Forensic psychiatry

Forensic psychiatry is a subspecialty of psychiatry. It encompasses the interface between law and psychiatry. Some practitioners of forensic psychiatry have taken extra training in that specific area. In the United States one year fellowships are offered in this field to psychiatrists who have completed their general psychiatry training. In Britain one is required to complete a three-year subspeciality training in forensic psychiatry, after completing one's general psychiatry training, before receiving a Certificate of Completion of Training as a forensic psychiatrist. In some countries general psychiatrists can practice forensic psychiatry as well. However, some countries require a specific certification from the government to do this type of work (e.g. Japan).

Court work
Forensic psychiatrists work with courts in evaluating an individual's competency to stand trial, defences based on mental diseases or defects (e.g., the "insanity" defence), and sentencing recommendations. There are two major areas of criminal evaluations in forensic psychiatry. These are Competency to Stand trial (CST) and Mental State at the Time of the Offence (MSO).

Competency to stand trial (CST)
This is the competency evaluation to determination that a defendant has the mental capacity to understand the charges and assist his attorney. This is seated in the Fifth Amendment to the US Constitution, which ensures the right to be present at your trial, to face your accusers, and to have help from an attorney.

In English and Welsh law a similar 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 opinion 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.

Mental state opinion
This gives the Court an opinion, and only an opinion, as to whether a defendant was able to understand what he was 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 that it was a criminal act bear on the final disposition of the case. Much of forensic psychiatry is guided by significant Court ruling or laws that bear on this area. "Not guilty by reason of insanity" is one potential outcome in this type of trial. It is important to note that insanity is a legal and not a medical term. Often there will be a psychiatrist(s) for the defense as well as the prosecution.

Forensic Psychiatrists are also involved in the care of prisoners, both those in jails and those in prisons, and in the care of the mentally ill and dangerous (such as those who have been found not guilty by reason of insanity).

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 teams containing 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 academic work being done in Ontario and British Columbia. This began with the attempt to predict the likelihood of a particular kind of offence being repeated, by combining "static" indicators from personal history and offence details in actuarial instruments such as the RRASOR and Static-99, which were shown to be more accurate than unaided professional judgement. More recently, use is being made also of "dynamic" risk factors, such as attitudes, impulsivity, mental state, family and social circumstances, substance use, availability and acceptance of support, to make a "structured professional judgement." 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. These schemes may be based on published assessments such as the HCR-20 (which incorporates 10 Historical, 5 Clinical and 5 Risk Management factors) and the RSVP (Risk of Sexual Violence Protocol) from Simon Fraser University, BC.

Britain
In Britain most forensic psychiatrists work for the National Health Service, in specialist secure units caring for mentally ill offenders (as well as people whose behaviour has made them impossible to manage in other hospitals). These can be either medium secure units (of which there are many throughout the country) or maximum security hospitals (also known as Special Hospitals), of which there are three in England and one in Scotland, the best known of which being Broadmoor Hospital. The other 'specials' are Ashworth hospital in Maghull, Liverpool and Rampton hospital in Nottinghamshire. There are also a number of private sector medium secure units, which sell their beds exclusively to the NHS, as there are not enough secure beds available in the NHS system. (There are no 'private' paying patients in Forensic Psychiatry!)

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 suffering from schizophrenia. Some units also treat people with severe personality disorder, learning disabilities (by which is meant, in Britain, intellectual impairment), autistic spectrum disorders or other illnesses.

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 it is this assessment which most commonly leads to the use of mental health legislation to detain people in hospital, as opposed to their getting a prison sentence.

A large proportion of prisoners are learning disabled, although those who are detected as such are more likely to be diverted into the mental health system before coming to trial. Learning disabled offenders who are a continuing risk to others may be detained in hospitals (or community-based units with a similar regime, as the hospitals have mostly been closed) as suffering from "Mental Impairment" in England and Wales, and without use of that term in Scotland. 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 (RNLD). Some psychiatrists doing this work have dual training in learning disability and forensic or LD and adolescent psychiatry. Some nurses would have dual training in mental health (RMN).

Many past offenders against other people, and suspected or potential future offenders with mental health problems or a learning disability, are supervised in the community by forensic teams containing 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.

Court work (medico-legal work) is generally but not exclusively undertaken by psychiatrists (most often 'forensic' psychiatrists who are consultants (senior doctors) in the National Health Service (NHS).

Fictional depictions
The television show, Wonderland briefly aired in the United States. It was based on the daily work lives of a fictitious group of forensic psychiatrists at Bellevue Hospital in New York City. Only two episodes aired of the six filmed. Dr. George Huang (portrayed by BD Wong) on Law and Order: SVU is a forensic psychiatrist. In addition, the CBS crime-drama Criminal Minds features a young forensic psychiatrist (portrayed by Matthew Gray Gubler (Dr. Spencer Reid)) on the FBI profiling team the show centers around.

Another fictional Forensic Psychiatrist is in the television show Bones, where Dr. Gordon Wyatt (portrayed by Stephen Fry) is assigned to counsel one of the protagonists (Agent Booth) after he shoots up an ice cream truck. This occurs in the episode "The Girl In The Gator." Hannibal Lecter from the novels Red Dragon, Silence of the lambs, Hannibal, and Hannibal Rising by Thomas Harris and their respective film adaptions is a Forensic Psychiatrist until it is found that he is a serial killer and is captured and incarcerated.