we know he's going to do that? Right? And then this argument I think interesting there was like, well, no, that's not the point. The point was actually that there was not treatment, adequate treatment in place. An interesting sidebar on this was obviously there was a criminal case. I was in the civil case. A criminal case usually takes precedent because it involved the deprivation of liberty. It's a higher priority than money settlement for damages. And he was found incompetent to stand trial, and he would send to what's called a competency restoration program at a state hospital and they could not. There were several attempts and they could not restore competency. And at the end of this process, he was by default found not guilty by reason

39:45 of insanity because his competency that sand trial could not be restored, which meant that that doesn't mean he walks free, meant that he was basically he received an indefinite sentence that wasn't called that to a state mental health hospital until such time as he was deemed no longer a danger to society. And I don't know what happened after that. I mean, medicine has evolved. There are now good what are called depot medications. You can get antipsychotic injections. What's a month. It's like slow release, and so people like this can be managed in terms of keeping them on their medication because I mean, if they didn't show up for their monthly shot, you'd have the same situation deja bou all over again. But you know, and you'd need a system that was going to follow up and make sure. But it's conceivable that he could be released from this indefinite sentence as not a danger to society if the civil authorities made sure that he got these monthly shot but I don't know that that was the outcome. The last I heard he was in a state hospital. But that's interesting too, So even this idea of how medical practice evolves and changes over time, you know, and I'm also thinking as anthropologist, you know, you know, do we see cultural attitudes towards like mental health changing also, and does that affect you know, how how like a deposition might happen

41:22 or something. So I'm curious if you have examples or you've seen that kind of in play too, either medicine changing or kind of cultural attitudes about mental health, and like how that affected a trial. The cultural attitudes have certainly changed. There's lots of examples. In my in my fifty year career, homosexuality has moved from being listed as a mental disorder in the Diagnostic Statistical Manual to gay marriage. So that's a huge social transition. It's which I find is so interesting in that regard as a digression, is in the same period that that thank Goodness has evolved, that are social thinking about choice of people to love has evolved, rov Wade has gone backwards. Yeah, So you know, it's it's weird when you get to these social issues and which often have large religious components, and how one, you know, at least in here evolves and the other regresses. It doesn't even stay static. But so when I was I graduated from medical school a long time ago in nineteen seventy one, and I moved from the East Coast from New York to California and

42:52 did my internship, and that ultimately did my residency there, although I was supposed to do it in Boston, and the that was a time when Ronald Reagan was governor of California and what was the norm nationally of state mental hospitals were being emptied out. It coincided with two factors. One was the advent of thorazine, the first antipsychotic drugs, which, like all technological changes, improvements, you know, brought with it many fantasies that it would you know, liberate mentally ill people, et cetera. And it also coincided with a conservative effort to cut state spending. And what the unintended consequence was beginning in California was homelessness because the efforts to make community mental health facilities, both residential and tree where these warehoused mentally severely mentally ill people would would be would move to from the state hospital and the institutions was never was an unfulfilled promise.

44:14 It was underfunded and understaffed and never really worked. And coincidentally, severely mentally ill people often duly diagnosed with drug addiction as well as severe mental illness ended up becoming the homeless population. And they started in California like many things back then, and then became national. So so that's that all was the beginning of reintegrating the warehouse mentally ill into the community been a very bumpy road. But but that you know that I think that has the homelessness is a severe, ongoing, unintended consequence problem. But I think that this general social attitude about mental illness has become more accepting and everyone either knows or may have a family member who has bipolar disorder or some severe mental illness. And so that's been a big social change. And you know, going back to the pre say seventies, when people will warehouse. To go back even further, Abraham Lincoln had his wife institutionalized. She had depression, as did he and I think after the death of a child, maybe had a postpart of depression.

