1. Introduction to Forensic Psychiatry World Psychiatric Association Scientific Section Forensic Psychiatry Secretary: Prof. Birgit A. Völlm

2. 2 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)

3. 3 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

4. 4 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

5. 5 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

6. 6 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

7. 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 7

8. 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 8

9. 9 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

10. 10 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

11. 11 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 Risk cannot be eliminated

12. 12 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