Forensic psychiatry is a subspeciality of
psychiatry
Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders. These include various maladaptations related to mood, behaviour, cognition, and perceptions. See glossary of psychiatry.
Initial psych ...
and is related to
criminology
Criminology (from Latin , "accusation", and Ancient Greek , ''-logia'', from λόγος ''logos'' meaning: "word, reason") is the study of crime and deviant behaviour. Criminology is an interdisciplinary field in both the behavioural and so ...
. It encompasses the interface between
law
Law is a set of rules that are created and are enforceable by social or governmental institutions to regulate behavior,Robertson, ''Crimes against humanity'', 90. with its precise definition a matter of longstanding debate. It has been vario ...
and psychiatry. According to the
American Academy of Psychiatry and the Law
The American Academy of Psychiatry and the Law (AAPL) is a professional organization in the field of forensic psychiatry.
History and organization
AAPL was founded in 1969. It currently has more than 1,500 members in North America and around the w ...
, it is defined as "a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory, or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment." A forensic psychiatrist provides services – such as determination of competency to stand trial – to a court of law to facilitate the adjudicative process and provide treatment, such as medications and psychotherapy, to criminals.
Court work
Forensic psychiatrists work with
court
A court is any person or institution, often as a government institution, with the authority to adjudicate legal disputes between parties and carry out the administration of justice in civil, criminal, and administrative matters in accordance ...
s in evaluating an individual's competency to stand
trial
In law, a trial is a coming together of Party (law), parties to a :wikt:dispute, dispute, to present information (in the form of evidence (law), evidence) in a tribunal, a formal setting with the authority to Adjudication, adjudicate claims or d ...
, defenses based on
mental disorder
A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
s (e.g., the insanity defense), and
sentencing
In law, a sentence is the punishment for a crime ordered by a trial court after conviction in a criminal procedure, normally at the conclusion of a trial. A sentence may consist of imprisonment, a fine, or other sanctions. Sentences for mult ...
recommendations. The two major areas of criminal evaluations in forensic psychiatry are competency to stand trial (CST) and mental state at the time of the offense (MSO).
Competency to stand trial
Competency to stand trial (CST) is the
competency evaluation to determine that defendants have the
mental capacity
Intelligence has been defined in many ways: the capacity for abstraction, logic, understanding, self-awareness, learning, emotional knowledge, reasoning, planning, creativity, critical thinking, and problem-solving. More generally, it can be des ...
to understand the charges and assist their attorneys. In the United States, this is seated in the
Fifth Amendment to the United States Constitution
The Fifth Amendment (Amendment V) to the United States Constitution addresses criminal procedure and other aspects of the Constitution. It was ratified, along with nine other articles, in 1791 as part of the Bill of Rights. The Fifth Amend ...
, which ensures the right to be present at one's trial, to face one's accusers, and to have help from an attorney. CST, sometimes referred to as adjudicative competency, serves three purposes: "preserving the dignity of the criminal process, reducing the risk of erroneous convictions, and protecting defendants' decision-making autonomy".
In 1960, the Supreme Court of the United States in
Dusky v. United States established the standard for federal courts, ruling that "the test must be whether the defendant has sufficient present ability to consult with his attorney with a reasonable degree of rational understanding and a rational as well as factual understanding of proceedings against him." The evaluations must assess a defendant's ability to assist their legal counsel, meaning that they understand the legal charges against them, the implications of being a defendant, and the adversarial nature of the proceedings, including the roles played by defense counsel, prosecutors, judges, and the jury. They must be able to communicate relevant information to their attorney, and understand information provided by their attorney. Finally, they must be competent to make important decisions, such as whether or not to accept a plea agreement.
In England, Wales, Scotland, and Ireland, a similar legal concept is that of "
fitness to plead
In the law of England and Wales, fitness to plead is the capacity of a defendant in criminal proceedings to comprehend the course of those proceedings. The concept of fitness to plead also applies in Scots and Irish law."During the period 1946 to ...
".
