This document discusses forensic psychiatry and the care of mentally disordered offenders in Zambia. It defines key terms like forensic psychiatry and forensic nursing. It describes the types of patients seen by forensic mental health clinicians, including prisoners requiring treatment or assessment and people found unfit to plead or not guilty by reason of insanity. The types of mental illnesses that may lead to offending are discussed. Nursing interventions aim to reduce risk of harm and rehabilitate patients. Risk assessment and crisis intervention are important. Functions of forensic nurses include advocacy and counseling. Mentally disordered offenders are detained and treated in hospitals and prisons under the Mental Disorders Act and various legal forms are used to facilitate their detention and transfer between facilities.

1. FORENSIC PSYCHIATRY
NWUCHAS

2. DEFINATIONS
• Forensic :relating to courts of law.
• Forensic psychiatry: It is the branch of psychiatry that deals with the
assessment and treatment of mentally disordered offenders and includes
those areas where psychiatry interacts with the law.
• Forensic nursing It is defined as a subspecialty of nursing that has as its
objective of assisting the mental health and legal systems in serving
individuals who have come to the attention of both the health personnel and
legal practitioners
• A forensic patient is a person who has: been found unfit to be tried for an
offence and ordered to be detained in a correctional centre, mental health
facility or other place

3. Forensic mental health referral agencies
• Offenders or alleged offenders may be referred to a forensic mental
health service or practitioner by a range of organisations, including:
• Police
• Courts
• Prisons
• Community corrections
• Other justice and mental health services

4. The type of person seen by forensic mental health clinicians may include:
• Prisoners who need inpatient treatment
• Prisoners requiring assessment or management of a mental illness
• People who are accused of crimes, but are considered unfit to plead because
of their mental impairment
• People who are found not guilty of crimes because of mental impairment
• Offenders or alleged offenders who are referred by courts or other agencies
for assessment
• People unable to be managed safely in mainstream mental health services
• People living in the community who have a serious mental illness and have
offended, or are at high risk of offending.

5. TYPES OF PATIENTS THAT NEED FORENSIC
PSYCHIATRY
• The patient in the forensic setting is guilty of committing a crime
believed to be caused by their mental illness.
• Alternatively, the forensic psychiatric patient might have committed a
crime independently of their mental illness, but is presently too ill to
participate in court proceedings.

6. • The following are types of patients that are admitted to forensic
facilities:
a. Anti-social personality disorder – is more strongly related to
offending and violence. Aspects related to offending in a person with
personality disorder include impulsivity, lack of empathy, paranoid
thinking, poor relationships with others, problems with anger and
assertiveness.
b. Substance dependence (alcohol and drugs such as cocaine,
heroine, chamba) Intoxication reduces inhibitions and is strongly
associated with crimes of violence, including murder. Neuropsychiatric
complications of alcoholism may also be linked with crime.

7. c. Mental retardation or Intellectual disability – People with learning
disability may commit offences because they do not understand the
implications of their behaviour, or because they are susceptible to
exploitation by other people. For example, property offences, sexual
offences such as indecent exposure
d. Schizophrenia and other psychotic disorders – are associated with
violence especially if paranoid or coupled with substance abuse.

8. • E.Mood disorders–Depressive disorder is sometimes associated
with shop lifting and may also lead to homicide and suicide. Manic
patients may spend excessively and fail to pay. They are also prone
to irritability and aggression leading to crimes of violence.
• f. PTSD in cases where battered women have killed a battering
partner.
• g. Morbid jealousy
• h. Organic mental disorders–Dementia and delirium. For example,
aggression
• i. Epilepsy–Violence is common in the post ictal state than ictally.

9. NURSING INTERVENTIONS
Nursing intervention is aimed at:
• Helping patients to reduce their risk of injury to themselves/others
• Rehabilitating patients back into society

10. RISK ASSESSMENT
• 1) Risk of harm to the patient – including deliberate self harm, self neglect or the
potential for abuse by others, including, physical abuse, the potential for actively
or passively leaving the unit/department/scheme/care home without the
knowledge and agreement of staff or financial exploitation.
• 2) Risk of harm to others – including physical violence or harm, sexual violence,
verbal or psychological abuse, harassment, potential harm to others through
passive or active unsafe actions including fire setting or other dangerous acts -
to include the potential for actively or passively leaving the
unit/department/scheme/care home, without the knowledge and agreement of
staff
• 3) Risk of damage to property – including damage to fabric or structure of
buildings or objects, including as a result of passive or active fire setting - to
include the potential for actively or passively leaving the
unit/department/scheme/care home, without the knowledge and agreement of

11. .
• CRISIS INTERVENTION
• This treatment helps patients cope with the crisis brought about by their criminal
behaviour and subsequent detention in their lives, and to learn effective ways of
dealing with future difficulties.
• Treatment is aimed at reducing emotional arousal that takes place during a crisis
together with any accompanying behavioural disorganization. This is done by
reassuring the patient and enabling him/her to have an opportunity to express
emotions, in a supportive environment (empathy, non-judgmental).
• Anxiolytic medication may be required for a few days. Once emotional arousal
has been contained, a problem solving approach is used, in which the nurse in
collaboration with the patient helps identify and list problems that are causing
distress.

