2 Expert Witness Script

Example of an expert witness in court (The Exorcism of Emily Rose, loosely based on a true story).

Our fictionalized court case takes place in 2007 following 2005 hospitalization.

Expert medical, psychologist & healthcare professional witnesses.

Medical Report from Bergen Regional Hospital – June 26 – July 8, 2005

“cognition intact”… then why was she sequestered in a mental institution if her cognition was intact?

“She had delusions of grandiosity and felt that she was directly in contact with Wall Street and had a big business.”   The truth is she did present on Wall Street on June 17, 2005 with several business collaborators who took steps to address the unsanitary conditions and the poor nutrition for patients once she was hospitalized.  

“You can call these people in Washington DC who will vouch for me.”  Her words, documented in the report, resulted in no validating actions by staff. She does have direct connections to The Executive Director, American College Personnel Association in Washington DC, Greg Roberts, a key sponsor for the Wall Street presentation.  Our shared vision is to ease the journey of college student mental health, specifically through education via publications and training tools associated with content in the DSM-IV v-code for Religious & Spiritual Problems.

 “She had grandiose delusions of being an entrepreneur.”   Again, the truth is, she is an entrepreneur.  She has a strong reputation throughout NJ in pharmaceuticals, healthcare, non-profits and community organizations since 1988 as an expert in organizational training and consulting. 

• Plaintiff Lawyer:  Dr. Cavanaugh would you state your professional credentials and where you are employed?
• include American Psychiatric Association Fellow
• Addiction Psychiatry Certification
• Plaintiff Lawyer: And what is your expertise in relation to spiritual experience and psychiatry?

(Flashback of Dr. Cavanaugh early training and exposure to spiritual experience in addiction treatment)

• Plaintiff Lawyer: You have reviewed Anna Biltmore’s medical records and have studied the character witness testimonies that vouch for Anna as a highly functioning corporate entrepreneur since 1988 as well as a highly functioning single mom of a son for 10 years prior to this hospitalization. You have also reviewed the records of Anna following discharge.  What do you have to say about the diagnosis of Bipolar with psychotic features?

• Plaintiff Lawyer: What do you say about the fact that she was not able to secure her release for 2 weeks despite being in compliance of submitting her action plan multiple times to no avail?

• Plaintiff Lawyer: How would you differentiate Anna Biltmore’s spiritual experiences from psychosis & bipolar disorder?

(Flashback to Dr. Cavanaugh personal experience of psychosis as part of personal therapy)

• Plaintiff Lawyer: What do you say about the use of medications in this case?

• Plaintiff Lawyer: In general, what do you see as the role and importance of addressing spiritual experiences in addressing psychiatric care? 

(Flashback to Cavanaugh experiences with Major Depressive Disorder dx and medication treatment)

• Plaintiff Lawyer:  Dr. Cavanaugh, you have written about the nature of spiritual experiences and emotional healing – would you explain to the Court how these are related?

• Plaintiff Lawyer: You have written about a specific approach to integrating
• spirituality into psychiatric care – would you explain to the Court your experience and recommendations?

• Plaintiff Lawyer: How would you relate this to Ms. Biltmore’s case?

(Flashback to interactions with Biltmore and Cavanaugh as a result of working on this case)

• Plaintiff Lawyer: Do you think that there was any harm in the manner in which Ms. Biltmore was treated? And what about the use of medications in this case?