45:44 In those days, women had no rights, and he was a you know, Abraham Lincoln, viewed as a very good man in our history, had his wife institutionalized for I don't know how long, but for a long it wasn't like a two week in the right. But we definitely call that like not not good now, right, like not exactly not a positive trait. But I think that's that's a challenge, that's it's an interesting challenge point too, because even this, like those are both great examples where we have the a kind of unintended social consequence, right that comes from both a political move of defunding or cutting out you know, state spending. But then on top of that too, like we see a medicine introduced into the into into the society, and then it's you know, there's kind of this desire to we can change I mean this, I mean it's got me thinking too in terms of both you know, pharmaceutical culture today and the rise of what we're seeing now. We're seeing you know, some back and forth about things like for Alzheimer's drugs, you know, and and weight loss drugs has been some back and forth, right but obviously there's a massive fentanyl crisis too, from an opiate and you know, opioids into into an epidemic of people getting coked on them, and so you know, it's interesting to kind of think about it.

46:53 I don't know if your work delves into these these realms, but just like sometimes the role I think this is not an anti antifarmer question, but just like just interesting in this idea of like do we see medicine come into play? Because it has it come to play more frequently? I wonder too, you know over the past fifty years in terms of the where we see people talking about or is it not not basically like seens as like something that we're looking to blame or the cause of some problem, but just like as a part of that conversation, whether it's like somebody's on some certain kind of med or they didn't take their meds to to the other point, as part of that game. I think it's an interesting thing because it's like in medical anthropology, you know, we we we see conversations in terms of the increasing kind of medicalization in air quotes of society, right that we can kind of medicalize an aspect of somebody's life and actually homosexuality being in the DSM three or four at the time, and like now not like there's an interesting that's a good point of like a a you know, a social attitude and perception changing around around a social practice you know that was then also incorrectly put into a mental category you know at the time. And so I'm just curious, like, do we see are the things like this that guy stand out to you that we see you know, medicine or the medicalization and things like this that that are that make for cases that that seem interesting, Like they may not be we don't preat them to be the kind of case. I guess in the future whe they're kind of changing what cases are about. I guess it's a very vague question, but I mean it's got me thinking about this idea in terms of like how cases are formed. Like when there's murder in a and a person that has a schizophrenia that that's that feels clear, you know,

48:24 not great, but it feels clear. Right, if there's domestic abuse that feels clear. I guess do we see anything that makes it kind of murky to know should this should we be calling in a forensic psychiatrist? Right that there's something somebody who's on our author mets or something like that does, is there Maybe you don't see that part of it too in they're deciding who they need to call for for expert testimony. But I'm curious if you've seen conversations around that idea. You're covering a really uh I think it. Yes, there's been a medicalization in behavioral aspects of medicine, So the prescription of stimulants for children who have a d D, or the prescription of any depressant for adults who have even as mild as situational depression. Let's say bereavement after the death. There there some people will get medicated for that, and that's you know, that's debatable. It's not necessarily wrong, but it is not necessarily right either because there, for example, there are natural processes like bereavement that you want a person two that are not pathological any more than pain during childbirth is pathological, although you might use you know, analgesics, a pain medicine to reduce that pain. But there is complicated bereavement. There are people

50:00 who's who lose a spouse and they stop functioning for years, and they're totally focused on the death of the spouts they can't move on. That's if a situation that needs treatment, it may involve medication and or psychotherapy whatever. So you know, I think it's another ball to keep one's eye on of how much is medication being used and is that overuse or is that justified. The other side of that is that fifteen percent of severely depressed people kill themselves. If I'm treated, it's a significant mortality. It's not you know, oh, you know, just go to the gym and exercise and you'll feel better, you know, or take a walk, and so to some extent, the use of antidepressants liberally reduces that. But it's also complicated because I don't know if you remember quite a few years ago, it's probably in the nineties, there were hearings in Congress about antidepressants leading to adolescent suicide. And there's now you know, your listeners made no But it's something called the black box warning, which means that in the pharmaceutical companies insert in a drug package, there's something that has a literally black box around it, and antidepressants all have

51:32 this black box may cause suicide. That's very controversial because many of the people who testified in Congress who tragically had lost children were of a deep anti psychiatry conviction. You know, it wasn't a random population. It was a very biased group who went to the trouble of testifying and gave a tip the scales, particularly with politicians. Subsequent large studies showed that the use of antidepressants with adolescens led to a reduction in suicide on large scale, but of course there are suicides even with people taking antidepressant. The problem, though, that wasn't understood sufficiently, was that if you have a tendency to becoming agitated or bipolar.

