Abstract
The search for truth is a foundational aim and value of forensic psychiatry. It is also a deeply spiritual exercise. It must, therefore, be possible to describe a spirituality of forensic psychiatry, which I attempt to begin in this article. This exploration opens with a discussion of spirituality and its contexts. I then examine the nature of vocation in its application to medicine, psychiatry and the law. This proceeds to a close evaluation of the attitudes and activities that I will argue occupy the groundwork of forensic practice and form pathways to truth: presence, empathy, compassion, and centering. I then examine some of the forces that harm the expression of truth in the courtroom, and the means for healing those injuries. Concern for the common good, an integral part of my own spirituality, arises repeatedly in this discussion. I conclude with thoughts on the search for truth, in our work and in ourselves, and an invitation to colleagues to imagine forensic psychiatry as a spiritual practice. My hope is that this endeavor will stimulate reflection among forensic clinicians and encourage further inquiry and explication.
Be not afraid to thrust aside half-truths and grasp the whole.—Ralph Waldo Trine [Ref. 1, p 111]
My title begins with the query put to Jesus by Pilate in John's account of the trial of Jesus (The Gospel of John 18:38). It is a profound question, with obvious importance to the field of forensic psychiatry. Pilate used this question dismissively though, to express indifference to the truth and to the witness and his testimony, revealing the nature of the “hasty affair in which truth is not served” (Ref. 2, pp 45, 49). But I wish to use this question as a probe, a device to begin to describe the terrain of a spirituality of forensic psychiatry residing within the daily toils of our profession.
This exploration requires some definition of spirituality, such that we might acknowledge it when we see it. It also calls for an examination of vocation, the first stirrings of our attraction to truth. It will further entail a deep evaluation of the postures and processes that I will argue occupy the foundation of forensic work: presence, empathy, compassion, and centering. Finally, I will describe how the healing arts might be applied in an interdisciplinary approach to the injuries inflicted on truth in the dynamics of the courtroom. I hope that this sketch will invite further exploration and detailed description.
Spiritual exploration is a personal matter; it is about relatedness.3,4 An external, anthropological methodology will not serve this endeavor. I choose to approach it from within, as an individual privileged by membership in a group of devoted colleagues, to whom this effort is addressed.
Search for Ultimate Meaning
At the end of the 20th century, there was a burst of professional interest in spirituality among various elements of organized medicine,5,6 including objectives for medical school7,8 and psychiatry residency9,10 training; American Psychiatric Association guidelines11,12; and Joint Commission requirements.13 The Association of American Medical Colleges (AAMC) noted that spirituality “is expressed in an individual's search for ultimate meaning through participation in religion and/or belief in God, family, naturalism, rationalism, humanism, and the arts” (Ref. 8, p 25). These interests were primarily focused on attention to the spiritual needs of patients, but the AAMC also noted the need for physicians to learn to recognize their own spirituality.8 Surveys of psychiatrists and other physicians in the last quarter of the 20th century tended to focus on the “religiosity gap,” or the lower rates of belief expressed by doctors compared with their patients.14,–,16 In 2007, Farr Curlin and colleagues17 found that psychiatrists were less religious than other physicians and were more likely to consider themselves spiritual but not religious compared with other physicians (33% versus 19%). Pat Fosarelli highlighted this observation in 2008:
Often ignored is that each physician has his or her own spirituality that gives meaning to his or her life. Although a physician might not believe in a personal God, he or she might believe in something (e.g., a Unifying or Universal Principle) that transcends the individual person and the physical realm [Ref. 18, p 838].
Given the expanding interest in spirituality, a large group of clinicians, researchers, and chaplains/clergy came together for a two-day Consensus Conference in February 2009, to identify areas of agreement about spirituality in health care.6 They arrived at a definition of spirituality focused on meaning, purpose and connectedness. Some physicians have advocated including the nature of the individual's relationship with the transcendent, recognizing the ultimately personal nature of such a definition.4,19 European and international consensus conferences have adopted this approach.20 (See Table 1 for a comparison of the three definitions.) Gary Hartz argued for distinguishing spirituality as it relates to the sacred or to ultimate reality from powerful experiences of connection to others or to nature. He emphasized the important spiritual element of doing what is in the best interest of others and oneself (i.e., the common good) (Ref. 21, pp 4–5). John Swinton offered the valuable observation of the overlapping dimensions of human spirituality: “All human beings have a spiritual dimension. Everyone's spirituality is like some other people's spirituality. Everyone's spirituality is like no other person's spirituality” (Ref. 22, p 22, emphasis in original).
