MedicoLegal Psychiatry in the Face of COVID-19

Over recent months forensic psychiatrists and medicolegal psychiatrists have been compelled to undertake assessments using internet-based technology such as Zoom and Skype. Whilst many of us have developed familiarity with these modalities in the past, we have not been compelled to use them in a medicolegal context to the extent that has been necessitated by COVID-19 restrictions. Early in the evolution of the restrictions, there was a consensus of opinion that compelling clients to travel, often by public transport, was inappropriate as it would represent a potential risk to the client, the client’s family, administrative staff and the assessing psychiatrist.

Remote assessments over the internet have presented challenges. The medicolegal context can be unfamiliar, stressful and daunting. In a clinical psychiatric setting, rapport between the doctor and client may be established over several sessions. In a medicolegal assessment, clients are immediately compelled to divulge personal information, often with a level of detail that would be unfamiliar to even their closest family. Typically, in civil matters such as workers compensation cases, motor accident insurance claims and public liability claims, clients are directed to a particular psychiatric assessor by the insurer or their own legal representative. In a forensic context, clients are often acutely aware of the potential influence of a psychiatric opinion on the criminal process. It is therefore unsurprising that clients find participating in a medicolegal assessment disquieting.

In all contexts in which medicolegal psychiatric assessments are undertaken, the opportunity to establish rapport is limited by virtue of the nature and brevity of the relationship between doctor and client. Being in the same room permits a level of connection that can never be achieved over the internet. Sharing a space allows the psychiatric assessor to gauge the mood of a client and then adjust their manner, pace of speech and body language to minimise discomfort, optimise rapport and facilitate a successful psychiatric evaluation.

Furthermore, the dynamic is inevitably different when assessing a client remotely. Some clients participate in the assessment from a solicitors’ offices, some are participating from their own home and some are participating from a relative’s home. Some are familiar with the technology and some require assistance or negotiate unfamiliar technology. Poor internet connection may lead to broken audio or frozen video. Sometimes the tone of voice is distorted and sometimes words are fractured. In addition, there is the complication of the almost total absence of body language. An impression of the client’s physical presentation can be distorted by the video image, lighting and camera angle. The assessing specialist should comment on any limitations conferred by the technology.

Notwithstanding the challenges, the availability of video based psychiatric assessments for those who either cannot travel or prefer not to travel has the potential to be beneficial.  In the future it may counter the costs associated with compelling a psychiatric assessor to travel to rural or regional areas to undertake assessments. It allows people who are physically compromised and cannot easily travel to have the option of a medicolegal report as part of their claim and it will potentially expedite finalisation of insurance claims, compensation claims, medical negligence claims and criminal matters in the future. As this method of psychiatric evaluation becomes more common and technology continues to evolve, concerns regarding the use of video assessments will diminish and even after COVID-19, more medicolegal psychiatric reports will undertaken based on video assessments.