With the passing of the gavel at the recently concluded 45th annual meeting of the American Academy of Psychiatry and the Law (AAPL), Emily Keram, MD, who has described herself as “the accidental forensic psychiatrist,” became the 41st president of the American Academy of Psychiatry and the Law and only the fifth woman to hold that office. As an early mentor and one of her many long-time friends and colleagues, I am privileged to introduce her formally to the broader membership through this article and to share some of the experiences that have shaped her and some of her thoughts about the challenges that face our profession and our organization. It is my hope that, in the year ahead, many of you will seek out opportunities to interact directly with Emily and share your ideas and stories with her. She will love it and you will no doubt be integrated into her ever expanding and evolving understanding of and vision for forensic psychiatry.
Emily Alyssa Halpern Keram, MD
Emily has the potential to be a different kind of president from those whom we have had before. With little need to draw attention to herself, she will instead try to draw attention to the unique ways our organization can contribute to the development of public policy directly related to the substance and practice of our profession. Through example, she demonstrates the best of what AAPL has to offer and what it needs from every member: excitement about how the field is evolving, long-term commitment to the needs of the profession and the community, humility, a sense of humor, and no retreat from the prospect of hard and most often nonglamorous work.
At the time our organization began, Emily was still navigating the public school system in Westchester County, New York. Under the tutelage of her older brother, John, and the close observation of her parents, Doryan and Michela, as well as an assortment of extended family members, who could, and may yet, populate a novel about her formative years, she grew up in New York. Her mother was an educator and an adventurous woman whom Emily fondly describes as a “big social justice person.” Her father was a psychologist within the Veterans Administration System. Although she loved all things science, she also demonstrated an early interest in music, but not in the violin and piano lessons her parents wished for her. She adamantly wanted to play the guitar, and, with her insistence and only limited resistance from her violin and piano teachers because of her refusal to practice, her parents finally gave in. She redeemed herself by quickly mastering the instrument and went on to teach guitar in Chapel Hill, NC, before starting medical school. She still views herself as a life-long music student and now plays her 1924 Martin.
Emily elected to leave New York, wanting to spread her wings a bit, and moved south to attend Duke University. She majored in zoology, graduating magna cum laude. Although never imagining herself as destined to be a researcher, she became a member of the Duke University Goat Watching Society and participated in the study of sensory dependent development of maternal/neonate attachment. She managed a short stint studying the physiology of nematodes. Even before graduating, she jumped ship to become a Tarheel and firmly solidified her non-Blue Devil position by attending medical school and completing her residency training at the University of North Carolina at Chapel Hill. It remains evident to anyone who knows her well that, even under the California sun, her blood continues to run Carolina blue.
So, where does Emily's self-professed view of herself as being an accidental forensic psychiatrist come from? Her interest in forensic psychiatry can be traced to a chance conference and “let's vacation” plan hatched by her attorney/psychiatrist husband Steve during their psychiatry residency training in Chapel Hill. On the recommendation of Dr. Seymour Halleck, they decided to use their $200 lifetime psychiatry residency meeting allotments to head to the 1990 AAPL meeting in San Diego. Being the honest person she is, Emily planned to attend at least one talk at the meeting before heading to the beach. She happened to choose a presentation by Dr. Philip Resnick on insanity, and, “like magic,” the world of forensic psychiatry opened up before her eyes. Not only did she spend the rest of the meeting attending as many sessions as she could, she decided to seek advice as to how to pursue her new interest in forensic psychiatry. She was referred, at that same meeting, to Dr. Jonas Rappaport, who in turn, referred her to me. We had just begun a forensic fellowship program, then jointly sponsored by Duke and the Federal Bureau of Prison facility in Butner, North Carolina. My first conversation with Emily was via a very excited phone call. Her response to our subsequent offer of a fellowship training position could be likened to her being offered a lead role in a television crime drama. Emily describes the moment as “winning the lottery.” She loved North Carolina and the idea of immersing herself in the study of forensic psychiatry. She was being presented with the opportunity to pursue her interests with a female mentor, and she did not have to move.