Consensus Definitions of Spirituality
Yet, even with such expansive definitions, reaching into multiple and capacious dimensions of human experience, most mental health professionals would acknowledge that they rarely perceive themselves as engaged in spiritual activity in their professional work. Gary Moon referred to this limited vision as the “resistance of self-sufficiency” (Ref. 23, p 265). The Lutheran pastor and theologian Dietrich Bonhoeffer described the essence of this “self-assurance” in his letters from a Nazi prison in June 1944: “Man has learnt to deal with himself in all questions of importance without recourse to the ‘working hypothesis’ called ‘God.’ In questions of science, art, and ethics this has become an understood thing at which one now hardly dares to tilt” (Ref. 24, p 325). A month later, Bonhoeffer continued this theme: “And we cannot be honest unless we recognize that we have to live in the world etsi deus non daretur [as if God did not exist]…. God would have us know that we must live as men who manage our lives without him…. Before God and with God we live without God.” (Ref. 24, p 360).
Bonhoeffer's confession of the zeitgeist of self-sufficiency continues to challenge us validly in the 21st century. Indeed, we must contemplate the definition of spirituality individually to reveal its application to our daily work, which brings us to the topic of vocation.
Vocation as Personal Truth
Viktor Frankl noted that everyone has a specific vocation, “a concrete assignment that demands fulfillment” (Ref. 25, p 172). It was the goal of his “logotherapy” to help the patient uncover this meaning in life as a truth that “imposes itself” on a person, a “spiritual reality” (Ref. 25, pp 175, 163, respectively). It is our desire for “a life that is as meaningful as possible” that constitutes the “main concern” of and what is “authentic and genuine” in humanity (Ref. 25, pp 156, 164).
Frankl thus depicted the sense of a calling or of being called, the Latin root (vocatio) of the word vocation (Ref. 26, p 3649). Originally, this term was used only to describe the calling by God to religious ministry, but after the Reformation, it was applied to secular work in which love of neighbor leads to service through one's occupation.27,28 More than two centuries before the Reformation, Meister Eckhart (German theologian and mystic) had expressed an idea preliminary to Luther's understanding: “Do not think that saintliness comes from occupation…. The kind of work we do does not make us holy, but we make it holy…. We bless each task we do, be it eating, or sleeping, or watching, or any other…. Thus take care that your emphasis is laid on being good….” (Ref. 29, p 6, emphasis in original). Pope Francis has praised vocations that seek the common good (Ref. 30, ¶ 205), noting that a correct understanding of work involves “the conviction that we need one another, that we have a shared responsibility for others and the world” (Ref. 31, ¶¶ 125, 229).
Saint Paul taught that love is fundamental to a proper orientation of all human activity; without it, for example, even the most gifted speaker is nothing but a noisy gong (1 Cor 13:1–3). Gandhi expressed similar thoughts in his autobiography: “To see the universal and all-pervading Spirit of Truth face to face one must be able to love the meanest of creation as oneself” (Ref. 32, p 504). Rabbi Samuel Karff, while he was a patient in a Houston hospital, noticed the same need for health care workers to rekindle their sense of sacred vocation.33 As a result, he co-created the Sacred Vocation Program at the University of Texas Health Science Center at Houston, with an objective to “help employees rediscover the richness and meaning inherent in their work, to renew and transform their workplace.”34
The experience of a vocation or calling is avowed in the modern version of the Hippocratic Oath: “May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.”35
Christina Puchalski and Margaret Guenther36 emphasized that medicine is a vocation, not a job; that it represents a choice; and that spirituality is the basis of that choice, the response to the call to be a physician. In their study of primary care physicians and psychiatrists, John Yoon and colleagues found that 81 percent of psychiatrists either agreed strongly or agreed somewhat that the practice of medicine is a calling (Ref. 28, p 192).
Perhaps some would assert that this notion of a calling might apply to our clinical work, but not as well to our forensic work, governed as it is by principles of law. Attorney Joseph Allegretti rejected this notion of compartmentalization in his appeal for attorneys to see their work as a calling: “I am one person, not several, and the work I do is an integral part of who I am” (Ref. 27, p 401). The idea of a calling “reminds lawyers that they cannot abandon moral responsibility for their actions” (Ref. 27, p 402). This unifying sensibility is a significant component of the robust professionalism that Philip Candilis and Richard Martinez37,38 argued for in forensic practice. They sought to adopt the same “wider frame of meaning” that Allegretti pursued, one in which “personal commitments and values are no longer irrelevant” to the work but “inextricably entwined” with the professional's image of self as a professional and as a person (Ref. 27, p 400).
While Allegretti's claim expresses this concern for the common good in the practice of law; the modern Hippocratic Oath likewise places this value within the practice of medicine: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.“35 The APA Principles of Medical Ethics cites a similar calling to the common good: “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health” (Ref. 39, § 7). The intersection of two professions seeking the common good, the position of forensic psychiatry, must surely also encompass that shared goal. Just as surely, the forensic psychiatrist has accepted the call to be present to “the meanest of creation” in the service of the common good.
