ORIGINAL ARTICLE
Graham D. Glancy,1,2,3,4 Daniel W. Miller5
1 Forensic Early Intervention Service, Centre for Addiction and Mental Health, Toronto, Canada; 2 Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, Canada; 3 Faculty of Medicine, McMaster University, Hamilton, Canada; 4 Faculty of Law, University of Toronto, Toronto, Canada; 5 The Hospital for Sick Children, Toronto, Canada
Cite: Glancy, G., & Miller, D. (2021). The Greats: Learning Strategies of Master Forensic Psychiatrists. International Journal of Risk and Recovery, 4(1), 43–50.
For forensic psychiatry to thrive as a profession, practitioners need to be committed to intentional, continuous learning and development throughout their careers. However, carving their way through the challenges of practice and finding room to grow can be daunting. Research can help lessen this burden by examining the careers of experienced and skilled practitioners, identifying the factors that influenced their development, and the strategies they used to direct it. To date, little research of this kind has been conducted in forensic psychiatry. In this study, we used the deliberate practice model of elite performance as a heuristic to interpret the accounts of several experienced and distinguished practitioners, revealing and characterizing the influences and activities they identify as having been most important to their development. Semi-structured telephone interviews were conducted with six participants from across North America who started their forensic careers between 1965 and 1980. Transcripts were analyzed using directed content analysis. Participants cited little in the way of highly structured activities designed specifically to improve performance. They instead described using opportunities to learn from real casework and additional knowledge pursuits, as well as using deliberate career management to structure the conditions of their work-based learning. They also stressed the effect of entering forensic practice during a period of increasing interest, demand and investment, which yielded early opportunities to learn through practice. We discuss limitations in the deliberate practice model’s capacity to capture key learning strategies in forensic psychiatry, connections between work-based learning and the discipline’s general historical trajectory, and the role of career management in professional development strategies.
Key words: Forensic psychiatry, deliverate practice model, career management, professional development
He who knows not and knows not he knows not, he is a fool—shun him.
He who knows not and knows he knows not, he is simple—teach him.
He who knows and knows not that he knows, he is asleep—awaken him.
He who knows and knows that he knows, he is wise—follow him.
―Bruce Lee, Tao of Jeet Kune Do
Introduction
In most martial arts, the beginner starts by repeatedly practising a set of basic movements or forms. Over months, through sustained, guided effort, the committed beginner may become a competent intermediate, one who can reliably perform the requisite movements when prompted. Over years, the practitioner learns to integrate movements into increasingly complex functional sets and to do so in increasingly dynamic and unpredictable circumstances. We come to call those who reach the highest levels exemplary, masterful, exceptional or great. Implied in these estimations is an awareness that they have transcended the static forms on which they had relied and which we, the beginners and intermediates, still depend. For us, the master embodies and exemplifies excellence, a future state to which we aspire, in a way that cannot be adequately represented by these stereotyped forms. Competency at its upper boundaries becomes encapsulated by the master. When asked to define what excellence is, we point to them. It follows from this that, while the general repetition of the blueprint or set of forms may be necessary for us to achieve mastery, this will never be sufficient. We need to return periodically to the masters and see what they do.
The analogy between martial arts and forensic psychiatry, or any other profession for that matter, is inexact in some important ways. However, the idea of the master or a highly skilled, highly experienced expert as a guide is one worth incorporating. In an era in which medical education is increasingly dominated by competency-based education, it is tempting to think of forensic psychiatric competency and excellence as phenomena that can be adequately codified, formalized in abstract frameworks and milestones.
While perhaps necessary and useful in contemporary subspecialty training, we argue that these tools are not sufficient to guide junior practitioners’ ongoing development. Specifically, we focus on a few of the integrative and situated skills needed to thoroughly embody and internalize the expert role and facilitate improvement over time in a dynamic professional terrain.
Methods
We draw on real examples of some masters in the field. As the next best thing to directly observing the work processes and career trajectories of exceptional and highly experienced practitioners, I (Glancy) spoke with six of them in informal, one-on-one phone interviews, using a narrative, journalistic approach. To protect anonymity, we refer to them by the pseudonyms of Dr. Baker, Dr. Smith, Dr. Foster, Dr. Gatsby, Dr. Riesman, and Dr. Rousseau, and we do not list their accomplishments. As a member of the subsequent generation of North American practitioners, for me these pioneers have served as models and inspirations, as exemplars of excellence to strive toward. As such, the conversations represent a portion of their influence on me and an attempt to encapsulate some of their perspectives and experiences in an ever-evolving conception of professional expertise.
