Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're highlighting the Forensic Psychiatry Program at Northwestern Medicine, bringing clinical knowledge to the courtroom. And joining me today is Dr. Chandrika Shankar. She's an Associate Professor of Forensic Psychiatry and General Psychiatry in the Department of Psychiatry and Behavioral Sciences at Northwestern Medicine.

Dr. Shankar, thank you so much for joining us today. I want to jump right in with a working definition. What is forensic psychiatry?

Dr. Chandrika Shankar: Thank you so much for having me, Melanie. Forensic psychiatry is a specialized area of psychiatry that focuses on the intersection between mental health and the law. Forensic psychiatrists are medical doctors who've completed training in Psychiatry and then specialized in forensic work. So, just like child psychiatrist or geriatric psychiatrist, or addiction psychiatrist, but they focus on helping and evaluating individuals involved in legal cases, assist their attorneys and courts understanding how mental illness impacts their behavior, decision-making, legal responsibility, and so forth.

Melanie Cole, MS: Wow, what a fascinating field you're in. So, how has it evolved over the past decade? What do you see as the most significant contributions to the legal system? And tell us just a little bit about what you do every day.

Dr. Chandrika Shankar: So, the question is about how forensic psychiatry has evolved. The big shift has been to do with the evolution of psychiatry itself and the integration of neuroscience and data-driven risk assessment tools into forensic evaluations. We now have more sophisticated ways to assess things like criminal responsibility, competency to strand trial and future risk of violence.

Our day-to-day task really depends on the type of evaluations we are doing. For example, forensic psychiatrists or I perform both criminal and civil evaluations as well. Criminal would entail competency to stand trial. This is to see whether someone is mentally fit to participate in their own defense. We also do evaluations for criminal responsibilities, to see if they were insane at the time of the crime. In those instances, I may have to go to a correctional facility to meet with the individual to do an in-person evaluation. At times, it can be done virtually. I have meetings with attorneys. I have a lot of records to review, including their mental health history, how they're doing in the jail system, some of the childhood evaluations as well. And then, part of the data collection is also talking to families who know these individuals really well. And then, if the attorney and the individual decide to move forward, then it may be completing a report and compiling all of this data into a narrative and answering the specific question that the attorney or the legal court is asking us to do.

There's also the civil cases, which include capacity to make decisions like writing a will or is the individual able to make health decisions or financial decisions? Fitness for duty. For example, a police officer, can they return to work? Or a teacher, can they resume the responsibility in the classroom? These evaluations, I don't have to go to jail fortunately. Most of the time, the individuals come to us, into our office where we do an assessment. But the crux of the work is sort of the same. It's compiling all the data and then preparing a report that would be helpful for their attorney in coming to a conclusion of the matter.

Melanie Cole, MS: Wow, how cool are you? So, how do you approach translating complex psychiatric concepts into language? Because not everybody has the same language that you do-- for judges and juries and attorneys-- that they can understand without losing that clinical accuracy and something that's clear and useful for the courts and for legal professionals.

Dr. Chandrika Shankar: We are often asked to explain nuanced mental health concepts to people who don't have medical training. But the way we view it, it's the same as when we are talking to patients or their families. We have to really break it down and explain what is going on in a way that they can follow and understand. So, clarity and precision is key.

One of the most important things is to really, A, understand what is a legal question at hand? And second, who is my audience? So, refraining from using jargons as much as possible, educating the concepts by breaking them down into simple terms and using analogies. So for example, my favorite analogy is when I'm trying to explain a manic episode to someone. And though mania is to some degree understood by the public, what it truly feels like for the individual who is having a manic episode is driving a car at a 180 miles an hour on a freeway where the speed limit is, say, 60. And while it feels amazing and you are on a high, it is also extremely dangerous, because they cannot stop on time or turn carefully. So, the individuals who are having a manic episode often feel completely out of control, feel very grandiose, talk too fast, do things that are very impulsive and dangerous, and can really have long-term consequences as a result. So really, breaking that knowledge down into ways that a common man would understand.

Melanie Cole, MS: Yeah, that's a great way to look at it and so understandable. Now, forensic psychiatry often sits at the intersection of medicine and law, which is what you're telling us. So, what are some of the most pressing ethical dilemmas that you encounter, Dr. Shankar, when serving as an expert witness, which you and I talked off the air a little and you told me that you do have to serve as an expert witness sometimes? How do you navigate that and that balance?

Dr. Chandrika Shankar: I think one of the most pressing dilemmas is maintaining objectivity while being retained by one side in a very adversarial legal system. There can be subtle pressures, sometimes even unconscious to align with the side that hired you. At the core, forensic psychiatrists are physicians. We've been trained to treat people and to empathize and to want to help the individual. And at times, the evaluation is about answering a specific legal question and really remembering that as the end goal and coming back to that every time one deviates or has a moment where you feel conflicted is really important. And in medicine in general and in psychiatry, confidentiality is key. Whereas in forensic psychiatry, everything they say or write may be disclosed in court. So again, were you cautious about the information that's collected, whether it's actually going to help the individual or harm the individual, and being very transparent with their attorney and the individual who we are assessing is really important as well.

