Reconciling Heart with Head in Forensic Psychiatry
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* Kimberly S. Resnick

*   forensic psychiatry
*   resilience
*   defense mechanisms
*   early career psychiatrist

“What do you do?” is a question that has become as identity-defining for me as “What is your name?” And, just like with my name, I have one response for professional settings and another for social settings. The professional one had been static: I name my specialty. The “dinner party response” has evolved with practice. At first, I would explain that I am a psychiatrist and that I specialize in forensic psychiatry. Then, it would be on to defining the scope of what a forensic psychiatrist does and the role we play at the intersection of psychiatry and the law. Examples would be offered of the types of cases we see, and the facial expressions of my audience would shift from fascination to confusion. An inevitable comment would arise in the flavor of, “You must see such horrible things. How do you keep your faith in humanity?” I would be ready for this question, too, quickly invoking clinical work to balance the image I presume had formed in their minds. I would end with an explanation about deriving pleasure and satisfaction from both areas of practice and move on to the finale of my over-recited description that “what clinical psychiatry does for my heart, forensic psychiatry does for my mind.” And that was indeed how I thought about it, until one particular case made me challenge that distinction and question why I needed such a defense in the first place.

During my forensic fellowship, I was asked to evaluate a man who had been convicted of a capital crime. Originally sentenced to death, his sentence was changed to life without parole on “high-security status.” This meant that he was alone in his cell for 21 hours a day, with 15 minutes for each meal and one shower a day, and two hours of solo recreation 6 days a week. Separated from other prisoners within the maximum-security facility, he was allowed to request visits only from his legal team, clergy, and medical staff. The legal team, meanwhile, was preparing a case arguing that his current situation was cruel and unusual punishment, a violation of his Eighth Amendment right. The questions for me were whether this harsh treatment caused this man psychological harm, and what would likely happen to his mental health if his circumstances were not changed.

Dedicated trainee that I was, I prepared by reading the literature on the psychological impact of solitary confinement. I familiarized myself with how the absence of social contact and the associated stress can provoke and exacerbate psychiatric illness. I read articles on the increased rate of suicide among inmates in solitary confinement, as well as papers that drew parallels between the distress of isolation and the stress of physical torture. In writing this reflection now, I notice the glaring absence in my preparation of reviewing anything written on resilience under distress or finding meaning amid hardship. Perhaps that should have been the first hint that I was starting to construct a dichotomy: “clinical work for the heart” and “forensic work for the brain.” Where was my heart now? The effect of my split was at best naïve and at worst obscuring. By the time I was driving to the prison, my confirmation bias was in full action. I had solidified the images of the man that I would meet: either paranoid and psychotic, disheveled and downtrodden, or a manipulative malingerer. I prepared myself for a painful interview that would illustrate the indifference of our correctional system in meeting the mental health needs of those it incarcerates. What would it feel like to have this man as a psychotherapy patient? A reprieve came before I had to answer this question as I realized my different role as his forensic evaluator. Within the defensive prison I had made for myself, this was a time for observation and truth-telling, not for emotions and feelings. What a relief! And, even better, there was still a chance for me to save the day (that I assumed needed saving) using my intellectualization and isolation of affect.

I walked into the meeting area, ego defenses locked and loaded, donning my forensic hard-hat. After presenting the evaluee with the standard disclosures about the limitations of our interview and our relationship, the interview began. He told me of his childhood, which was marked by struggle, death, and desperation, and how he had turned to gang life to support himself and his family. His brother had died by suicide, his father had left the family, and the transition to violence came quickly for him as he engaged more deeply in the drug culture. There was no self-pity in his stories, and he spoke with understanding and forgiveness for his parents, his neighborhood, and all those who failed to protect him. His arrest, conviction, and long sentence wrenched him from his mother, his children, and their mother. How could this man, with all his developmental trauma, survive the near-isolation of prison, I wondered.

By the time he and I met, he had been incarcerated for over 20 years—half his life. He had not been hugged in 24 years and had not seen his family in 15 years. I caught myself imagining the bitterness he might feel in this situation, especially as he had maintained his innocence and was still working on appealing the verdict. But what I found instead was resilience and a few life lessons that I took from him, the first of which was the importance of hope. His response was to share with me “a quote about suicide—something about it not being a means to an end as long as there is hope.” He laughed at himself when he couldn't quite remember the quotation and instead clarified its meaning that “once there is no hope, that's when things fall apart. And, that's what I am living off now, hope.” He gave multiple examples of the things that he had been working on changing within the prison system since his incarceration, the letters he had written, the advocacy projects he had undertaken, and the self-driven legal education he had pursued to help himself and other inmates who were in a similar position. Then he listed all the things for which he still had hope: a list of possibilities and accomplishments that seemed longer than the list I had for myself, despite my innumerable freedoms relative to his. I was through the looking glass.

