Myth #1: No History of Mental Illness = No Mental Illness

Mental illness alone does not render a defendant incompetent. However, mental illness can undermine communication, understanding, and/or the ability to assist counsel. Because mental illness can come with poor insight, or a lack of understanding that something is wrong, people may not report mental health problems or may not have a history of seeking out care/receiving a diagnosis. Populations over-represented in the criminal justice system face heightened stigma and myriad barriers to care. Just because someone has no prior diagnosis or history of mental health treatment, does not mean they have no problem. In fact, the population’s social determinants of health greatly increase their risk of mental illness. 

Myth #2: Odd or Disruptive Courtroom Behavior Equals Incompetence

There is a difference between someone being unwilling to participate in their defense and being unable to do so. Defiant or disruptive behavior may reflect personality traits, the transient effects of substance use, malingering, or situational stress. Courts and evaluators must distinguish between uncooperative behavior and true functional impairment rooted in mental illness or cognitive limitations relevant to competency.

Myth #3: No History of Intellectual Disability or Learning Disorders = No Problem

The population over-represented in the criminal justice system often attended underfunded schools, has limited formal education – or both. Additionally, people with Intellectual Disabilities and Learning Disorders are over-represented in the criminal justice system, making these issues highly relevant in the criminal court context. While a prior diagnosis of Intellectual Disability or Learning Disorder is clear evidence that these conditions are present, the lack of prior diagnosis is not clear evidence that they are not.  

Myth #4: Competency Evaluations are Straightforward

While the legal standard may appear straightforward, competency evaluations can be very complex. Clients may present with limitations from cognitive issues, manifestations of trauma, impacts from neurodevelopmental disorders or symptoms of untreated/under-treated symptoms of mental illness. Symptoms overlap, interact and fluctuate. And the degree of impairment is not able to be determined based on diagnosis alone. Further, malingering must also be considered.  Oversimplifying competency can lead to flawed conclusions that result in violations of a defendant’s right to effectively participate in their defense. 

Myth #5: Competence Restoration = Treatment and Rehabilitation

Competency restoration is short-term, focused, and, especially when hospitalization is involved, very expensive. Defendants may regain competency through treatment, education, or stabilization, but the process does not allocate resources or develop plans for the individual’s ongoing care. This can contribute to a cycle of short term restoration, deterioration in the correctional facility or community, then re-evaluations of competence. If the goal is to facilitate successful societal re-entry or decrease recidivism, competency restoration alone is not the path.

Myth #6: Competency Evaluations Are All the Same

Not all evaluations are equal. In some cases, evaluators are paid by evaluation, potentially incentivizing quantity over quality. Further, when evaluations are not trauma-informed or lack structural or cultural competence, key considerations may be overlooked. Further, inadequate use of  collateral data and/or testing in relevant cases may result in insufficient information for a strong expert opinion. Relying on assumptions or incomplete evaluations can expose the integrity of the court process to avoidable risk.

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A fluent Spanish speaker, Dr. Izenberg earned his medical degree from the Yale University School of Medicine and completed his psychiatry residency at the University of California, San Francisco (UCSF). He went on to become a Public Psychiatry Fellow of the American Psychiatric Association, further strengthening his expertise in working with vulnerable and underserved populations.

Currently, Dr. Izenberg serves as Clinical Assistant Professor of Psychiatry and Behavioral Sciences at UCSF, where he provides direct psychiatric care in the San Francisco County Jail and the San Francisco General Hospital Psychiatric Emergency Service. His daily work includes assessing individuals in high-stakes, high-pressure environments—skills directly transferable to forensic evaluations in the legal arena. His focus on recovery and re-entry also equips him to provide valuable insights into risk assessment, mitigation, and rehabilitation potential.

Beyond clinical practice, Dr. Izenberg is deeply engaged in quality improvement, policy development, and teaching. His research explores the intersection of incarceration, mental health, and disparities—topics often central to legal arguments around culpability, mitigation, and competency. His published work on issues such as HIV in incarcerated populations, police practices, and community health shifts underscores his ability to analyze complex systems and communicate findings with clarity. Legal teams presenting psychiatric evidence in court will find a tremendous asset in Dr. Izenberg.