As an expert witness
Forensic psychiatrists are often called to be
expert witness
An expert witness, particularly in common law countries such as the United Kingdom, Australia, and the United States, is a person whose opinion by virtue of education, training, certification, skills or experience, is accepted by the judge as ...
es in both
criminal
In ordinary language, a crime is an unlawful act punishable by a state or other authority. The term ''crime'' does not, in modern criminal law, have any simple and universally accepted definition,Farmer, Lindsay: "Crime, definitions of", in Can ...
and
civil
Civil may refer to:
*Civic virtue, or civility
*Civil action, or lawsuit
* Civil affairs
*Civil and political rights
*Civil disobedience
*Civil engineering
*Civil (journalism), a platform for independent journalism
*Civilian, someone not a membe ...
proceedings. Expert witnesses give their opinions about a specific issue. Often, the
psychiatrist
A psychiatrist is a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders. Psychiatrists are physicians and evaluate patients to determine whether their sy ...
will have prepared a detailed report before testifying. The primary duty of the expert witness is to provide an independent opinion to the court. An expert is allowed to testify in court with respect to matters of opinion only when the matters in question are not ordinarily understandable to the finders of fact, be they judge or jury. As such, prominent leaders in the field of forensic psychiatry, from Thomas Gutheil to Robert Simon and Liza Gold and others have identified teaching as a critical dimension in the role of expert witness. The expert will be asked to form an opinion and to testify about that opinion, but in so doing will explain the basis for that opinion, which will include important concepts, approaches, and methods used in psychiatry.
Mental state opinion
Mental state opinion (MSO) gives the court an opinion, and only an opinion, as to whether a defendant was able to understand what he/she was doing at the time of the crime. This is worded differently in many states, and has been rejected altogether in some, but in every setting, the intent to do a criminal act and the understanding of the criminal nature of the act bear on the final disposition of the case. Much of forensic psychiatry is guided by significant court rulings or laws that bear on this area which include these three standards:
*
M'Naghten rules: Excuses a defendant who, by virtue of a defect of reason or disease of the mind, does not know the nature and quality of the act, or, if he or she does, does not know that the act is indeed wrong.
*
Durham rule
A Durham rule, product test, or product defect rule is a rule in a criminal case by which a jury may determine a defendant is not guilty by reason of insanity because a criminal act was the product of a mental disease. Examples in which such rul ...
: Excuses a defendant whose conduct is the product of mental disorder.
*
ALI test
ʿAlī ibn Abī Ṭālib ( ar, عَلِيّ بْن أَبِي طَالِب; 600 – 661 CE) was the last of four Rightly Guided Caliphs to rule Islam (r. 656 – 661) immediately after the death of Muhammad, and he was the first Shia Imam. ...
: Excuses a defendant who, because of a mental disease or defect, lacks substantial capacity to appreciate the criminality (wrongfulness) of his or her conduct or to conform his conduct to the requirements of law.
"
Not guilty by reason of insanity" (NGRI) is one potential outcome in this type of trial. Importantly,
insanity
Insanity, madness, lunacy, and craziness are behaviors performed by certain abnormal mental or behavioral patterns. Insanity can be manifest as violations of societal norms, including a person or persons becoming a danger to themselves or to ...
is a legal and not a medical term. Often, psychiatrists may be testifying for both the defense and the prosecution.
Forensic psychiatrists are also involved in the care of
prison
A prison, also known as a jail, gaol (dated, standard English, Australian, and historically in Canada), penitentiary (American English and Canadian English), detention center (or detention centre outside the US), correction center, correc ...
ers, both in jails and prisons, and in the care of the mentally ill who have committed criminal acts (such as those who have been found not guilty by reason of insanity).
Risk management
Many past offenders against other people, and suspected or potential future offenders with mental health problems or an intellectual or developmental disability, are supervised in the community by forensic psychiatric teams made up of a variety of professionals, including psychiatrists, psychologists, nurses, and care workers. These teams have dual responsibilities: to promote both the welfare of their clients and the safety of the public. The aim is not so much to predict as to prevent violence, by means of risk management.
