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. Forensic science has gained incredible attention through popular crime investigation shows. People love to watch as the clues, and tell-tale signs of guilt unfold, playing along by making their guesses about what the evidence means. One of the most interesting of the forensic sciences is forensic psychiatry.
Specialty Guidelines for Forensic Psychologists were developed by Division 41 of the American Psychological Association, but are not an “official statement” of this organization. The guidelines offer a model of practices to which psychological experts should aspire, and are intended to amplify standards expressed in the American Psychological Association’s Ethical Principles of Psychologists. The Specialty Guidelines define as forensic psychologists those licenced psychologists who regularly function as experts in legal proceedings, who work in correctional and/or forensic mental health facilities, or who serve in agencies that adjudicate judicial or legal matters.
Forensic psychiatrists regularly provide expert witness evidence to courts at all levels. Psychiatrists in other specialties may also have sufficient training to do this, but, more commonly forensic psychiatrists are called to the higher courts – including crown courts or the Court of Appeal in more serious criminal cases such as homicide, other serious violence and sex offending. They may also be asked for expertise in the family court or on other civil matters, such as compensation after major trauma or disaster. Areas of expertise required include:
- defendant’s fitness to plead and fitness to stand trial
- capacity to form intent
- advice to the courts on the available psychiatric defences
- appropriateness and circumstances required for an individual’s admission to hospital for assessment
- appropriateness of a mental health disposal at the time of sentencing
- nature of a particular mental disorder and link to future risks
- prognosis and availability of “appropriate treatment”
- level of security required to treat a patient and manage risk
When advising colleagues in the care of patients deemed to be a risk to others, forensic psychiatrists will need to be competent to provide a detailed assessment including advice on:
- risk of harm to others, including use of structured risk assessment/professional judgement tools
- risk management
- expertise on pharmacological and psychological treatment approaches to violent behaviours associated with mental disorders
- psychodynamic formulation of the case, including psychotherapeutic strategy
- therapeutic use of security
Community forensic work provides opportunities to assess and to work with mentally disordered offenders in facilities run by HM Prison and Probation Service and/or third sector organisations. In addition, although all psychiatrists should have a basic understanding of the system of Multi-Agency Protection Panels, in practice forensic psychiatrists must be very experienced in such work. Ethical issues, such as information sharing, differ under such working arrangements from usual clinical practice. Skills needed include knowledge of when and what otherwise confidential information must be shared with others in these circumstances, clarity of understanding of role in the arrangements and appropriate confidence in requiring information from other agencies when necessary for good and safe care.
Forensic psychiatrists must participate in regular audit within and outside the specialty, thus helping to improve the quality of the service offered to patients.
They must understand clinical governance procedures, attend meetings and investigate complaints and serious incidents alongside colleagues in the multi-disciplinary team.
Teaching and training is also an important part of the work. This includes weekly supervision of specialist higher trainees in forensic psychiatry, but also more junior trainees in any specialty. With recruitment and retention in mind, it is important to engage with undergraduate medical trainees too. Given the multi-professional nature of the work, a contribution to the teaching and training of people from other relevant disciplines is also expected.
People with needs relevant to the whole psychiatric spectrum may offend or become dangerous to others. In some areas this is so common that joint training has been set up to allow those who complete the training to be able to claim expertise in both (or more) areas. There is a growing need for old-age forensic psychiatry, and most offender patients have problems with substance misuse, but the three recognised combinations to date are:
- adolescent forensic psychiatry
- forensic learning disability psychiatry
- forensic psychotherapy