12. .
Rehabilitation
• In order for patients in this setting to be eligible for return to the
community, both the criminal act and the psychiatric illness must be
addressed. If anger is behind the criminal act specific programs
targeting anger management should be offered.
• Suicide prevention–treatment for depression and close observation
by staff in the ward should be ensured and supported by relatives in
the community if discharged.

13. • Behaviour management – any abnormal behaviour such as being
anti-social or manipulative is treated using behaviour modification
approach.
• Substance abuse treatment – Detoxification is done in the
psychiatric unit and thereafter the patient is referred and
connected to long term support groups.
• Discharge planning–begin to plan for the discharge of the patient
together with him/her and relatives with the input of the Multi
Disciplinary Team (MDT). The way forward and how he/she will go
back into the community.

14. Functions of a forensic nurse
• Patient advocate in which she speaks out for the rights of clients
• A trusted counsellor in which she is able to offer psychological
support to patients.
• A provider of primary, secondary, and tertiary health care
interventions to clients before during and after forensic admission to
psychiatric hospital

15. Care of patients during detention In Zambia
• mentally disordered offenders are cared for under the Penal Code 87 and Prisons Act of the
Zambian Constitution as follows:
• Presumption of sanity: Every person is presumed to be of sound mind, and to have been of
sound mind at any time which comes in question, until the contrary is proved. When a
person getting psychiatric treatment commits a serious offence while they are not
documented legally that they are suffering from mental disorders, such a person is liable to
prosecution until proven mentally ill by a qualified and registered psychiatrist.
• Insanity: A person is not criminally responsible for an act or omission if at the time of doing
the act or making the omission he is, through any disease affecting his mind, incapable of
understanding what he is doing, or of knowing that he ought not to do the act or make the
omission. But a person may be criminally responsible for an act or omission, although his
mind is affected by disease, if such disease does not in fact produce upon his mind one or
other of the effects above mentioned in reference to that act or omission.
• Defence of diminished responsibility: Where a person kills or is a party to the killing of
another, he shall not be convicted of murder if he was suffering from such abnormality of
mind (whether arising from a condition of arrested or retarded development of mind or any
inherent causes or is induced by disease or injury) which has substantially impaired his
mental responsibility for his acts or omissions in doing or being party to the killing.’(Laws of
Zambia).

16. Treatment settings for mentally disordered
offenders
• In Zambia according to the Mental disorders Act of 1951, mentally
disordered offenders are treated in all hospitals administered by the
Government; and all places declared to be prisons under section
three of the Prisons Act; under compulsory detention (Detention
Order) to safe guard the lives and property of the public.
• In Zambia, Chainama East is used to confine people who have
committed homicide or grievous bodily harm to others, as a result of
being insane. It is heavily guarded by prison warders

17. During detention correspondence between the courts of law and the head of
the psychiatric department is entered into concerning the detention and care of
patients using the following methods:
• Adjudication order forms: Is to hear and settle a case by judicial procedure. In
the case of forensic patients it means the patient has to be tried before a court
of law, and it has to be determined whether they are guilty of a crime or not.
However, before they can be tried, two psychiatrists have to examine and
determine whether they are competent to stand trial or not.
• Control order forms: After an adjudication order has been made, the courts
shall make a control order, for the control, care or detention of the patient,
specifying that the patient be detained in a prescribed place whilst his or her
case undergoes judicial review. The patient may therefore be transferred from
prison to the prescribed place

18. • Detention Order form – This is a form that restrains the client with
mental illness to be admitted in a mental hospital for a minimum of
14 days after which psychiatric personnel should furnish a report to
the magistrate about their findings concerning the patient.

19. • Court reports: Psychiatrists provide a report of the patient’s progress whilst in
detention. Court reports – are required by the prosecution, court and lawyer. The
reports consist of a psychiatric assessment that should be objective, and
professional, and should not be influenced by which ‘side’ has made the request.
The report should indicate whether the offender was mentally insane at the time of
committing the crime or not. It should also indicate the competence of the mentally
disordered offender to stand trial, and whether he understands what he has been
accused of, and the meaning of pleading guilty or not guilty. Give evidence in
criminal proceedings on the patient’s dangerousness, so that a suitable sentence
may be made.
• Transfer Order form–This is a form that is used when transferring a patient with
mental illness from one hospital to another. It has to be duly filled in by a senior
magistrate in the subordinate court

20. • THE END