The Evolution of Forensic Psychiatry at Yale: A Festschrift Honoring Howard Zonana and the Discipline of Forensic Psychiatry ============================================================================================================================ * Madelon V. Baranoski On April 22 and 23, 2010, the Law and Psychiatry Division of the Yale School of Medicine Department of Psychiatry hosted a tribute to Howard V. Zonana, MD, to acknowledge his contributions to forensic psychiatry in scholarship, teaching, ethics, policy development, and clinical work. In the tradition of a Festschrift, forensic scholars, faculty, and former and current fellows demonstrated Dr. Zonana's influence on their work. The articles recall Dr. Zonana's career in the specialty but also hint at the rich evolution of forensic psychiatry from a scholarly experiment into a full-fledged, respected subspecialty that has been defined though established practice guidelines and ethics. An account of his evolving career is also an account of the evolving discipline and its ever-expanding expertise and sphere of influence. Dr. Zonana is forensic psychiatry at Yale, and his story embodies the development of forensic psychiatry at Yale. Dr. Zonana arrived at Yale in 1968 to join the junior faculty in psychiatry with a position in the outpatient clinic, one year before the inception of the American Academy of Psychiatry and the Law (AAPL). At that time, the 10-city-block distance between the medical and law schools at Yale was representative of the chasm that separated the two spheres in scholarship, practice, and influence. Law was law and psychiatry was psychiatry; each was irrelevant to the other in practice and theory. But times were changing. Deinstitutionalization of persons with mental illness was well under way and the effect of *O'Connor v. Donaldson*1 in imposing a legal standard for commitment created a demand for both psychiatry and the law to establish practical guidelines for commitment. Dr. Zonana volunteered to work with the law school in developing commitment legislation and in applying the new legal standard to assess the status of persons who had been long-term residents in psychiatric hospitals. That foray into the law laid the early foundation of the Law and Psychiatry Division and the Yale Forensic Psychiatry Fellowship. As other psychiatrists contributed to the growing interface between the legal and psychiatric professions, Dr. Zonana extended the practice at Yale, developing expertise case by case in this academic and practice frontier. An evolutionary leap in forensics at Yale occurred when he decided that his emerging expertise should be shared with residents and medical students as part of the curriculum in psychiatry. In 1975, he established the Law and Psychiatry Unit as a hub of consultation and teaching about forensic psychiatry at the Yale University School of Medicine. In 1979, the Yale Forensic Psychiatry Program admitted its first fellow, Roy O'Shaughnessy, MD, a Canadian, who made Law and Psychiatry at Yale an international program. Seventy-one fellows later, the Yale program is one of the nation's largest, admitting five fellows per year and including an emphasis in child forensic psychiatry. Evident at the Festschrift was how far the Yale graduates have stretched the New Haven experience. ## Challenges and Evolution As the articles in this issue will affirm, Dr. Zonana's success and that of forensic psychiatry emerged from the willingness to tackle the challenges presented by the interface of law and mental health. Tough questions of ethics did not deter him or the leaders of AAPL from exploring the potential benefits (and perhaps the unavoidable pitfalls) of applying psychiatric expertise to any area relevant to psychiatry, mental health, or human behavior. Starting with that first involvement in the shaping of commitment statutes and continuing to the current exploration of the ethics and policies related to psychiatrists’ involvement in military interrogation of terrorist suspects, Dr. Zonana and the AAPL leadership have contributed to major legislative and educational developments that have shaped not only forensic psychiatry but also community and correctional psychiatry, the practice of law, and policing and detention policies. The scope of forensic psychiatry and the rate of its expansion are dizzying when one considers the implications that derive from the landmark cases that underpin the education of forensic psychiatrists. Since the late 1960s, cataclysmic change has occurred in psychiatry, the law, our communities, and the world, and the most substantial of these changes have provided opportunities for forensic psychiatrists to apply their expertise. Since the 1960s, the specialty has had nearly meteoric growth in size, prestige, and influence. How seductive are the power of knowledge of the law and the ego-nourishing requests for expert testimony and involvement. And how difficult it is to keep the ethics compass point from drifting. For those of us who know Dr. Zonana well as a colleague, teacher, friend, and fellow Eli, it is the moral and ethical dimensions of his guidance and character that elicit the greatest admiration and appreciation. In a field in which the boundaries of practice are sometimes blurred and the seduction to step out of role is great, Dr. Zonana has contributed clarity, simplicity, and example. His notable accomplishments notwithstanding, it is his humility and compassion that set him apart at Yale and in the field. ## Principles in Praxis Dr. Zonana has contributed four principles that guide the work and all new developments in forensic psychiatry and in the related fields of psychology, nursing, law, and social work that make up the Law and Psychiatry Division. These principles are obvious in his scholarship, teaching, policy endeavors, and consultation and are fundamental to his definition of the specialty. First, forensic psychiatry is the practice of medicine. The forensic psychiatrist is primarily a physician. Although the practice of forensic psychiatry may not involve physician-patient relationships in all cases, the moral and professional obligations still apply. By tradition and society's expectation, the physician is expected to be compassionate and not to seek to benefit from the suffering of others. From this principle, the ethics of the obligation of respect for persons are derived. Through his teaching, practice, and scholarship, Dr. Zonana provides the collaborative model for engaging defendants, clients, and patients to explore the roots