Talks about psychiatry and the law, the Rights of psychiatric patients

1. FORENSIC
PSYCHIATRY
Dr Audu A A
Consultant Psychiatrist

2. • Introduction
• Crime
• Mental disorders and crime
• Psychiatry and the law

3. Forensic psychiatry is a branch of
psychiatry that deals with the
assessment and treatment of
mentally disordered offenders
– It deals with the interface
between psychiatry and the
criminal justice system

4. Forensic mental health services may
support:
– a person who was mentally unwell at
the time of committing the offence
– a person in prison for an offence
unrelated to a mental health
problem, who becomes mentally
unwell whilst in prison
– a person with mental health
problems in the community who has
a significant history of risk issues
or poses significant risk to others

5. • Psychiatric assessment (and if
appropriate, treatment and
rehabilitation) of offenders charged
with a serious crime
• Providing treatment for convicted
prisoners
• Assessment and treatment of non-
offenders with difficult or dangerous
behaviour in a secure setting
• Giving advice to other psychiatrists
encountering forensic issues

6. – Understanding of relationship
between mental illness and
criminality
– Evolution of legal tests to define
legal insanity
– New treatment methods providing
alternatives to custodial care
– Change in attitudes/perception of
mental illness by the public

7. • Assessing behavioural abnormalities
• Writing Court reports and giving
evidence
• Using security as means of treatment
• Treatment of personality and
behavioural disorders
• Knowledge of mental health laws as
well as aspects of Penal and criminal
codes relevant to insanity

8. Intentional act or omission in violation of criminal
law, committed without defense or justification
and sanctioned by the state as felony or
misdemeanor
– Defined by each society
Types
– Violent crimes (“crimes against a person”)
are based on the use of force or the threat
of force. E.g. rape, murder, armed robbery
– Nonviolent crimes (“Property Crimes”)
involve the destruction or theft of
property, but do not use force or the threat
of force. E.g. theft, vandalism

9. Personal factors
Unemployment, poverty,
drugs, gender, personality
Family factors
Poor parental supervision,
harsh discipline, marital
disharmony, large
dysfunctional family,
broken homes
Disturbed social structure
Anomie (lack of common
social, ethical standard)
Psychological factors
id dominated, eros
dyscontrol, super ego
lacuna, ego fractures,
deprivations leading to
inability to cope with
societal norms

10. • The relationship between psychiatric
illness and criminality has been the
topic of intense debate and scrutiny in
the recent past
• The popular belief is that people with
mental illness are more prone to
commit acts of violence and aggression
• A large body of data however suggests
otherwise

11. The public perception of psychiatric
patients as dangerous individuals is often
rooted in
– Media portrayal of criminals as
“crazy”
– Society at large views behaviour
and conduct problems as a symptom
of a psychological disorder
– Many prisons once served as lunatic
asylums, where the mentally ill were
kept
– Evidence for overrepresentation of
mentally ill persons in correctional
facilities

12. • Offending by psychiatric patients is
more related to the factors which serve
as general predictors of criminal
behaviour than to their mental disorder
• Unusual or irrational behaviour may be a
symptom of serious mental disorders,
but the person may not necessarily be
dangerous or a threat to others
• Mentally ill persons are more likely to be
victims of crime than perpetrators

13. • Mentally ill people may be arrested
for drug possession or for a crime
carried out under the influence of
drugs
– In many cases it is the result of
attempts to self‐medicate with drugs or
alcohol in order to alleviate the impact of
their untreated psychiatric symptoms or
to relieve the debilitating side effects of
medications
• Poor judgement and low IQ may put a
mentally ill person at a greater risk
of getting arrested

14. • An untreated mental disorder can
strain relationships with friends and
family, which also constitutes a
contributing factor to violence and
criminal activity
• Certain psychiatric conditions can
actually increase a person’s risk of
committing a crime
– This is however rare compared to
senseless acts of violence carried out by
non-mentally ill criminals in the general
population with criminal intent

