James L. Knoll IV, MD: Balance and Harmony

Early Years

James Knoll IV is a man of the South, born in New Orleans to a family of two generations of doctors. His father, James Knoll III, was a United States Navy psychiatrist, and his grandfather was a general practitioner in rural Louisiana. Austere yet gentle, James Knoll III was a man of integrity, loyalty, and self-discipline, much of which young James came to admire and absorb. His father also happened to be a member of the APA district branch that investigated Dr. James Grigson, or “Dr. Death,” about whom Knoll would go on to teach later. His mother was loving and nurturing. She taught French and music at Tulane University and instilled in young Knoll a lifelong love of art and music.

Despite an attentive, loving upbringing, human suffering and death emerged from the mere abstract into reality for young Knoll. This was in part related to early deaths in his family, and his father's medical career and service during the Vietnam War. And when he was ten, he found a copy of TIME Magazine on his family's dining room coffee table. On its cover was a big tub of cyanide, surrounded by hundreds of dead bodies in what later became known as the Jonestown Massacre. His 10-year-old mind wasn't sure how to wrap itself around this image, but he nevertheless fixated on it. Later, his schoolteacher gave his class an assignment to write a short story. While his classmates were describing their family pets or favorite baseball stars, he was busy crafting a fictional memoir of a lone Jonestown survivor. In it, Knoll portrayed himself as having survived the gruesome massacre by feigning his death. “If there was a concerned parent–teacher conference, I wasn't invited to it,” Knoll recalls. “But surely, this was a red flag that I would be a forensic psychiatrist.”

Death was not just a distant notion confined to a magazine cover. A series of unfortunate family deaths blighted his childhood. He lost his grandfather from mental illness and suicide, and his mother died relatively young from a painful, progressive course of multiple sclerosis. Dr. Salomon Grimberg, a renowned psychoanalytic art historian and Knoll's godfather, remembers Knoll being “a good son” who was “particularly compassionately attuned to his dying mother.” Her death powerfully affected him, compelling him from a young age to speculate on the meaning and purpose of this transient life.

Search for Meaning and Purpose

As the oldest of three boys, Knoll remembers having the “heavy weight of carrying [his] family name, being James the IV, on [his] shoulders.” Yet, he observed that he was shorter in stature than his towering father and two younger brothers. He struggled to reconcile the discrepancy until one day, while watching the “Green Hornet” TV show, he saw a small-framed but commanding figure on the screen. The man was surrounded by some 30 angry adversaries encircling him, ready to strike. What followed next was an awe-inspiring ballet of athletic prowess in which the mentally and physically focused Bruce Lee overcame the odds with skill, technique and precision. “He seems to have some special knowledge and training,” the young Knoll mused.

To young Knoll, Bruce Lee was a living example of overcoming one's limitations with dedication, discipline, and technique. He watched and studied all of Bruce Lee's movies, sometimes 20 or more times, and carried Bruce Lee's philosophy and technique book around like a bible. “Bruce Lee was my inner Buddha in that he pointed the way,” Knoll recalls. Sure, Lee captured young Knoll's attention with his dynamic charisma and abilities, but much more importantly, Bruce Lee opened the door for Knoll to find meaning through the study of Asian philosophy.

As a young man, Knoll became convinced that Asian philosophy contained the answers he needed to such life questions as: What does it mean to face death and suffering? How could we achieve inner peace? And what does it mean to live a life worth living? Knoll was a studious boy, and he sought answers in books. Reading Bruce Lee's essays led him to deeper exploration into Asian philosophy and literature. Among the works that influenced him heavily were Lao Tzu's Tao Te Ching, Thomas Cleary's translation of Asian Classics, and Alan Watt's books on Zen Buddhist traditions. He let the Taoist and Buddhist ideas seep through him, page after page, which he embraced wholly and gratefully. He then put what he learned to practice, starting with daily meditation. While lost in silent mindfulness, he sought inner peace and enlightenment.

Choosing Forensic Psychiatry

Experience with death and Zen Buddhism led to a desire to study the mind. He graduated Phi Beta Kappa from the University of Texas with a bachelor's degree in psychology and went to UT Southwestern to study medicine. While searching for the right medical specialty, he came across the exhibit Zenga at the Dallas Museum of Art. Zenga was a collection of paintings and calligraphy by Zen monks from Japan's Edo period. “These works seemed so vastly profound, yet simultaneously precise and meaningful about lived human experience,” Knoll reminisced. After exams, he rewarded himself with a replenishing trip to the museum, where he spent hours lost in thought, appreciating the wisdom, beauty, and meaning in the artists' works. Knoll also spent what little time he had in between exams practicing Zazen (seated Zen meditation) at a local Buddhist temple. In selecting his medical specialty, then, it was only natural that he chose psychiatry, the field that seeks to understand the mind and its ailments and, more fundamentally, what it means to be human. After a brief dalliance with neurosurgery, he settled on a psychiatry residency at the same institution.

