Forensic Psychiatry in the Nordic
countries
Iceland, problems or possibilities
Sigurður Páll Pálsson MD PhD
Problems or possibilities
• History: The first inpatient unit for forensic psychiatric patients was
established in 1992. Before that time these individuals were placed in
farms, prisons but for some years before 1992 they were sent to Sweden,
Västervik (Bogi Melsted).
• Administered by the department of Justice the first years but since 2002
the department of Welfare became responsible*
• In 2009 the forensic unit was finally made part of the psychiatric section of
Landspitali-University Hospital*
• We have 7 beds and the ward is located 45 km from Reykjavik called Sogn í
Ölfusi.
• Approximately 0-2 patients are sentenced each year (pop. Iceland
318.452).
• Deaths caused by murder or by physical assault, mean = 2 each year in
Iceland.
• range 0-6 *
Problems or possibilities
• Legal system:
• If a patient is judged unaccountable by reason of insanity (severe
mental disorder) the court has to rule the patient innocent of his
crime and no punishment is possible.
• In another verdict the court decides on his placement. Usually this
is Sogn if it is a serious crime like murder but placement can be in
another facility depending on the case.
• The laws concerning forensic psychiatric patients are since 1940 in
the General Penalty Act (similar: “Brottsbalken”, Sweden).
• No special law exists.
• Patients can after one year get their case revalued by the court.*
• The court can then oppose or rule for release with special
restrictions or none at all. In this court the judges are 3 one of them
a psychiatrist.
Problems or possibilities
• Outpatients are now 5 (6).
• Outpatient unit part of our general outpatient unit at Kleppur
• When a patient is permitted by the court to be released the court sets up
different but usually strict follow-up criteria:
• 1) Concerning use of illegal drugs and alcohol, regular monitoring
• 2) Regular visits to the psychiatrist or other health professionals
• 3) Patients if needing antipsychotics has to follow the psychiatrist advice,
concerning medication.
• 4) Time-frame for our supervison, surveilance*
• 5) In these sentences, court ruling, usually demanded that the patient will
be sent back to Sogn if not compliing.* Or if become mentally ill again,
threatening or thought to be dangerous again
In essence the old verdict for forensic psychiatric ward is demanded to be
re- initated as stated in the release verdict. Release verdict expires.
The problems
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Small unit, old unit, no unit in Reykjavik
We have still no step down units
Housing after discharge, service units lacking
The rehabilitation process versus security aspects
How the courts understand these cases
How the public understands our cases
How psychiatric investigations are conducted*
• The meaning of ,,insanity” and thus
unaccountable
Problems or possibilities
• Most penal codes include a requisite of accountability for a person to
be considered legally responsible for his or her deeds.
• Accountability is usually defined in terms of the M'Naghten rules that
state that in order to be legally responsible for a criminal act, the
perpetrator must have:
(i) known what he was doing, and (ii) known that what he did was wrong
• No person is criminally responsible for an act committed or an omission
made while suffering from a mental disorder that rendered the person
incapable of appreciating the nature and quality of the act or omission or
of knowing that it was wrong
• A person must also be able to control his or her actions.
• The offender is not criminally responsible if at the time of the act, due to
mental illness, severe mental deficiency or a serious mental disturbance
or a serious disturbance of consciousness, thus is not able
to understand the factual nature or unlawfulness of the act, or his/
her ability to control his/her behaviour is decisively weakened
Laws, codes concerning forensic psychiatry in Iceland !!
•
15. gr. Þeim mönnum skal eigi refsað, sem sökum geðveiki, andlegs vanþroska eða hrörnunar, rænuskerðingar
eða annars samsvarandi ástands voru alls ófærir á þeim tíma, er þeir unnu verkið, til að stjórna gerðum sínum.
The offender is not criminally responsible, will not be punished if at the time of
the act, due to mental illness, severe mental deficiency or a serious mental
disturbance or a serious disturbance of consciousness, thus was not able to
control his/her behaviour
•
16. gr. Nú var maður sá, sem verkið vann, andlega miður sín, svo sem vegna
vanþroska, hrörnunar, kynferðilegs misþroska eða annarrar truflunar, en þetta
ástand hans er ekki á eins háu stigi og 15. gr. getur, og skal honum þá refsað fyrir
brotið, ef ætla má eftir atvikum og eftir að læknisumsagnar hefur verið leitað, að
refsing geti borið árangur
If mental state milder than 15, medical evaluation concerning if prison sentence
does have any purpose
Laws, codes concerning forensic psychiatry in Iceland
• 62. gr. Nú er maður sýknaður samkvæmt ákvæðum 15. gr., eða niðurstaða dóms verður sú, samkvæmt
ákvæðum 16. gr., að refsing sé árangurslaus, og má þá ákveða í dómi, ef nauðsynlegt þykir vegna réttaröryggis, að
gerðar skuli ráðstafanir til að varna því, að háski verði að manninum. Ef ætla má, að vægari ráðstafanir, svo sem
trygging, bann við dvöl á ákveðnum stöðum eða svipting lögræðis, komi ekki að notum, má ákveða, að honum sé
komið fyrir á viðeigandi hæli…
• Says what the court can do if the individual is jugded unacountable
Prevent the individual to become dangerous but the mildest
alternative should be used. Example insurance, forbidden to go to
some places or use the law concerning statutary
In the serious cases send to an institution
• 17. code says act under influence of alcohol or drugs should be
punished for
Possibilities
• Statutable, statutory
• Special law in Iceland, “Lögræðislög”
• In these laws given possibilities to bring mentally ill to
hospital for treatment
• Since 2004 a special unit for those patients needing
longer stay than some weeks
• Postive experience having a special unit for these
individuals. Clinically similar as those that come to
Sogn.
• CBT used, special emphasis in most cases on drug
abuse problems* Observation usually makes things fall
into place.
It is worth the effort
• Since 1992, 47 individuals* have been
admitted to Sogn
• None has yet committed a serious crime
again!
• Two have commited suicide and one died of
natural causes