2. ˜Forensic comes from the Latin forensis (the forum or court). The
scope of forensic psychiatry can be broadly defined as those areas
where psychiatry interacts with the law.
Although all psychiatrists may be involved, from time to time, in
forensic work, forensic psychiatrists in the UK are specifically
involved in the assessment and management of mentally
disordered offenders and other patients with mental disorders who
are, or have been potentially or actually, violent.
2
3. Provision of forensic services
varies across the country and forensic psychiatrists
work in a variety of settings (e.g. high-security
hospitals; medium-secure units; low-secure wards
and sometimes open wards; outpatients, day
hospitals, and within community teams; prisons).
3
4. This section on forensic psychiatry concentrates on mentally
disordered offenders. A separate section (Legal and ethical issues)
covers mental health legislation and other non-criminal legal
matters.
The practice of forensic psychiatry is dependent on legislation,
the criminal justice system, and local service provision.
4
6. Subspecialty of psychiatry in which
scientific and clinical expertise is applied to
legal issues in legal context embracing
civil, criminal, legislative matters;
practiced in accordance with
guidelines and ethical principles
enunciated by the profession of psychiatry
6
7. Forensic psychiatry is a branch of medicine which
focuses on the interface of law and mental health.
It may include psychiatric consultation in a wide
variety of legal matters
◦ expert testimony
◦ clinical work with perpetrators and victims.
7
8. The word "forensic" refers to anything that has to do with
the law.
Forensic psychiatrists thus may be involved with:
◦ criminal matters
◦ fitness to stand trial, insanity defense, sentencing
considerations, etc.
8
9. Options following assessment if person appears to be mentally
disordered
admission to hospital informally or under mental health legislation
treatment in the community
recommend further assessment on remand in custody or on bail
9
10. The prevalence of mental disorder in the prison population is high,
especially in remand and female populations. Psychotic disorders:
10%; affective/neurotic disorders: 59%; alcohol-related disorder:
63%; drug-related disorder: 73%; personality disorder: 75%. It has
been estimated that 55% of prisoners have psychiatric treatment
needs, with 5% requiring transfer to psychiatric hospital.
10
11. Psychiatrists may be asked to assess prisoners for the following
reasons:
To provide court reports
To provide assessment and treatment at the request of a prison
medical officer
For statutory purposes (e.g. preparing reports for the parole board)
11
12. Is there evidence of mental disorder?
Is assessment and/or treatment in hospital required?
If so, how urgently?
What is the nature of the alleged offence and is there
any evidence of a serious risk to others?
12
13. When arranging to see a prisoner, a psychiatrist should make an
appointment which will fit in with the prison routine. There will
usually be only 2-3 hours in the morning or afternoon when there is
access to prisoners. The psychiatrist will have to wait to be escorted
by prison staff.
Assessment of prisoners
Prisoners should be seen on their own unless prison staff or other
sources indicate this would be unwise. It may be difficult to get
13
14. relevant information about the prisoner's day-to-day functioning and
presentation from prison staff, although attempts should be made to
do this. Ask the prisoner for a relative's telephone number and
permission to speak to them.
14
15. If a psychiatrist assesses a prisoner and finds that they are mentally
disordered he may:
Treat the person in prison
Arrange for the person to be transferred to mental health services,
either by arranging direct transfer from prison or by
recommending a mental health disposal through the courts if the
prisoner has not been sentenced yet.
15
16. All prisoners with severe mental illness should be transferred to
hospital for treatment.
16
17. Medication, monitoring, and modest psychological treatment
(supportive psychotherapy & other therapy) may be offered to
prisoners with mental disorders who do not require treatment in
hospital.
17
18. Suicide in prison
Suicide is the most common mode of death in prisons. The rate is
approximately 9 times that in the general population. The most
common means is by hanging.
18
19. young offenders, and those with histories of substance misuse and
violent offences are at particular risk.
Many factors probably contribute to the increased rate of
suicide in prisons, including:
histories of psychiatric disorder
previous self-harm
alcohol and substance misuse
social isolation
19
20. A psychiatrist may be required to provide reports and give
evidence in criminal and civil proceedings; the following deals
with reports in criminal proceedings.