Emily quickly integrated into life (as a clinician evaluator) in federal prison, always demonstrating a droll sense of humor and a keen interest in all things criminal. She thrived on the interactions she had with the other clinicians and staff and with the inmate patient population. She found the opportunity to delve into the lives of those facing federal charges to be a fascinating extension of her general psychiatry training. She had a natural ability to look beyond the crime to find the person behind it: never judgmental and always cognizant of the need to understand behavior in its full context. She was exposed, for the first time, to a new set of complex questions, such as the concept of “just” or “fair” punishment within our criminal justice system and the dilemma of how this concept should be applied to the mentally ill. She approached this new type of learning as a detective. The importance of having all of the data she could before arriving at a conclusion and the merits of refusing to pass judgment too quickly in any situation hit home with her. They were lessons learned and valued, not only during that training year, but in the years ahead.
The fellowship year introduced her to a broader type of multidisciplinary practice. She had her first opportunities to interact with different types of law enforcement personnel, as well as professionals from other federal and state agencies. By the end of the year, she appeared ready and eager to embark on a career in criminal forensic work and correctional psychiatry. I offered her a staff psychiatrist position as her training came to a close, but she sadly told me she would have to decline. Unable to reconcile Emily's East Coast government job interests with Steve's aspirations to return to the West Coast to start a private practice, the couple resorted to flipping a coin to determine their immediate future. Emily lost the toss.
They landed instead in Santa Rosa, California, 3,000 miles away from the only forensic connections she had. She described feeling a type of “forensic loneliness” as she began her solo practice of clinical and forensic psychiatry. So, she turned to AAPL to develop a network for continued involvement in forensic psychiatry. She sought out colleagues and mentors and early on began her involvement in the committee work of the organization. Then the chance occurrence of an appointment by Dr. Renée Binder to the California Psychiatric Association's Judicial Action Committee threw her together with Dr. Robert Weinstock, who was chairing it, and Drs. Charles Scott and Christopher Thompson. She was no longer alone in her forensic interests and formed the first of many close friendships in forensic psychiatry that she continues to value dearly.
Her own personal experiences fostered her continued belief in the usefulness and value of the committee structure and functions within AAPL. She has been or is currently involved with, or has chaired, a variety of committees, including Private Practice, Program, Membership, Law Enforcement Liaison, and Education. She founded two new committees for the organization: Early Career Development and Human Rights and National Security. She has also served on the Executive Council, as Councilor, Secretary, and Vice President. She was involved in developing the Practice Guidelines for Insanity Defense Evaluations. In 2012, she was awarded the Red Apple Award for Service in recognition of her ongoing work within the organization.
The development of Emily's career through several opportunities that came her way quite by chance has shaped her current interests and ideas about forensic psychiatry. Early on, she was drawn into the area of law enforcement consultation. She accepted a referral to work on a wrongful-arrest case with the local Deputy City Attorney, Brien Farrell, who later asked her to take a look at the files of a series of officer-involved shootings. When she admitted her lack of detailed knowledge in that area, Mr. Farrell proposed that she attend the Santa Rosa Police Department's Citizen's Police Academy. That was where her interest in law enforcement contacts with mentally ill citizens, including the complicated phenomenon of Suicide by Cop (SBC), really took off. After reviewing a series of cases, she coauthored a paper on SBC and was invited to present her findings at the FBI Academy.
In 1996, Emily accepted the position of Clinical Chief at the Santa Rosa Veterans Administration community-based outpatient clinic. In that capacity, she was immersed in the assessment and care of a veteran population, which at the time was still composed only of pre-Iraq and -Afghanistan war veterans. The work was in many ways all-encompassing and, after four years, she elected to move into a more academically oriented setting. In 2000, she helped to found the Psychiatry and Law program at the University of California, San Francisco (UCSF). Dr. Binder, whose expertise was in civil evaluations, asked Emily to join her and focus on the criminal work coming into the program. Emily was directly involved in supervising and mentoring the fellows in the training program. She herself was exposed to a mentor in Dr. Binder, who introduced her to a variety of forensic experiences involving legislation, civil cases, and research.