I asked him about the realities of prison life and how difficult it could be. He said, “There are some things around here that are so ridiculous, you just have to laugh.” I had noticed how he used his sense of humor throughout the interview, sometimes to relieve tension, sometimes to bring joy, but always attuned to social cues. I asked him how he deals with the bad days and he told me he “just pushes through,” knowing that “tomorrow will be another day.” It went unspoken that that day would structurally be identical to the day before, but his perspective that it could feel different struck me forcefully. It was also deeply conflicting for me. I had asked this question as part of my screening for depression, trying to quantify how often he felt down, how long these episodes lasted, and how severely they affected him. I realized that the answer he gave me would have made me pleased (relieved?) had he been my clinical patient, but my heart broke a little as his forensic examiner given my growing awareness of what it would likely mean for his legal case. I pushed further to ask how imprisonment and his current “high-security” status had changed him, perhaps with some part of me hoping for symptoms of posttraumatic stress disorder, sadness, or irritability. Instead, he said that he had become “older, smarter, and a little wiser.” He spoke of his renewed spirituality and his improved relationship with his family, and of the regret he felt for having been the person he used to be. When I asked him about anger, he told me, “You can't be mad because you let someone else push your buttons. And you can never be in the next man's shoes.” I felt my imagined “forensic hat” of ego defense starting to slip off my head.

The interview continued and I asked him if he had thought about this evaluation and what findings would be most helpful to his case. Legally savvy, he responded, “If I had some sort of serious psychiatric problem, it would go toward showing solitary confinement does create serious problems.” He was right. He had named the game, and yet he had not played it. I scrambled to locate the damage I had come to find. Every place I searched for symptoms, I found resilience. His lessons about hope, humor, and humility inspired me. Amid the horribleness of solitary confinement, social isolation, and the restrictions of a 12 by 7 foot cell, his patience and optimism, absent in his former self, had evolved and flourished.

I left the interview questioning why I had always assumed that my forensic endeavors fed my intellectual drive while my clinical responsibilities fed my heart. Why had I felt the need to separate them? Was my “dinner party response” actually an admission that I was afraid to see “the horrible things” myself that were readily apparent to others? Was it a clue that I was concerned that a career in forensic psychiatry could cause me to lose both my empathy and my optimism in humanity? I thought about how limiting the early ethics principles of truth-telling and respect for persons seemed, trying to reconcile why I was feeling both inspired and uncomfortable.

Now I faced the dreaded phone call to retaining counsel. My evaluation had not revealed significant negative psychological consequences from his years spent as a “special circumstance inmate,” a living death for many in his situation. A part of me could not wait to share the remarkable story of a man thriving amid terrible circumstances. Another part of me resisted acknowledging this narrative. How could my report depict a “poster child” for the dangers of cruel and unusual punishment? Ultimately, the legal team requested no report be written; they would proceed with the liability component of the case, but not pursue damages at this time. The case that had the most profound impact on me psychologically would leave no tangible trace. I thought of the man's words that some things are “so ridiculous you just have to laugh.”

I am reflecting on this interaction several years later, amid the current crisis that health care workers are facing in the COVID-19 pandemic. I have treated many patients since fellowship, yet I realize it is this prison inmate whom I find myself quoting internally throughout the day. He modeled for me something I now try to model for my own patients, and in doing so changed the finale of my answer to “What do you do?” I realized the distinction I had drawn initially between clinical and forensic psychiatry was a false one: it served more as a defense against the fear that forensic practice would erode my humanity, and it perpetuated my self-inflicted distortion that forensic psychiatry is best done in the absence of emotion. What this case taught me, however, was not how to reconcile my interest in clinical psychiatry with my passion for forensic psychiatry, but how to reconcile my heart with my head. I have learned that I am better able to fulfill my professional roles by infusing the work with my whole self. Now when someone asks what I do for a living, I would like my dinner party response to be that “I'm a forensic psychiatrist. I apply science, compassion, and humility to help answer tough questions with an open mind—whether my client is sitting across from me in my office or in the visitation room of a prison.” No dichotomy (or hard-hat) required. But I am still working on it.

## Acknowledgments

I would like to thank Kenneth J. Weiss, MD at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, for his mentorship and supervision during the writing process.

*   © 2020 American Academy of Psychiatry and the Law