Howard Zonana and the Subspecialty Maturation of Forensic Psychiatry

Specialization and Subspecialization in Medicine

At the start of the 20th century, accepted standards on who could call himself a physician, let alone a specialist, did not exist. In his 1908 Presidential Address to the American Academy of Ophthalmology and Otolaryngology, Derrick T. Vail, Sr, MD, decried this situation stating, “It should no longer be possible for a man to be called an oculist … after he has spent a month or six weeks in some postgraduate school.” Instead, he called for adequate institutional training and approval by “a proper examining board” as requirements for licensure.¹ It did not take long for the call to be answered.

In 1914, the American Medical Association (AMA) began to approve internship programs, and in 1915 the independent and nonprofit National Board of Medical Examiners (NBME) was established to offer a voluntary examination that could be used as a nationwide standard for medical licensure. Training standards underwent further refinement in 1928 when the AMA promulgated its “Essentials of Approved Residencies and Fellowships.” In 1932, NBME created a Committee on Specialists, which included the Surgeons General of the U.S. Public Health Service and the U.S. Army. The committee issued a report, “Suggestions Concerning National Qualifying Boards in Clinical Specialties,” which, along with other developments, ultimately led to the 1934 formation of the Advisory Board for Medical Specialties, now known as the American Board of Medical Specialties (ABMS).¹ Together with the AMA, ABMS offers official recognition of medical specialty boards.

The medical profession generally embraced these developments, and the number of specialty boards grew from 2 in 1929, to 12 in 1939, to 18 in 1949. This period of growth in the number of recognized medical specialties occurred in conjunction with an expanding body of medical knowledge and skills. In the 61 years since 1949, only 6 additional specialty areas have been recognized, bringing the current total to 24.² A new board can be established only if such an additional area of medicine would be in the interest of the public and if the board would elevate the standards of medical education and practice. Candidates for certification require a specific number of years of additional education in approved institutions, including designated clinical and practical experiences, followed by examination by peers.

The emergence of subspecialties followed not long behind the acceptance of medical specialty boards. In response to an increasing number of subspecialty certificate areas (10 by 1970), ABMS formed a Committee on Certification, Subcertification and Recertification (COCERT) in 1972. The following year, ABMS formally recognized the authority of its member boards to grant “special certification” to qualified physicians with extra competence in specific areas. ABMS changed the terminology in 1985 from special certification to “added qualifications” for subspecialization within the physician's primary discipline and special qualifications for diplomates from one discipline who passed subspecialty examination by the primary board for a different discipline. These terms were subsequently thought to be too confusing and were themselves dropped in 1995 in favor of the term subspecialty certification. The number of recognized subspecialty certificates has grown from 74 just after this change in terminology to at least 121 now being issued by the 24 ABMS member boards, with 10 of those certificates co-sponsored by anywhere from 2 to 10 primary boards.³

Despite the broad acceptance of specialization and subspecialization in medicine, the process has not been without its critics.⁴ Fragmentation of patient care is perhaps the most significant concern, and there has been increasing recognition of the value of primary care physicians to serve both as coordinators of care and as gatekeepers to other services. Recognition of subspecialty areas also can effectively limit the practice of uncertified physicians through privileging restrictions, disparate third-party reimbursement scales, and malpractice coverage restrictions. Together with the added costs of subspecialty education and credentialing, these factors all tend to lead to an increased cost of services.

Certification in Forensic Psychiatry: The Years Before Formal Recognition

Forensic psychiatry has had an often prominent presence within the broader field almost from the start. Psychiatry itself began to emerge as a specialty area in the United States in the late 1700s and early 1800s. Benjamin Rush, one of the founding fathers of our nation and signer of the Declaration of Independence, is also regarded as the father of American psychiatry. His image adorns the seal of the American Psychiatric Association (APA), and he published what may have been the first psychiatric textbook in the United States, Medical Inquiries and Observations upon the Diseases of the Mind, in 1812.⁵ Two years earlier, however, on November 5, 1810, at the University of Pennsylvania he gave his “Lecture on the Medical Jurisprudence of the Mind.”⁶ Forensic psychiatry figured prominently in the works of this revolutionary scholar who participated in the birth of our profession and our nation. Isaac Ray, another of the early leaders in both psychiatry and forensic psychiatry in the United States, published A Treatise on the Medical Jurisprudence of Insanity in 1838.⁷ Ray went on in 1844 to be one of the 13 initial founders of the Association of American Institutions for the Insane, which is now the APA. Thus, at its inception, the APA included the foremost forensic psychiatrist of the day.