15. Schizophrenia
• Acts on a delusion
• Responds to a
hallucination
• Irresistible urge or
loss of control
• Becomes violent if
feelings of personal
threat emerge
• Irrational behaviour
contravening social
norms
Epilepsy
• Loss of control
can lead to crime
Mania
• Grandiosity
leading to fraud,
public disorder,
impersonation,
disinhibition,
irritability,
aggression,
violence
• Low mood /
hopelessness / guilt
feelings leading to
suicide, altruistic
homicide
Depression
• May lead to
distraction or need
to leave shop quickly
without paying
Anxiety disorder

16. Substance abuse
• May lead to loss of
control
• May offend to procure
drug
• Implicated in family
violence, child abuse,
rape, sex offences,
homicide
• In Nigeria, alcohol and
cannabis use is high
among criminals
Personality disorder
• People with antisocial
personality disorder
have a personality style
that finds impulsive,
high-risk behaviour
rewarding
• People with borderline
personality disorder
have unstable
relationships, identity
disturbance, and are
prone to suicidal
attempts
• People with paranoid
personality disorder
may be arrested for
stalking or issuing
threats
Learning disability
• Unable to understand
implications of behavior
• Susceptible to
exploitation – lack IQ
to plan crimes properly
• Prone to arrest
• Sexual offences
common because they
are rejected/denied
legitimate expression
of sexuality
• Theft and arson also
common
• Violent crime less
common

17. Dementia
• Impaired judgment
/ disinhibition may
lead to crime
• May make false
confessions due to
failing memory
Pathological
gambling
• May offend in order
to obtain money or
evade debts
Kleptomania
• Unable to resist
impulse to steal
• Steal to relieve
tension
• Objects stolen are not
needed and may be
discarded or hoarded
• Delusion of infidelity
commonly lead to
criminal behavior
Pathological jealousy /
Othello syndrome
• Delusion of love by distinguished person,
unattainable by reason of social class
• Physical pursuit of “lover”, invasion of privacy,
leading to criminal acts
Erotomania / De Clerambault’s syndrome

18. Legal issues requiring psychiatrist’s
intervention
– Fitness to plead
– Criminal responsibility
– Insanity defense
– Mental capacity/competence
• Testamentary capacity
• Capacity to give consent
• Competence to be executed, etc.
– Duty to warn/protect
– Expert witness

19. A defendant's capacity to fully comprehend
the course of criminal proceedings, and the
ability to understand and participate in the
legal process; a prerequisite to a fair trial
• A fitness to plead report is traditionally
sought before a defendant is put on
trial/ahead of a hearing into alleged
crimes committed by the accused party

20. Historical aspect / landmark case
• 'Alderson B. in R v Pritchard' case
(1836)
– A deaf and mute defendant whose sanity
was famously brought into question in
March 1836, to ultimately determine his
ability to fully grasp the gist of the
criminal case brought against him at the
time of his trial
“Pritchard Criteria” used till date to assess
fitness to plead

21. Pritchard criteria
In determining fitness to plead, it is necessary
to determine how far the defendant can:
1. understand the nature of the charge
2. understand the difference between
pleading guilty and not guilty
3. instruct counsel (his lawyer)
4. challenge jurors
5. challenge a witness
6. follow the proceedings in court

22. • Refers to mental state during
alleged offence
• Before anyone can be convicted of a
crime, the prosecution must prove
that
– he carried out an unlawful act
(actus reus)
– he had at the time the state of
mind necessary to commit a
crime (mens rea)
– There must be a concurrence in
time between both
• Must be proved beyond reasonable
doubt before conviction can be
made for most offences
– Traffic offences only require
actus reus

