Beyond DSM-5 and IQ Scores: Integrating the Four Pillars to Forensic Evaluations

The current adult and child forensic psychiatrist is well trained, familiar, and comfortable with the use of the semi-structured Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, APA 2013 (DSM-5) [In APA, 2003] interview style. The author's assertion is not that this method is invalid or unreliable; rather, that it can be complemented by integrating elements of the defendant's four pillar assessment. Assessing the four pillars expands on the information provided by a semi-structured DSM-5-style interview in psychiatry. The four pillars are the foundation of a person's personality; temperament, cognition (learning abilities or weaknesses), cognitive flexibility (theory of mind) and internal working models of attachment, within the backdrop of the family and of the social and cultural environment in which they have lived. The importance of the study of four pillars is based on the understanding that human behavior and psychopathology as a complex and multifaceted process that includes the level of social-emotional maturity and cognitive abilities (In Delgado et al. Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015). The four pillars are not new concepts, rather they had been studied by separate non-clinical disciplines, and had not been integrated to the clinical practice. As far as we know, it wasn't until Delgado et al. (Contemporary Psychodynamic Psychotherapy for Children and Adolescents: Integrating Intersubjectivity and Neuroscience. Springer, Berlin, 2015) incorporated the four pillars in a user-friendly manner to clinical practice.