Forensic psychiatry
Forensic psychiatry is a subspecialty of psychiatry and is related to criminology. It encompasses the interface between law and psychiatry. According to the American Academy of Psychiatry and the Law, it is defined as "a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory, or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment". A forensic psychiatrist provides services—such as assessing competency to stand trial—to a court to help with the legal process and provides treatment, including medications and psychotherapy, to offenders.
Court work
Forensic psychiatrists work with courts in evaluating an individual's competency to stand trial, defenses based on mental disorders, and sentencing recommendations. The two major areas of criminal evaluations in forensic psychiatry are CST and mental state at the time of the offense.Competency to stand trial
CST evaluations are to determine that defendants have the competence to understand the charges and assist their attorneys. In the United States, this is seated in the Fifth Amendment to the United States Constitution, which ensures the right to be present at one's trial, to face one's accusers, and to have help from an attorney. CST, sometimes referred to as adjudicative competency, serves three purposes: "preserving the dignity of the criminal process, reducing the risk of erroneous convictions, and protecting defendants' decision-making autonomy".In 1960, the Supreme Court of the United States in Dusky v. United States established the standard for federal courts, ruling that "the test must be whether the defendant has sufficient present ability to consult with his attorney with a reasonable degree of rational understanding and a rational as well as factual understanding of proceedings against him." The evaluations must assess a defendant's ability to assist their legal counsel, meaning that they understand the legal charges against them, the implications of being a defendant, and the adversarial nature of the proceedings, including the roles played by defense counsel, prosecutors, judges, and the jury. They must be able to communicate relevant information to their attorney and understand information provided by their attorney. Finally, they must be competent to make important decisions, such as whether or not to accept a plea agreement.
In England, Wales, Scotland, and Ireland, a similar legal concept is that of "fitness to plead".
As an expert witness
Forensic psychiatrists are often called to be expert witnesses in both criminal and civil proceedings. Expert witnesses give their opinions about a specific issue. Often, the psychiatrist will have prepared a detailed report before testifying. The primary duty of the expert witness is to provide an independent opinion to the court. An expert is allowed to testify in court with respect to matters of opinion only when the matters in question are not ordinarily understandable to the finders of fact, be they judge or jury. As such, prominent leaders in the field of forensic psychiatry, including Thomas Gutheil, Robert Simon, Liza Gold, and others, have identified teaching as a critical dimension in the role of expert witness. The expert will be asked to form an opinion and to testify about that opinion, but in so doing will explain the basis for that opinion, which will include important concepts, approaches, and methods used in psychiatry.Mental state opinion
A mental state opinion gives the court an opinion, and only an opinion, as to whether a defendant was able to understand what they were doing at the time of the crime. This is worded differently in many states, and has been rejected altogether in some, but in every setting, the intent to do a criminal act and the understanding of the criminal nature of the act bear on the final disposition of the case. Much of forensic psychiatry is guided by significant court rulings or laws that bear on this area which include these three standards:- M'Naghten rules: Excuses a defendant who, by virtue of a defect of reason or disease of the mind, does not know the nature and quality of the act, or, if he or she does, does not know that the act is indeed wrong.
- Durham rule: Excuses a defendant whose conduct is the product of a mental disorder.
- ALI test: Excuses a defendant who, because of a mental disease or defect, lacks substantial capacity to appreciate the criminality of his or her conduct or to conform his conduct to the requirements of law.
Forensic psychiatrists are also involved in the care of prisoners, both in jails and prisons, and in the care of the mentally ill who have committed criminal acts.
Forensic psychiatry vs psychology
Forensic psychiatry
Forensic psychiatrists focus on how biological factors apply to the legal system. They focus more on the scientific facts as well as diagnosing and treating mental disorders. They legally assess clients, provide a diagnosis, and can prescribe medication if necessary. Forensic psychiatrists are physicians and have a doctorate of medicine or doctorate of osteopathic medicine. They can prescribe medications.Forensic psychology
examine how various disorders and conditions can be applied in court. Their jobs typically entail working as research assistants and probation officers. They often determine trial competency, assess the risk of inmates, and aid in jury selection. Forensic psychologists can use information learned about mental health and criminal justice to advocate for those who have a mental illness. After earning a master's degree and a PhD in psychology or a doctorate of psychology, they can become forensic psychologists. While they are required to be licensed by the state, they are not required to be medical doctors. This means that they cannot prescribe medication.Risk management
Many past offenders against other people, and suspected or potential future offenders with mental health problems or an intellectual or developmental disability, are supervised in the community by forensic psychiatric teams made up of a variety of professionals, including psychiatrists, psychologists, nurses, and care workers. These teams have dual responsibilities: to promote both the welfare of their clients and the safety of the public. The aim is not so much to predict as to prevent violence, by means of risk management.Risk assessment and management is a growth area in the forensic field, with much Canadian academic work being done in Ontario and British Columbia. This began with the attempt to predict the likelihood of a particular kind of offense being repeated, by combining "static" indicators from personal history and offense details in actuarial instruments such as the RRASOR and Static-99, which were shown to be more accurate than unaided professional judgment. More recently, use is being made also of "dynamic" risk factors, such as attitudes, impulsivity, mental state, family and social circumstances, substance use, and the availability and acceptance of support, to make a "structured professional judgment." The aim of this is to move away from prediction to prevention, by identifying and then managing risk factors. This may entail monitoring, treatment, rehabilitation, supervision, and victim safety planning and depends on the availability of funding and legal powers.
Risk management in forensic psychiatry is often done using standardised tests called structured professional judgement tools. Two such tools include the HCR-20 and the newer SAPROF developed in the late 2010s. These tools are used to measure the likelihood of recidivism and identify protective factors for offenders.
United Kingdom
In the UK, most forensic psychiatrists work for the National Health Service, in specialist secure units caring for mentally ill offenders. These can be either medium secure units or high secure hospitals, of which three are in England and one in Scotland, the best known of which is Broadmoor Hospital. The other 'specials' are Ashworth hospital in Maghull, Liverpool, and Rampton hospital in Nottinghamshire. Also, a number of private-sector medium secure units sell their beds exclusively to the NHS, as not enough secure beds are available in the NHS system.Forensic psychiatrists often also do prison inreach work, in which they go into prisons and assess and treat people suspected of having mental disorders; much of the day-to-day work of these psychiatrists comprises care of very seriously mentally ill patients, especially those with schizophrenia. Some units also treat people with severe personality disorder or learning disabilities. The areas of assessment for courts are also somewhat different in Britain, because of differing mental health law. Fitness to plead and mental state at the time of the offence are indeed issues given consideration, but the mental state at the time of trial is also a major issue, and this assessment most commonly leads to the use of mental health legislation to detain people in hospitals, as opposed to their getting a prison sentence.
Learning-disabled offenders who are a continuing risk to others may be detained in learning-disability hospitals. This includes those who commit serious crimes of violence, including sexual violence, and fire-setting. They would be cared for by learning disability psychiatrists and registered learning disability nurses. Some psychiatrists doing this work have dual training in learning disability and forensic psychiatry or learning disability and adolescent psychiatry. Some nurses would have training in mental health, also.
Court work is generally undertaken as private work by psychiatrists, as well as forensic and clinical psychologists, who usually also work within the NHS. This work is generally funded by the Legal Services Commission.