Introduction Reports
may be requested by the prosecution, the court. The assessment
should be objective and professional, and should not be
influenced by which side has made the request.
20
21. The clinical issues The clinical issues will involve those
that psychiatrists usually assess: diagnosis, treatment
needs, prognosis, etc. However, specific attention needs
to be given to how these clinical issues interact with the
legal issues in question.
21
22. What is the relationship between any psychiatric
disorder and past, present, and future offending? How
might treatment or the natural course of the disorder
impact on the likelihood of further offending?
22
23. What impact might the current mental state have on the person's
ability to participate in the court process?
The legal issues The request for psychiatric assessment should
indicate the legal issues towards which the psychiatrist should
direct the assessment. However in many cases the instructions are
not specific. The main issues to consider are usually:
23
24. Responsibility
The presence of mental disorder and whether assessment and/or
treatment under compulsion (or otherwise) is required
The risk the person poses (may be relevant in whether a restriction
order is imposed, in determining if disposal should be to a secure
unit or special hospital, or perhaps in determining the nature of the
sentence imposed; .
24
25. Comprehensive background information should usually be
provided by those requesting the report. Unfortunately this is often
lacking. Ideally one should have the opportunity to examine:
document specifying the charges, police summary, witness
statements, records of interviews with the accused, records of
previous offences, other reports. Sometimes tape recordings of
interviews, photographic or video evidence may be available.
25
26. Arrangements should be made to interview the person in prison (if
they have been remanded in custody), as an outpatient (if they
have been remanded on bail), or in hospital (if they have been
admitted to hospital). The psychiatrist should be given reasonable
time to complete the assessment and produce a considered report.
If there is insufficient time then this should be stated in the report
and any opinion given should be qualified.
26
27. Check the person's correct name and details. Introduce yourself
and state who has requested the report.
Make it clear that the interview is not confidential and that the
information in the report will be seen by others.
Clarify that the person has understood this, and seek their consent
to prepare the report.
27
28. If the person refuses to be interviewed then this should be
respected and reported to the person requesting the report.
Ask the person's permission to contact a relative and/or their GP
for further information.
Follow the usual format for a psychiatric assessment.
Enquiry about the circumstances of the offence and
28
29. the person's understanding of the court process will need to be
made in addition.
More than one session may be necessary in some cases.
Physical examination and investigations should be performed if
indicated.
After the interview
Further information may be gathered from the following sources:
29
30. Interviews with relatives or staff (health care, prison, or social
services):
Health (psychiatric or general practice), prison, social work, or
educational records.
In some cases specific psychometric testing by a psychologist may
be necessary (e.g. where a person appears to be learning disabled).
30
31. Court reports and giving evidence
The report
The various strands of the assessment should be brought together
in the report.
The report should be clear, concise, well structured, and jargon -
free.
Technical terms (e.g. schizophrenia, personality disorder,
delusions, hallucinations, thought disorder) should be explained if
they are used.
31
32. If a number of sources of information have been used, indicate
where the particular factual information in the report has come
from, particularly when there are inconsistencies (e.g. according
to the stated that.)
32
33. The main body of the report should present the information
gathered; the opinion should present the conclusions concerning
the relevant issues and lead to the recommendations.
The opinion and recommendations should confine themselves to
psychiatric issues. Punitive sanctions,.
33
34. such as imprisonment, should never be recommended.
There is no set format for a report, just as there are different ways
of presenting history and mental state.
34
35. The report becomes the property of whoever requested
it.
Defence reports may or may not be produced in evidence
in a particular case; prosecution reports must be revealed
to the defence
35
36. Copies of the report should not be sent by the psychiatrist to others
(such as the patient's GP, another psychiatrist, or a probation
officer) without the consent of both the person examined and the
person who commissioned the report.
A psychiatric report may come to be included in various records
(health, prison, probation), and may in the future be used for
reference or in further legal proceedings.
36
37. Giving evidence
In most cases a psychiatrist will not be required to give oral
evidence. However under some circumstances this will be the
case: a report requires clarification, the court finds it difficult to
accept the opinion, there are conflicting reports, in specific
circumstances where oral evidence is obligatory (e.g. where a
restriction order is under consideration).
