FORENSIC PSYCHIATRY:
A State of Mind
Marilou Patalinjug Tyner, M.D., FAPA
Highland Behavioral Health Services
Charleston, WV
FORENSIC PSYCHIATRY
Subspecialty of Psychiatry in which
scientific and clinical expertise is applied
to legal issues in legal contexts
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Private practice
Clinic
Inpatient
Forensic Hospital
Corrections
Academe
Areas of Concern
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Civil
contracts, testamentary capacity, negligence & malpractice, disability
determination, child abuse & neglect, custody issues, etc.
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Criminal
fitness to stand trial, insanity defense, sentencing considerations, issues
in correctional settings, etc.
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Legal Regulation
civil involuntary commitment, confidentiality, right to refuse treatment,
informed consent, ethical guidelines, etc.
Competency
Definition:
Having the mental capacity to
understand the nature of an act
Competency
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Understanding
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Appreciating
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Choosing
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Reasoning
Competency
Decisional capacity is preferred term for
assessment of specific competencies
Declaring a person incompetent is a legal
matter and is decided by a judge
Civil Competencies
Civil Competencies
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Testamentary capacity
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Work ability/Disability
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Family related issues
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Guardianship/conservatorship
Civil Competencies
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Is there a mental disorder?
Does the disorder impair the capacity to
carry out the specific civil function in
question?
Will the disorder be likely to respond to
treatment or intervention?
Testamentary Capacity
Assess the ability to know and understand that:
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The person is making a will
The natural objects of their bounty and
claims upon them
The general nature and extent of their
property
Work ability/Disability
Assessment includes thorough evaluation of:
 Activities of daily living
 Social functioning
 Concentration and memory functionin
 Ability to keep up pace
 Ability to tolerate stress/changes
 Evidence of deterioration of symptoms in
work-like settings
Parenting capacity in Abuse cases
o
o
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Are there specific legal tests in this jurisdiction that
must be addressed?
What mental health issues/factors gave rise to the abuse
or neglect? To what extent have these been treated?
What interventions are needed to improve or maintain
the parent’s functioning?
What is the likelihood of relapse?
What is the likelihood of recurring abuse or neglect?
What are the parenting need of the particular child?
Can the parent meet the child’s needs? How will the
parent carry out essential functions like providing for
child’s safety, basic needs, medical care, discipline,
education, and emotional needs?
What is the nature of the relationship between parent
and child?
-Peter Ash. M.D. in Textbook of Forensic Psychiatry by Robert Simon, M.D. and Lisa Gold, M.D. (editors), 2004
Criminal Competencies
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To
To
To
To
To
stand trial
defend one’s self (pro se)
be a witness
be sentenced
receive death penalty
Criminal Responsibility
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Knowledge of act committed
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Differentiate between right and wrong
Psychiatry in Correctional Settings
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Census: 15,000-17,000
30% homeless prior to
incarceration
75% drug-related crimes
25% have been treated
for mental disorders
75% of those released
will re-offend and will be
back in a year
Rikers Island: NY’s largest jail facility
Psychiatry in Correctional Settings
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Shift from long term psychiatric hospital care to
community based treatment has contributed to the
increase in population of seriously mentally ill in the
jail/prison systems
Civil Commitment
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Dangerous to self or others
Presence of mental illness
Presence of addiction
Presence of both mental illness and
addiction
Civil Commitment
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Police Power of the State
to protect society
issue of dangerousness
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Parens Patriae Power
to address needs of the individual
issue of treatment
Malpractice
D
D
D
D
amages
irect Causation
ereliction
uty
injury
causal relationship
negligence
standard of practice
Treatment refusal
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Informed Consent
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Risks and benefits of treatment
Alternatives to proposed treatment and their
risks and benefits
Risk of no treatment
Assessment of decision making capacity
Becoming a Forensic Psychiatrist
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Degree in Medicine (M.D. or D.O.)
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Residency in Psychiatry
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Subspecialty training in Forensic Psychiatry
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Practice devoted to doing forensic psychaitric
work
Some concerns in the practice of
Forensic Psychiatry
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Delineating clinical work from forensic
work
Time issues
Billing issues
Question of truths
Helpful websites
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www.lawandpsychiatry.com
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www.reidpsychiatry.com
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www.aapl.org
The Four-Step Conceptual
Framework
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What is the specific psychiatric-legal issue to be
considered?
What are the legally defined terms and criteria that will
be used to resolve the specific psychiatric-legal issue?
What information obtained from clinical examination is
pertinent to the legal criteria that will be used to resolve
the psychiatric-legal issue?
How can the available relevant data be applied to the
legal criteria so as to yield a rationally convincing
psychiatric-legal opinion?
Rosner, Principles and Practice of Forensic Psychiatry, 2003