While at UCSF, Emily helped the San Francisco Police Department set up their first Crisis Intervention Team (CIT). From there, she was asked to join a California Peace Officers Standards and Training (POST) which was tasked by the legislature with developing a statewide curriculum on law enforcement interactions with mentally ill citizens.
In 2004, missing the treatment aspect of her previous work and the opportunity to work with a growing and expanded veterans population and realizing how much of her time was tied up with commuting, she returned to working with veterans in Santa Rosa. This time, however, she limited her VA clinic work to half time so as to allow adequate time to devote to her private forensic practice, pursuing her continued interest in the law enforcement/mental illness interface, and doing volunteer work. She continues with this hybrid job description to the present and has maintained her affiliation with the San Francisco training program. Her work over the past decade has expanded to include veterans of the latest conflicts, allowing her to work with problems and concerns arising immediately after their discharge from military service and enabling her to follow the course of their illnesses as time elapses after their active-duty experiences.
Emily has been integrally involved in and supportive of the VA's current efforts to promote a nationwide application of clinical practice and forensic expertise to the care of veterans. Before the establishment of the national VA's Veterans Justice Outreach Initiative, Emily led the formation of the Sonoma County Veterans Justice Services Program, linking VA services to the local court, jail, and probation office. She now participates in the VA's Workplace Safety program as a member of the San Francisco VA's Disruptive Behavior Committee. She recognizes and uses the benefits, both clinically and forensically, of the VA's Suicide Prevention Program, which focuses on means restriction. Limiting access to lethal means of committing suicide has been found to be an effective intervention technique, with practical implications across populations. It is consistent with Emily's interest in engaging clients or patients and their support systems in the problem-solving process.
Over the course of her career, Emily's work has “accidentally” exposed her to similar important matters in a variety of different populations and settings. Her work with veterans fueled her interest in disabilities and disability rights, including the myriad aspects of posttraumatic stress. The needs of the community and direct requests for assistance following public concern over police conduct exposed her to what was for her new areas of law enforcement training, developing standards for policing, treatment of law enforcement officers, and Suicide By Cop. In 2004, after a chance discussion with a colleague at the AAPL annual meeting, she entered yet another new forensic area. The controversy over the detention and long-term management of individuals captured during the Iraq and Afghanistan wars and kept at the Guantanamo detention facility was destined to attract her attention when she was pulled into evaluating several individual cases. This experience opened up the worlds of national security and human rights to her thoughtful consideration.
These experiences, though seemingly quite different on the surface, would ultimately become the heart of her current work: the study of trauma and its potentially transformative impact on human emotion, cognition, and behavior. How does trauma affect victims and perpetrators? How do traumatized communities, nations, and regions react to trauma? Group exposure to trauma can create dissension and drive people toward the extremes of human response. It can also create sympathy and evoke empathy. It can inform liability, require restitution, or establish disability. It can raise the question of credibility or the accusation of weakness in the claimant. The understanding of trauma can bring relief; a lack of understanding can bring shame, isolation, or hopelessness. Group exposure to trauma creates powerful political symbols, influences legislators and the judiciary, informs national security decision-making, and ultimately influences the national character. Trauma and its aftermath run through much of what faces the forensic psychiatrist in almost every endeavor that is undertaken. Emily firmly believes that it remains our collective responsibility to be aware of its presence and the potential consequences of that presence as we practice our trade.
As forensic psychiatrists, we are faced with trying to understand how trauma affects the clinician, the evaluator, and the testifying expert. Numerous questions and potential problems confront us, such as how easily and how often does the forensic clinician fall prey to the experience of secondary trauma when working with these challenging populations? What are the potential impacts of the political climate and public sentiment on the work of the forensic evaluator who chooses to become involved with these populations? How can the psychiatrist and the forensic psychiatrist hold the middle ground in divisive situations and yet remain open to understanding both sides of the question and appreciate the merits of multiple points of view?
