1. Criminal Forensic Psychiatry ACGME Requirement Treatment Court Competency to Stand Trial Forensic Report 1

2. Quick Links Forensic experience materials: http://forensicpsychiatry.stanford.edu/Seminars/materials.htm California Penal Code: http://www.leginfo.ca.gov/calaw.html 2

3. Law of Crimes Protective purpose Protective purpose Restrain, rehabilitate, deter, vindicate law Restrain, rehabilitate, deter, vindicate law Penal Code Penal Code Crime is union of actus reus and mens rea Crime is union of actus reus and mens rea 3

4. Link Between Mental Illness and Crime Impaired executive functions Impaired executive functions Delusions and hallucinations Delusions and hallucinations Overwhelming emotion Overwhelming emotion Overreaction to “threat” Overreaction to “threat” Substance abuse Substance abuse TBI TBI Personality disorder Personality disorder 4

5. The Forensic Psychiatrist Answer legal question in legal arena Answer legal question in legal arena No “best interests” No “best interests” No “do no harm” No “do no harm” Need to know law as well as psychiatry Need to know law as well as psychiatry Must understand legal reasoning Must understand legal reasoning Must consider malingering in every case Must consider malingering in every case Need good writing skills Need good writing skills Need to adapt to adversarial system Need to adapt to adversarial system 5

6. Ethics Honesty, objectivity, neutrality, competence Honesty, objectivity, neutrality, competence Duty to law and to truth Duty to law and to truth Must respect patient’s “personhood” Must respect patient’s “personhood” Consent and non-disclosure statement Consent and non-disclosure statement Consider all evidence Consider all evidence Explicate reasoning process Explicate reasoning process 6

7. Percipient vs. Expert Testimony  Evidence must be relevant, probative  Judge decides admissibility  Jury decides weight to be given  Percipient vs. expert witness  Rule against admissibility of junk science  Frye: special expertise, general acceptance  Daubert: special expertise, general acceptance, focus on methodology (peer reviewed, known error rates, etc.) 7

8. Forensic Questions  Is defendant mentally ill now?  If so, is he currently incompetent to stand trial?  Was defendant mentally ill at time of crime?  If so, was he insane under California law?  Did illness impair ability to form legal intent?  What are the treatment options?  What is risk to community if not incarcerated? 8

9. Forensic Assessment  Fact heavy  Answer legal question  Consider all the evidence plus malingering  Write for legal as well as medical audience  Explicate scientific and legal reasoning  Expose limits of certainty 9

10. Reasoning Process Scientific Scientific question Scientific question Focus on methodology Focus on methodology Empirical Empirical Quantitative Quantitative Reproducible Reproducible Statistical reliability Statistical reliability Legal Legal question Legal question Legal rule Legal rule Relevant facts Relevant facts Reasoning process Reasoning process Major premise Minor premise Logical conclusion Logical conclusion 10

11. Treatment Court Movement Decrease jail time / cost Decrease jail time / cost Law as first responder Law as first responder Therapeutic sentencing Therapeutic sentencing Reduce risk to community Reduce risk to community Drug, mental health, veterans courts Drug, mental health, veterans courts 11

12. Forensic Experience Rotation Pathways Program Pathways Program Assess applicants for mental health court Assess applicants for mental health court Prepare report to Pathways team Prepare report to Pathways team Third Thursday of month Third Thursday of month Maguire Jail or Probation Dept., Redwood City Maguire Jail or Probation Dept., Redwood City Supervision by ACF forensic psychiatrist Supervision by ACF forensic psychiatrist Write report Write report Meet with supervisor Meet with supervisor Other opportunities Other opportunities 12

13. San Mateo “Pathways” Program  Joint Program – Probation and Mental Health  Misdemeanor defendants who are Axis I SMI  Reduce recidivism / protect community  Modify sentence to community treatment  Progressive sanctions  Therapeutic sentencing 13

14. Pathways Forensic Questions Is the defendant seriously mentally ill? Is the defendant seriously mentally ill? Is there a link between illness and crime? Is there a link between illness and crime? Is there community treatment? Is there community treatment? Would sentence modification to community treatment decrease the likelihood of reoffending without exposing the community to undue risk of harm? Would sentence modification to community treatment decrease the likelihood of reoffending without exposing the community to undue risk of harm? 14

15. Therapeutic Sentencing Outpatient psychotherapy Outpatient psychotherapy Medication management / psychotherapy Medication management / psychotherapy Residential care / supportive housing Residential care / supportive housing AA, NA, CBT, anger management AA, NA, CBT, anger management Monitoring substance use, med compliance Monitoring substance use, med compliance Rehabilitation / reintegration programs Rehabilitation / reintegration programs Intensive case management Intensive case management 15

16. Generic Forensic Report  Identify referral source  Identify forensic question and relevant law  Consent / statement of non-confidentiality  Case facts  Identify and analyze relevant documents  Clinical and forensic examination  Diagnosis  Diagnostic and forensic discussion  Medical and Legal Conclusions 16

17. The Forensic Report for Pathways Two parts: Two parts: The mental health court report The mental health court report The competency to stand trial report The competency to stand trial report The online report template The online report template 17

18. Competency to Stand Trial (1) Fundamental fairness – 5 th, 6 th, 14 th Amendments Fundamental fairness – 5 th, 6 th, 14 th Amendments Defined at Cal Penal Code Section 1367 Defined at Cal Penal Code Section 1367 Principle case law – Dusky and Sell Principle case law – Dusky and Sell Critical phases of trial: Critical phases of trial: confess, waive Miranda, plead guilty, testify, represent self, be executed confess, waive Miranda, plead guilty, testify, represent self, be executed 18

19. Competency to Stand Trial (2) Dusky vs. US “whether he has sufficient present ability to “whether he has sufficient present ability to consult with lawyer with a reasonable degree of rational understanding and consult with lawyer with a reasonable degree of rational understanding and whether he has a rational as well as factual understanding of the proceedings against him.“ whether he has a rational as well as factual understanding of the proceedings against him.“ If incompetent, remand to hospital for restoration of competency If incompetent, remand to hospital for restoration of competency 19

20. Competency to Stand Trial (3) Sell vs. US Involuntary drugs to restore competency Involuntary drugs to restore competency Defendant must be facing serious charge Defendant must be facing serious charge Drug must be medically appropriate Drug must be medically appropriate Side effects unlikely to undermine fair trial Side effects unlikely to undermine fair trial 20

21. Competency to Stand Trial (4) Assessment Mental status examination Mental status examination Case related motivation / knowledge Case related motivation / knowledge Quality of relating to attorney Quality of relating to attorney Capacity to engage legal needs at all critical points in the case Capacity to engage legal needs at all critical points in the case 21