We used directed qualitative analysis in this study. As described by Assarroudi et al. [1], this method is reliable and transparent for qualitative researchers. We refer the reader to the reference for a full description of this method.
Some features of the advanced skill set
While our conversations covered the usual list of competencies, discussion of advanced skills gravitated toward three principal themes representing key aspects of internalization and embodiment of the expert role. These skills are notable in that they constitute integrative or balancing functions, denoting the abilities:
- to maintain a balance between interpersonal identification and maintenance of social distance while interviewing, providing testimony, and interacting with the legal community;
- to balance comprehensiveness and succinctness in researching and writing forensic reports; and
- to internalize the legal reasoning.
Results
Maintaining intersubjective balance
Forensic psychiatry requires routine interaction with individuals radically different or subjectively distant from ourselves: patients with histories of extreme behavioural disorders and mental disorders, lay jurors, and legal professionals. The advanced practitioner balances the skills of closeness, attentiveness, forensic empathy, and collaboration with the equally important ability to obtain and retain the distance called for in the expert role.
The clearest example of this relates to interactions and relationships with treated or evaluated individuals. Drs. Rousseau and Baker emphasized the ability to develop a rapport with these individuals. As Dr. Rousseau put it: “you do need to be able to establish rapport with people, because, in my opinion, you’re seeing the sickest of the sick. Not only that, they have, also, usually committed some act of violence.” As noted by Dr. Baker, the imperative to use empathy and develop rapport is particularly challenging because the practitioner simultaneously must maintain sufficient distance to avoid manipulation under circumstances in which the other party also has reason to obfuscate or malinger.
The idea that the excellent forensic psychiatrist possesses the skills to maintain simultaneous attentiveness and intersubjective distance was applied also to the provision of testimony. Being a professional expert implies a significant distance between themselves and the lay juror, the bridging of which was described by Dr. Riesman as one of the most fundamental and challenging aspects of advanced practice. In this context, he emphasized the need to strike a delicate balance, to project confidence in stating one’s expert opinion, while also “see[ing] the other side’s response or understanding of what you’re saying, so watching your audience trying to break it down.” He went on to say that “if you basically have a sense of how to take something and present it in lay terms without seeming like you’re dumbing it down, that might be one of the single most key things.”
A similar theme was also expressed about communication and interaction across the intersubjective gap between practitioners and the legal community. Particularly interesting was how this related to the practitioner’s general functioning within a potentially alienating professional environment where they may be the only member of the discipline. Dr. Riesman noted that “you have to be able to work with attorneys, who usually will begin by regarding you as a physician.” This alienation cannot be eliminated but is intrinsic to the job. An advanced practitioner develops an awareness of this and builds it into their approach to working with the legal community and advocating for their perspective and expertise, both in general and during examination. One needs to be able to collaborate while asserting one’s position and expertise. Dr. Baker also identified this as critical, “when an attorney pushes you to answer a question a certain way or to do something … not to get pushed around.”
Balancing comprehensiveness and precision
The process of researching and writing the forensic report presents two broad imperatives to the practitioner wishing to do excellent work. On the one hand, they need to review a potentially large range and volume of information to adequately answer the question at hand. On the other hand, they need to identify and incorporate only that which is relevant and as little of the rest as is possible. In particular, Dr. Baker stressed the need to be attentive to detail, even compulsive, while examining huge volumes of information, both within and between cases, “to be able to go through records in meticulous detail and to pick things up … to try and remember when you saw a similar thing beforehand or a different thing.” She also noted that an exceptional report is one in which the practitioner “only puts in the information that is relevant to the case and doesn’t put in everything under the sun that they happen to know from any kind of source.”
Dr. Smith described the report itself and its preparation as the primary locus of reasoning and integration. Preliminary drafts serve as a tentative, critically examined record of an emerging scientific opinion (the practitioner’s). In his words, rather than simply being the codification of a chain of reasoning contained in an abstract realm, the writing process is “when some insights are achieved … when some hypotheses get discarded and others confirmed.” Hence, we might say that the process of medicolegal reasoning is inseparable from that of researching and writing. The process of organizing empirical data facilitates both conceptual synthesis (new insights) and ongoing critical examination of the data and preliminary attempts to explain the phenomenon in question (hypotheses). Thus, the report is not only a communication tool, but it is also a practical record of and critical tool in the reasoning process—the integration of a large amount of information into a tightly reasoned, highly relevant representation of thought.
Thinking legally
Because the practitioner’s expert opinion is conveyed in testimony and reports, it is tempting to adopt a strictly communicative notion of what it means to translate clinical findings into a legal opinion. From a superficial perspective, this could be seen to involve a sort of input-output relation: clinical information in, legal opinion out. But true expertise involves something deeper, internalization of the mode of reasoning intrinsic to the law, one markedly distinct from that used in medicine. Dr. Riesman expressed the view that “unless you can get your head around the law and how it works conceptually … you’re never going to be that good.”