If you are requested to attend court:
37
38. Clarify with the court when you should attend.
Prepare in advance by examining the papers and re-reading your
report.
Consult references and anticipate questions.
Present in a smart, confident, professional manner and be punctual.
Counsel may request a conference before the court sits.
38
39. Have a brief interview with the accused in the court cells if he
has not been seen for sometime and particularly where fitness
to plead may be an issue.
When called to give evidence you will be asked to take the
oath, and then will be questioned by the barrister or solicitor
who called you. You will then be cross-examined by the other
side before
39
40. being re-examined. You may take notes with you, but ask the
judge before referring to them. Speak clearly and slowly, and
explain technical terms. Address the judge. If counsel's
questioning is not allowing you to get the appropriate information
across, then ask the judge if you may clarify your response.
40
42. Ethical issues in psychiatry have been long recognized as complex
and challenging. Patients can be particularly vulnerable due to the
nature of mental illness (Arboleda-Flo´ rez & Weisstub, 1997) and
the stigma attached to it.
42
43. (Goffman, 1961, 1963; Link, Mirotznik & Cullen, 1991;
Schlosberg,1993; Wahl, 1999). Power imbalances, including the
possibility of involuntary treatment, add a dimension to
therapeutic relationships that is often absent in other specialty
areas
43
44. Ethical guidelines and a knowledge of ethical principles
help psychiatrists avoid ethical conflicts (which can be
defined as tension between what one wants to do and
what is ethically right to do) and think through ethical
dilemmas (conflicts between ethical perspectives or
values).
44
45. Ethics deal with the relations between people in
different groups and often entail balancing rights.
Professional ethics refer to the appropriate way to act
when in a professional role. Professional ethics derive
from a combination of morality, social norms, and the
parameters of the relationship people have agreed to
have.
45
46. Four ethical principles that psychiatrists ought
to weigh in their work are respect for
autonomy, beneficence, nonmaleficence, and
justice. At times, they are in conflict, and
decisions must be made concerning how to
balance them.
46
47. Autonomy requires that a person act intentionally
after being given sufficient information and time to
understand the benefits, risks, and costs of all
reasonable options. It may mean honoring an
individual's right not to hear every detail and even
choosing someone else (e.g., family or doctor) to
decide the best course of treatment.
47
48. Psychiatrists need to provide patients with a rational
understanding of their disorder and options for
treatment. Patients need conceptual understanding;
the psychiatrist should not simply state isolated facts.
Patients also need time to think and to talk with
48
49. friends and family about their decision. Finally, if a
patient is not in a state of mind to make decisions
for himself or herself, the psychiatrist should
consider mechanisms for alternative decision-
making, such as guardianship, conservators, and
health care proxy.
49
50. Treating psychiatrists are obligated to act in the best
medical interests of their patients.
As a result of the role obligation of trust, psychiatrists
must heed their patients' interests, even to the neglect of
their own.
The expression of the principle is paternalism, the use of
the psychiatrist's judgment about the best course of action
for the patient or research subject. Weak paternalism is
acting beneficently when the patient's impaired faculties
prevent an autonomous choice.
50
51. Strong paternalism is acting beneficently, despite the
patient's intact autonomy.
Guidelines have been proposed for permitting
beneficence to overrule patient autonomy; when the
patient faces substantial harm or risk of harm, the
paternalistic act is chosen that ensures the optimal
combination of maximal harm reduction, low added
risk, and minimal necessary infringement on patient
autonomy.
51
52. To adhere to the principle of nonmaleficence (primum
non nocere or first do no harm), psychiatrists must be
careful in their decisions and actions and must ensure
that they have had adequate training for what they do.
They also need to be open to seeking second opinions
and consultations. They need to avoid creating risks
for patients by an action or inaction.
52
53. The concept of justice concerns the issues of reward
and punishment and the equitable distribution of
social benefits. Relevant issues include whether
resources should be distributed equally to those in
greatest need, whether they should go to where they
can have the greatest impact on the well-being of
each individual served, or to where they will ultimately
have the greatest impact on society.