With his rare combination of academic rigor, clinical expertise, and first-hand experience in correctional settings, Dr. Izenberg enhances Lorio Forensics’ capacity to provide credible, insightful, and persuasive forensic evaluations to both prosecutors and defense attorneys. We are honored to welcome Dr. Izenberg to the firm and look forward to the significant value he will bring to our clients.

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1. Forensic Expert Work and Clinical Expertise are Related – but Distinct

Though strong clinical and evaluation knowledge are foundational for forensic mental health expertise, not every strong clinician is a strong expert. Treating clinician and mental health expert/consultant are two distinct roles. Notes and documentation for patient charts are very different than mental health expert reports. And questions and interview techniques for diagnosis and treatment of illness will be insufficient for answering most forensic questions. Forensic training, experience and/or access to supervision by experienced experts are all critical and your hire should understand these distinctions. It’s imperative that they possess the required skill set and supports to be an asset to your team. 

2. Professional Degrees Only Tell You So Much

Different cases may require that the expert has advanced study, scholarship, or clinical experience with certain populations, diagnoses, and/or social determinants of health. Mental health professionals often have areas of specialization or pockets of clinical experience. Thus you can only get so far just knowing if they are a psychologist, psychiatrist or social worker. Whether the question is one of competence to stand trial, criminal responsibility, mitigation, psychic injury or fitness-for-duty, knowing someone’s professional designation isn’t enough to know if they’re a good fit. The forensic question and client’s background should inform a  detailed review of the potential experts’ scholarship, clinical experience, and areas of study. In doing so, legal teams can ensure the clinician’s training and case history align with the case needs.

3.Assessing the Expert’s Objectivity is Important

Hired guns hold little credibility with courts. Your team is best served by an expert who can help your team identify your case’s strengths and vulnerabilities, whose opinion is defensible, and who reviews relevant information before making conclusions. Attorneys should be cautious of experts who promise a favorable opinion or can not acknowledge multiple sides of a case.  A skilled forensic expert understands their role is to assist the trier of fact by providing a credible professional opinion – not retrofitting their finding to what the hiring attorney wants. 

4. Past Work is the Best Predictor of Future Report Quality

In most cases, the expert report is the primary, or even only, forensic mental health consultation product. A strong expert should reliably produce reports that are clear, well-organized, grounded in data, and effective in conveying issues relevant for the court’s consideration. Legal teams often attempt to extrapolate what the report quality may be from an expert’s resume or an initial phone call. While this may provide some helpful information, the best predictor of future report quality is past report quality. Requesting redacted reports in similar cases is an under-used vetting method by legal teams.

5. Evaluating Courtroom Experience and Communication Skills

Even the most impressive credentials can fall short if testimony is required and the expert cannot explain opinions clearly in deposition or open court. Attorneys should inquire about testimony experience, comfort with cross-examination, and ability to communicate complex mental health concepts in plain language. Testimony is, in effect, teaching.  Does the expert have experience with transmitting information verbally to a lay audience in classroom, community or court settings? And how do they do when respectfully challenged by the legal team?

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Dr. Starks’ career spans both medicine and policy. He earned his medical degree from Louisiana State University Health Sciences Center, completed a psychiatry residency at Baylor College of Medicine, and pursued a clinical fellowship in geriatric psychiatry at Yale University. Beyond the clinic, Dr. Starks served as a Health and Aging Policy Fellow in the Office of the Speaker of the U.S. House of Representatives and an American Political Science Association Congressional Fellow during the 116th Congress — giving him a rare understanding of how systems, law, and policy intersect with mental health care.

This blend of clinical and policy insight makes Dr. Starks an invaluable expert in cases where psychiatric complexity, cognitive decline, dementia, or testamentary capacity are at issue. His extensive medical scholarship — covering addiction, the opioid crisis, dementia, and the use of antipsychotic medications — underscore his authority on conditions frequently central to competency, capacity, and culpability evaluations.

Dr. Starks’ experience includes service with the Veterans Administration, academic appointments at Baylor College of Medicine and the University of Houston’s Tilman J. Fertitta Family College of Medicine, and leadership roles on advisory boards such as the Alzheimer’s Association, NAMI Greater Houston, and the National Committee for Quality Assurance’s Geriatric Measurement Advisory Panel.

Dr. Starks offers attorneys expert evaluations and testimony rooted in scientific rigor, compassion, and a nuanced understanding of how mental health influences behavior, judgment, and accountability. His presence strengthens our mission to deliver credible, defensible, and clinically sound forensic assessments to both defense and prosecution.