The Art of Presence
The search for truth in forensic practice cannot begin without the clinician's establishing authentic presence to the people and problems at hand. Much of forensic practice involves being present to the suffering of others. The narratives of victims and perpetrators occupy our clinical work in prisons, secure hospitals, and community, where we accompany patients and their families on long journeys of illness and recovery, pain and reconciliation. Criminal (and some civil) evaluations abound in personal accounts of pain, loss, burdens, and violence (often extreme).
Both sides of our professional lives as forensic psychiatrists (treatment and evaluation) are forms of bearing witness, despite the distinctions of their purpose. We are witness to much darkness in this work, and its accompanying vicarious trauma,40,–,43 and to occasional renewals and re-creations. The Mental Health Foundation has asserted the primacy of this witness: “It is the responsibility of mental health professionals to listen to people's accounts and ‘bear witness,’ before—or perhaps instead of—forming an opinion as to diagnosis” (Ref. 44, p 105). This role of witnessing by the forensic professional was noted by Candilis and colleagues (Ref. 37, p 171) and explored further by Ezra Griffith and Madelon Baranoski in their discussion of the construction of narrative and meaning-making from data and the voices of the individual participants in the story at hand (Ref. 45, p 353).
We could describe this witnessing as “presence”; the heading for this section is borrowed from the name of the annual retreat that the George Washington Institute for Spirituality and Health (GWish) holds in Assisi, Italy for health care professionals and care providers to offer them “respite and renewal, reflection and nourishment” and to allow them to “reconnect with their original call to serve in the health care field.”46 My wife and I had the privilege of attending this retreat in 2015, during which these ideas about the spirituality of forensic psychiatry began to take form.
Christina Puchalski,47 the Director of GWish, described the steps to presence as cognitive, emotional, and spiritual preparation and an attitude of attentiveness or mindfulness. Cognitive preparation includes forming the intent to be present and compassionate. Emotional preparation includes self-awareness of one's own woundedness, loss, and suffering. Spiritual preparation involves connecting to one's call to service, recalling one's sense of meaning and purpose, and a sense of transcendence and an openness to mystery. Ronald Epstein noted two elements of mindfulness that are particularly relevant to forensic practice: “curiosity about the unknown and humility in having an imperfect understanding of another's suffering” (Ref. 48, p 835). He listed other characteristics of mindful practice that have clear application to our work:
Active observation of oneself, the patient, and the problem
Critical curiosity
Courage to see the world as it is rather than as one would have it be
Willingness to examine and set aside categories and prejudices
Humility to tolerate awareness of one's areas of incompetence
Connection between the knower and the known
Compassion based on insight
Presence [Ref. 48, Table 2, p 835].
Several of these qualities call to mind the AAPL Ethics Guidelines regarding “honesty and striving for objectivity” and “qualifications.”49
David DeMarco referred to the integration of the practitioner's spirituality into clinical practice as a “contemplative attitude, a receptive, relational, self-aware stance of immediate attentiveness to the patient, to self, and—through both to the transcendent,” which he distinguished from “the Transcendent” of theistic belief (Ref. 19, p 921).
Compassionate presence also requires a “respect for boundaries” that allows the clinician to “be in the present” (Ref. 50, p 806). Seth Aronson described this as the establishment of “psychological space” that permits a tension between the “struggle to make contact with patients, empathize with them, understand them … while retaining my own sense of personal integrity” (Ref. 51, p 456). In the forensic context, that tension also includes the clinician's need to maintain personal safety.52
Forensic presence also raises the need to address countertransference, whether focused on the clinician's resistance to addressing spiritual/religious matters53,54 or simply to the “wicked acts” (Ref. 52, p 20) committed by the subject. One approach to the former is to ask “deconstructive questions” about the subject's history of beliefs and practices and how they constitute the person's social identity; grasping the context of the person's beliefs enables empathy and understanding.54 The latter involves compassion toward the self (discussed further below) as well as the subject.52
The forensic professional is expected to give public witness to the individual's pain and life circumstances, as well as to the concerns and understandings of collateral observers. The forensic report, properly executed, should also testify to the writer's presence with the subject and other stakeholders in a way that demonstrates authentic human understanding of the other, a necessary component of truth-telling. There are challenges to the faithful representation of all the voices in any given forensic story,55 but the narrative approach in forensic psychiatry37,38,56,57 is always grounded in presence and witnessing.
Pathways to Truth
Empathy and compassion are the tools of presence, both in forensic treatment and in forensic evaluations. They are the means by which the forensic practitioner achieves clearer truths. These terms, however, are not used in a consistently clear manner and first require some definition.