53
54. When serving the interests of justice, forensic psychiatrists
must adhere to the general moral rule of telling the truth (both
in subjective case of honesty and in the objective case of
stating the limitations of the accuracy of one’s opinions and
testimony).
54
55. Forensic psychiatrists as evaluators should inform
the evaluee of the absence of a physician-patient
and treatment relationship between them and of
the limits of the confidentiality of the data obtained
from the evaluee.
55
57. Focus on:
◦ Confidentiality in forensic evaluations
◦ Informed consent to forensic evaluations
◦ Qualifications of forensic examiners
◦ Honesty and striving for objectivity in conducting forensic
evaluations
57
58. Forensic psychiatrists are exposed to the potential for unintended
bias and the danger of distortion of their opinion.
AAPL guidelines prohibit contingency fee arrangements with
forensic psychiatric evaluators.
58
60. Maintain examiner objectivity and neutrality.
Respect examinee autonomy.
Protect confidentiality of the forensic evaluation.
Obtain informed consent for the forensic evaluation unless the
evaluation is properly compelled by law.
Interact verbally with the examinee.
60
61. Avoid sexual contact with the examinee.
Preserve the relative anonymity of the evaluator.
Establish a clear, noncontingent fee policy with the retaining
party.
Provide a suitable examination setting for the evaluation.
Define the time and length of the evaluation.
61
62. Ensure no previous, current, or future personal relationship
with the examinee .
“Treating psychiatrists should generally avoid agreeing to be
an expert witness or to perform evaluations of their patients
for legal purposes”
62
63. From a practical point of view, several specific issues
most frequently involve psychiatrists. These include
(1) sexual boundary violations
(2) nonsexual boundary violations
(3) violations of confidentiality
(4) mistreatment of the patient (incompetence, double
agentry), and (5) illegal activities (insurance, billing,
insider stock trading).
63
64. For a psychiatrist to engage a patient in a sexual
relationship is clearly unethical. Furthermore, legal
sanctions against such behavior make the ethical
question moot. Various criminal law statutes have
been used against psychiatrists who violate this
ethical principle. Rape charges may be, and have been,
brought against such psychiatrists; sexual
64
65. assault and battery charges also have been used to convict
psychiatrists.
In addition, patients who have been victimized sexually by
psychiatrists and other physicians have won damages in
malpractice suits. Insurance carriers for the APA and the American
Medical Association (AMA) no longer insure against patient
therapist sexual relations, and the carriers exclude liability for any
such sexual activity.
65
66. The issue of whether sexual relations between an ex-patient and a
therapist violate an ethical principle, however, remains
controversial. Proponents of the view, Once a patient, always a
patient,•
insist that any involvement with an ex-patient even one
that leads to marriage should be prohibited.
66
67. They maintain that a transferential reaction that always exists
between the patient and the therapist prevents a rational decision
about their emotional or sexual union. Others insist that, if a
transferential reaction still exists, the therapy is incomplete and
that as autonomous human beings, ex-patients should not be
subjected to paternalistic moralizing by physicians. Accordingly,
they believe that no sanctions should prohibit emotional or
67
68. sexual involvements by ex-patients and their psychiatrists. Some
psychiatrists maintain that a reasonable time should elapse before
such a liaison. The length of the reasonable•period remains
controversial: Some have suggested 2 years. Other psychiatrists
maintain that any period of prohibited involvement with an ex-
patient is an unnecessary restriction. The Principles, however,
states: Sexual activity with a current or former patient is unethical.
68
69. Although not spelled out in The Principles, sexual activity with a
patient's family member is also unethical. This is most important
when the psychiatrist is treating a child or adolescent. Most
training programs in child and adolescent psychiatry emphasize
that the parents are patients too and that the ethical and legal
proscriptions apply to parents (or parent surrogate) as well as to
the child. Nevertheless, some psychiatrists misunderstand this
concept. Sexual activity
69
70. between a doctor and a patient's family member is also unethical.