Forensic psychiatry has maintained a central presence within the APA over the years. Noteworthy events include the first report in 1925 of the APA Committee on Legal Aspects of Psychiatry, chaired by Karl Menninger; the creation of a section on forensic psychiatry in 1934; the formation of the Council on Psychiatry and the Law in 1980 during the presidency of Alan Stone; and the 1982 Statement on the Insanity Defense. Formal recognition as a subspecialty area, however, would have to wait.

Examinations for board certification in general psychiatry began in 1935, one year after the formation of the American Board of Psychiatry and Neurology, Inc. (ABPN). The ABPN, however, was slow to recognize subspecialty areas. The first examination in Child and Adolescent Psychiatry occurred in 1959, but another 32 years would pass before the ABPN began a more rapid-fire approval of other subspecialty certifications. The first examinations in geriatric psychiatry, clinical neurophysiology, and addiction psychiatry were held in 1991, 1992, and 1993, respectively. Forensic psychiatry, which had been approved by the ABPN in 1992, held its first examination in 1994. Eleven fields now qualify for subspecialty certification by ABPN.

Even before the 1992 approval of forensic psychiatry by ABPN, Dietz⁸ called for sub-subspecialization into the four branches of criminal behavior, mental disability, forensic child psychiatry, and legal aspects of psychiatric practice with the warning that “those undertaking [practice in all 4 areas] … risk mediocrity or incompetence in some of them.” Bloom and Benson⁹ echoed this call almost 20 years later suggesting the need for “third generation” certifications. In contrast to Dietz, however, they identified the areas of treatment of sex offenders, correctional psychiatry, and civil law. They divided even these areas into yet more narrow foci, such as traumatology under civil law, and offenders with substance abuse, sexual abuse, or antisocial personality disorder in the area of correctional psychiatry. They opined that training programs would require an extension to two years, with the first covering the broader aspects of the field and the second focused on one of the sub-subspecialty areas. Nevertheless, just achieving acceptance of second generation certification in the general subspecialty of forensic psychiatry required a concerted effort by practitioners of the discipline. Howard Zonana has figured prominently in almost all aspects of that effort.

Certification in Forensic Psychiatry: The Zonana Era

Over a period that must exceed 25 years, Howard has contributed probably more than any other person to the full development of forensic psychiatry as a subspecialty and to the development of quality fellowship training programs.—Joseph Bloom, MD, Professor Emeritus of Psychiatry, Dean Emeritus, School of Medicine, Oregon Health Sciences University (OHSU); American Academy of Psychiatry and the Law (AAPL) President 1989–1990

ABMS and ABPN criteria for recognition of subspecialties include the general requirements that these fields involve special functions and bodies of knowledge taught in advanced training programs of a year or longer. ABPN criteria also include, among other things, a teaching faculty that participates in research and clinical activities, a national subspecialty society composed primarily of ABPN-certified members, and a recommendation from an authorized nominating society such as the APA.

Along with spearheading the efforts to obtain ABMS and ABPN recognition, Dr. Zonana's role as a clinician, scholar, leader, and mentor contributed significantly to meeting these thresholds. He has been a leader within forensic psychiatry organizations and a respected representative and persuasive advocate for forensic psychiatry with other key organizations such as the APA, AMA, ABMS, and ABPN. As I explored Dr. Zonana's contributions and accomplishments, I found several images from popular culture that kept coming to mind. The movie characters Zelig, played by Woody Allen, and Forest Gump, played by Tom Hanks, had the remarkable habit of turning up at all of the major events of their time. In the same fashion, Dr. Zonana has been present at all of the main events that have led to the recognition of forensic psychiatry as an accredited medical subspecialty area. Zelig and Forest Gump, however, were ordinary individuals in most respects, who appeared repeatedly at extraordinary occasions. Dr. Zonana, in contrast, has been anything but ordinary. Thus, the pop culture comparison that came most to my mind was a tongue-in-cheek radio superhero from the 1960s called Chickenman, who had the tag-line “He's everywhere, he's everywhere.” As I looked for Dr. Zonana's presence at key moments over the past several decades I found that he was indeed everywhere, and in heroic fashion.