Terminology
The terms sympathy, empathy, and compassion are often used interchangeably and have overlapping etymologies: sympathy is feeling (or suffering) together (syn+pathos); empathy is feeling in (en+pathos); compassion is to suffer together with (com+pati).58 But these terms have been distinguished in health care research. Shane Sinclair and colleagues interviewed patients in palliative care to assess their understandings of the three constructs. Participants described sympathy as “an unwanted and misguided pity-based response” (Ref. 59, p 440) used to alleviate the observer's distress toward a patient's suffering. Drawing on participant responses, they arrived at this definition of sympathy: “a pity-based response to a distressing situation that is characterized by a lack of relational understanding and the self-preservation of the observer” (Ref. 59, p 440). In contrast, participants found empathy to be beneficial. The researchers summarized the participants' understanding of empathy: “an affective response that acknowledges and attempts to understand an individual's suffering through emotional resonance” (Ref. 59, p 443).
Empathy
Empathy is thought of as having two domains.59,–,61 The first is cognitive, reflecting the ability to understand and acknowledge another's inner experience and view the world from the other's perspective. The other domain is affective: “the capacity to enter into or join the experiences and feelings of another person” (Ref. 60, p 1563), or understanding “a person's situation by ‘feeling with’ the person” (Ref. 59, p 438). Mohammadreza Hojat and colleagues added the “capability to communicate this understanding” (Ref. 60, p 1564) to the definition of empathy, an amendment clearly relevant to forensic reports and testimony. Hojat et al. argued that while sympathy may interfere with objectivity, empathy may be unrestrained in clinical work because understanding is assumed always to be beneficial.60 Psychiatrist and philosopher Jodi Halpern advocated such an expanded use of empathy (as opposed to detachment) in clinical practice as a way of understanding the patient and his problems more fully.62 In his recent critique of empathy, psychologist Paul Bloom acknowledged that he supports the kind of empathy characterized by the capacity to understand another person's experiences, while arguing against a kind of empathy in which one “absorb[s] the suffering of others” (Ref. 63, pp 35–36). That kind of empathy, he argued, prevents objectivity and rational decision-making, in agreement with the way Hojat and colleagues described sympathy.
Empathy has a particularly important place in the history of psychiatry. The use of empathy as a psychological method was first described by Heinz Kohut in his 1959 paper on the subject.64 Charles Strozier noted that although Freud mentioned empathy, using the German word einfühlen [“to find one's way into another's state of mind” (Ref. 65, p 141)], he never elaborated the idea. Kohut described empathy as “vicarious introspection” (Ref. 64, p 207) and declared that “introspection or empathy can never be absent from psychological observation” (Ref. 64, p 209). Given this insight and the meaning of the original German word, empathy should also never be absent from forensic evaluation or treatment.
Forensic Empathy
In 1984, Richard Ciccone and Colleen Clements saw respect for persons as part of the “fiduciary responsibility” of the forensic psychiatrist, which included empathy (Ref. 66, pp 275–6). In another article, those authors observed that a “high degree of professionalism” is necessary to “maintain empathy” and “achieve understanding” (Ref. 67, p 396). Daniel Shuman characterized “receptive empathy” in forensic practice as “the perception and understanding of the experiences of another person” (Ref. 68, p 298). Kenneth Appelbaum described “forensic empathy” as the “awareness of the perspectives and experiences of interviewees” (Ref. 69, p 44). Neil Kaye recently advocated for such empathy in forensic evaluations:
I … hope that each and every one of us is affected by the stories we hear from evaluees regarding their trauma. To fail in this endeavor would be inhuman and impede our goal of truly hearing what is being expressed during the evaluation. Empathic listening does have a role in forensic psychiatry, so long as it is not used inappropriately to disarm an evaluee in the effort of obtaining information that would not otherwise be shared [Ref. 70, p 9].
In his work on the chaplain's ministry of presence, Christopher Swift noted that presence requires “great patience, compassion and faithfulness to the value of the human being in front of you” and that this is “the product of considerable preparation, maturity and deep personal self-knowledge” (Ref. 71, p 175). Applied to forensic practice, this empathic attitude and description of personal qualities constitute part of the spirituality of the forensic practitioner, part of the task of seeking truths.
Compassion is the Core
In clinical care, empathy has been described as “the first step toward the full expression of compassion” (Ref. 61, p 937). Thich Nhat Hanh, the Vietnamese Buddhist monk, expressed a similar thought in a talk he gave to a group of prisoners in Maryland: “Understanding is the substance out of which we fabricate compassion” (Ref. 72, p 34).
Compassion is thus born of empathy, but requires an added dimension of action or reaction. Sinclair and colleagues summarized their participants' understanding of compassion as “a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action” (Ref. 59, p 444). Swinton went further in arguing that we must also see compassionately because how we view the world shapes what we think we see, and how we respond to it (Ref. 52, p 15).