An egregious example of a sexual boundary violation was
reported in the Medical Board of California Action Report (July
2006) of a psychiatrist who had a 7-year affair with a patient who
was schizophrenic. The doctor not only had sex with the patient
but had her procure prostitutes
70
71. with whom he and the patient would have group sex. He paid for
their services by providing them with prescriptions for controlled
substances and went so far as to bill Medi-Cal for these
encounters as group therapy. The physician's license was revoked
and he was also criminally convicted of fraud.
71
72. The relationship between a doctor and a patient for the purposes
of providing and obtaining treatment is what is usually called the
doctor patient relationship. That relationship has both boundaries
around it and boundaries within it. Either person may cross the
boundary.
Not all boundary crossings are boundary violations. For example,
a patient may say to a
72
73. doctor at the end of an hour I have left my money at home and I
need a dollar to get my car out of the garage. Will you lend me a
dollar until next time? The patient has invited the doctor to cross
the doctor patient boundary and set up a lender borrower
relationship as well. Depending on the doctor's theoretical
orientation, the clinical situation with the patient, and other
factors, the doctor may elect to cross the boundary. Whether
73
74. the boundary crossing is also a boundary violation is debatable. A
boundary violation is a boundary crossing that is exploitative. It
gratifies the doctor's needs at the expense of the patient. The
doctor is responsible for preserving the boundary and for ensuring
that boundary crossings are held to a minimum and that
exploitation does not occur.
74
75. nonsexual boundary violations may be grouped into several
arbitrary (overlapping and not mutually exclusive) categories.
Business
Almost any business relationship with a former patient is
problematic, and almost any business relationship with a current
patient is unethical. Naturally, the circumstance and location may
play a significant role in this admonition. In a rural area
75
76. or a small community, a doctor might be treating the only
pharmacist (or plumber or couch upholsterer) in town; then when
doing business with the pharmacist patient, the doctor tries to keep
boundaries in check. Ethical psychiatrists try to avoid doing
business with a patient or a patient's family member or asking a
patient to hire one of their family members. Ethical psychiatrists
avoid investing in a patient's business or collaborating with a
patient in a business deal.
76
77. The particular locale and circumstances must be considered in any
discussion of the behavior of an ethical psychiatrist in social
situations. The overarching principle is that the boundaries of the
psychiatrist patient relationship should be respected. Further, if
options exist, they should be exercised in favor of the patient.
Problems often arise in treatment situations when friendships
develop between the psychiatrist and the patient.
77
78. Objectivity is compromise, therapeutic neutrality is impaired, and
factors outside the consciousness of either party may play a
destructive role. Such friendship should be avoided during
treatment. Similarly, psychiatrists should not treat their social
friends for the same set of reasons. Obviously, in an emergency, a
person does what a person must.
Financial
For psychiatrists who practice in the private sector, dealing with
the patient about money is a part of treatment.
78
79. Issues surrounding setting the fee, collecting the fee, and other
financial matters are grist for the mill. Even so, ethical concerns
must be observed. The Principles advises the doctor on such
matters as charging for missed appointments and other contractual
problems. Ethics complaints against doctors are
79
80. frequently precipitated by financial issues; thus, the doctor must
recognize the power that these issues have in the therapeutic
relationship. Because the psychotherapeutic relationship is so
much like a social relationship the office looks like a living room,
the doctor wears
80
81. regular clothes, some patients might, without recognizing it,
assume that a friendship exists that forgives payment of a fee.
When the bill is presented, feelings, even though they are
unconscious, are ruffled. Early in their careers, psychiatrists are
often reluctant to discuss fees openly out of a sense of
embarrassment over discussing money or a sense of protecting the
patient.
81
82. Confidentiality refers to the therapist's responsibility not to release
information learned in the course of treatment to third parties.
Privilege refers to the patient's right to prevent disclosure of
information from treatment in judicial hearings. Psychiatrists must
maintain confidentiality because it is an essential ingredient of
psychiatric care, as it is a prerequisite for patients to be willing to
speak freely
82
83. to therapists. Violating confidentiality by gossip embarrasses
people and violates nonmaleficence. Violation of confidentiality
also breaks the promise that a psychiatrist has explicitly or
implicitly made to keep material confidential.
Confidentiality must also give way to the responsibility to protect
others when a patient makes a credible threat to harm someone.
