Q. A patient asked me to evaluate her for a workplace disability claim.
She is claiming that her depression was caused by harassment on the job. I'm
uncomfortable agreeing to such a claim as she has a long history of
psychiatric problems, including depression. Can I effectively provide
treatment and forensic services to the same person?
A. In general, acting as both a treating psychiatrist and performing
an evaluation for legal purposes (or acting as an expert witness) could
adversely affect both the therapeutic relationship and your objectivity as an
These are two common scenarios in which psychiatrists find themselves:
In these scenarios, the psychiatrists are initially treating psychiatrists.
Once they start giving opinions for the purposes of litigation or employment,
however, they move beyond the role of treating psychiatrist and into the role
of forensic psychiatrist or expert witness.
Multiple roles bring with them the very real possibility, even the
inevitability, of conflicting obligations (that is, the patient's clinical
needs versus the patient's legal needs). Conflicting obligations increase the
risk of clinical, ethical, and legal problems.
The American Academy of Psychiatry and the Law states in its Ethical
Guidelines for the Practice of Forensic Psychiatry, "A treating
psychiatrist should generally avoid agreeing to be an expert witness or to
perform evaluation of his patient for legal purposes because his forensic
evaluation usually requires that other people be interviewed and testimony may
adversely affect the therapeutic relationship."
It is appropriate for a psychiatrist, as the treater, to provide factual
information in a report or testimony about the patient's clinical status, with
proper consent from the patient, but if the assessments, recommendations, and
opinions do not exactly match the litigation needs of the patient/party as the
lawsuit develops, then the psychiatrist's usefulness as a witness is finished.
He/she might even be detrimental to the patient's case, which could have
serious implications for the therapeutic relationship.
If, in contrast, a psychiatrist tailors his/her assessments,
recommendations, and opinions to the needs of the lawsuit, then his/her
effectiveness as a treating psychiatrist is compromised, if not destroyed, and
he/she may fall below the standard of care.
In either situation, if the patient thinks he/she has been harmed by the
doctor's involvement, the patient may then have a cause of action against the
psychiatrist based in negligence (that is, negligent treatment or negligent
Psychiatrists should be wary when asked for opinions or predictions by
third parties, such as patients' employers, disability insurance companies,
and attorneys. The safest response is for the psychiatrist to discuss the
issue with the patient, explain the limits of his/her role as a treating
psychiatrist, and outline the potential conflicts. The psychiatrist can advise
the requesting parties that if they want a specific opinion or prediction,
then they should obtain an independent medical exam for that purpose.
Unfortunately, psychiatrists who practice in small towns or rural areas
sometimes find that it is difficult to avoid dual roles.
Many medical professional liability insurance policies do not cover the
risks inherent in forensic practice, but forensic work is covered under the
APA-endorsed Psychiatrists' Professional Liability Insurance Program.
This column is provided by PRMS, manager of the Psychiatrists'
Program, for the benefit of members. More information about the Program is
available by visiting its Web site at<www.psychprogram.com;
calling (800) 245-3333, ext. 389; or sending an e-mail to