(Flashback to Cavanaugh experience in research with spiritual interventions)

(Flashback to struggles of Biltmore as a result of maltreatment)

Add to Dr. Cavanaugh

• Plaintiff Lawyer: In 1980 Dr. Youngman, Anna’s psychiatrist at The College of NJ discovered that Anna did well on a lower than therapeutic dose of Lithium and he approved this lower dose maintenance for the remainder of the semester for 3 months. You heard Dr. Youngman’s testimony in regard to Anna being a high sensitive in regard to medications. Is there research on the efficacy of lower doses of these types of medications? Is there research to determine if an individual is sensitive and responsive to medications and requires lower doses?
• What is the impact on a doctor attempting to diagnose Anna in 2005 when they hear of a former diagnosis of manic depressive in 1979? Do you see this as prejudicial?
• What is the impact on Anna’s psyche to have held in her experience for 25 years?
• What is the impact on Anna to have her family not believe her story after a successful presentation on Wall Street and hopeful to tell the truth and feel understood?
• What is the impact on Anna to not be believed by the healthcare professionals on the ER on June 26th? What is the impact on Anna when the professionals didn’t believe she had a business, connected to Wall Street & Washington DC? How might that impact her behaviors on the 24-hour watch on the ER?

Jonathan Cavanaugh, MD portrays Dr. John Calvin Chatlos, Professor of Psychiatry at Rutgers University Robert Wood Johnson Medical School. 

David Lukoff, PhD, is a licensed psychologist and co-author of the DSM-IV and DSM-5 diagnostic category Religious or Spiritual Problem which increased awareness of spiritual issues in clinical practice.

Dr. Lukoff has published over 80 articles on spirituality and mental health, and is an active workshop presenter internationally on spiritual competency, grief, death, recovery, and spiritual crises. He is a Professor Emeritus of Psychology at the Institute of Transpersonal Psychology in Palo Alto, CA and previously served on the faculties of Harvard and UCLA.

My initiation into spirituality both personally and professionally began with some lived experience in my early twenties that met all the diagnostic criteria for a psychotic episode. This 2 month episode was also my spiritual awakening. It led me from being an atheist to becoming a spiritual seeker. I started a meditation practice and attended retreats with Lamas and Zen Masters, trained in qigong and aikido, and studied Medicine Wheel teachings and ceremonies with Wallace Black Elk, a Lakota Medicine Man. (Link to a video of my personal spiritual crisis and integration). This experience also led me to decide to become a psychologist.

My initial professional focus was on spiritual emergencies like my own, and that led me to becoming one of the coauthors of the Diagnostic and Statistical Manual’s category Religious or Spiritual Problem (also in DSM-5) which covers such episodes without diagnosing them as mental disorders. As a result of its acceptance, I received requests to conduct trainings related to spirituality. But having worked in public mental health at Camarillo State Hospital, UCLA Neuropsychiatric Institute, and the San Francisco Veterans Hospital, I knew that spiritual emergencies themselves were not a common diagnosis. Yet surveys show that most clients do want to talk to their therapists about religious and spiritual beliefs and practices. So for over 25 years, my workshops have focused on training mental health professionals in the broader coverage of spiritual competencies that includes spiritual crises, but also focuses on clients’ spiritual strengths.

David Lukoff, Ph.D. – Spiritual Competency Academy

To be updated with Dr. Francis Lu latest research which will be included at the end of the movie when the experts discuss the 2007 case in the 2022 – 2023 present day time frame.

1. Lawyer: I have the DSM-IV Diagnostic and Statistical Manual of Mental Disorders in my hand. Dr. Davidson will you tell the court what this is & how it is used?
2. Lawyer: I’ve turned to page___Code V62:89 in the DSM IV (1994) in which you were instrumental in establishing. Please tell the court what motivated you to lead the way in establishing this v code.
3. Lawyer: We now know this V code is used to identify problems to attend to but are not categorized as disorders as bipolar would be. Will you tell us the purpose of the DSM-IV Code V62:89 and how it is used to care for a patient?
4. Dr. Davidson how do professionals differentiate between spiritual experiences from psychosis?
5. What did the ethical mandate say about required training on the DSM IV Code V62:89 in 1994?
6. To what extent is their training on this V code in the university curriculum for these professions at this time?  How effective is the training? What more needs to be done with training? How are you addressing this at The Spiritual Competency Academy?
7. How would you describe the academic research on protocols/recommendations from 1994 on the DSM IV Code V62:89 up to now in ____2007? (potential court date) In 2022?
8. What does the academic research say about appropriate protocol for patients in spiritual experiences? Appropriate care…Where is the leading research on protocol being supported?