The situation becomes complicated when the risk is not to a
particular individual, such as when a doctor is
83
84. impaired or someone's mental state adversely affects his or her
performance of a dangerous job, such as police work, firefighting,
or use of dangerous machinery. Erosion has also arisen from the
demands of an insurance company for detailed information.
Patients must be told that information may be released to
insurance companies, but they do not need to be warned that
information concerning abuse of a child or threat to themselves or
others needs to be reported.
84
85. Various settings exist in which patient data can be used to some
degree. The general rule for doing so is to disclose only that
information that is truly necessary. In teaching, research, and
supervision, patients' names or information that might allow
others to identify them should not be unnecessarily released. In
ward rounds and case conferences, in which patient material is
presented, attendees should be reminded that what they hear
should not be repeated.
85
86. Confidentiality endures after death, with the ethical obligation to
withhold information unless the next of kin provides consent
A psychiatrist can petition the judge for an in-camera (private)
review to define what precise information must be disclosed.
86
87. Psychiatrists have certain responsibilities toward patients treated
in managed care settings, including the responsibilities to disclose
all treatment options, to exercise appeal rights, to continue
emergency treatment, and to cooperate reasonably with utilization
reviewers.
Responsibility to Disclose
Psychiatrists have a continuing responsibility to the patient to
obtain informed consent for treatments or procedures
87
88. . All treatment options should be fully disclosed, even those not
covered under the terms of a managed care plan. Most states have
enacted legislation making gag rules illegal that limit information
about treatment provided to patients under managed care.
88
89. Responsibility to Appeal
Physicians are liable for failure to treat their patients within the
defined standard of care. The treating physician has sole
responsibility to determine what is medically necessary.
Psychiatrists must be careful not to discharge suicidal or violent
patients prematurely merely because continued coverage of
benefits is not approved by a managed care company.
89
90. Impaired Physicians
A physician may become impaired as the result of psychiatric or
medical disorders or the use of mind-altering and habit-forming
substances (e.g., alcohol and drugs). Many organic illnesses can
interfere with the cognitive and motor skills required to provide
competent medical care. Although the legal responsibility to
report an impaired physician varies, depending on the state, the
ethical responsibility remains universal. An incapacitated
90
91. physician should be reported to an appropriate authority, and the
reporting physician is required to follow specific hospital, state,
and legal procedures. A physician who treats an impaired
physician should not be required to monitor the impaired
physician's progress or fitness to return to work. This monitoring
should be performed by an independent physician or group of
physicians who have no conflicts of interest.
91
92. Professional misconduct in New York State is defined as one of
the following:
Practicing fraudulently and with gross negligence or
incompetence.
Practicing while the ability to practice is impaired.
Being habitually drunk or being dependent on, or a habitual user
of, narcotics or a habitual user of other drugs having similar
effects.
Immoral conduct in the practice of the profession.
92
93. Permitting, aiding, or abetting an unlicensed person to perform
activities requiring a license.
Refusing a client or patient service because of creed, color, or
national origin.
Practicing beyond the scope of practice permitted by law.
93
94. Being convicted of a crime or being the subject of disciplinary
action in another jurisdiction.
Professional misconduct complaints derive mainly from the public
in addition to insurance companies, law enforcement agencies, and
doctors, among others.
94
96. Section 1 and 2
◦ Provide competent medical service and practicing outside the are
of the psychiatrist’s expertise respectively.
Violated by general psychiatrists without the necessary specialized
forensic training, experience, and expertise.
◦ Serve with compassion and respect for human dignity.
Violated by abusive behavior toward the evaluee by the forensic
examiner.
96
97. Section 2
◦ Honesty with patients and colleagues.
Deliberate withholding or distortion of data.
Testifying under oath that:
Claim credentials or experience (in truth, no experience)
Stating that interviews were conducted (but not done)
Stating that documents were reviewed (but not reviewed)
97
98. Section 4
◦ Confidentiality of psychiatric data and the limits of that
confidentiality.
Violated by release of otherwise confidential information
obtained through the course of the forensic evaluation
beyond that permitted by the consultation or the litigation
process
Failing to disclose the nonconfidentiality of the forensic
evaluation process to the evaluee.
98