Risk assessment
Broadly speaking, a risk assessment is the combined effort of:
# identifying and analyzing potential (future) events that may negatively impact individuals, assets, and/or the environment (i.e. hazard analysis); and
# making judgments "on the to ...
and management is a growth area in the forensic field, with much Canadian academic work being done in Ontario and British Columbia. This began with the attempt to predict the likelihood of a particular kind of offense being repeated, by combining "static" indicators from personal history and offense details in actuarial instruments such as the
RRASOR and
Static-99, which were shown to be more accurate than unaided professional judgment. More recently, use is being made also of "dynamic" risk factors, such as attitudes, impulsivity, mental state, family and social circumstances, substance use, and the availability and acceptance of support, to make a "structured professional judgment." The aim of this is to move away from prediction to prevention, by identifying and then managing risk factors. This may entail monitoring, treatment, rehabilitation, supervision, and victim safety planning and depends on the availability of funding and legal powers. These schemes may be based on published assessments such as the
HCR-20 (which incorporates 10 Historical, 5 Clinical and 5 Risk Management factors) and the risk of sexual violence protocol from
Simon Fraser University
Simon Fraser University (SFU) is a public research university in British Columbia, Canada, with three campuses, all in Greater Vancouver: Burnaby (main campus), Surrey, and Vancouver. The main Burnaby campus on Burnaby Mountain, located from ...
, BC.
United Kingdom
In the UK, most forensic psychiatrists work for the
National Health Service
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...
, in specialist secure units caring for mentally ill offenders (as well as people whose behaviour has made them impossible to manage in other hospitals). These can be either medium secure units (of which there are many throughout the country) or high secure hospitals (also known as special hospitals), of which three are in England and one in Scotland (the State Hospital, Carstairs), the best known of which is
Broadmoor Hospital
Broadmoor Hospital is a high-security psychiatric hospital in Crowthorne, Berkshire, England. It is the oldest of the three high-security psychiatric hospitals in England, the other two being Ashworth Hospital near Liverpool and Rampton Secure ...
. The other 'specials' are Ashworth hospital in Maghull, Liverpool, and Rampton hospital in Nottinghamshire. Also, a number of private-sector medium secure units sell their beds exclusively to the NHS, as not enough secure beds are available in the NHS system.
Forensic psychiatrists often also do prison inreach work, in which they go into prisons and assess and treat people suspected of having mental disorders; much of the day-to-day work of these psychiatrists comprises care of very seriously mentally ill patients, especially those with
schizophrenia
Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social withdra ...
. Some units also treat people with severe
personality disorder
Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture ...
or
learning disabilities
Learning disability, learning disorder, or learning difficulty (British English) is a condition in the brain that causes difficulties comprehending or processing information and can be caused by several different factors. Given the "difficult ...
. The areas of assessment for courts are also somewhat different in Britain, because of differing mental health law. Fitness to plead and mental state at the time of the offence are indeed issues given consideration, but the mental state at the time of trial is also a major issue, and this assessment most commonly leads to the use of mental health legislation to detain people in hospitals, as opposed to their getting a prison sentence.
Learning-disabled offenders who are a continuing risk to others may be detained in learning-disability hospitals (or specialised community-based units with a similar regimen, as the hospitals have mostly been closed). This includes those who commit serious crimes of violence, including sexual violence, and fire-setting. They would be cared for by learning disability psychiatrists and registered learning disability nurses. Some psychiatrists doing this work have dual training in learning disability and forensic psychiatry or learning disability and adolescent psychiatry. Some nurses would have training in mental health, also.
Court work (medicolegal work) is generally undertaken as private work by psychiatrists (most often forensic psychiatrists), as well as forensic and clinical psychologists, who usually also work within the NHS. This work is generally funded by the Legal Services Commission (used to be called Legal Aid).
Canada
Criminal law framework
In Canada, certain credentialed medical practitioners may, at their discretion, make
state
State may refer to:
Arts, entertainment, and media Literature
* ''State Magazine'', a monthly magazine published by the U.S. Department of State
* ''The State'' (newspaper), a daily newspaper in Columbia, South Carolina, United States
* ''Our S ...
-sanctioned investigations into and diagnosis of mental illness. Appropriate use of the
DSM-IV-TR
The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
is discussed in its section entitled "Use of the DSM-IV-TR in Forensic Settings".
Concerns have been expressed that the Canadian criminal justice system
discriminates based on DSM IV diagnosis within the context of Part XX of the
Criminal Code
A criminal code (or penal code) is a document that compiles all, or a significant amount of a particular jurisdiction's criminal law. Typically a criminal code will contain offences that are recognised in the jurisdiction, penalties that migh ...