We are honored to have Dr. Starks join our team and confident that his expertise will be a tremendous asset to our attorney partners navigating complex mental health cases.

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The presence of psychoactive substances of abuse can shape nearly every stage of a case. For defendants, substance use may contribute to the behaviors that led to their arrest, and it often affects their decision-making capacity, impulse control, and judgment. For courts and prosecutors, this creates a challenge: balancing accountability for criminal conduct with recognition that untreated substance use disorder, colloquially often referred to as addiction, is a medical condition requiring intervention.

Most people who use addictive substances do not become addicted to them. But there are some notable exceptions. Research consistently shows that individuals exposed to trauma are far more likely to progress from substance use to the development of a substance use disorder, which are often colloquially referred to as addiction. A national epidemiological survey found that people with post-traumatic stress disorder (PTSD) are up to four times more likely to meet criteria for substance dependence or abuse compared to the general population. And Adults with any history of Adverse Childhood Experiences (ACEs) have a 4.3 fold higher likelihood of developing a substance use disorder. 

Unfortunately, many accused individuals face harsher outcomes precisely because their substance use, and its drivers, are misunderstood or underappreciated. Without proper evaluation, a defendant’s addiction history may be seen only as a character flaw, rather than a diagnosable and treatable illness or an outward manifestation of unresolved trauma. This gap can lead to missed opportunities for diversion programs, mitigation at sentencing, or treatment options while incarcerated or under court supervision that could change the trajectory of a person’s life.

An exploration and understanding of the substance use, trauma, and criminal justice interplay is essential for any criminal case substance use is an issue.  With our holistic approach to evaluation, Lorio Forensics clinicians are primed to appropriately evaluate for these factors. Additionally, our team features two psychiatrists who are boarded in addiction psychiatry: Michelle Durham, MD (Texas based) and Billina Shaw, MD (Maryland based). They have additional training and have successfully completed a national board exam demonstrating their knowledge in deciphering the complex relationship between substances, trauma, and observed behaviors. 

Dr. Billina Shaw, MD

Dr. Michelle Durham, MD

Attorneys who leverage this expertise are better positioned to advocate effectively—whether that means supporting effective accountability measures or ensuring treatment is prioritized when appropriate. As the criminal justice system continues to grapple with the pervasive role of addiction, high-quality forensic evaluations become increasingly essential. Lorio Forensics offers demonstrable, highly-relevant expertise through a comprehensive evaluation and consultation process.

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The nature of grief can change drastically when the loss is sudden, violent, or traumatic. Research shows that individuals who lose loved ones to homicide, suicide, or accidents face a dramatically higher risk for mental health complications: Post-Traumatic Stress Disorder (PTSD) affects up to 52% of people bereaved by violent death. Complicated Grief—now formally recognized as Prolonged Grief Disorder (PGD)—affects up to 78% of this population (Rynearson et al., 2011). This kind of grief is characterized by unrelenting sorrow, anger, and difficulty finding meaning in the loss. In cases of homicide, survivors often report a deep sense of injustice, which can further intensify feelings of rage and retribution. These emotions, when left unaddressed, may evolve into actions that would otherwise be uncharacteristic for the individual. 

Rage, Retribution, and Loss of Control Grief—especially when sudden and unjust—can provoke intense anger. In homicide-bereaved populations, researchers have observed high levels of resentment, especially when survivors feel the justice system has failed them. In some instances, this rage becomes externalized through acts of violence or property damage, or internalized through substance abuse or self-harm. One longitudinal study even found reciprocal links between prolonged grief and anger, indicating that unresolved mourning can perpetuate a cycle of destructive emotion that leads to impulsive, and sometimes criminal, behavior (Psychological Medicine, 2023).

In a society where services can be difficult to access due to personal stigma and structural barriers, many individuals turn to drugs or alcohol to numb the pain of grief. Unfortunately, substance use can impair judgment, lead to dependency, and contribute to secondary criminal behaviors such as theft, assault, or impaired driving. The National Institutes of Health notes that the bereaved often experience increased risk for substance abuse when they lack proper support or therapy (NIH, 2012). It should be noted that grief isn’t a one-time event. For those who are incarcerated or system-involved, grief can be cumulative—stemming from the deaths of family members, estrangement from children, or even the symbolic loss of identity and autonomy. Recent research describes this phenomenon as “cumulative grief,” and it plays a role in reentry struggles and recidivism (Ward et al., 2024). 