In making these comments, Dr. Riesman emphasized the different conceptual terrains of medicine and the law. If we unearth these different terrains, we might find that the contrast is even more profound than at first sight. Our conversation with Dr. Foster conveyed just such an impression in that he consistently emphasized the uniqueness of forensic psychiatric mastery as something based on legal thinking ability, undergirded by linguistic reasoning skill:
I’ve had some very bright fellows with a PhD in [a scientific discipline] before they went to medical school and were clearly bright but have not necessarily translated that into a skillful reasoning capacity. And other fellows are very able and just grasp those concepts quickly, some are mediocre, they can take the template and apply the facts in a workman-like way but not as skillful in seeing the bigger picture or subtleties in their organization.
Discussion
The path to excellence
In preparing for our conversations with these experienced practitioners, we were informed by three basic perspectives concerning the development of advanced expertise and expert performance. These were situated within our reading of the research on advanced performance.
- The first perspective, predominant for much of the latter half of the 20th century, posits that advanced performance is primarily a function of innate ability, intelligence for instance.
- This was challenged in the 1990s by the work of K.A. Ericcson who argued that the number of hours of rigorous, expert-guided deliberate practice was the decisive factor [2].
- In turn, this perspective was critiqued as having limited relevance for the complex expertise characteristic in the professions [3,4], neglect of contextual variation in local meanings attributed to expertise, work resources, culture, [5] real-world task demands, professional goals [5], social motivators like parental pressure and societal expectations and, coming full circle, innate talent contributing to early and sustained experiences of successful execution [6].
We do not pretend to adjudicate between these various perspectives but merely state that this was our conceptual starting point. Stated broadly, the three basic avenues of explanation, innate ability, practices and circumstances informed our conversations. The discussions did not suggest to us that any one of these factors was critical alone. What we did notice were the interesting ways in which these different elements seemed to relate to each other within the experts’ accounts. Our experts alluded to seemingly intrinsic or stable traits, sometimes situated within their biographies, which they felt had helped them to obtain, seize, and build upon opportunities, and to function well in multiple key domains. In turn, they viewed these experiences as being linked to their development, where high quality opportunities allowed high quality learning and execution. In most cases, it was not clear whether the personal assets referred to were intrinsic traits or long-term habits and practices. But, from their perspectives, these assets played a role in facilitating development and the progressive embodiment of the expert role.
Before discussing personal characteristics and practices, it is important to dispense with the general notions that judgments concerning who is and is not excellent are purely objective or that the circumstantial determinants of excellence are standard across time and place. The stories of our expert practitioners provide strong counterexamples to such assertions. From the perspective of acquiring distinction and opportunities for growth, all of our experts entered forensic practice during an opportune time. In the 1970s, North American forensic psychiatry was rapidly ascending as a distinct, valued, and institutionalized domain of specialization, culminating with official recognition in 1992 in the United States and in 2011 in Canada. There were few practitioners in the 1970s. This was a dynamic and stimulating period in which the worlds of law and psychiatry were becoming more relevant to each other and in new ways, with a variety of issues related to their intersection. Dr. Gatsby described this as “an extremely exciting time in the field when a lot of law was being made that continues to shape psychiatry, psychiatric practice, and forensic psychiatry today.”
This dynamically emerging professional environment potentiated a wide range of opportunities, even for those who had just chosen to concentrate. “I quickly became the most knowledgeable person in forensic psychiatry in [city]” said Dr. Foster, “because there was no competition.” Consequently, even inexperienced fellows and practitioners had a range of opportunities and options available at the beginning of their forensics careers. As Dr. Gatsby put it while discussing the American Academy of Psychiatry and the Law (AAPL): “It was good to be in at the early stages because you could actually do stuff.” Dr. Rousseau’s story suggested a similar insight but in a particularly poignant manner. He had started forensic practice in a country outside of North America where the discipline had a longer history. A subsequent move to North America provided the chance, as he put it, to be “a bigger fish in a smaller sea.”
In addition, all of our experts referred to the fact that organizations, particularly AAPL, were in their early stages. This afforded opportunity for contact with and feedback from the few experts from across the continent in a small group setting. As noted about deliberate practice, it is not just blind practice that makes perfect; expert guidance and feedback on performance are as important as the sheer hours put in. Having access to the senior experts of the time through association participation was a notable advantage.