. This part sets out provisions for, among other things, court ordered attempts at "treatment" before individuals receive a trial as described in section 672.58 of the Criminal Code. Also provided for are court ordered "psychiatric assessments". Critics have also expressed concerns that use of the DSM-IV-TR may conflict with section 2(b) of the
Canadian Charter of Rights and Freedoms
The ''Canadian Charter of Rights and Freedoms'' (french: Charte canadienne des droits et libertés), often simply referred to as the ''Charter'' in Canada, is a bill of rights entrenched in the Constitution of Canada, forming the first part o ...
, which guarantees the fundamental freedom of "thought, belief, opinion, and expression".
Confidentiality
The position of the Canadian Psychiatric Association holds, "in recent years, serious incursions have been made by governments, powerful commercial interests, law enforcement agencies, and the courts on the rights of persons to their privacy." It goes on to state, "breaches or potential breaches of confidentiality in the context of therapy seriously jeopardize the quality of the information communicated between patient and psychiatrist and also compromise the mutual trust and confidence necessary for effective therapy to occur."
An outline of the forensic psychiatric process as it occurs in the province of Ontario is presented in the publication ''The Forensic Mental Health System In Ontario: An Information Guide'' published by the
Centre for Addiction and Mental Health
The Centre for Addiction and Mental Health (CAMH, pronounced , french: Centre de toxicomanie et de santé mentale) is a psychiatric teaching hospital located in Toronto and ten community locations throughout the province of Ontario, Canada. It re ...
in Toronto. The Guide states: "Whatever you tell a forensic psychiatrist and the other professionals assessing you is not confidential." The Guide further states: "The forensic psychiatrist will report to the court using any available information, such as: police and hospital records, information given by your friends, family or co-workers, observations of you in the hospital." Also according to the Guide: "You have the right to refuse to take part in some or all of the assessment. Sometimes your friends or family members will be asked for information about you. They have the right to refuse to answer questions, too."
Of note, the emphasis in the guide is on the right to refuse participation. This may seem unusual given that a result of a verdict of "Not Criminally Responsible by reason of Mental Disorder" is often portrayed as desirable to the defence, similar to the
insanity defense
The insanity defense, also known as the mental disorder defense, is an affirmative defense by excuse in a criminal case, arguing that the defendant is not responsible for their actions due to an episodic psychiatric disease at the time of the cr ...
in the United States. A verdict of "Not Criminally Responsible" is referred to as a "defence" by the
Criminal Code
A criminal code (or penal code) is a document that compiles all, or a significant amount of a particular jurisdiction's criminal law. Typically a criminal code will contain offences that are recognised in the jurisdiction, penalties that migh ...
. However, the issue of the accused's mental state can also be raised by the Crown or by the court itself, rather than solely by the defence counsel, differentiating it from many other
legal defences.
Treatment/assessment conflict
In Ontario, a court-ordered inpatient forensic assessment for criminal responsibility typically involves both treatment and assessment being performed with the accused in the custody of a single multidisciplinary team over a 30- or 60-day period. Concerns have been expressed that an accused may feel compelled on ethical, medical, or legal grounds to divulge information, medical, or otherwise, to assessors in an attempt to allow for and ensure safe and appropriate treatment during that period of custody.
Some Internet references address treatment/assessment conflict as it relates to various justice systems, particularly civil litigation in other jurisdictions. The American Academy Of Psychiatry and the Law states in its ethics guidelines, "when a treatment relationship exists, such as in correctional settings, the usual physician-patient duties apply", which may be seen as contradiction.
South Africa
In South Africa, patients are referred for observation for a period of 30 days by the courts if questions exist as to CST and MSO. Serious crimes require a panel, which may include two or more psychiatrists. Should the courts find the defendant not criminally responsible, the defendant may become a state patient and be admitted in a forensic psychiatric hospital.
They are referred to receive treatment for an indefinite period, but most were back in the community after three years.
Training standards
Some practitioners of forensic psychiatry have taken extra training in that specific area. In the United States, one-year
fellowship
A fellow is a concept whose exact meaning depends on context.
In learned or professional societies, it refers to a privileged member who is specially elected in recognition of their work and achievements.
Within the context of higher education ...
s are offered in this field to psychiatrists who have completed their general psychiatry training. Such psychiatrists may then be eligible to sit for a board certification examination in forensic psychiatry. In
Britain
Britain most often refers to:
* The United Kingdom, a sovereign state in Europe comprising the island of Great Britain, the north-eastern part of the island of Ireland and many smaller islands
* Great Britain, the largest island in the United King ...