Dr. Zonana: The Clinician

Howard and I go back a long way, beginning with our residency years at the Massachusetts Mental Health Center in Boston, more than 40 years ago… . From time to time, Howard calls me about a psychopharmacology problem. He is a great clinical psychiatrist who remains devoted to his most difficult patients … he never gives up on a patient.—Carl Salzman, MD, Professor of Psychiatry, Harvard Medical School

As with any other branch of medicine, clinical skills provide the foundation for all professional activities in forensic psychiatry. Dr. Zonana's foundation is strong, and he has never strayed far from it. He has maintained a clinical practice throughout his career, and anyone who has regular contact with him soon observes his dedication to his patients. Former fellows have praised him as “loyal to your role as a physician” and “always present and available to your patients,” and in the words of AAPL Executive Director, Jacquelyn Coleman, “No one who spends time with you can escape knowing about your compassion for your patients.” Given the clear value that Dr. Zonana places on his identity as a treatment provider, one might wonder why he has devoted so much of his career to forensic pursuits that take him away from that role and sometimes require opinions or actions detrimental to the person being evaluated. Part of the answer lies in a deep intellectual curiosity and an understandable attraction to a field that combines some of the most interesting and challenging aspects of medicine, law, ethics, social policy, and philosophy. Perhaps he recognized his innate talent, so obvious to the rest of us, as “an incredibly logical thinker when it comes to deconstructing and analyzing complex psychiatric issues.” Perhaps he also recognized that by subspecializing in forensic psychiatry he might have greater opportunities to apply his clinical skill and compassion to the care of often neglected population groups, as illustrated in the following testimonials: Howard has been critically important to the clinical care, health, and well being of many thousands of women incarcerated in Connecticut's women's jail and prison; … from the late 1980's he has advocated consistently, vigorously, and successfully for [mental health] resources … some of our very best psychiatrists are graduates of Howard's fellowship program.—Robert L, Trestman, MD, PhD, Executive Director, Correctional Managed Health Care, Professor of Medicine and Psychiatry, University of Connecticut Health CenterSince the mid-1970s, Howard has … worked to improve mental health treatment in our correctional facilities … been a ready source of wise and practical consultation … [and] projected a constant sensitivity to the rights and needs of the individuals we evaluate and treat.—Michael Norko MD, Director of Forensic Services, Connecticut Department of Mental Health and Addiction Services, Yale University School of Medicine Forensic Psychiatry Fellow, 1987–88You are always there! As if you were the guardian angel of our Immigration Legal Services clients.—Jean Koh Peters, Esq., Sol Goldman Clinical Professor of Law, Yale Law SchoolYou and the psychiatry residents and fellows are not solely expert evaluators or witnesses, but are integral members of the professional team providing legal services to the Law School clinics' clients, enabling us to help, sometimes even rescue people and at times, literally, to save their lives.—Stephen Wizner, Esq., William O. Douglas Clinical Professor Emeritus of Law, Yale Law SchoolYou have been a true force for good throughout your career. As a new lawyer, I quickly learned the value of a “Zonana consultation.”—Brett Dignam, Esq., Clinical Professor, Yale Law SchoolYou have for this office since the early 70s, not only served as an expert witness, but also as a teacher, mentor, and friend… . [W]e continue to marvel at the exemplary high quality of services provided by you and the Law and Psychiatry Unit.—Michael Dearington, Esq., State's Attorney

Dr. Zonana's advocacy on behalf of forensic populations brought him into contact with Connecticut's political leaders who quickly recognized his talents and integrity. As a result, he and the Law and Psychiatry Division that he directs at Yale have consulted on all major state legislation regarding mental health law for several decades. His contributions have been acknowledged with a Citation of Merit from the Connecticut Civil Liberties Union in 1984, a Service Award from the Connecticut Psychiatric Society in 2004, and a General Assembly Official Citation from the Connecticut Legislature in 2010: “In recognition of more than 40 years of invaluable consultation with the General Assembly on landmark public policy reforms affecting persons with mental illness… .” The areas noted in the Citation from the Legislature include: “… civil commitment law … competency-to-stand-trial statutes … establishment of the Psychiatric Security Review Board … creation of alcohol and drug treatment programs as alternatives to incarceration … revisions of our involuntary medication statutes … possession of firearms by persons demonstrating valid predictors of violence … Persistent Serious Sexual Offender statutes … Juvenile Competency statute … Parole Risk Assessment process …, and continuous efforts fostering cooperation between mental health and legal professionals.” It is no exaggeration to say that Dr. Zonana has left an indelible imprint on mental health laws in Connecticut and elsewhere in the nation, fostering rationality, common sense, and compassion in broad areas of public policy.

Thus, Dr. Zonana's foray into forensic psychiatry has allowed him to amplify his contributions as a clinician and healer. In addition to providing dedicated care to his own patients, he has served as the preeminent clinical advisor to the courts and legislature in Connecticut. Throughout his career, he has been “an advocate for those who have no voice, a sought after activist for ethical and just causes” (Mariefi O'Malley, Law and Psychiatry Division, Yale University School of Medicine).