In considering characteristic personal attributes and practices particular to these individuals, it is critical to bear in mind these good conditions and the opportunities they afforded. In reflecting on these conversations, the picture that emerged for us was of a set of personal assets that situated these individuals well to obtain and make the most out of these opportunities. Despite the access enjoyed at the association level, being one of the few forensic specialists meant that opportunities for guidance and supervision at the local and subject-specific level were minimal. In this way, our discussants were true pioneers. To flourish more than they floundered, they needed and had a variety of integrating skills that would facilitate the strong performance of professional duties and strong career management. This was likely particularly important as the field grew and became more populated. Reliably doing excellent and gaining a reputation for doing so helped them to ensure that their services were in demand. As such, they were offered exceptional opportunities early on. For example, Dr. Smith was selected early in his career for a “‘cost is no object’ opportunity to explore wherever the evidence went,” allowing him to establish an early benchmark of thorough work.
Several personal traits or practices that may have facilitated discussants’ progression to greater levels of expertise and distinction were mentioned. Perhaps in part because of modesty, they did not place extensive emphasis on intrinsic characteristics like intelligence as distinguishing the excellent practitioner from the competent one or as the decisive factor in their unusual success and development. They extended this judgment not only to themselves but to the field in general. As expressed by Dr. Smith, “you had to be smart, but there were lots of smart enough people” suggesting a view that intelligence, while essential, is not uncommon among professional peers nor is it sufficient in gaining expertise.
To the extent that anyone did explicitly emphasize some form of apparently intrinsic intelligence, this was mentioned in specific relation to the unique opportunity presented by the forensic subspecialty. Dr. Foster attributed much of his success to the combination of opportunity and aptitude. Self-described as having had to “work hard to get Bs in chemistry, physics, biochemistry, and calculus,” he felt that the emerging option to specialize in forensic psychiatry provided the chance to stand out in a field where “the skill requirements were analytic ability and language skill,” in which he felt he was much stronger. This raises some interesting questions for further consideration. Does the advanced capacity, alluded to by Dr. Rousseau, of being able to “get your head around the law” point to mental faculties more characteristic of the arts and sciences than to the hard sciences?
The other set of assets clearly indicative of some form of innate or stable attributes were social skills, specifically those applicable to multiple domains of forensic competence and career success. For example, one can easily imagine how Dr. Smith’s self-described facility as a child in “passing among all of the social classes … the bad kids and preppies and jocks and studious kids” could lend itself to effective navigation of the challenging intersubjective domains described previously. One might also speculate that Dr. Riesman’s childhood skill in “firing back the average wisecrack” prepared him not only for cross-examination, as he stated, but also a more general ability to think legally and advocate confidently for his expertise and opinion as a psychiatrist in a legal environment. Similarly, Dr. Gatsby’s life-long strength and interest in debating—having excelled in the debate teams in junior high, high school and college—likely prepared him for these challenges as well.
With some of the other assets discussed, it was less clear whether they indicated innate aptitudes or simply long-term habits, attitudes, or ethics. Most notably, discussants emphasized the indispensable importance of extremely hard work, more specifically long hours, consistent with the aforementioned deliberate practice model. Participants described having, for the course of their careers, customarily invested extraordinary amounts of time on their work, almost always a minimum of 50 to 60 hours a week, frequently as much as 70, 80, 90 or 100 hours, for sustained periods. This again is consistent with Ericsson’s concept of deliberate practice, wherein there is no substitute for years of hard work [2]. Dr. Smith nicely captured the centrality of this by contrasting it with the innate intelligence explanation:
here’s the one that separates the men from the boys [or the women from the girls], you have to be willing to work twice as hard as everyone … [Those who excel] may not be smarter than the average person in the field but [they] certainly work harder than the average person.
Other assets, whether reflecting innate aptitude or merely habit, reflected the central importance of hard work and long hours but seem to have implied some interesting qualifiers, assets that made huge volumes of work manageable and effective. Such was the case with the asset emphasized most consistently by Dr. Baker, who repeatedly stressed impeccable organization obtaining and making the most out of opportunities. By high school, her organizational skills had earned her a reputation as “a competent person and a very good organizer [who could] organize things and get things together and follow through on whatever [she] said [she] was going to do.” This links organizational skills to accountability and dependability, something that, in her view, proved to be critical in affording opportunities over multiple decades of practice through a reputation of dependability. Underlying this, she felt, was the role of organizational skills in facilitating the production of comprehensive, succinct, and relevant reports on time. A strong organizational system made it possible to review thousands of pages of material with acute attention to detail, obtaining “all the information after the first time.” Similarly, she identified exceptional organization as a requirement for taking advantage of certain opportunities, such as proximity of office space to clinical space, which she felt could save time and afford flexibility only if one is “very well organized.”