, one is required to complete a three-year subspeciality training in forensic psychiatry, after completing one's general psychiatry training, before receiving a
Certificate of Completion of Training
The Certificate of Completion of Training (CCT) is the certificate that medical doctors in the United Kingdom receive to indicate that they have completed training in their chosen specialty and are therefore eligible for entry onto the specialis ...
as a forensic psychiatrist. In some countries, general psychiatrists can practice forensic psychiatry, as well. However, other countries, such as Japan, require a specific certification from the government to do this type of work.
See also
*
Forensic psychology
Forensic psychology is the development and application of scientific knowledge and methods to help answer legal questions arising in criminal, civil, contractual, or other judicial proceedings. Forensic psychology includes both research on various ...
*''
Daubert v. Merrell Dow Pharmaceuticals, Inc.
''Daubert v. Merrell Dow Pharmaceuticals, Inc.'', 509 U.S. 579 (1993), is a United States Supreme Court case determining the standard for admitting expert testimony in federal courts. In ''Daubert'', the Court held that the enactment of the Fede ...
'' which established the
Daubert standard
In United States federal law, the ''Daubert'' standard is a rule of evidence regarding the admissibility of expert witness testimony. A party may raise a ''Daubert'' motion, a special motion ''in limine'' raised before or during trial, to exclude ...
delimiting the admissibility of scientific
expert witness
An expert witness, particularly in common law countries such as the United Kingdom, Australia, and the United States, is a person whose opinion by virtue of education, training, certification, skills or experience, is accepted by the judge as ...
testimony
*''
Rennie v. Klein
''Rennie v. Klein'', 462 F. Supp. 1131 (D.N.J. 1978), was a case heard in the United States District Court for the District of New Jersey in 1978 to decide whether an involuntarily committed mental patient has a constitutional right to refuse psyc ...
'' - right to refuse treatment
*''
Kansas v. Hendricks
''Kansas v. Hendricks'', 521 U.S. 346 (1997), was a Supreme Court of the United States, United States Supreme Court case in which the Court set forth procedures for the indefinite civil commitment of prisoners convicted of a sex offense whom the s ...
'' - involuntary civil commitment for sexual predators
*
Settled insanity
Settled insanity is defined as a permanent or "settled" condition caused by long-term substance abuse and differs from the temporary state of intoxication. In some United States jurisdictions "settled insanity" can be used as a basis for an insanit ...
*
Ultimate issue
*
Twinkie defense
"Twinkie defense" is a derisive label for an improbable legal defense. It is not a recognized legal defense in jurisprudence, but a catch-all term coined by reporters during their coverage of the trial of defendant Dan White for the murders of ...
*
Bruneri-Canella case
The Bruneri-Canella case, called in Italian the case of the ''Smemorato di Collegno'' (the Collegno Amnesiac), is a notorious judicial and media affair concerning the alleged reappearance in 1926 of a man who had gone missing in World War I. The q ...
, an early landmark case which introduced new forensic techniques in juridic debate
References
External links
*
Studies in Forensic Psychiatry by
Bernard Glueck, Sr. Bernard Charles Glueck Sr. (December 10, 1884 - October 5, 1972) was a Polish-American forensic psychiatrist and psychoanalyst. He established the first prison psychiatric clinic and was an expert witness in the Leopold and Loeb trial.Staff report ( ...
, 1916, reprinted 1969, from
Project Gutenberg
Project Gutenberg (PG) is a Virtual volunteering, volunteer effort to digitize and archive cultural works, as well as to "encourage the creation and distribution of eBooks."
It was founded in 1971 by American writer Michael S. Hart and is the ...
The Role of a Forensic Psychiatrist in Legal Proceedings by
Harold J. Bursztajn, MD
Harold may refer to:
People
* Harold (given name), including a list of persons and fictional characters with the name
* Harold (surname), surname in the English language
* András Arató, known in meme culture as "Hide the Pain Harold"
Arts a ...
, 1993, from Journal of the Massachusetts Academy of Trial Attorneys with permission of Harold J. Bursztajn, MD.
Forensic psychiatry by
Samuel Lézé, Ph.D, 2014, from Andrew Scull (ed.), Cultural Sociology of Mental Illness : an A-to-Z Guide, Sage, pp. 313–14
MedicoLegal Psychiatry
{{DEFAULTSORT:Forensic Psychiatry