Dr. Zonana: The Scholar

William Blake said, “The man who never alters his opinion is like standing water, and breeds reptiles of the mind.” Ever open to new data and receptive to the opinions of others, one will find no reptiles in the mind of Dr. Zonana. Dig deep enough, however, and a cephalopod or two might turn up. Dr. Zonana's first publications, one of which appeared in the journal Nature and both of which he authored while still a medical student, involved research on the structure and function of the squid retina.^10,11 Fortunately for the squid, and even more fortunately for the rest of us, Dr. Zonana soon shifted his sights from cephalopod vision to his own visions on timely and controversial areas of mental health and public policy. Over the ensuing years he has authored more than 80 publications, which can be categorized into four main themes. He has written about legislative reform and the mandatory outpatient treatment aspects of civil commitment. His violence-related publications include papers on limiting the duty to protect, prosecution of assaultive patients, response to threats to the President, monitoring insanity acquittees, and mandated reporting of child abuse. Regarding sex offenders, he has addressed psychiatric testimony, civil commitment, and treatment. In the area of death penalty cases, he has written about evaluation, testimony, treatment, and execution competency. These scholarly endeavors have made noteworthy contributions to the research, special functions, and body of knowledge required for the subspecialty recognition of forensic psychiatry.

Dr. Zonana: The Leader

Howard Zonana has resolutely and calmly kept the organization focused on its goals … ushering us into the internet age; marshaling our efforts at advocacy; and supervising the development of guidelines. But if you asked AAPL members … they would talk about his openness to each of them individually and the value of the advice and perspective he gave them.—Jacquelyn Coleman, Executive Director, American Academy of Psychiatry and the Law

A handful of other modern forensic psychiatrists have made clinical and scholarly contributions on a par with those of Dr. Zonana. Few, if any, however, have achieved a comparable breadth and depth of leadership responsibility. Dr. Zonana has played a central role in all of the organizations whose support was critical to the acceptance of forensic psychiatry as a recognized medical subspecialty. This is a remarkable accomplishment for a man who impressed his future spouse as “a handsome, shy, and rather uncertain young man” when they first met almost 50 years ago. Those of us with an attraction to expert witness work despite the anxiety that testifying can evoke can perhaps understand this seeming contradiction. It is fortuitous for forensic psychiatry, however, that Dr. Zonana, for whatever reason, chose to confront rather than avoid his natural shyness. He has over many years proven to be a valued leader within AAPL and its affiliated organizations and a highly effective ambassador to other organizations, including the APA, AMA, ABPN, and ABMS. A brief review of that history will illuminate the many ways in which he has advanced the status of forensic psychiatry.

The seminal event in the long road to subspecialty recognition for forensic psychiatry occurred in December 1967, when Jonas Rappeport, MD, began to contact directors of existing training programs. At the May 1969 meeting of the APA, exactly 125 years after that organization's founding by its original 13 members, Dr. Rappeport and 13 others met to establish a new organization to exchange “information, knowledge and ideas … at the interface between psychiatry and the law.”¹² This organization, the American Academy of Psychiatry and the Law (AAPL), held its first official meeting in November 1969 in Baltimore, the home town of Dr. Rappeport. With dues at only $10.00 per year, the organization grew over the next 12 months to 142 members, and it has not stopped growing. AAPL currently has over 1,500 members from North America and countries all over the world.

Dr. Zonana joined AAPL in 1975. As a review of past annual program schedules and committee rosters will quickly reveal, he has been one of AAPL's most active members. He also has held many leadership positions with AAPL, including Program Chair (1982–1983), Councilor (1985–1988), Vice President (1987–1988), and President (1992–1993). His service since 1995 as Medical Director, a position previously held by Dr. Rappeport from 1972 to 1995, has had special significance for the organization. Other than the Medical Director, AAPL has no salaried leadership positions. The organization entrusts the Medical Director with significant operational responsibilities and relies upon this individual to provide astute stewardship in both day-to-day decisions and long-term planning. The transfer of these responsibilities from AAPL's founding father to someone new represented a critical juncture for the Academy. As a past president of AAPL observed: Many of us were somewhat anxious about the future of AAPL when Jonas Rappeport stepped down as Medical Director in 1995. We should not have been. Howard has done just a splendid job for AAPL, and the organization has thrived under his thoughtful and diligent leadership.—Larry R. Faulkner, MD, AAPL President 1998–1999

AAPL has recognized Dr. Zonana's service by honoring him with all of its awards, including the Red Apple Outstanding Service Award (1991), the Silver Apple in recognition of service as President (1993), the Seymour Pollack Award for distinguished contributions to teaching and education in forensic psychiatry (2000), and the Golden Apple for significant contributions to the field (2006).