During residency, Knoll was initially drawn to psychoanalysis. Many of his respected teachers were psychoanalysts, including his father. He underwent psychoanalysis, which enriched his understanding of the self and the world. Yet in the late 90s, the future of psychoanalysis seemed uncertain to him. In search of answers, he attended the American Psychiatric Association Annual Meeting in 1996. During the conference, he participated in a violence risk assessment seminar. He left the course awestruck. The speaker had “a thundering presence with absolute command of the subject matter and audience attention. He explained difficult concepts with jarring clarity, all while entertaining with humor,” recalls Knoll. In this speaker, he found the antidote to his nagging reservations: forensic psychiatry.

Of course, the lecturer was the legendary Dr. Philip J. Resnick. He knew he had to train with this man and immediately began listening to Dr. Resnick's cassette lecture tapes upon returning home. He also volunteered to moonlight at the nearby Dallas County Jail to test his fitness for forensic psychiatry. The jail's psychiatric director was an attending who showed up to work dressed like a cowboy and hence was known as “Dr. Clint Eastwood.” Upon learning of Knoll's request to moonlight, Dr. Eastwood flatly discouraged him, listing ten reasons not to work there, ranging from despicable inmate behaviors to demoralizing institutional failures. This advice merely cemented Knoll's conviction to work in the jail: “I wanted to work there ten times more after hearing this.” There was no doctor other than himself during the night's wee hours at the jail. He took great satisfaction in being available to treat patients in the jail who were in desperate need of help. And through this experience, he resolved to learn more about how and why they landed there.

Academic Career

There was no better place to do this than a forensic psychiatry fellowship at Case Western Reserve University with Dr. Resnick. He flew to Cleveland after residency to continue training with the living legend. True to its reputation, the fellowship was rigorous, intense, and painfully ego-annihilating. But to Knoll, in a nod to his inner Bruce Lee, this only meant growth. He performed exceptionally well and soaked up knowledge like a sponge. Inspired by his mentor, Knoll decided to devote his career to honing the craft and teaching forensic psychiatry.

After the fellowship, he went on to direct forensic psychiatry programs at Northwestern and Dartmouth before coming to SUNY Upstate in 2006, where he has since stayed. He brought much of what he learned from Dr. Resnick to Syracuse, plus his experience, humor, and aphorisms. He was tireless in his dedication to the craft of forensic psychiatry: some 200 publications, editor-in-chief of Psychiatric Times (the nation's most widely read psychiatric publication), regular panelist at AAPL conferences, and go-to expert witness on numerous high-profile cases such as the Cleveland Strangler serial murders, “137 Shots” Cleveland police shooting case, and the murder of Kenneth Chamberlain Sr. He regularly consulted with businesses, universities, and law enforcement on workplace violence and threat assessments. Over the next decade and a half under his leadership, the Upstate Forensic Psychiatry Program grew steadily in its reputation. Dr. Mantosh Dewan, the President of SUNY Upstate Medical University, writes: “through his energetic and brilliant practice, teaching, and writing, Knoll has taken, in a very short time, a good program to one that is among the most recognized in the country.”

Despite the growing fame and recognition, Knoll never lost sight of humility and the spirit of truth-seeking and craftsmanship. His daily focus has always been “to develop more accuracy and objectivity in the opinions that [forensic psychiatrists] offer the court.” When he receives new records, the foremost concerns are always: “Can I objectively and rigorously answer the legal question? And can I communicate it clearly to the court?” To do so, he teaches his fellows, “we have to be good psychiatrists first and foremost, listen, and ask good questions.”

Fellows watch Knoll demonstrate these ideals throughout the fellowship. For example, he routinely invites his fellows to watch him perform forensic psychiatric interviews of inmate-patients. Knoll's interview is gentle and collaborative yet uncompromising. He asks pointed questions, gently unpacking their thoughts and probing for evidence. The fellows hold their breath while he slowly investigates the interviewee's mind. After the interview, the fellows are subjected to the rite of passage: the painfully ego-shattering, red-inked scrutiny of their written reports. The same goes for courtroom testimony. But by the end of the year, fellows learn to state their opinions clearly and concisely, supported by compelling behavioral evidence, and testify on the stand confidently. In recognition of his dedication to the craft and teaching of forensic psychiatry, he received the 2007 AAPL Best Teacher in Forensic Psychiatry Fellowship Award and the 2020 AAPL Seymour Pollack Distinguished Achievement Award.

Knoll encourages trainees during the fellowship to consider collaboration with law enforcement. To him, working with law enforcement is “like cross-training, using teamwork to solve a mystery.” His disposition was particularly influenced by mentorship from the late Roy Hazelwood (pioneering FBI profiler of sexual predators) whom he met while taking one of Hazelwood's seminars on sexual violence. From Hazelwood, he learned the importance of the primacy of behavioral evidence, and how to think from the perspective of offenders. He was also compassionately sensitized to the tragedies and traumatization that law enforcement officers undergo in the line of duty.