Informing the court of the DSM-IV Code V62:89  1994  & expertise in this area. GENERAL background. We do not address DSM V because I think that was 2013.

Dr. Luke Davidson’s personal spiritual experience in the 1970s is shown as a scene outside court in a private conversation if given permission by Dr. Lukoff.

Dr. Davidson: (credit to & to obtain permission from Dr. Garbe on Assessing for Spiritual Emergency | Spiritual Emergency) The proposal for this diagnostic category was specifically aimed to increase the competence and sensitivity of mental health professional to spiritual issues, based on:

• The high prevalence of religious and spiritual problems reported by the public.
• The lack of training of clinicians in religious or spiritual issues.
• An ethical mandate (1994) for institutions to provide training in social and cultural factors that may affect assessment and treatment pertaining to these issues.

• Judith Miller Ph.D., a professor of developmental psychology at Columbia University, has spent her life and career bridging the two worlds of mainstream psychology and spirituality. More than twenty years ago, Judith began to have spontaneous mystical experiences that ultimately led to experiences of Christ Consciousness. There was nothing in her background that prepared her for these experiences: she was a traditionally trained psychologist working clinically with persons diagnosed psychotic and schizophrenic, an agnostic, and a Jew. A search for an explanation led to her discovery that all spiritual traditions have the same mystical roots and meaning

Peggy Lesniewicz, MA, PhD, LPCC-S

Ever since the term Spiritual Emergency was coined by Stan and Christian Grof, this phenomenon has mostly been studied within the framework of Eastern religious practices. The mainstream Western Christian religion, largely ignoring mystical experiences, has been unaware of spiritual emergency, leaving the job of helping those persons having these experiences to mental health professionals who may pathologize this experience.

Expert MD witness: We may change this to a new MD.

An emergency room doctor and university researcher as portrayed by Dr. Graham Daniels (Dr. Daniel Ingram).