As the preeminent professional society for forensic psychiatrists, AAPL's existence as a thriving association meets the necessary criteria for subspecialty recognition, and Dr. Zonana has been a factor in AAPL's success. Organizations affiliated with AAPL, such as the now-defunct American Board of Forensic Psychiatry (ABFP), also helped pave the way for formal recognition.

ABFP was established in 1976 under the joint sponsorship of AAPL and the American Academy of Forensic Sciences. Although unsanctioned by ABMS, ABFP offered board certification in forensic psychiatry. Applicants generally required five years and 3,500 hours of post-residency forensic experience, along with prior certification in general psychiatry by ABPN. Candidates who passed a written test were then eligible to take a three-part oral examination that included defense of three forensic reports submitted by the applicant, questions based on a videotaped case presentation, and a general inquiry into knowledge of landmark cases and related material. Dr. Zonana served as a board examiner (1982–1991), member of the Board (1985–1991), Chair of the Oral Examination Committee (1985–1987), Treasurer (1986–1987), President (1987–1988), and Chair of the Nominating Committee (1988–1991). ABFP certified over 200 diplomates before sunsetting in 1994 when ABPN began offering subspecialty certification in forensic psychiatry.

During its 18-year life-span, ABFP helped demonstrate that the field had widely recognized core functions and content areas and that knowledge and expertise in these areas could be meaningfully assessed. Official recognition of these realities by organized medicine, however, still required nomination by the APA for subspecialty status for forensic psychiatry and approval by ABMS and ABPN.

The presence of many highly respected forensic psychiatrists within the APA helped secure that organization's support. For three decades, Dr. Zonana has been one of the more prominent figures in that process. Throughout this time, he has served almost continually on both the APA's Council on Psychiatry and the Law and its Commission on Judicial Action. On both the Council and the Commission he has served as a member, consultant, corresponding member, and Chair, along with other positions. In these and other capacities, he helped shape APA policies on challenging matters such as the management of sex offenders and psychiatric involvement in death penalty cases, and he has represented the APA in testimony before the United States Congress. On the local level, Dr. Zonana served as President of the Connecticut Psychiatric Society (1983–1984) and as Area I Legislative Representative to the Joint Commission on Government Relations (1980–1987).

As observed by APA Past-President and AAPL President 1995–1996, Paul Appelbaum, MD: Howard has played a critical role helping to formulate APA's policies related to psychiatry and law for more than two decades … and a leading role in bringing APA's input to the AMA.

And in the words of Richard Ciccone, MD, Director of Psychiatry and Law at the University of Rochester, AAPL President 1986–1987: Howard's report on sexually dangerous offenders continues to be an important resource after all these years. He has been a leader in the field of forensic psychiatry.

In 2003, the APA awarded Dr. Zonana a Special Presidential Commendation “in recognition of outstanding leadership in forensic psychiatry for the APA and the American Academy of Psychiatry and the Law.”

The support of the APA was a necessary, but not sufficient, component of obtaining ABMS recognition of forensic psychiatry. ABMS still needed to be convinced that forensic psychiatry had a distinct body of scientific knowledge, training programs of appropriate length and complexity that could not be included in general psychiatric residency programs, and a sizable group of physicians concentrated in the subspecialty. Dr. Zonana jumped into the fray and spearheaded the process of seeking ABMS approval. Howard led the effort to gain subspecialty status for forensic psychiatry from the ABMS. He marshaled leaders of the field to assemble the needed documentation and achieved consensus on key issues, such as the extent to which correctional psychiatry would be built into the definition of forensic psychiatry and the curriculum of the fellowships.—Paul S. Appelbaum, MD

When the time came for oral argument of the case for recognition before the ABMS, AAPL sent two representatives: its founder and first President, Jonas Rappeport, and its President-elect and eloquent spokesperson, Howard Zonana. Howard did a beautiful job convincing them that we were a legitimate subspecialty. He was principally responsible for our getting approval from ABMS.—Jonas Rappeport, MD

ABMS, however, would not have granted recognition to forensic psychiatry without the concurrence of its psychiatric member board, ABPN. Although one might assume that obtaining this concurrence would have been straightforward, this was not necessarily the case. As described above, the history of subspecialization within psychiatry suggests a long period of reluctance by the ABPN to approve subspecialty certificates. Dr. Zonana again played a crucial role as champion for forensic psychiatry. Howard was very instrumental in getting the ABPN to establish its subspecialty of forensic psychiatry, and he was a long-term member and Vice Chair of the Forensic Psychiatry Examination and MOC Committees. Having worked with Howard on those committees for many years, I know the magnitude of his efforts on behalf of the ABPN.—Larry Faulkner, MD, President and CEO, ABPN