52:32 You know, someone can present as depressed, but they actually have really the neurobiology to be bipolar. They go between very down and very elated and manic, and without judgment, you can unmask mania in a person who's really bipolar by bipolar by just giving them an antidepressant. And so what needs to be done at the first science is at a mood stabilizer so they can benefit from the antidepressant without being launched into really crazy and it can be psychotic mania.

53:13 So what was happening to a large extent is a GP or more likely a pediatrician would see, this kid's depressed, I'll give them any depressant. I'll see you in six weeks, where the psychiatrist would have said, i'll see you in two days, or we'll talk on this, you know today, we'll talk on a video, you know, before the end of the week, and to see how they're responding. If they're going from being inert and depressed to being agitated and excited, that's an important warning sign that you need to you maybe be masking a bipolar disorder, which doesn't mean the antidepressdant is not indicated, but it means you got to add a mood stabilizer.

53:54 And that is a dangerous situation because a kid who's thinking about suicide but too inert to act on it may then be activated and act on it and you know, a tragedy, uh, you know, to say the least so that you know it's complicated more complicated species, you know, right, But it's it's a good point too. I mean, even what you're saying up top about there's the there's also the treating psychiatrist, right, and then there's then there's the phrasy psychiatrist in the in the law space, and like this is a great example of why those two can't mix, right, because if you're if you're prescribing meds and working with somebody and then you're on a case talking about how those two meds that didn't interact in a potential scenario, right, you don't want it. You can't be the treating doctor, you know, and also talk about the fact and then objectively weighing all the objective evidence.

54:50 And that's the that's the I think the biggest difference is a treating psychiatrist is dealing with subjectivity because the state at which psychiatry is today is primitive compared to the rest of medicine, whereas a forensic psychiatrist is trying to look at as much object to that as that they can gather and it will give a different perspective. And it's interesting. I'm talking the other day to a prominent neuros psychopharmacologist. He's someone who is like the caboose on the train of referral.

55:32 So when people don't respond to medications and this is all psychopharm this isn't psychotherapy a different issue, they get to him. It's like a tertiary referral call. And he was saying, you know, he was critiquing the DSM, which is a diagnostic and cistical manual that you and I have referred to. That's the list of diagnoses for psychiatry, but the way that psychiatry still diagnoses things, for example, a major depressive disorder. He said, the depression is a symptom, just like fever is a symptom. It's not a disorder. It's a symptom. We don't necessarily understand the disorders. But if you go back to the first two decades of the twentieth century, there were elaborate descriptions of different kinds of fevers. You know, there was this kind of a fever disorder and that kind of a fever disorder, and it's because they didn't understand the underlying biology that was giving rise to the fevers. And he was likening that to where psychiatry is today. That the biomarkers and the neurophysiology and general physiology that results in things that we identify as patterns of a disorder, it's really at a primitive state. That's interesting, I mean,

57:06 is that kind of an arena that because I know you also you also mentor a lot of folks coming into the into the field and is this is this also an area I guess, Like, I think that's a fascinating question to kind of think about, Like do we see any shifts like this in psychiatric training that are trying to find either I don't know, if it's more connectivity between you know, neurophysiology and biomarkers and things like that, you know, or I guess, or maybe the other question is like what is what is your hope to kind of then help move forward psychiatry thinking to either include some of these frameworks or deeper frameworks, like what might it look like? I guess, because I don't even know, right, I mean, I'm imagining going back to Freud's couch and psychoanalysis to start, and then coming forward to still talking about that, and then getting some meds as part of that.