Knoll wanted to help and learn from the law enforcement community. He initially started with small steps. He volunteered to give pro bono lectures about crisis negotiation and mental illness at local police departments. He engaged in pro bono consulting with detectives on cases of stalking, going on to assist in approximately 100 cases of stalking threat assessments. During his work in corrections, he taught local correctional officers Brazilian jiu-jitsu (another passion of his) for free, to promote their physical and mental wellness and team cohesion. His efforts to engage the local law enforcement community, over time, attained national reputation. Steven Conlon (FBI Director of Education) recalls meeting Knoll at a law enforcement conference years ago. At the time, Mr. Conlon writes, “his reputation preceded him from his association with law enforcement.” Mr. Conlon felt Knoll was the right man to teach a course on mental illness to police executives at Quantico. His choice was proven right. Knoll had not only carefully prepared his materials for the course but also amassed a 70-page reference booklet for the students. Mr. Conlon writes of Knoll's presence at the FBI Academy as following: The first time he delivered the training … in my mind thought “wow”—what a fabulous presentation. What made it a “wow?” His passion for the subject matter was obvious. His enthusiasm was contagious. The information [presented] validated his [deep] expertise on the topic. As soon as he started talking, I could see he had a natural gift for teaching and conveying information. His sense of humor caught their attention and reinforced his ability to engage the students … the classes [over the years] have expressed their gratitude by sending him signed class photos as a token of their appreciation.

In hindsight, collaboration with the law enforcement community was very much baked into Knoll's identity as a forensic psychiatrist. He had relatives steeped in law enforcement and knew he had much to learn from them about human behavior.

Balancing Act

The more he devoted his career to forensic psychiatry, the more he discovered afresh the truth he had learned when he was ten: that to seek the truth, he had to, at times, immerse himself in the dark side of humanity. Working in the criminal justice system, he encountered daily the minds of murderers, stalkers, sexual predators, and psychopaths. These individuals were often declared “evil” by the public and frequently evoked powerful countertransference. But decades of correctional work taught Knoll to think differently. These individuals were, in fact, awash with suffering, despair, and tragic circumstances. Sometimes so much so that it affected their capacity for empathy or rational thinking.

Having been exposed to his own psychoanalysis and Buddhist principles, he could not turn a blind eye or form a hard callus over his emotions. He wrote and taught extensively about mass violence, mental illness, and homicide-suicide. Through his experience, combined with years of studying forensic psychiatry and Buddhism, Knoll realized that two of the mind's greatest foes are “fear and a powerful pull to value one's self.”

To balance this recognition of the dark side, Knoll began to place great emphasis on an appreciation for art and humanities. This he partly inherited from his mother and developed during his time at the Dallas Museum of Art. Knoll is convinced that “art and creativity are things that don't have an end” and “carry meaning, joy, and ultimately help achieve a sense of balance” crucial for well-being. It is no surprise that Knoll always invokes Freud's two ingredients to happiness in his annual AAPL review course: love and work, or meaningful relationships and expression of creativity. And Knoll practices what he preaches. On weekends, he can be found at a Brazilian jiu-jitsu academy sweating profusely. At other times, he may be trying to learn a new blues riff on his favorite guitar.

Social Harmony

Finally, for Knoll, forensic psychiatry is also about social harmony and mitigating communal harm. This too, he inherited from his parents, reinforced by Buddhist philosophy. For example, in 2010, Jiverly Wong carried out a mass shooting in Binghamton, NY. Knoll immediately reached out to the shaken Binghamton community and convened Upstate's first annual forensic conference. He invited Binghamton's police chief and district attorney to join him on a panel intended to facilitate community healing and educate the public about the gunman's delusional state of mind. Similarly, in the aftermath of the 2012 Sandy Hook tragedy, he joined David Kaczynski (brother of Ted Kaczynski, known as the “Unabomber”) and two Buddhist monks in an open public dialogue to promote community recovery from a severe trauma.

Knoll is also a dedicated advocate for inmates with serious mental illness. In his writings and lectures, he repeatedly calls for decriminalizing mental illness as a top priority facing American psychiatry. He regularly participates in advocacy movements to discourage the use of prison as de facto mental asylums. His passion may be apparent to those who attend his AAPL Review Course lecture on civil commitment. Knoll is equally devoted to preventing suicide. He is the former president of the Central New York American Foundation for Suicide Prevention, and regularly joins suicide survivors for fundraising events.

AAPL President

James Knoll IV, MD, is the 49th President of the American Academy of Psychiatry and the Law. In serving as AAPL President, Knoll is fulfilling his obligation to give back to the organization that has immensely benefited him and his students. It should be no surprise that he has chosen the theme of “balance” for his presidency: a product of his development, study and philosophy. Although balance can have many connotations, stability and discerning judgment seem important topics of reflection as we cautiously emerge from a global pandemic. Knoll feels strongly that the understated value of balance may be of use to AAPL as it moves forward in its mission of dedication to excellence in practice, teaching, and research in forensic psychiatry.