As with the ABMS, Dr. Zonana helped make the case for subspecialization in forensic psychiatry before ABPN. More than that, he took the lead in establishing the process by which ABPN would grant certification to candidates. In November 1992, ABPN established a Committee on Certification of Added Qualifications in Forensic Psychiatry (now called the Committee on Certification in the subspecialty of Forensic Psychiatry) to decide on the content and mechanics of an examination. In the words of Renee Binder, MD, an initial member of the committee and AAPL President 1997–1998: Howard took the leadership role from the beginning … putting content areas into categories and ranking their importance … ensuring the exam was fair, equitable, scorable and reproducible.

Dr. Zonana served as Vice-Chair of this committee from 1993 to 2004 and Chair from 2004 to 2008. His efforts significantly contributed to the preparation of the first examination given in 1994 and all subsequent examinations leading to the issuance of a total of 1,814 certificates in forensic psychiatry as of December 31, 2009, with 1,168 still active certificates in 2010.¹³

The existence of a vibrant subspecialty organization, AAPL, and the support of the APA were among the factors that led to formal recognition of forensic psychiatry by ABMS and ABPN. Dr. Zonana has been, and continues to be, a leader and advocate within these organizations. He has also done much to advance the recognition and status of forensic psychiatry in the broader house of medicine, as represented by the AMA. Over the years, AMA positions on matters such as the insanity defense, physician participation in death penalty cases, and medical expert witness activities have had significant implications for forensic psychiatry. The AMA, however, has at times formed opinions on these matters, seemingly without the benefit of cogent counsel and nuanced understanding. As a result, the positions taken by the organization have sometimes led to the dismay of competent and ethical practitioners of forensic psychiatry. In this venue too, Dr. Zonana has overcome his innate shyness and even aversion to organizational activities and has become “a reluctant hero” in his chosen field. When it was first seated in the AMA House of Delegates in 2003, AAPL appointed Robert Phillips, MD, as its delegate, with Dr. Zonana as deputy delegate. His involvement and influence within the AMA have directly contributed to more thoughtful policies addressing both forensic practice and ethics. Forensic psychiatry has achieved great prominence in the House of Delegates due to Howard's influence. CEJA [AMA's Council on Ethical and Judicial Affairs] will frequently seek out AAPL opinions as a result of the respect Howard has brought to forensic psychiatry within the AMA.—Robert T. M. Phillips, MD, PhD, AAPL AMA Delegate, AAPL President 2004–2005

Psychiatry as a whole, not just forensic psychiatry, has benefited from the counsel that Dr. Zonana has provided to the AMA. Howard has been a great representative for forensic psychiatry and psychiatry in general. He is such a clear thinker and calming voice … thoughtful when passions are high … [and] great at staying on point and not backing off an issue, but doing so in a way that makes people feel good about it.—Jay Scully, MD, Medical Director, APA

Dr. Zonana: The Mentor

To this day when faced with a difficult forensic case or conundrum I find myself asking “what would Howard do?”—Roy O'Shaughnessy, MD, Yale Fellow 1978–1979, AAPL President 2002–2003

The ABPN criteria for subspecialty recognition include the existence of at least 25 training programs in all geographic regions with faculty involved in both research and clinical activities. The field as a whole also must have at least 500 practitioners, with a continually increasing number over the previous 10 years. The forensic psychiatry fellowship, founded by Dr. Zonana at the Yale University School of Medicine (YUSM), has long been one of those programs, and as of 2010 it has contributed 69 graduates to the ranks of forensic psychiatry.

Under the leadership of Dr. Zonana, YUSM began forensic psychiatry training activities in 1973 with the introduction of a curriculum for psychiatry residents and an advanced clinical elective for fourth-year medical students.¹⁴ Together with Lansing Crane, JD, Dr. Zonana established the fellowship program itself in 1979, and accreditations were obtained as soon as they were available from the Accreditation Council of Forensic Fellowship Programs in 1989 and from the Accreditation Council for Graduate Medical Education in 1997. Currently with five trainees per year, the YUSM program is the largest in the nation.