The nature of compassionate action is context dependent. In a secure treatment facility, the actions may more closely resemble those studied in palliative care and hospice settings.59,73 In the conduct of forensic evaluations, Candilis, Martinez, and Christina Dording proposed that the “compassionate professional” may go beyond the “aseptic assessment” of the forensic question, to include an openness to the multiple aspects of the subject's suffering (Ref. 37, p 169). The professional is able to express empathy and compassion through narrative and humanistic language. Such an approach, they suggested, allows for the integration of personal morality and professional identity and integrity and is better suited to the varied and complex realities surrounding the subjects of forensic evaluations. Ciccone and Clements similarly affirmed that the medical value of compassion “must be maintained by physicians working with the legal system, both to be true to their medical identity and to assist in the legal goal of justice” (Ref. 66, p 276).
Charles Sasser and Puchalski noted that compassion “provides the unspoken language to address unspeakable suffering” and that the behaviors of the “witnessing professional … honor and affirm the experience of illness.” But they also discussed the challenging task of using language compassionately to develop a “narrative epistemology … (a story way of knowing)” (Ref. 61, p 937). This generation of narrative is the core competency of forensic practice.74 It is through narrative that compassion is expressed in forensic evaluations56 and “medical knowledge is seen as storytelling knowledge” (Ref. 37, p 171).
In the forensic treatment setting, Eluned Dorkins and Gwen Adshead cautioned against the aseptic response: “professionals' accounts could be distant and detached and might reflect their own discomfort at witnessing suffering” (Ref. 75, p 183), echoing the argument advanced by Halpern.62 Clinical staff can succumb to the temptation to view some patients as evil, which “dehumanizes and depersonalizes” them (Ref. 52, p 17). As Swinton put it, “The stories we tell and the language we use create the patients we see” (Ref. 52, p 17).
The stories we tell also create the persons others see, which makes the truth of our stories so imperative. Consider the following two fictional progress reports in a forensic inpatient setting:
Mr. Smith has continued to struggle with his intellectual limits and social skills deficits, but in the last several months has made a sustained effort to attend and participate in therapeutic activities and has met the goals agreed upon with the treatment team.
Mr. Jones continues to engage in multiple verbal altercations with peers, is easily frustrated by limit-setting on the unit, and was physically aggressive with a peer in July, resulting in a drop in privilege level.
Now consider that Smith and Jones are aliases, and that both of these stories describe the same person, Mr. Adams, over the same time period. These are not conflicting accounts, but they do not tell the same story to the reader. As Swinton might describe the author of the Mr. Smith version, “Compassionate people see the world differently, compassionately, even within the strange world of forensic mental health care” (Ref. 52, p 18, emphasis in original).
As I have held previously, compassion is “an approach to justice that allows us to attend to and engage the humanity of all the subjects of our evaluations” (Ref. 76, p 388). I now extend that discussion to agree wholeheartedly with Swinton that “compassion is a basic spiritual practice” (Ref. 52, p 18) and to claim compassion as an essential element of the clinician's spirituality: a call to service, an expression of meaning and purpose, and a connection to self and others and to what is considered significant for all and sacred for some.20
I offer two illustrations of these ideas. The first is a forensic evaluation I conducted of a death row inmate's competency to waive appeals of his sentence. His attorneys and another expert argued that his years of solitary confinement made him incompetent to make such a decision, based on observations of the same effects in other inmates. The condemned man had an intellectual understanding of their postures, but he resented the assumptions made by the other expert. He immediately perceived he was not being heard. I endeavored to be fully present to him, mindful of the gravity of the circumstances. Epstein's description of mindful presence (described earlier)48 aptly describes my process. In our interviews, the man perceived that he was being heard and thus respected as a human being. He knew that most of the world had dismissed him as a self-serving liar and a monster. When I eventually testified about his competence, one of his long-term companions, a Catholic priest, stopped me in the hallway afterward to thank me and tell me that he thought my testimony was fair. I will return to the matter of fairness in the section on centering, below.
The second example is from forensic treatment practice. When testifying in probate court (in a civil commitment or involuntary medication hearing) about a patient in a secure treatment facility, it is usually necessary to describe in some detail the patient's medication refusals, lack of cooperation with treatment, agitation, verbal outbursts, and violent behavior. One of my colleagues recently posed the question, “How can the forensic psychiatrist be compassionate while needing to describe all these negative attributes and behaviors?” The answer may be found in Swinton's article on compassion in forensic settings: “Compassion occurs when one has a deep awareness of the suffering of another accompanied by the desire to bring relief” (Ref. 52, p 13, emphasis in original). The job of the forensic psychiatrist is to convey that deep awareness and that desire for healing, that concern for the patient, in the testimony, through narrative and humanistic language, through tone and body language. To achieve this result authentically requires preparation, mindfulness, centering, and humility.