These layers of unprocessed grief create fertile ground for behavioral relapse and can make reintegration into society difficult without clinical or community-based intervention. 

Prosecutors often represent victims and their families—but they must also weigh the emotional and psychological backgrounds of defendants. Understanding the role grief may have played in a criminal act allows for more nuanced decisions about charging, plea bargains, or sentencing. Further, it can inform risk assessment and re-entry planning. Prosecutors can also benefit from recognizing the frustration grieving families may feel toward the court process itself, helping to reduce potential conflict and confusion during trial. In some cases, prosecutors may consider restorative justice pathways when grief, not criminal inclination, appears to be the primary driver of the behavior. 

For defense attorneys, understanding the grief history of a client can be vital when building a mitigation narrative. Judges and juries may better understand the motives behind impulsive or destructive acts when framed within the context of trauma and loss. It may be helpful to request a mental health evaluation that screens for Prolonged Grief Disorder. It may also be possible to 

present expert testimony to establish links between grief, trauma, and behavior. In many cases it may be helpful to recommend therapy and community-based grief support as part of sentencing or probation terms. This not only humanizes the defendant but also opens the door to rehabilitative, rather than punitive, outcomes. 

Grief is not just a private emotion, but a public driver of behavior. Whether you’re defending someone facing serious charges or representing the interests of the state, understanding the psychological terrain of grief adds clarity and compassion to your role.

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Dr. Shaw is the Founder and CEO of ViCat Consulting, where she focuses on child, adolescent, and adult psychiatry, as well as addiction medicine. She previously served as Medical Director of Prince George’s County Health Department. Dr. Shaw’s federal service includes her role as a Senior Medical Advisor at the Substance Abuse Mental Health Services Administration (SAMHSA), where she was a lead author and medical consultant to several sentinel documents, including the 2023 updates to the Certified Community Behavioral Health Criteria. Dr. Shaw previously served as Clinical Assistant Professor in the Department of Psychiatry at the University of Maryland’s School of Medicine. She also led a Federal Advisory Committee, the Interdepartmental Serious Mental Illness Coordinating Committee, spearheading national leadership for behavioral health strategy for the care of those with significantly impairing psychiatric conditions.

Lorio Forensics boasts an impressive roster of mental health professionals from a variety of professional backgrounds. Dr. Shaw’s extensive contributions to public health are a tremendous value add to our clients, allowing Lorio Forensics to provide a range of insights that few firms can offer.

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Board-certified in Adult Psychiatry, Dr. Aguilera Nunez recently completed a prestigious Forensic Psychiatry Fellowship at the UCLA David Geffen School of Medicine. Her clinical experience spans a wide range of settings, including the West Los Angeles VA Medical Center, where she has provided care for veterans with complex psychiatric needs, as well as community-based programs focused on behavioral health disparities.

In addition to her clinical and forensic expertise, Dr. Aguilera Nunez is bilingual and a native Spanish speaker—a skill that enhances her ability to serve diverse populations with cultural competence and linguistic fluency. With over a decade of professional and academic accomplishments, Dr. Aguilera Nunez is recognized nationally for her leadership and contributions to the field. She is an active member of the American Psychiatric Association and the American Academy of Psychiatry and the Law. Her work consistently emphasizes mental health equity, community engagement, and innovative treatment models.

Dr. Aguilera Nunez brings a thoughtful, evidence-based approach to Lorio Forensics and will be an invaluable asset to our clients and the legal professionals we support. Please join us in welcoming Dr. Aguilera Nunez to the Lorio Forensics family. We look forward to the meaningful impact her expertise will bring to our work and the communities we serve.

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May is National Anxiety Month, a time dedicated to raising awareness about anxiety and its profound effects on mental health. While anxiety can affect anyone, individuals involved in the criminal legal system, be it in criminal or civil court, often experience heightened levels of stress and anxiety that are overlooked. Understanding how anxiety manifests in this context is crucial for legal professionals, mental health providers, and the broader community. 