Given the evolution of Emily's career as a forensic psychiatrist and her continued involvement in the clinical practice of psychiatry, I was interested to know how she would summarize some of what she has learned along her unique journey through the world of forensic psychiatry. I asked her whether she had developed any maxims to apply to the present-day challenges of forensic practice and whether she wanted to share any advice. A bit of what she shared follows.
The real focus of a forensic psychiatrist's work must be first to solve the most important problem in any case or consultation, which is the need to define the scope of the role of the forensic psychiatrist within that particular referral or context. The second task is to take whatever steps are necessary to make sure one is hewing to that role. The forensic psychiatrist must always take time to stop and ask herself, what is the concern? What is the science? What are the limitations of available data? What is the expertise required? How can your skill set be applied where you are only one of the players and the expectation is that your involvement will bring added value to the process? A third piece of advice when deciding whether to accept a case or a consultation, is always to ask yourself first whether you would accept it, regardless of which side is seeking you out. If the answer is no, you should consider declining involvement.
Emily, without a doubt, remains cognizant that her expertise and that of the field of psychiatry itself is not without limits. It remains the responsibility of the forensic psychiatrist to bring the limits of the science and understanding of human behavior to the attention of those seeking his expertise. There is danger in practicing our craft in isolation. She has made it a practice to address openly her need to seek consultation and retain the ability to conduct honest discussion with selected and identified colleagues in the process of exploring a forensic question. All cases, even if on the surface routine, require current review of the relevant literature, as well as detailed study of the unique fact patterns of illness and behavior presented by the individual case. Collateral information must be assessed for its validity and for its value by understanding it, not only as a trained clinician and evaluator, but through the values, expertise, and vantage points of its providers. The data must be collected and reviewed without getting lost in the process. Understanding applicable law and remaining cognizant of forensic and medical ethics should serve as the backdrop of our work regardless of the questions posed to us.
It is Emily's belief that the field of forensic psychiatry has much to offer to the broader field of psychiatry. Of paramount usefulness is our heightened focus on problem-solving through a multidisciplinary approach. Clear identification of the problems to be addressed, the specific questions to be asked, and the importance of understanding context as well as content are core skills to be exercised in every forensic evaluation or consultation. This understanding can often best be achieved when the forensic psychiatrist, at least initially, assumes the roles of quiet observer and careful listener within the evaluation team and the evaluation process. The ability to let others feel valued and comfortable in bringing their expertise to the table and to recognize the merit of considering the problem from multiple perspectives cannot be underestimated. It can also go far in dispelling public perceptions of the forensic clinician as a self-proclaimed and self-promoted expert who sometimes holds predetermined views and is often highly paid for opinions.
Forensic psychiatry, as is true of all areas of psychiatry, can be demanding and draining work. It is therefore important to take time to turn our attention to other outlets, less prone to debate and deadlines, that can serve to replenish our energy and keep us attuned to the nonpsychiatric, nonpathologic aspects of the world around us. Emily has found that the worlds of dog ownership and showmanship, the creative worlds of music and food, and, most of all, her relationships with husband Steve, her family, and her friends provide those outlets and keep her on the even keel she believes is needed to tackle the complexities of forensic work.
It is that work, not a need for public recognition that remains the driving force for Emily in her role as a forensic psychiatrist. Her belief is that the practice of forensic psychiatry requires a willingness to have one's ideas challenged and opinions questioned and, when necessary, the ability to admit to being in error. It calls for providing services across a spectrum of settings and abilities to pay, and acceptance that it may take more hours than can be reasonably billed to assure that the work that we do is of a quality that can serve as the public face of our profession.
We are fortunate to have Emily serve as the current face of our professional organization. It may have been a series of accidents that brought her into our midst, but she would be the first to acknowledge that it has been the support and interaction of many individuals within this organization that have inspired and encouraged her to assume a leadership role. I have no doubt that she will continue to provide just such inspiration to many others within our membership as she fulfills her duties as our 41st president in the year to come.
- © 2016 American Academy of Psychiatry and the Law