Dangers of Compassion
The dark side of compassion, of course, is vicarious suffering40,–,43 and the potential for compassion fatigue.61,73 Keeping track of such costs requires self-awareness, “a gentle acceptance of our human limits” (Ref. 61, p 936). It requires vigilance about self-care and personal support,41,70 and may involve the need for peer consultation70 or active treatment.43 Swinton warned that, in forensic settings, creating space for compassionate interactions can be dangerous for the clinician, and must be managed with appropriate respect and care for oneself. His Christian theological understanding of this tension is that the call to love one's enemies is balanced with the call to love one's neighbor as oneself, which presumes the primacy and legitimacy of love of self. Such self-compassion in the clinical setting may require physical withdrawal from, but not abandonment of, the dangerous patient.52
Self-Compassion
Thich Nhat Hanh noted that compassion for self is a “very important practice” of mindfulness, which involves treating oneself with respect and tenderness (Ref. 72, pp 23, 43). From a psychiatric perspective of mindfulness, Walter Sipe and Stuart Eisendrath recommended “cultivating nonjudgmental present-moment awareness of one's experience, including sadness itself” to enhance self-compassion (Ref. 77, p 65). Psychologist Kristin Neff has developed an assessment of self-compassion and multiple practices to promote it.78 Puchalski and Guenther proposed several questions for this purpose: “What gives my life meaning? Why did I choose this profession? How do I care for my deepest self? How am I restored after a day surrounded by suffering and loss?” (Ref. 36, p 256).
Simone Weil, French activist, philosopher and mystic of the first half of the 20th century, proposed that “[c]ompassion directed toward oneself is humility” (Ref. 79, p 143). Martinez and Candilis maintained that humility is “inherently necessary” to the forensic ethics of adhering to honesty and striving for objectivity (Ref. 80, p 58). By recognizing that we too, even as experts, are limited, we acknowledge and contemplate that our knowledge is incomplete, our skills are not perfect, and our expertise is only relative. By acknowledging our limitations, we accept the compassion we owe ourselves in humility. The author of the forensic report, then, becomes one limited being trying to make sense of the lives of other limited beings to assist an imperfect process of justice-making.
Obligations to Humanity
Forensic psychiatrists should also concern themselves with the societal-institutional aspects of compassion. As federal district judge Marvin Frankel argued, “It is our duty to see that the force of the state, when it is brought to bear through the sentences of our courts, is exerted with the maximum we can muster of rational thought, humanity, and compassion” (Ref. 81, p 124). In 1943 Simone Weil drafted a “Statement of Human Obligations,” outlining her thoughts about the irreducible societal obligation laid on us all to respect all human beings and be concerned for their needs. In her Statement is a passage about public power, empathy and compassion, which never seems to lose its political currency, and which has important reminders about the authority that is entrusted to forensic evaluators, among others:
If any power of any kind is in the hands of a man who has not given total, sincere, and enlightened consent to this obligation such power is misplaced. If a man has willfully refused to consent, then it is in itself a criminal activity for him to exercise any function, major or minor, public or private, which gives him control of people's lives. All those who, with knowledge of his mind, have acquiesced in his exercise of the function are accessories to the crime…. Any State whose official doctrine is not primarily directed against this crime in all its forms is lacking in full legitimacy…. Any collectivity, institution, or form of collective life whatsoever whose normal functioning implies or induces the practice of this crime is convicted ipso facto of illegitimacy and should be reformed or abolished…. It is the aim of public life to arrange that all forms of power are entrusted, so far as possible, to men who effectively consent to be bound by the obligation toward all human beings which lies upon everyone, and who understand the obligation. Law is the totality of the permanent provisions for making this aim effective [Ref. 79, pp 137–8].
In 2009, world religions scholar Karen Armstrong created a contemporary statement of our common human obligations in her Charter for Compassion, calling on all people “to restore compassion to the center of morality and religion” and “to cultivate an informed empathy with the suffering of all human beings.”82
Compassion as Truth
Gandhi expressed the view that “there is no other God than Truth … the only means for the realization of Truth is Ahimsa …” (Ref. 32, pp 503–4). Ahimsa is often translated as “non-violence,” but as Gandhi explains, “Ahimsa is a comprehensive principle…. A votary of ahimsa therefore remains true to his faith if the spring of all his actions is compassion … underlying ahimsa is the unity of all life …” (Ref. 32, p 349). Thus, Gandhi taught that the search for truth itself is centered in compassion for all beings.
Centering to Seek Clearer Truths
I have come to view the forensic evaluation and the writing of a forensic report as exercises and expressions of compassion in the search for truth. Epstein described a mentor's approach to a resident who was about to have a difficult encounter with an angry patient facing end-stage disease.48 He articulated a “centering process” that the mentor used in preparation for all patient visits, whether implicitly or explicitly, involving self-observation and critical reflection. This description closely parallels my perceptions of the evaluation and report processes, in which the forensic clinician must be prepared for difficult encounters and challenging decisions.