57:49 You can't get pretcribed cocaine anymore, you know, but probably for the best, you know. Yes, an interesting question about that of like where where where are we I guess, you know, if we're in a less kind of evolved in medical state in this perspective, like what where could we go? I guess. I'm curious, like, is it kind of more like threads in the brain to read the neurology of what's happening, or like, what might that look like in your in your view, well, I think that there. I think again, your question is broad and there's several important different threads in it. One is, yes, there's been an increased medicalization of psychiatry, which has its benefits and its disadvantages. Its benefits are that as the understanding of the brain advances, people who are in training in psychiatry are learning more about that. What's bad is they're doing it at the expense of not learning psychotherapy. Current residents in psychiatry have about twenty five percent of the training in psychotherapy that I had, and I became a psychoanalyst because in those days that was the most advanced level of psychiatric training. But that had whether or not that should be the same today as it was then, it had advantages to me because I really learned how to listen, and learning to

59:23 listen is such an important part of all medical practice, you know, at the bedside manner, whereas and today it's very hard to find a physician, forget about the chiatry, who will spend forty five minutes with you taking a careful history and listening and going down those rabbit holes where they're a question. It will be much closer to you know, maybe putting a stethoscope on your shirt and you know, and not even feeling your abdomen or looking in your ears or your mouth and saying, well, let's go order tests. And that's also complicated because there are medical legal reasons for that too. People are worried about being sued and they want but it's often not a brain MRI that's needed. It's actually a sympathetic fear that can help the person find their way through the forest they're stuck in at the moment. And that is an important part of being a physician and certainly important part of being a behavioral physician a psychiatrist. So but you know, both are happening. The former head of the National Studentmental Health was a big advocate for changing the nosology a diagnosis, to a biologically driven system the problem. And there are some very good researchers now at leading medical institutions in psychiatry working on biomarkers, meaning what can we

1:00:55 learn from things that we can test for biologically that says this person is going to respond to prozac and this person is not. They both have symptoms of depression. What's different in their chemistry, in their circuitry that makes one person respond and another So that we can target our medicine to work better and ultimately so that we can understand what's going on on a circuit level. You know, back in the one hundred years ago, it was areas of the brain. This area is involved with hearing. In this area is that you know, a right or left brain with you know, abstract in verbal things or with visual things, et cetera. And the brain has been divided into sort of gross anatomy, but that's not really the level in which things happen because all these parts connect and it's the circuitary understanding that they're the key. That's a that's super fascinated I think for walking through that too, because I think that that's a such an interesting point that you know, I get also as a as a you know, as a as a corollary that we often see in business that when we want to do things like consumer research and understand you know, human behavior, in human psychology and cognition, even if it's around the marketplace too, that there's a kind of distrust of the ethnographic method, which you know comes from anthropology because it takes a long time, because it's it's disciplined listening, right, and it's a it's long engagement and sympathetic listening and kind of getting to know somebody's worldview through engaging with them, versus like,

1:02:29 you know, on an NPS, you know, one out of ten score, how would you rate this experience? You know, because it's like, how would you like if your wedding was then like, oh yeah, well on a score from one to ten, how was your wedding? You're like, uh, you know, versus like let me, let's talk about that experience. You know. So there is that interesting kind of back and forth as we think about the desire for data right and and to your point, I think you also wisely said that oftentimes, like organizations don't want to get sued, right, and so having data saying well, we had this MRI that pointed this thing out. Therefore we did the best we could in terms of having scientific data. Right. So it's actually we face a very similar challenge in terms of continuing to promote the efficacy, you know, and value of sympathetic listening, right of engaged conversation and getting to know someone and like listening to their history and their associations as an important part of the subjective experience, right, But then also it makes it adds I think some levels of important reality to also the objective experience is weird? Does that that sounds right? Like? There is an objective reality that the sky is a certain color, even though we might perceive it all a little bit differently different state of blue right now, But there's a chemical composition that does up there, right, And there may be some chemicals in my brain or my eyes that make me see a certain shade versus you. But you know, we can agree that the sky is blue, you know, But then you know, being able to spend time talking about what the blue sky might mean to somebody that might shape the way I'm perceiving the world right now. It's an important part of what that is like. So it's never just do I see, you know, this shade of blue, and you see that shade of blue, But it's also like, you know, what is what the sky or

