The role of an independent psychiatric expert and how it differs from clinical practice
[ *Spoiler alert — discusses plot lines in the new Netflix drama, Adolescence]
It’s been a while since I have been utterly transfixed by a depiction of a mental health professional in the media. The character Briony Ariston, played by Erin Doherty in Netflix’s Adolescence was utterly brilliant and so deeply authentic that it would be remiss not to write about it and study exactly why she did it so well.
Amongst a cast of especially gripping characters, clinical psychologist Briony Ariston was especially relevant to me. Like me, she worked as an independent expert, tasked with preparing a pre-hearing report for a 13 year boy accused of murder. He was not her patient, and she was unable to offer him any advice or treatment. We watched on as she stated and re-stated her role to an increasingly frustrated and unravelling child, who demonstrated that he understood her, but that didn’t mean he was going to like it.
Although I don’t work with forensic matters, I do examine people who are pursuing claims for compensation after a personal injury. One of the biggest challenges I’ve faced after moving away from years of being a therapist to an independent medicolegal expert is learning how to balance rapport and empathy building with independence and an unbiased approach. In this work I no longer serve the patient, but the court and the legal process. I no longer advocate for the person I am interviewing but for truth and clarity about their predicament with its associated consequences.
As I watched episode three of Adolescence, I felt all of the attacks on Briony and at times was so moved I had to remember this was a depiction and not fact. I watched as she traversed the delicate balance between rapport-building and oversharing. She greeted Jamie with a hot chocolate with extra sprinkles because she remembered what he liked, and she shared a sandwich that she had made herself. He tested her out when he rejected her choice of sandwich fillers, but she remained constant that she wasn’t offended. She demonstrated kindness and a conviction to show him that she was listening, and she wanted to understand him. Her disclosure that she called her grandfather “Pop Pop” could be seen as oversharing, but it did disarm Jamie to reveal the legacy of men in his life, his male role models, and his description of how anger was expressed in his family, with his beliefs about what constituted violence. There are no absolutes but reflection on practice is essential here to ascertain when we may stray. Purist therapists would never offer a tea or coffee to a patient, but I think it’s a nice gesture regardless.
It is simplistic to overstate the need for absolute non-disclosure on behalf of the examiner, especially in historical matters. Often the person I am assessing has not revealed details of prior abuse to anybody. Sometimes the lawyer who refers the case to me is unaware of the depth or the details of what we call the “subject abuse”, probably because at the time the person has instructed their lawyer, they haven’t even revealed these details to themselves. It would be an impossible task for them to then attend an assessment and re-live their trauma to a psychiatrist who demonstrated no capacity for kindness or compassion. The finessing for the examiner is around how to demonstrate these qualities without disclosing or revealing anything about who we are or what we think about the person we are examining.
As Jamie railed against boundaries, Briony Ariston did her best to uphold them, and despite such great force she managed to mostly keep to task and role. On one occasion she left the room to gather her composure, and she did her utmost to maintain control of the situation, refusing offers from the guard to intervene. By doing so, she got exactly what she needed in order to provide her expert opinion — Jamie was a boy who disrespected authority, especially female authority. As he breached her personal space, raised his voice and raged, she stood her ground and requested repeatedly for him to sit down.
When Jamie asked her what she thought about his father displaying shame when he watched his attempt to play footy, she refused to waiver and merely expressed that she had heard he felt shamed. When he asked her repeatedly if she liked him, she refused to answer. When he acted out his feelings of abandonment and rejection when she told him this was her last visit, she merely stated the facts about the next steps. Ultimately, she invested so much of herself in the dynamic without giving much of herself at all.
This dynamic plays out regularly in medicolegal assessments. We may examine people riddled with shame, who seek constant reassurance that they are ok because they may constantly feel that they are not. And never as much as a time when they have been completely vulnerable and honest in front of a stranger in authority.
Psychotherapy is not for the faint-hearted, patient or therapist alike. Drama happens, patterns are played out and change happens after the truth is exposed. When the truth is revealed, which generally lies behind the facades of everyday life, the growth and shedding of past wounds can ultimately occur.
Performing independent assessments adds another layer of complexity and sophistication to this. Maintaining allegiance to the legal process, examining the consequences of cases of historical abuse and working with the emotion that accompanies these predicaments is a skill that is not taught anywhere but needs to be learnt to do the work.
Throughout the assessment with Jamie Miller, Briony Ariston went to the next level, exhausted and visibly shaken. If every was this intense the work would not be sustainable. The rub is that the independent examiner is never aware of which case will be the exhausting one until the process begins and the drama unfolds. Remembering that the person in front of us is demonstrating their pain and their defences when they get tripped up by intrusive thoughts and images of prior abuse is critical. Personalisation is inappropriate despite the behaviours feeling very personal at times. The skills emerge when the examiner deciphers the comments and behaviours and provides their observations in the form of a mental state examination.
The way Jamie behaved and the ultimate reveal of his true self, full of shame and insecurity, not believing he could be liked was crucial information to capture. Merely stating that he was abusive, belligerent and demonstrated a disregard for authority, or that he was just an angry child, would be borderline useful knowledge to have when going to the eventual trial. Shame was key here as it led to the ultimate form of violence, ending another child’s life at that moment.
Although the purpose of an independent assessment is never to provide clarity or understanding for the client, it is important to note that this could happen regardless. I wonder if Jamie did develop some understanding of himself or was able to reflect on what transpired in the sessions with Briony Ariston. I wonder if it led to him changing his plea, a hint of remorse that he hadn’t shown to this point. By the end, Briony must have felt that she needed to offer something to this child she was about to leave after having an intense, short-lived relationship with, as she recommended that he take up any offers for help when provided to him.
So much of what a psychiatrist does is not obvious to many. That doesn’t make it useless, but quite the opposite. Our ability to take what we have learnt and communicate it through our words is our skill, both in the therapeutic space and as we work for the legal system, guiding the process with our understanding of what makes people behave and do the things they do. But we can only do that when we reflect on our work, actively seek out support and guidance and ultimately treat ourselves with compassion too.