The prelude to the actual writing of the report is for me a significant moment in the evaluation process. It has always been a moment of pause and reflection. I consider it to be a hallowed moment, a meaning-making moment. This is the process that occurs after data gathering and before the formulation of an opinion and the construction of the written report. It is a process of sitting with the array of (sometimes conflicting) data and seeking to come to a unifying understanding of the material and its relation to the forensic questions posed. Demonstrating respect for and giving voice to all the participants in a story represents a significant challenge to the forensic clinician tasked with answering specific medicolegal questions.55 The written forensic report is a one-time opportunity to get right a set of descriptions and decisions that may well be life-altering for the subject of the evaluation. So, this sitting with the case is an important procedural element, which requires serious and intentional preparation, a process of centering.
This process might also be described as an exercise in mindfulness. After sitting and quieting, the next step is bringing intentional awareness to feelings and thoughts, assumptions and biases that might be at play in my interaction with the subject and the case. Regarding the data, I use two mental images: one of sifting and sorting data so that it falls into place in a best fit matrix of conceptual categories; the other of balancing bits of data, as if on a scale, weighing them one against the other. In the end, there is a final critical examination of whether that process of sorting and balancing, as well as the process and products of the evaluation, have met a test of fairness to all parties, involving empathy and compassion.
There is another dimension, though, to this process, one that is not easily articulated. For me, it involves more than the affective or cognitive elements of empathy. There is a bodily manifestation to the sorting and weighing, a vague physical feeling about whether the balancing is yet right. It is part of the “sitting with” that is hard to explain. Only recently, have I come across the depiction by Elfie Hinterkopf83 of spirituality in the counseling experience, in which he details such elements. He describes “a subtle, bodily feeling with vague meanings” which “brings new, clearer meanings” as the unclear, subtle feelings are attended to in a gentle, caring way. The original frame of reference gives way to a broader and more inclusive perspective in a “transcendent growth process.”
Centering is thus, for me, an exercise in empathy and compassion in the search for broader, higher, or clearer truths. This search represents an important aspect of the spirituality of forensic psychiatry. There are forces, however, that weigh against the expression of truth in forensic psychiatry, as I next explore.
Healing Ministry of the Search for Truth
In this section, I wish to build a case for the limits imposed on truth in our justice system and argue that forensic psychiatry is positioned well to bring healing to these structural lesions in processes I regard as part of the spiritual journey of the forensic practitioner.
Judge Frankel struggled with “the knowledge that ‘selling' our [lawyers’] stories rather than striving for the truth cannot always seem … such noble work as befits the practitioner of a learned profession” (Ref. 84, p 1055). He suggested that the adversary system should be modified to “make truth a paramount objective and … impose upon the contestants a duty to pursue that objective” (Ref. 84, p 1052).
Legal scholar Carrie Menkel-Meadow expressed similar concerns about the limits inherent in the adversary system: “Binary, oppositional presentations of facts in dispute are not the best way for us to learn the truth; polarized debate distorts truth, leaves out important information, simplifies complexity and obfuscates where it should clarify” (Ref. 85, p 6). Thomas Gutheil and colleagues have argued that an expert must not only form an opinion “with reasonable care and diligence” but also attempt to “defend that opinion against misrepresentation by either attorney” (Ref. 86, p 425). As Judge Frankel put it, “it is the rare case in which either side yearns to have the witnesses, or anyone, give the whole truth” (Ref. 83, p 1038, emphasis in original). Menkel-Meadow noted that the reality that “lawyers seek to achieve their client's interests and ‘win’” means that the adversary system lacks the important quality of the “genuine search for truth” (Ref. 84, p 13). Griffith's phrasing of this problem with the adversary system was that “attorneys are there in court to weave a story of their own creation” (Ref. 87, p 429).
Menkel-Meadow advanced the possibility of developing and teaching altruism in lawyering as one way to mitigate the problems of the adversary system.88 This approach included an “ethic of care to balance the ethic of justice,” (Ref. 88, p 410) and empathizing with the client as well as the other party. Such an approach would be part of the means to realizing the legal profession as a helping profession.
As Allegretti observed, “The world has many great needs—for justice, healing, and compassion just to name a few—that the work of lawyers can help to meet” (Ref. 27, p 404). His sense of law as a calling allowed him to imagine law as a “healing ministry” (Ref. 27, p 409). He had no less an authority than Chief Justice Warren Burger to support this claim:
The entire legal profession … has become so mesmerized with the stimulation of the courtroom contest that we tend to forget that we ought to be healers—healers of conflicts. Doctors, despite astronomical medical costs, still retain a high degree of public confidence because they are perceived as healers. Should lawyers not be healers? Healers, not warriors? Healers, not procurers? Healers, not hired guns? [Ref. 89, p 66]
On the mental health side of courtroom practice, the search for truth requires more than science and technology can offer.90 In a commentary on Teilhard de Chardin's Phenomenon of Man,91 Edward O. Dodson noted that “it is essential to assert that science and truth are not coextensive. Sound science is truth, and there can be no truth which is inconsistent with sound science, but truth goes beyond the limits of natural science“ (Ref. 92, p 243). We can understand this perspective in forensic work from Griffith's cultural formulation and concern for nondominant groups,56,87,93 from the various calls for multiple narratives in forensic reports and testimony37,38,57,94 and the challenges of holding them together in forensic evaluations,55 from the support of a robust professionalism in forensic work seeking unity of professional identity,37,38,95 and from the appeals to empathy and compassion as part of that identity.37,56,66,67,76 But there is still more.