1:04:00 the stayer I mean to us in a certain point. And I always find find that interesting to kind of, uh, you know, think about what does this mean, as we need in the science advances, as medicine advances, you know, how do we also keep the human right, keep the the We're looking at human behavior to keep that, keep that human right. It's one of those that maybe it's just my just comfort of you know, I don't I don't. I don't think we can be but also don't want to see us all reduced to like you know, a circuit board, right, like turn the switch on, turn that switch off, and then these genes on, those genes off, and then you can either make me tall or shorter or what you know, whatever it is, will be more likely to go be a policeman versus anthropologist or something. But you know, there's there's more see that, there's more to the box, I guess than that. But I think it's an interesting question in this regardoons. So I'm getting us off into philosophy here, but you know, I think there's good he is good. You know, yeah, that's some good good overlap in our thinking process. But I appreciate the conversation so far, and I think just as as a kind of a wrap wrap up point. You know, so you mentioned that there's you know, sub tooth thousand certified forensic psychiatrists. But I think it's really it seems a really interesting field. So I'd be curious just to hear a little bit about, you know, your organization and how you help folks kind of move into that into that field, right so that they now I want to be a psychiarist. But I didn't even realize that this is a career option. Some folks might be saying, Hey, this sex year, this will be a very cool blend that I'd love to see.

1:05:16 So how does that work with your with your organization? Yeah, thank you for asking that, because I'd like to say a little bit about how we are organizing and what we do and what my role is in that. We are one of as far as I know, only two forensic psychiatric groups in the country, and I'm not sure the ultimate the ultimate reasons for that, but they're Originally medicine general practice was solo practice. It's all been consolidated now into group practice, multi specialty practice, insurance company owned practices, hospital owned practices. That's been an evolution of medical economics over of the course of my career. A last bastion of solo practice for many years was clinical psychiatric and psychological practice. You know what's now done by quote unquote therapists and even psychiatrists have moved into working in larger groups, being employees and larger groups.

1:06:29 Forensic psychiatry is a much younger subspecialty. The boards were only offered in the late nineties in forensic psychiatry, and so those were psychiatrists who were interested in the interface of law and psychiatry and got and made that gift, such as myself me, And so that was a solo practice, solo practitioner profession and I just had the you know, I don't know, perhaps entrepreneurial thought. When I was I had been on the volunteer faculty at University California, San Francisco and now more recently also Stanford, and I was working teaching the fellows taking this one year fellowship in forensic psychiatry. And I realized that I was, at that time, probably twenty five years into my clinical practice. My brain was already slowing down, and I had these really bright, really interesting young fellows, and I had an abundance of referral So I thought, well, why not form a group with them and share that? And I didn't at any to any extent then know what I know now, which is excuse

1:08:00 me. It's very difficult to get started in forensic psychiatry. You don't generally yet have gray hair. The attorneys are looking for gravitas in their experts. It's because of the theatrics as well as whatever that may represent, and so by what has evolved now into actually a whole system in our group. We have built our group to about thirty two experts now, ten of whom are forensic neuropsychologists who do all the testing, and twenty two our Boorchuer divide forensic psychiatrists. But we build it primarily by finding really the very best graduates of fellowships. You know, we have a relationship with the directors of those fellowships, and they come in and very well trained. They have been psychiatrists usually for five years or more, and they've seen patients, but they have this threshold to cross in getting retained. If they just go out on their own, it's very difficult because in the initial interview, the attorney can say, well, how many cases have you seen and been an expert in where a woman has been harassed by her boss and sexually propositioned, and their answer is