In criminal matters, the initial encounter with law enforcement can be a significant source of anxiety. Fear of arrest, uncertainty about legal rights, and the potential for confrontation can trigger acute stress responses. Individuals may experience panic attacks, hypervigilance, or dissociation, which can impact their behavior during police interactions. This heightened anxiety can lead to misunderstandings, potentially escalating encounters with law enforcement. 

For incarcerated individuals, the prison environment presents numerous stressors that can intensify anxiety. Overcrowding, lack of privacy, exposure to violence, and uncertainty about release dates contribute to chronic stress. Additionally, the limited access to mental health resources in many correctional facilities means that anxiety often goes untreated. Individuals with anxiety disorders may experience worsening symptoms, including insomnia, irritability, and difficulty coping with the prison environment. 

Reintegrating into society after incarceration presents its own set of challenges. Individuals face obstacles such as securing employment, housing, and rebuilding personal relationships. The stigma of a criminal record and the fear of re-offending or violating parole conditions can cause persistent anxiety. Support systems, including mental health services and community programs, play a vital role in easing this transition. 

Navigating the court system for civil matters is also an anxiety-inducing experience. Both plaintiffs and defendants face uncertainty about court processes and legal outcomes.  Anxiety can impair cognitive functions, making it difficult to participate in interviews, understand legal proceedings, or communicate effectively with officers of the court. For those with pre-existing mental health conditions or prior traumas, the stress associated with the legal process can cause symptoms to worsen or re-appear.  Further, clients often do not fully understand the breadth and depth of personal exposure that comes with bringing a lawsuit with a psychic injury claim. Having to tell of their experiences in high stakes circumstances, with strangers, and under intense scrutiny can be triggering.

To mitigate the impact of anxiety on individuals involved in the criminal legal system, a multifaceted approach is necessary: 

1. Early Intervention: Implementing mental health screenings during initial encounters can identify individuals at risk of anxiety disorders. 
2. Mental Health Services: Expanding access to counseling and psychiatric care within jails and prisons can address acute and chronic anxiety. And for civil cases, maintaining a referral list of local mental health clinicians. 
3. Trauma-Informed Practices: Training law enforcement, legal professionals, and correctional staff in trauma-informed approaches can reduce anxiety-inducing interactions. 
4. Supportive Reentry Programs: Providing comprehensive reentry services, including mental health care and practical support for basic needs, can ease the transition back into society. 

Anxiety is a pervasive issue within the criminal legal system, affecting individuals at every stage of the process. By recognizing the unique stressors faced by those involved in this system and implementing targeted interventions, we can promote mental well-being and foster a more compassionate and effective legal framework.

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May 2 marks Childhood Depression Awareness Day, a vital opportunity to shed light on an often-overlooked issue: the link between childhood depression and juvenile delinquency. While childhood is typically seen as a carefree period, many children grapple with depression, which can manifest externally and be misinterpreted as a mere behavioral problem. Lorio Forensics features a number of clinicians with expertise in child psychiatry, who have extensive experience in diagnosing, treating, and evaluating children with depression, irritability, and acting out behaviors. 

Childhood depression is more than just sadness. It can present as irritability, withdrawal, loss of interest in activities, changes in appetite or sleep, and difficulty concentrating. Without proper recognition and treatment, these symptoms can significantly impact a child’s academic performance, relationships, and overall well-being. When childhood depression goes unaddressed, it can increase the risk of juvenile delinquency. The apathy, short-sightedness and hopelessness associated with the disorder can lead to behaviors such as truancy, self-medication through substance use, and aggressive acts. Frustration and a lack of supportive outlets can also contribute to delinquent acts. 

Early identification and intervention are key. Children who have experienced trauma and who have a family history of depression are at elevated risk. Parents, teachers, and caregivers should be aware of the signs of depression and seek professional support when concerns arise or there are marked changes in a youth’s mood, countenance and/or functioning,. Providing children with coping strategies, therapy, and a supportive environment can address underlying symptoms and prevent an escalation into delinquent behavior. Communities and schools play a crucial role in addressing childhood depression. Promoting mental health education, reducing stigma, and ensuring access to mental health services can make a profound difference. Open communication and empathy are vital in helping children feel understood and supported.

On Childhood Depression Awareness Day, let’s commit to recognizing the signs of childhood depression and understanding its potential consequences. By addressing these issues early, we can support children in leading healthy, productive lives and reduce the risk of juvenile delinquency.

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