23. • Children below 10 years are
considered in most jurisdiction to
lack the capacity to form the intent
to commit crime (this is termed Doli
incapax)
• Children between the ages of 10 and
14 years may be convicted if there is
evidence of mens rea and that the
child knew that the offence was
legally or morally wrong
The Nigerian perspective
– Section 50 (Penal Code)

24. A defense can be made that the offender is
not culpable because he did not have a
sufficient degree of mens rea e.g.
– Not guilty by reason of insanity
– Diminished responsibility (not guilty of
murder, but guilty of manslaughter,
which requires a lesser degree of
criminal intent)
– Incapacity to form an intent because of
an automatism (performed without
conscious awareness)

25. Embodied in the McNaghten rules
– In 1842 Daniel McNaghten, a wood turner
from Glasgow, shot and killed Edward
Drummond, private secretary to the Prime
Minister, Sir Robert Peel, while suffering
from paranoid delusions

26. The Nigerian perspective
– Section 51 (Penal Code)
– Section 28 (Criminal Code)

27. • This defense applies only to a
charge of murder

28. • If the plea is acceptable to the
judge and prosecution, there is no
trial but a hearing and a sentence
of manslaughter (culpable
homicide) is passed
• If a mother kills her child in the
first year of life, she is not
usually held legally responsible for
murder, but for the lesser charge
of infanticide
– Diminished responsibility refers
only to sentencing, not
responsibility for the act in terms
of guilt

29. If a person has no control over an act,
he cannot be held responsible for it
Sane automatism
• Seen to be due to an
‘external cause’
• Leads to a full acquittal
• E.g. absent-mindedness in
association with depression
Insane automatism
• Are due to an ‘internal cause’
(arise due to disease of the
mind)
• The appropriate defence is
insanity and the McNaghten
rules apply
• E.g. epileptic automatism,
hypoglycaemia,
hyperglycaemia, sleep-
walking

30. • Capacity refers to having sound mind and
also memory sufficient to understand
relevant facts and to appreciate potential
outcomes
• Testamentary capacity refers to an
individual’s legal and mental ability to make or
alter a valid will
• A Will or Testament is a legal declaration by
which a person (the testator), names one or
more persons to manage his/her estate and
provides for the distribution of his/her
property at death
• The will may still be legally valid if the
testator is of ‘sound disposing mind’ at the
time of making it

31. The following is used to decide whether or
not a testator is of sound disposing mind:
1. He/she understands what a will is and
what the consequences are
2. He/she knows the nature and extent of
his property (though not in detail)
3. He/she knows the names of close
relatives and can assess their claims to
his property
4. He/she is free from an abnormal state
of mind that might distort feelings or
judgements relevant to making the will
 A deluded person may legitimately make a
will, provided that the delusions are unlikely to
influence it

32. The judgement of competence relies
upon patient’s ability to
• comprehend and retain information
about treatment
• to believe this information
• to be able to use it to make an
informed choice

33. • Competent adults have a right to refuse
medical treatment, even if this refusal
leads to death or permanent disablement
• In some situations consent is not needed,
e.g:
– Implied consent – such as where a patient is
unconscious and a reasonable person would
consent
– Necessity – in which grave harm or death are
likely to occur without intervention and there is
doubt about the patient’s competence
– Emergency – in order to prevent immediate
serious harm to the patient or to others, or to
prevent a crime

34. Historical aspect / landmark case
• Tarasoff v Regents of the
University of California
– Tarasoff 1----1974 (Dec 23):
Duty to warn
– Tarasoff 2----1976 (Jul 1):
Duty to protect

35. The Tarasoff Ruling
• Therapists have a duty to protect
an individual they reasonably
believe to be at risk of injury on
the basis of a patient's
confidential statements
• The professional may discharge the
duty by
– notifying police
– warning the intended victim
– taking other reasonable steps to
protect the threatened individual

36. The Nigerian perspective
• National Health Act 2014,
Sections 26 and 27
• MDCN Code of Ethics, Rule 44
– All allow discretionary breach of
confidentiality in the interest of
public safety

