Forensic Psychiatry

Narrow definition: a branch of psychiatry concerned with the assessment and treatment of mentally abnormal offenders.

Developed following the Butler report (1975). Note the clinical bias.

Mental disorder and crime:-

Change in emphasis over time, away from hopes that mental disorder would explain crime, towards a concern with services for mentally disordered offenders. less than 1% of all court appearances result in a psychiatric disposal (including probation with a condition of treatment) i.e. most offenders are not mentally ill, most of the mentally ill are not offenders.

1. Services

Prison surveys: one third of sentenced prisoners given a diagnosis, 2% have a psychosis, around 3% require hospital transfer (Gunn et al, 1991).

NB distinguish responsibility (not a psychiatric concept) from need for treatment (medical model).

Diversion schemes: avoid remands in custody by providing psychiatric care at an early stage (Joseph).? long-term outcome; "Revolving door" patients.

With the advent of contracting, it is important to have an idea of the components of a good service in various settings e.g. courts, prisons.

Landmarks in legislation

1975 Butler report following Graham Young tragedy.

1984 Death of Ms Isabel Schwarz. Resultant inquiry led to:

1990 Royal College of Psychiatrists guidelines on good practice in aftercare of potentially violent or vulnerable patients. Endorses the Care Program Approach, Section 117 of MHA 1983

1991 Inquiry established under Dr. William Boyd, Royal College: looking at homicides and suicides in psychiatric patients. Estimated 35 (of total 500) homicides in England and Wales have clear psychiatric link.

1992 Reed. Principle: mentally disordered offenders are the responsibility of health and social services, not the criminal justice system.

1993/4 Furore over homicides by psychiatric patients ?tighter controls on discharged patients. No community treatment order (yet?) but "supervised discharge" and patient register proposed.

NB:?:

I. MHA 1983 speaks of patient's "health or safety" as reason for detention

ii. the restriction order (541), to "protect the public from serious harm", allows compulsory supervision as a conditionally discharged patient.

2. Links between mental disorder and violence

There is a small but significant link between schizophrenia and offending in general and schizophrenia and violence in particular (Taylor & Gunn, Hafner & Boker, Lindqvist & Allebeck) but:

i. Only a small proportion of people with schizophrenia are violent, only a small proportion of violent offenders are schizophrenic.

11. Methodological problems, esp. reporting.

iii. Useless for individual prediction.

iv. Many of the same rules apply to mentally disordered violence as to other violence e.g. role of substance abuse, environment, ?experience of violence in childhood. Some distinctive rules may also apply e.g. psychotic men may be more likely to kill a stranger, have bizarre motives.

Epidemiology V studies of individual cases.

Homicide by a patient is a negative outcome and may be best studied as such i.e. analogous to the question of why the engine falls off a jumbo jet. A large sample and control group is not the way to answer the question.

Mechanisms undying violence in mental disorder

Why do some patients act on delusions, others not? Strong associated affect and

seeking information to confirm delusions were associated with acting on them

(Buchanan et al).

Dangerousness V. Risk Assessment

The former is a less useful concept. Risk assessment can be based on more specific questions and situations.

.Assessment of a defendant for court

TRIAL

I. Fitness to plead

new legislation allows a "trial of the facts'^t and flexibility in disposal.

2. Discontinuance as "not in public interest"

3. Insanity defense

4. Diminished Responsibility (in homicide only)

DISPOSAL

Except in murder (mandatory life sentence) the psychiatrist may be asked to advise

(not decide) on a range of options.

- hospital order (537). NB if "suitable": no mention of responsibility

- guardianship

- probation with condition of treatment

- offer of voluntary treatment

suggest alternatives to custody (now policy for all offenders where possible, since Criminal Justice Act 1991)