Introduction
to
Forensic Psychiatry
World Psychiatric Association
Scientific Section Forensic Psychiatry
Secretary: Prof. Birgit A. Völlm
Definition
“Forensic psychiatry is a subspecialty of psychiatry in
which scientific and clinical expertise is applied to legal
issues in legal contexts embracing civil, criminal,
correctional or legislative matters; it should be practiced in
accordance with guidelines and ethical principles
enunciated by the profession of psychiatry.”
(American Academy of Psychiatry and the Law Ethical Guidelines)
“Interpreters of medical and psychological findings into
language which judges, attorneys and administrators and,
in common law jurisdictions the ‘common man’, can
understand and to which they can apply their rules.”
(Nedopil 2009)
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What do forensic psychiatrists do?
• Assessment of mentally disorders offenders
• Expert witness
- Civil
- Criminal
• Advice to general psychiatrists and other professionals
• Treatment of mentally disordered offenders
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Mental disorder and offending
• Methodological issues: follow up, time at risk, self report,
etc.
• Modest association between mental illness & violence
• Patients with schizophrenia particularly at risk
• Life time risk of violence in people with schizophrenia is
3 - 5 X that of general population
• But: risk is markedly higher among people with
substance misuse disorders and antisocial personality
disorder
• Factors associated with violence are the same in people
with mental illness than in those without
• Majority of people with mental illness are never violent
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Why does this link exist?
• Factors pre-dating onset of active symptoms
-
Childhood factors: upbringing, neglect, abuse
Antisocial traits
Poor social skills
Poor education
• Factors arising as a direct result of symptoms
-
Particular symptoms, e.g. delusions, hallucinations
• Factors arising as a long-term consequence of illness
-
Stigma
Social exclusion
Unemployment
Deterioration of social skills
Substance misuse
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Legal proceedings and mental disorder
• Pre-trial
– Person may not be fit to be interviewed
• Fitness to stand trial
– Person may not be able to participate in the trial
• Fitness to plead
– Person may not be able to follow the court proceedings
• Sentencing
– ‘Psychiatric defences’ – e.g. milder sentencing due to
mental disorder
• Most systems allow ‘diversion’ away from legal process
to health setting for mentally disordered offenders
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Fitness to plead
• Concerns accused mental state at time of trial
• Current mental state would not allow person to conduct proper
defence
• Defendant due to mental disorder not able to
-
Understand the charge
Enter a plea (guilty or not guilty)
Follow course of trial
Instruct legal advisors
Challenge jurors
• If found unfit to plead may be diverted to hospital system or
acquitted
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Mens rea
• Actus reus non facit reum nisi mens sit rea = “The act is
not culpable unless the mind is guilty"
• I.e. a ‘guilty mind’ (mens rea) is a prerequisite of
responsibility for a crime and so to be punished
• Individuals with mental disorders may not have mens rea
due to mental state at the time of the offence
• Different levels of mens rea:
– Intent: wants consequence to happen
– Recklessness: foresees consequence, taking risk
– Negligence: does not foresee or desires consequence but
should have done
– But: accident: would not have been possible to predict the
outcome; no guilt
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Insanity
• Every person is presumed to be sane, unless the
contrary is proved
• Punishment requires ‘guilty mind’, i.e. ability to form
intent to commit crime
• Someone with severe mental disorder may be ‘insane’,
i.e. not guilty due to their disorder
• McNaughten rules for insanity – used in common law
countries - At the time of the act the defendant was:
– “labouring under defect of reason, from disease of the mind, as
to not know the nature or quality of the act he was doing, or, if he
did know it, that he did not know that what he was doing was
wrong”
• Usually associated with severe mental illness Schizophrenia, Bipolar Disorder
• Can result in diversion to hospital or absolute discharge 9
Issues in the role as expert witness
• ‘Dual role dilemma’ (e.g. psychiatrist has responsibility
towards offender patient and society, i.e. court,
protection of public)
• Not usual doctor – patient relationship
• Limitations of confidentiality
• Only advice not decision making
• Translation of concepts
• Expertise potentially leading to adverse outcome to the
offender patient, i.e. admission to secure hospital
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Risk assessment
• Part of all forensic-psychiatric assessments
• Risk domains, e.g. risk
- To others
- To self
- Risk of violence
- Sexual risk
• Time frame of risk
• Short term – easier to predict
• Longer term – much more difficult to predict
• Static – dynamic risk factors
• Static – won’t change, e.g. male gender
• Dynamic – can change, e.g. symptoms of disorder
• Aim to develop risk management plan, not just to make
predictions
• Accuracy limited – false positives and false negatives
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• Risk cannot be eliminated
Prison psychiatry
• Prevalence of mental disorders high
• More MDOs in prison than in psychiatric institutions
• Assessment of prisoners
- Advice to transfer to treatment institutions
• Issues with transfer to psychiatric institutions
- Identification of cases
- Delays
- Highly dependent on systems available in country
• MDOs in prison system
- Is it ever appropriate?
- Ill people need to be in hospital? Depends on
criminal responsibility?
- Equivalence of care
• High risk of reoffending
- Higher than after forensic-psychiatric treatment
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