37. • A marriage contract is not
valid if at the time of
marriage either party was so
mentally disordered as not
to understand its nature
• If mental disorder can be
proved, a marriage may be
decreed null and void by a
divorce court

38. • If a person makes a contract and later
develops a mental disorder, then the
contract is binding
• If a person is of unsound mind when the
contract is made, a distinction is made
between the ‘necessaries’ and ‘non-
necessaries’ of life
– Necessaries are legally defined as goods
(or services) ‘suitable to the condition
of life of such person and to his actual
requirements at the time’

39. • A contract made for necessaries is
always binding
• In a contract for non-necessaries
made by a person of unsound mind, the
contract is binding unless it can be
shown that
1. he did not understand what he was
doing
2. the other person was aware of the
incapacity

40. A medical officer or head of the facility may, upon
application, admit a person with mental health
condition involuntarily, or involuntarily admit a person
who had been admitted voluntarily, where he
determines that the person has a mental health
condition and —
a. because of the mental health condition, there is a
serious likelihood of imminent harm to that
person or to other persons; or
b. where there is evidence that the mental health
condition is so severe that failure to admit the
person is likely to —
i. lead to a serious deterioration in the
condition of that person, or
ii. hinder the provision of appropriate
treatment that can only be given by
admission to a facility in accordance with the
principle of the least restrictive alternative
NATIONAL MENTAL HEALTH ACT, 2021

41. • Allows one person (the donor) to give
legal authority to another person
(the attorney) to manage their
affairs
• Requires the patient to give written
authorization for someone else to
act for him during his illness
• In signing such authorization, the
patient must be able to understand
what he is doing

42. Ordinary Power of Attorney
• Allows the attorney to
deal with the donor’s
financial affairs
generally, or can be
limited to specific
matters
• It is automatically
revoked by law when the
donor loses their mental
capacity to manage their
own affairs
• The donor may revoke it
at any time
Enduring Power of Attorney
• Allows people to decide who
should manage their affairs
if they become mentally
incapable
• It continues in force after
the donor has lost the
mental capacity
• Useful in patients with
early dementia who can set
their affairs in order early
in the illness

43. • An expert witness is an individual who is a specialist in
a subject who may present his/her expert opinion
without having been a witness to any occurrence
relating to the lawsuit or criminal case
Duties
– To educate the court
– To clarify psychiatric issues
– To offer opinions based on actual data and sound
reasoning
– To strive for honesty and objectivity while doing
all of the above
– To readily acknowledge his limitations

44. • Act in condescending
manner
• Be Pompous
• Be verbose
• Appear egotistical
• Argue with counsel
• Praise yourself
• Fumble for papers or
documents
• Be boring
• Look or act anxious,
nervous or worried
• Be overconfident
• Be arrogant

45. Forensic psychiatry deals with issues arising in the
interface between psychiatry and the law
Psychiatrists are called on by the legal system to provide
testimony in a wide variety of cases, criminal and civil
In criminal cases, forensic psychiatrists may be asked to
comment on the competence of a person to make
decisions throughout all the phases of criminal
investigation, trial, and punishment
In civil cases, forensic psychiatrists are asked to
evaluate a number of civil competences, including
competence to make a will or contract or to make
decisions about one's person and property

47. • http://www.trickcyclists.co.uk
• Harrison P, Cowen P, Burns T, Fazel M.
Shorter Oxford Textbook of
Psychiatry. 7th ed. Oxford University
Press; 2018.
• Azam M, Qureshi M, Kinnair D.
Psychiatry: A Clinical Handbook. Scion
Publishing Ltd, 2016
• Forensic Psychiatry : Assessment /
Services and Specific Disorders in
Forensic Psychiatry. By Dr.
Majekodunmi Oluyinka E. Delivered at
the revision course of the National
Postgraduate Medical College of
Nigeria