Another asset, this one palpable in all of the discussions, was the apparent drive to learn, to expand understanding of the field, and to face and master new challenges. All those we spoke with expressed strong intrinsic interest in the subject matter. Dr. Rousseau described how this facilitated the accomplishment of what might look like an excessive workload to the outside observer, saying “even though I have worked hard, it has never been much of a chore, to be honest.” These practitioners’ love of the work may plausibly help explain how they managed to do so much of it—they simply wanted to. Critically, this also facilitated their maximal exploitation of opportunities. For instance, this is reflected in Dr. Gatsby’s taking advantage of unusual casework to better understand how evaluations in rare or unique scenarios have and can be approached, by tracking down cases, law review articles and academic literature. Similarly, this can be seen in Dr. Smith’s commitment to expansive and complementary expertise through the acquisition of graduate degrees in health and social sciences. A steady, long-term drive to engage with and understand not just the field proper but also a range of overlapping biological, social, and legal knowledge domains arguably allowed these practitioners to excel, not just in attaining recognition, but in advancing the perimeter of the field’s knowledge base.
Conclusions
In this article, we have presented some of the features of advanced or excellent practice in forensic psychiatry based on our interpretation of the perspectives of six highly experienced and accomplished practitioners. We have also highlighted some of the factors that may be important in developing toward higher levels of expertise and distinction. Regarding features of advanced practice, we have emphasized three themes. These are:
- integrative capacities, the kinds one needs to get a feel for, so to speak: achieving and maintaining an optimal intersubjective distance between oneself and others (e.g., balancing neutrality with forensic empathy);
- balancing comprehensiveness and succinctness in the forensic report; and
- thinking legally.
Regarding the determinants of excellence, we also emphasize integration as a key theme. Whether by innate abilities, the experts we spoke with highlighted some key assets (e.g., stable, enduring behaviours and inclinations) that seemed to serve them well. While all entered practice at a good time and as such enjoyed opportunities, they worked a lot. Undoubtedly, intelligence played a role, though this was not generally emphasized, except in connection with language-based reasoning by one of the experts.
Other assets on which more emphasis was placed included social skills, love of the work, and organizational skills. We argue that these widely applicable abilities were particularly significant to fulfilling the forensic psychiatric role and flourishing in one’s career.
We interviewed the people who have inspired me (Glancy) during my career. We would hope that those embarking on a career in forensic psychiatry can emulate these characteristics. What was clear is that if an early career forensic psychiatrist has a passion for forensic psychiatry, they will put in the hours of deliberate practice that is necessary to become an expert in the field. As we have expressed elsewhere [7], our recruits are getting better, and we are developing new models for giving better feedback [8]. Despite the important distinction between excellence and success, we assert that the two can be viewed as mutually reinforcing and, to some extent, achieved through complementary skill sets.
Conflict of Interest: none
References
1. Assarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: The description and elaboration of its underpinning methods and data analysis process. Journal of Research in Nursing. 2018;23(1):42-55. https://doi.org/10.1177/1744987117741667.
2. Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100(3):363-406. https://doi.org/10.1037/0033-295X.100.3.363.
3. Gardner H. Why would anyone become an expert? Am Psychol. 1995;50(9):802-803. https://doi.org/10.1037/0003-066X.50.9.802.
4. Macnamara BN, Hambrick DZ, Oswald FL. Deliberate practice and performance in music, games, sports, education, and professions: A meta-analysis. Psychol Sci. 2014;25(8):1608-1618. https://doi.org/10.1177/0956797614535810.
5. Berliner DC. Learning about and learning from expert teachers. International Journal of Educational Research. 2001;35(5):463-482.
6. van de Wiel MW, Van den Bossche P, Janssen S, Jossberger H. Exploring deliberate practice in medicine: How do physicians learn in the workplace? Adv Health Sci Educ Theory Pract. 2001 Mar;16(1):81-95. https://doi.org/10.1007/s10459-010-9246-3.
7. Glancy GD. The case for progress in forensic psychiatry. J Am Acad Psychiatry Law. 2020 Mar;48(1),7-11. http://jaapl.org/content/48/1/7.long.
8. Booth B, Chatterjee S, Watts J, Glancy G. Towards a new model of training in Canadian forensic psychiatry. J Am Acad Psychiatry Law 49: In Press, 2021. http://jaapl.org/content/early/2021/05/20/JAAPL.200112-20.
Corresponding author
Graham Glancy, 1001 Queen Street West, Unit 3, 4th Floor, Room 471, Toronto, ON M6J 1H4, Canada; graham.glancy@utoronto.ca