In the area of law, the model curriculum developed at YUSM included an overview of the legal system, an exploration of key legal concepts related to psychiatry, and an in-depth review of landmark legal cases. [For trainees] the law and the legal process was alien and forbidding territory, but with a year of the landmarks cases, it became familiar, comfortable and manageable.—Lansing Crane, JD

Dr. Zonana has continued to play a central role in the evolution of the landmark case list, which has become a national core content area both for trainees and for practitioners seeking subspecialty certification.

Such details, however, cannot convey the career-altering influence that the year at YUSM had on so many of Dr. Zonana's fellows. He taught us to think carefully and clearly, to appraise our strengths and weaknesses honestly and accurately, to accept our limitations, and always to do our best. He modeled each of these characteristics for us in his own actions and self-reflections, and in doing so, he “allayed [our] fears.” He could impart more guidance in fewer words than anyone we had known. He could be challenging but respectful, erudite but humble, and always helpful. His door was open to us, even when it was closed, and he gave his time freely, even when he had none to spare.

He welcomed, not merely invited, us to accompany him on professional outings and assist him with projects, and we learned something new and valuable on every occasion. In recalling an event that occurred when she was nine years old, his daughter Elisa described what we all felt and experienced more than once during our fellowships: Vivid to this day [is] seeing my dad on the witness stand, speaking in measured tones, attentive, thoughtful, unrushed and unruffled in every response. I was struck by his confident ability to listen, consider, and respond; defending, not defensive. That's my dad, I thought. I was overcome with pride.

We quickly grew to “cherish the time spent sitting around a conference table learning this trade from a master.” We were busy, challenged, and at times anxious, but the professional stimulation of trying to even approach his intellectual rigor was exhilarating. Representative comments from former fellows describe him as “the most influential teacher I've had” or “the central figure in the formation of my identity as a physician.” We continue to “strive to live up to [his] example of excellence,” and many of our subsequent professional achievements had him as an impetus. The fellowship year was a rare, precious, and even “life-altering” gift and “a turning point in [our] career[s].” Many of us view it as “one of the very best years” of our lives, and we will never cease to be grateful for it.

This bounty, however, did not come without a price. More than one fellowship applicant still recalls the trauma of the initial meeting with Dr. Zonana: I can still remember the day you interviewed me for the fellowship … the neutrality in your face and voice, I remember feeling myself being dissected.It all began on the day of my Fellowship interview with Howard … When I sat in the leather chair across from him, I was already intimidated. But when I heard his booming voice, I knew I was going to have a meltdown or panic attack.The questions posed by him were by no means easy; and since he is also, at times, hard to read, I left not knowing where I stood. And then came the phone call that changed my life forever.

Despite his initially imposing and sphinxlike demeanor, Dr. Zonana's fellows invariably discovered a gracious and gentle mentor. This is not to say that we didn't remain awed by his intellect and the breadth and depth of analysis that he brings to bear on a topic. We often struggled to keep up with him, and we rarely showed up unprepared for seminars. Our anxieties, however, were a small price to pay. “Magic [took] place at the end of the hall” in his corner office when we had supervision, and “what a storehouse of wonders” we found in that all too brief fellowship year.

And what are some of the things that we learned during that year? Great diligence and compassion and a striving for excellence … Howard showed us that with every class, seminar, or meeting;To write excellent, detailed reports … [leave] nothing to chance … not to make assumptions or take shortcuts;The discipline of critical thinking and a passion for forensics, which has stayed with me throughout my career;To be someone who speaks softly, but whose words have much force and power behind them.

Given his abilities and what he taught us, it's not surprising that some of us concluded that “Howard Zonana has superpowers.” But even as Superman is powerless in the face of kryptonite, Dr. Zonana has one area of weakness and incompetence: Thank you, Howard, for reminding me that money is not the reason I pursued medicine, and that it's okay not to know much about it.

Dr. Zonana: The Mensch and the Family Man

It is possible to be a professionally powerful person and a mensch at the same time.—Former fellow describing one of the things she learned from Dr. Zonana.

In addition to all that he taught us as fellows, Dr. Zonana treated us like “respected colleagues.” He “invited us to hike with [him] … and into his home,” offered us “fatherly advice,” and gave us his “personal warmth and kindness.” Those of us who experienced significant losses, illnesses, or misfortunes during our fellowships discovered a compassionate ally who provided support and mobilized connections and resources on our behalves. His graciousness did not end with our fellowship years, and he reached out with similar compassion and support to more than one of us who experienced later traumas. When he invited us to call him with professional questions or problems after we left the fellowship, it was not an empty offer. If we thought ourselves unique in his willingness to take our calls, we were mistaken. He was accessible, often immediately, to every one of us.