1. Dr. Daniel, will you tell the court your medical credentials & medical background?
2. How long have you practiced medicine and where?
3. Is it true that you are recognized as a…published articles in…are an active member in…
4. So you were an Emergency Room Attending physician at Huntsville Hospital in Alabama during the period of July 2006 to March 2018.  
5. How did you use this V code when you were the Emergency Room Attending physician at Huntsville Hospital?
6.  Even though patients entering the ER present with mental disorders but also present with spiritual language and behaviors….you did not admit them to the psychiatric ward. What were the treatment protocols for these patients and how would you describe the success rate of these patients…reintegrating into functional life after release? What does the research state on requirements for successful reintegration when a patient goes through a spiritually transformative experience?
7. To what extent to you notice medical/psychological/psychiatric professionals in the ER use the V code modifier to ask questions to the patient about their cultural/spiritual frame of reference…. determine diagnosis?
8. To what extent is the V code modifier in the conversation with the medical team when determining diagnosis…treatment…protocol?
9. What is the role of an Emergency Room Attending physician in patients presenting with psychological issues?  
10. What is the role of the emergency room psychiatrist? How did you interact with the emergency room psychiatrist who is responsible to evaluate, diagnose & prescribe the treatment plan?  How did you interact with the intake nurse….to steer the care & treatment direction of the patient being admitted?  What is the intake nurse’s role? What is your typical interaction with the intake nurse?
11. During your time as an Emergency Room Attending physician how many patients who presented with mental disorders also present with spiritual language & spiritual experiences? How many of those with presenting spiritual experiences were admitted to the psychiatric ward?  Would you differentiate between spiritually transformative experiences (STE) & a mental illness or psychotic episode/…..?  How did you differentiate in your patients? When someone presents with STE language/behavior how common is it to also observe psychotic symptoms? How common is it to hear patients experiencing a psychotic episode to talk of God or a Higher Power?
12. How do you differentiate between STE & psychotic episodes to determine the appropriate protocol?
14. Is there sufficient direction for a medical doctor, intake nurse or psychiatrist (to follow a basic protocol that respects the intent of the V code as it is currently documented in the DSM & offer a patient presenting with spiritual issues a protocol that includes a holistic and spiritual treatment plan that does not always require pharmaceutical anti-psychotic drugs and hospitalization? 
15. Dr. Daniel you have reviewed the medical records of Anna Biltmore.
16. Dr. Daniel you have a copy of the medical report on Anna Biltmore who was involuntarily committed to the ________ Psychiatric Hospital in NJ from June 26, 2005 to July 11, 2005. (true story:  2005) You have also interviewed Anna Biltmore extensively. You have studied her long history of normal functioning before and normal functioning after being released. You have had your team fact check the statements in her medical report & they have been verified by….
17.  Dr. Daniel you have never heard of a patient providing DSM research while inside the psychiatric institution.  Correct? (Cut to scene in Spy in the House of Crazy where Anna Biltmore is sharing her research with her doctor.)
18. Dr. Daniel in your interview with Anna Biltmore & the medical team who treated her during those 11 days you verified that Anna Biltmore gave the medical team & specifically Dr.Nanjami a copy of her research which included the DSM-IV V code.  Dr. Nanjami admitted that he held a conversation with Anna Biltmore in her room took a copy of her research to share with the medical team. You also verified that Anna Biltmore requested to be treated from this V code protocol. What would you do if a patient handed you research from the DSM resource of your profession?  Dr. Nanjami handed back her research the next day and said nothing to acknowledge its value.  What would you say to Dr. Nanjami if you were his supervisor who is reviewing his records of meeting with Anna Biltmore?
19. Anna Biltmore knew that she was required to take at least 1 of the many psychotropic  medicines prescribed for what she knew was a mislabel as Bipolar.  She requested to be given ¼ of the Lithium dose knowing she did not want or need any Lithium. She knew of the detrimental side effects of Lithium.  Dr. Nanjami refused to lower her Lithium dose even though Anna Biltmore presented a historical fact that some 25 years before when also misdiagnosed…her psychiatrist agreed that she functioned well under the therapeutic dosage of ¼ Lithium pill. This is a copy of Anna Biltmore’s research along with the medical records of her prescribing psychiatrist from 1979. What would you do if a patient told you of this history and requested a lower than therapeutic dosage of Lithium? Would you fact check the notes of her previous prescribing psychiatrist in regard to lower dosage of Lithium?
20. Hard to get an MD prescribe lower dose. (Cut to true life scene in 2020 but set it in 2006: JayJay was hospitalized from a Spiritual Emergency. Family insisted JayJay not be medicated & called in her former psychiatrist who also insisted that JayJay not be medicated or offer reduced meds based on history of being overdosed.)
21. Was there anything that Anna Biltmore said or did that might have raised questions in the minds of the medical team as to which protocol to be applied?  To fact check?Ie. Anna do you sense a spiritual experience…..what is your religious orientation?
22. Specific things anna said or did that should have triggered Spiritual/Religious problems questioning & treatment..…..see Anna’s testimony…
23. Then ask Daniel what questions should the treating physician have asked Anna.
24. Given Anna’s presentation which indicated a clear spiritual experience based on xyz.
25. What do you notice about the traditional cocktail of multiple drugs pushed on patients presenting with psychotic symptoms? POST Anna’s list of medications)

ORIG DRAFT Witness stand recording/Prep of expert witness prior to witness stand: 

Notes: differentiate Treating physicians & expert physicians.   

Do a deposition. Get a printed copy of deposition & hand in at trial.

A full process with experts going into trial.  All parties agree.