And the last, I think, quite common dilemma that at times faces people who are working in corrections or an inpatient psychiatric unit where they're treating the individual as clinicians, but maybe ask to testify in court for, say, continued involuntary commitment or when somebody has to be petitioned to court for treatment when they're refusing medications. So, on one hand, they're taking care of the individual. But on the other hand, they have to testify against them even if it is for their benefit can be very tricky because the question is how do you go back after having said all of those things that the individual perceives as things against them, and then try to rebuild that relationship, which is supposed to be therapeutic and empathic, can be really challenging.

Melanie Cole, MS: You have such an interesting job. And while we're talking about those assessments and serving as a witness, walk us through the nuances a little bit of assessing that competency to stand trial versus criminal responsibility. I mean, we've all seen the television shows, and you've spoken about guardianship or fitness for duty, some civil matters. How do you assess someone on their competency to stand trial in the case of maybe some really heinous crime?

Dr. Chandrika Shankar: The concepts can be very confusing, because competency or capacity is used on the civil side as well, as well as on the criminal side. On the civil side, capacity or competency can be medical decision-making. So, say, somebody is admitted in a hospital and they have to have a surgery, but they're refusing, do they have the capacity to deny the treatment, or do they have the capacity to write a will or do they have the capacity to make financial decisions? So, that's one aspect of the civil side of assessing whether somebody has the cognitive ability to make all these very important decisions.

On the criminal side, again, when we are going to assess somebody-- whether they have competency to stand trial-- it's essentially seeing is the person mentally able to understand what's happening in court and help a lawyer with their defense. And it's about their mental state right now, not when the crime happened. And the key to remember is it's not about the crime. We are not there to determine whether the individual did the crime or not, however heinous it may be. The question is, do they understand what the police are saying they did, and are they able to weigh the evidence and the witness that's against them, and are they able to assist in their own defense with the help of a council? Do they have the cognitive ability to make decisions to move their case forward? So, it is really important and, you know, it comes back to your previous question of ethical dilemma of remembering it's not about the crime, it's not about whether they did it or not. It's do they understand what have they been charged with and can they work with their defense attorney in moving things forward? Very specific question and very targeted interview.

Melanie Cole, MS: Wow. So, you really did just clear that up, because I think that that is something that many people don't really understand. It's not about the crime itself, it's about do they understand what they're being charged with. So while we're kind of along those lines, misconceptions about your field and about what you do. What do people ask you when they find out what you do for a living? What misconceptions do you frequently encounter both in the courtrooms and in the real world?

Dr. Chandrika Shankar: Well, psychiatry itself, there's so many misconception because you walk into a party and somebody asks you what you do and you tell them you're a psychiatrist, they assume that you can read their mind. And the first joke that I always hear is, "Oh, we need to be careful what we say in front of you."

In forensic psychiatry, a lot of time people assume that it's forensic pathology. For some reason, they assume that it has to do with dead bodies. And then, they realize that we work with criminals. They assume that it's dangerous. They assume that we are trying to get people off, and that we are overly empathetic with violent individuals.

Melanie Cole, MS: . Now, for certain fields of medicine, Dr. Shankar, we have risk assessment tools for cardiovascular disease, your risk of diabetes or a genetic disease. So in your situation and forensic settings, how do you balance a predictive value with individualized clinical judgment, especially when public safety might be at stake? And while you're telling us that if you're teaching trainees this same skill to remain objective when testifying or to use these predictive values, how do you do that?

Dr. Chandrika Shankar: Risk assessment tools can be definitely helpful. They're designed to look at patterns and behavior, historical data and other factors to estimate how likely someone to be violent again, to re-offend. But the way we look at them is it's a tool that can be helpful. It's a checklist or a calculator , but not to oversimplify the data that's provided. It'll not replace an in-depth evaluation. That's where the clinical judgment comes in. And as a forensic psychiatrist, it's really important to look at the whole person, not just the numbers and not just at what the risk assessment tools provide, because we have to be mindful about what the tools are, what is the population that they're being tested on? Because a lot of times, these risk assessment tools have been tested on forensic populations of people who are in the correctional system, not necessarily those who are mentally ill.