In Wilfred Smith's analysis of the “comprehensively human” quality of faith, he made the following observation: “Humankind's awareness of the Truth, in the past and still to-day, … may outrun its capacity to form propositions that embody that truth in any but transient and culturally specific and always vulnerable ways.” He went on to contrast “truth itself and truth articulated in the midst of the relativity of human life and history,” inviting our sympathetic understanding of our limits and the limits of those who have preceded us (Ref. 96, p 208). This imperfect quest for truth is part of the comprehensive nature of human faith: “… it is evident that at most times and in most places humankind has been effectively aware that one lives in a world whose greatness transcends one's grasp but does not fully elude one, that Truth, Beauty, Justice, Love beckon one imperiously yet graciously” (Ref. 95, p 130).
The poetry of Arthur James Balfour alerts us to this beckoning:
Our highest truths are but half-truths;
Think not to settle down for ever in any truth.
Make use of it as a tent in which to pass a summer's night,
But build no house of it, or it will be your tomb.
When you first have an inkling of its insufficiency
And begin to descry a dim counter-truth looming up beyond,
Then weep not, but give thanks:
It is the Lord's voice whispering,
“Take up thy bed and walk.” [Ref. 97, p 6]
Conclusions
I now return to the deceptively simple question posed by Pilate: what is truth? Perhaps to the chagrin of the philosophers in our midst, I have largely skirted the obvious postmodern critique of the possible response, because I could not do it justice and it is largely tangential to my main interest in this exploration. I will offer, however, Judge Frankel's comment about the protective self-reassurance of partisan legal combatants: “What will out, we sometimes tell ourselves and often tell others, is the truth. And if worse comes to worst, in the end who really knows what is truth?” (Ref. 83, p 1039) This somewhat defeatist resignation to reality could be interpreted as an attempt at postmodern psychological comfort.
I prefer to seek comfort elsewhere, in seeing the quest for truth as guiding the spiritual journey of the forensic psychiatrist, part of our calling as physicians. We would do well to recall the unequaled gift of that call, as Puchalski and Guenther reflected:
Being attentive to our call, to who we are as authentic, whole people, and to the healing relationship we co-create with our patients, is a way to restore ourselves and to continue to grow in our lives as healers…. What an amazing life we have where we evolve in the presence of others, where others give us windows into experiences and insight that we might never see ourselves, and where we continually discover our inner self in the reflection of those we serve. The daily awareness, gratitude and celebration of our vocation, our calling, are perhaps the secret of restoration and re-creation [Ref. 36, p 258].
This conceptualization requires no translation for the treatment aspects of forensic psychiatry in secure hospitals and correctional facilities. But we can extrapolate further. While we have no patients in court, we are still physicians in that setting. What would the search for truth look like if we could adopt more fully and faithfully a sense of the spirituality of both law and forensic psychiatry in our daily occupations? Imagine a courtroom where lawyers and psychiatrists see their work as vocation, as part of their spiritual connectedness to their fellow human beings embroiled in conflicts. If Allegretti, Menkel-Meadow, and Burger can see lawyers as healers (or at least advocates of care) in the courtroom, can we not see forensic psychiatrists as healers in that setting as well?
Daniel Sulmasy argued that “If we are to be true healers, we must rediscover what it means for medicine to be a spiritual practice” (Ref. 4, p 1003). Thus, I have attempted to create a portrait of forensic psychiatry as a spiritual practice, a journey in which we recall our vocation, wherein we are present to and give witness to suffering, where we regularly exercise empathy and compassion in all aspects of the work, and whereby we seek to discover and attest to larger and fuller truths with humility and self-compassion.
In the early 20th century, Marc Sangnier was a devout French activist who founded the Sillon movement and worked diligently for democracy, fellowship, and peace among all people. I will close with the words with which he charged his companions:
The truth must be sought with all one's soul.98
Acknowledgments
I wish to express my gratitude to Debra Brown, MD, Elaine Betoncourt, CSJ, John Young, MD, and four anonymous reviewers for their careful and thoughtful analysis and helpful comments on earlier drafts of this article.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2018 American Academy of Psychiatry and the Law
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