We were not alone in our experience of Dr. Zonana's graciousness. His wife, Linda, observed, “One of the first things I noticed and admired about Howard was the respectful way he related to everyone.” His daughter Jessica spoke of the “model for character” that he provided for his children, and in the words of his son, Jeremy, “Deep respect and tolerance for individuality is one of the most important beliefs that I have inherited from my father.”

In the same fashion that his former fellows have experienced his ongoing backing of our diverse careers, Dr. Zonana's children “grew up secure in the knowledge of his full support for whatever path we chose to follow.” To his wife and his kids, he's deeply attached, You can honestly say that they're perfectly matched.

His respectful demeanor has also earned Dr. Zonana the deep admiration of staff members of the YUSM Law and Psychiatry program: You created a division that felt like family;A great boss … wise leader, teacher and mentor; a good listener, a visionary …;Howard has no peer;Always dead honest … in the kindest possible way;You set the moral compass for each of us;You have no idea how special you are.

Dr. Zonana: The Complete Package

For over three decades, Howard Zonana has been a leader, eloquent spokesperson, and respected ambassador for forensic psychiatry. In all this time, he has maintained his perspective as a practicing physician. He has integrated, not abandoned, his clinical roots in his successful efforts to better inform attorneys, courts, legislatures, and the general public about psychiatric matters. His tireless and effective advocacy on behalf of persons within the criminal justice system has positively influenced policy on the local and national level. His contributions in any single area would be enough to ensure his elite status within psychiatry, let alone forensic psychiatry. In combination, however, his work as a clinician, scholar, leader and teacher greatly advanced the formal recognition of forensic psychiatry as a medical subspecialty.

Dr. Zonana is among a small group of individuals in our field who are widely referred to by their first names only. He is one of the founders of modern forensic psychiatry, and he is instantly recognizable. One need not mention any identifier other than “Howard” when referring to a significant presentation, opinion, achievement, or contribution that he has made. Granted, it is not as common a name as Ken, or John, or Mortimer, but even if there were a multitude of Howards in our profession, there would still be only one “Howard.” Although many people refer to him only as Howard, fewer have had the pleasure of really knowing him on a first-name basis. And even fewer have had the good fortune to count him as a mentor, colleague, and friend. To be one of his former fellows is to belong to a relatively small and very privileged group. Those of us who have had this experience know how special it is.

As one of his former fellows, I am, admittedly, not the most objective observer of Dr. Zonana's career. He will forever hold a very special place in my professional and personal esteem. Some might accuse me of hyperbole in my analysis of and praise for his contributions. Despite my obvious bias, however, such accusations would be unjust. Dr. Zonana has more than earned any accolade that I can bestow. The praise that he has received, the awards that have been given to him, and the trusted leadership positions to which he has been elected and appointed all attest to the central role that he has played in the maturation of forensic psychiatry as a subspecialty. They also give a sense of the many contributions that he has made to the populations that we serve and to society in general. I have been able to include in this article only a miniscule sample of what I heard and read from others about Dr. Zonana. Although I have had the singular honor of presenting this testimonial, I have tried to channel the thoughts and feelings of scores of others who would have welcomed the chance to take my place. Therefore, I will end this article with just a few more of their representative comments.

Voices from the psychiatric community: One of the most astute minds in American psychiatry today;A treasure in our field;Vast breath of knowledge, wisdom … good humor, and friendship;Selflessness and generosity have been remarkable;Teacher, mentor, and role model to an entire generation of forensic psychiatrists who practice all over North America;Contributions have been simply stellar;Speak[s] both forcefully and thoughtfully at the same time;A steadfast advocate and practitioner of reason.

Voices from the legal community: Howard is a jewel among us and I am proud to call him a friend;The patience and care found in all great healers informs your every decision;We know that you call it straight;You have been a true force for good throughout your career;You are an admirable, enthusiastic, perceptive and unflagging resource upon which all of us rely to keep things in balance;On behalf of my clients past and to come, and my students past and to come, and on behalf of my grateful self, I send my admiration and endless thanks.

Voices of former fellows. Thank you for: Taking chances on the talents of your trainees;Encouraging my love of learning;Being always present and available;Being such an inspiring teacher;Treating me like a respected colleague;The warmth of your voice;Humbly sharing that you, even you, still get nervous before testifying;Opening my eyes to our legal system;Making me feel welcome to a new world;Graciously welcoming me into your home and personal life;Your mentorship and unwavering support;Your never ending patience;The push to do my best;Setting high standards, offering fatherly advice, and giving me an opportunity that has changed the course of my career. Thank you, thank you, thank you;With boundless thanks.