Now, it's a different thing that nowadays because of deinstitutionalization. And with reduction of hospitals, most of the mentally ill population are housed in correctional facilities. But the same risk assessment tools don't apply as accurately to them, even if they have a history of legal enmeshment and violence. One has to consider the individual's mental state, are they taking treatment, their willingness to engage in treatment, the social support, sobriety, all of those factors. Whereas risk assessment tools sometimes mostly focus on historical data, which can be helpful, and which can be used as a guide, but cannot replace an in-depth assessment at all. So when we are training our fellows or medical students and residents, we try to highlight the fact that to use the risk assessment tools as a guide. But it should not prevent you from seeing the individual, doing an in-depth record review, contacting collateral, and building a full case as you would otherwise.

Melanie Cole, MS: Well, that's not only that clinical judgment, but the experience of the forensic psychiatrist such as yourself. So, you've been doing this and you're an expert, so I imagine imparting that knowledge and expertise to these trainees is just so, so important so that they can go in the right direction with these things.

I only have a few more questions, but boy, you and I could talk a while because this is really such an interesting topic, and what you do for a living is absolutely fascinating. And with the rise of telepsychiatry and we're seeing that all over the place and AI-assisted evaluation, like even chat. How do you foresee technology shaping forensic psychiatry in the next five years or so? Do you see AI and things like that coming into play with this? And what about telepsychiatry? You mentioned that some of what you do can be done in televisits.

Dr. Chandrika Shankar: That's a very complex developing area now. Technology has already reshaped how we practice and how we do things, especially post-pandemic. Things have shifted in a very, very big way. And the next five, ten years, who knows how it'll transform even further.

But let's start with a simple one, I guess telepsychiatry, because it's been there for a while and is very well-established now. It's really a game-changing in many ways, you know, especially in rural and undeserved areas. But it doesn't entirely place the importance of a nuanced in-person evaluation, because there's certain subtle things that are just not captured on camera and plus, at times, the in-person assessment allows you to build a relationship that's just missing when you do it on the screen. However, it does allow people access. So, courts and correctional facilities don't have to spend a lot of time now waiting to have an in-person appointment. They don't have to transfer or transport an individual long distance for an evaluation. And this means faster assessments, reduce costs, better continuity of care. So, there are a lot of advantages to telepsychiatry, which think is here to stay.

AI now and AI-assisted evaluation is still growing and developing, and remains to be seen how it'll evolve over the years. It helps us analyze patterns in behavior, maybe predict risk , and it has created some algorithms that can sift through large volumes of data because part of our work is really reviewing copious amount of records, such as mental health history, criminal history, psychological testing, treatment, all of that. And AI can be very helpful and quick in just reviewing all of that information very quickly and compiling information. But the question is, it's so fast-growing, and still so much is unknown whether this technology is going to be fair and unbiased. Because ultimately, the human component, the clinical judgment, the empathy, the ethical reason remains essential to our assessment and is not there yet. Will it be there in five, 10 years? Maybe, but it remains to be seen. So again, helpful tool, but we need to be cautious.

Melanie Cole, MS: Well, it still needs that personalized expert, as you said, and the empathy and the compassion and the critical thinking skills that you must possess in so many ways. So as we wrap up, Dr. Shankar, for psychiatrists, psychologists, anybody who's interested in forensic work, what are some of the core competencies or mindset shifts that are essential for success in this unique arena? For people that might be interested, what advice would you give them about developing those necessary skills and resilience to succeed in forensic psychiatry?

Dr. Chandrika Shankar: At the core of it, I remember my fellowship program director saying, "In order to be a good forensic psychiatrist or an expert, or even a forensic psychologist--" I think it applies to them as well-- is to be a good clinician first." You have to be just a good, solid psychiatrist or a psychologist, and then to be very aware, curious about the differences in the role, that the role is not therapeutic. In forensic work, you're not treating the person, you're evaluating them for a legal purpose. And that means our primary duty is to the legal question at hand and keeping that at the forefront.

Being objective, being comfortable sitting in the gray or sitting in the middle of an adversarial system. Knowing when to say no, being aware that this will create a conflict or I may not be able to be objective and to recognize that maybe this is not the case that I am able or willing to do. We often can say no to patients. But in this case, it's even more imperative that we understand where we are emotionally or whether our subconscious will impact our ability to do objective work and have curiosity about the legal literature. Again, we don't have to be lawyers because thankfully we work with attorneys, but to have some understanding about the legal standards, and being very aware of the ethical boundaries, like we talked about confidentiality, and the dual role complexity that some settings may present with.

But it is a fascinating field. It never gets boring and you get to work with some of the greatest minds. And the individuals that we work with are equally interesting, compelling stories, and it's extremely gratifying. So, I encourage anyone who is interested to apply and ask questions.

Melanie Cole, MS: It must be so rewarding to bring that clinical insight into the legal process and see your work influence both patient care and justice outcomes. Thank you so much for joining us today, Dr. Shankar, and sharing your unique and incredible expertise for other providers today. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/psychiatry to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.