1:09:31 invariably no, not that that's a rare phenomena, but they haven't been practicing long enough to acquire this. So in addition to mentoring, just because I've been down the road more than they have, I often get on that phone call with them in the background and can convey to the attorney that they're a member of a team. In the team, we have, you know, hundreds of years of experience and sub sub specialty experts. We have you know, now half a dozen people who also have boards in psychiatry, forensic psychiatry and child adolescents psychiatry, or boards in substance abuse and addiction medicine, or boards in neuropsychiatry, whatever. So if they have any questions, there are people they can call upon. I'll be in the background, and that usually reassures I didn't know it would, but it usually reassures the attorney that they don't just have this young wet behind the ear as a person they're relying on.

1:10:41 But they come with a lot of backing up, and that's been very helpful because then they get the two or three cases under their belt and they're off to the rage. Just because they're smart and they're great communicators. Our profession, what we sell is the ability to communicate. You know, it's important to have the training, but you know, a CV curriculum VITI that looks like an old fashioned telephone book doesn't do it if you're a pompous jerk when you're communicating with a jury or whatever. You need to be able to use simple, understandable language and talk about abstract phenomena in concrete ways and lots of stuff like that. Because where a team, we have the ability to handle multi plaintiff cases, and that's been really evolving as especialty for our group.

1:11:33 So we get retained when there's been a say, an industrial explosion, and there are many plaintiffs who have been in subsequent lawsuits. We get retained if there's been someone's quote unquote gone postal and there's been a shooting in a workplace and people have been killed and other people traumatized by this, and there's civil litigation after that, so that say, the widows and family members children of the decedents may be suing for a loss of spoused, loss of parent, emotional damages, and others who were in the scene of the of the accident or of the shooting are also suing for the emotional damages and being traumatized by that, and that's a whole different I call that. It's like it's the logistics are very complicated. It's like turning you know, an aircraft carrier.

1:12:40 You don't do it on a dime. There are so many moving parts. But we've been down that road a lot of times and have a fair amount of experience and it so that's a whole other interesting dimension that has evolved accidentally from becoming a group. Are also this I'm very proud of exceedingly diverse, not just gender but ethnic race. And we didn't in any way consciously build that, but it came from looking for really good people and they brought with them different ethnicities. So I really, really I'm proud of that aspect of our group. Yeah, that's great. I think that that's such a fascinating arena. And I appreciate the idea too that a lot of this work on one level is translation, right, It's like translating the requirements to legal worlds, but how to communicate that and be a good communicator, And it's like it's a fundamental skill that the world needs. And then it's like then you add the extra layer there in terms of subspecialties in psychiatry and legal practice, and it's like you got to you gotta a wizbang combo there right that that we need in terms of how do we actually bring those conversations to bear.

1:13:48 So really excited and enthused by by the work and excited to have folks check out the organization and all the other good stuff that you are doing. And of course I doubt people are listening to this to necessarily saying, hey, I need to go find one, go find a forensic psychiatist. But if you need to, we got the guy for you right here, sir, that could be the way. But thank you so much for joining me on the podcast today, Mark and sharing your thoughts has been been a great conversation. It's a pleasure, Adam. I've really enjoyed talking with you. And that's a wrap on today's deep dive into the nuances and intricacies of forensic psychiatry with doctor Mark Levy. A huge thank you once again to Mark. We're joining me on the podcast. You know, it's clear there's a whole world where the mind meets the law, and that's filled with stories of challenge and transformation and the pursuit of truth. And whether you're thinking about the ethics of medicalization, what it means to work as or with a forensic psychiatrist or expert in the courtroom, or you're just simply intrigued by the human stories that are behind the cases. Remember the importance of communication and the role that we all play in understanding each other's realities. As always, I'd love to hear from you your thoughts, comments, questions from this episodes. You can get in touch on social media or over email. And thank you as always for tuning in and until next time, keep thinking deeply and look beyond the surface.

1:14:57 I'm Adam Gamwell and this is this Anthra life. We'll see you next time.