NOTE

I think it will be important to really unpack the use of the V-code, as it is a very complex issue. For example, I know highly ethical psychiatrists who are well aware of the code and do not use it, for various reasons including insurance. So, in such cases, the clinician may not use the code in order to protect the patient and ensure they can receive insurance. Of course, there are other reasons for it to not be used, and some of these reasons may be more sinister. But I think it is important not to assume that clinicians are being unethical for not using the code. The problem, as I see it, is more about the uselessness of the code and its practical implications, despite the best intentions of its authors and champions. That is, unless there is a clear incentive to use the code, which there generally is not, clinicians will not use it. This needs to be thoroughly unpacked. Kylie.

NOTE:  Janet’s point is the training in awareness & acknowledgement/conversation with the patient that a spiritual frame of reference will aid in treatment. So even if the V code is not used for diagnosis it should be used in treatment/protocol.

NOTE: dsmrsproblem.pdf (spiritualcompetency.com)

Traditional neglect of the issue of spiritually has led to five broad areas of failure: occasional devastating misdiagnosis; not in frequent mistreatment; an increasingly poor reputation; inadequate research and theory; and a limitation of psychiatrists’ own personal development. As a result, research on both psychopathology and mental health has largely ignored religion. Larson et al. Systematic analysis of research on religious variables in four major psychiatric journals, 1978-1982 Surveys conducted in the United States consistently show a “religiosity gap” between the general public and patients who in many surveys report themselves to be more highly religious and to attend church more frequently than mental health professionals. And studies of training for psychologists and other mental health professionals show that despite the importance of religion and spirituality in most patients’ lives, adequate training is not provided by most graduate programs and internship sites to prepare them to deal with these issues. (For a review see Lukoff D, Lu F, Turner R. Toward a more culturally sensitive DSM-IV: Psychoreligious and psychospiritual problems). The pathologizing and ignoring of religion and spirituality has also resulted in clinical insensitivity towards individuals who present with religious and spiritual problems and issues.

V62.89: This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of other spiritual values which may not necessarily be related to an organized church or religious institution. (American Psychiatric Association, 1994, p. 685) Articles on this new category appeared in The New York Times, San Francisco Chronicle, American Psychiaric Association Psychiatric News, and the American Psychological Association Monitor, where it was described as indicating an important shift in the mental health profession’s stance toward religion and spirituality.

According to the American Psychological Association Ethical Principles of Psychologists and Code of Conduct, psychologists have an ethical responsibility to be aware of social and cultural differences that impact treatment. Section 1.08 Human Difference states, Where differences of age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, or socioeconomic status significantly affect psychologists’ work concerning particular individuals or groups, psychologists obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals. Ignorance, countertransference, and lack of skill can impede the untrained psychologist’s ethical provision of therapeutic services to clients who present with religious or spiritual problems. Differential diagnosis require knowledge of the patient’s religious subgroup and/or the nature of acceptable expressions of subculturally validated forms of religious expression. Allen Bergin (1980)[4] wrote in the American Psychologist, Psychologists’ understanding and support of cultural diversity has been exemplary with respect to race, gender, and ethnicity but the profession’s tolerance and empathy has not adequately reached the religious client. (p. 95) In contrast to psychiatric residency training where the Accreditation Council for Graduate Medical Education in 1995 issued “Special Requirements for Residency Training in Psychiatry” that mandates instruction about gender, ethnicity, sexual orientation, and religious/spiritual beliefs, such training is not specifically required in psychology.

• Brief scene; stipulation between parties. DSM IV…standard all doctors need to follow in diagnosing. Diagnosing not treatment manual. Standard of care.  How that patient presents/responds to treatment.

• Look at all symptoms. Treatment & id deviations for standard of care at this time. Battle of the experts.  Which would be good to show anyway. 
• The problem:  research re right thing to do. Standard of care behind the research.  MD have a duty to keep up with research.