and meaning of their behavior. The second principle is that psychiatric expertise is based on the application of scientific knowledge and as such is never absolute or complete. In all sciences, the conclusions are merely the hypotheses for the next investigation. As is certainly true of the study of the brain, emotion, and behavior, the gaps in scientific knowledge must temper any expert opinion. Dr. Zonana has again provided an example by the genuine humility of his opinions, with allowance for doubt in his certainty. Indeed, his effectiveness as an expert witness emerges from an implied apology that the science of medicine cannot offer more definitive answers. This informed humility contributes to his effectiveness as a teacher and clinician. With this principle, Dr. Zonana epitomizes the essence of the second mandate of ethics in forensic psychiatry—truth-telling. The third principle establishes the uniqueness of the specialty: forensic psychiatry is more than the combination of psychiatry and the law. Through teaching and scholarship, Dr. Zonana has emphasized the complexity of forensic psychiatry and its unique contribution to problem solving that goes beyond the separate analysis provided by either the law or psychiatry. In work with insanity acquittees, in examining the aspects of competency to stand trial, in ethics, and in policy-making, forensic psychiatry brings perspectives and values to bear that cannot be brought by any other specialty. This principle lends rigor to assessments, formulations, and consultation and to the development of educational strategies for attaining expertise in testimony and report writing. The fourth principle is one that defines character and is applicable not only to one's profession but also to one's life in total: integrity above all else. Integrity provides the compass for ethical decision-making. It is more than honesty and truth-telling; it includes authenticity and a basic moral appreciation of one's identity, obligations, responsibilities, and commitments to medicine, patients, colleagues, students, the community, the law, and oneself. Dr. Zonana has been the model of integrity in his professional and personal life. ## Special Festschrift Section This special section mirrors last spring's Festschrift and presents the addresses by scholars in law and forensic psychiatry that acknowledge the impact of Dr. Zonana's contributions to the field and the evolution of forensic psychiatry as a discipline. In his article, “Coping with the Ethical Conundra of Forensic Psychiatry: A Tribute to Howard Zonana,” Paul Appelbaum, MD, Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law at Columbia University and Dr. Zonana's close colleague, addresses the ethics-related challenges of the profession through two examples in which forensic psychiatry has shaped policy: evaluations and treatment of competence to be executed and the participation of psychiatrists in military interrogations. Kenneth Appelbaum, MD, a former fellow of the Yale program and now Professor of Clinical Psychiatry and Director of Correctional Mental Health Policy and Research at the University of Massachusetts, presents the history and development of forensic psychiatry in “Howard Zonana and the Subspecialty Maturation of Forensic Psychiatry,” in which he describes Dr. Zonana's career trajectory as a personification of the advances in the field. Two of the articles are by legal scholars who have worked with Dr. Zonana on legislation and policy. Based on his address at the Festschrift, Richard Bonnie, LLB, the Harrison Foundation Professor of Medicine and Law at the University of Virginia, has authored an article on the legal perspective of forensic psychiatry, “Howard Zonana and the Transformation of Forensic Psychiatry,” and has described the enhancement of law through its partnership with psychiatry. Stephen Wizner, JD, William O. Douglas Clinical Professor Emeritus of Law and Psychiatry at Yale University Law School, describes the benefits to psychiatrists and law students of collaborative teaching of cases in which legal and psychiatric issues have been decided. In his paper, “Learning to Collaborate: The Teaching Legacy of Howard Zonana in Forensic Psychiatry,” Professor Wizner presents the Zonana model, in which fellows and law students join to formulate cases. He illustrates the positive results by examining three collaborative projects: an *O'Connor v. Donaldson* review of civil patients at a state hospital, a case in which the law school represented long-term patients of a state hospital who were asking to leave, and an asylum case. In their commentaries, Reena Kapoor, MD, Assistant Professor of Psychiatry at Yale, and Patrick Fox, MD, Assistant Professor of Psychiatry at Yale and Director of the Whiting Forensic Division of Connecticut Valley Hospital, provide the psychiatric perspective and advantages and disadvantages of the model of joint education of law students and forensic fellows and collaborative case formulation. Michael Norko, MD, Associate Professor of Psychiatry at Yale and Director of Forensic Services for the Connecticut Department of Mental Health and Addiction Services, describes in his article, “The Dynamic Evolution of Forensic Psychiatry at Yale and the Zonanian Sphere of Influence,” some of the history and context of Dr. Zonana's influence in shaping the field of forensic psychiatry in statutes, policy, teaching, and scholarship. The Festschrift was diminished only by the unavoidable absence of two leaders, Jonas Rappeport, MD, and Joseph Bloom, MD. Dr. Rappeport sent reflections that were presented at the spring tribute and Dr. Bloom sent a letter acknowledging the contributions that Dr. Zonana has made to an area of Dr. Bloom's active interest, the aftercare of those found not guilty by reason of insanity. ## Conclusions Howard Zonana is the everyman of forensic psychiatry; acknowledgment of his career and contributions is a celebration of its development. This reflection on the career and contributions of one doctor does honor to the discipline and to the collective accomplishments of all who participated in the creation, definition, and standardization of a prestigious and influential subspecialty. ## Footnotes * Disclosures of financial or other conflicts of interest: None. * American Academy of Psychiatry and the Law ## Reference 1. O'Connor v. Donaldson, 422 U.S. 563 (1975) ![ Figure 1. ](http://jaapl.org/https://jaapl.org/content/jaapl/38/4/547/F1.medium.gif) [ Figure 1. ](http://jaapl.org/content/38/4/547/F1) **Figure 1.** Howard V. Zonana, MD