Introduction to Forensic Psychiatry

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Introduction to Forensic Psychiatry

• Magdoline Daas, M.D.
• Forensic Psychiatry Fellow

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Forensic Psychiatry

• Forensic psychiatry is a subspecialty of
  psychiatry in which scientific and clinical
  expertise is applied to legal issues in legal
  context embracing civil, criminal, and
  correctional or legislative matters forensic
  psychiatry should be practiced in accordance with
  guidelines and ethical principles enunciated by
  the profession of psychiatry.
• American Academy of Psychiatry and Law

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AAPL

• It is the first professional organization of
  forensic psychiatrists.
• Was established with only ten members in 1969.
• Few fellowship in Forensic Psychiatry were
  offered as early as 1965.

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History

• The term mad-doctors was once the standard
  English expression for those medical men who
  sought to make a living from the treatment of the
  mentally disordered.
• The term most commonly used in the 19th century
  was alienists to describe psychiatrists.
• The modern term psychiatrist originated in
  Germany and did not come into widespread use
  until the last third of the 19th century.
• Terms such as the lunatics, the deranged,
  the distracted, the mad men, and the insane
  were used to describe the individuals with mental
  illnesses.

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Development of Forensic Psychiatry

• In 1840, Edward Oxford was tried for firing a
  pistol at Queen Victoria. He pled not guilty by
  reason of insanity.
• The testimony in the Oxford case demonstrated a
  professional identity based on expertise in the
  evaluation of insanity (1840).
• Before that time, the legal professional had seen
  little need for advice on legal issues.
• By the mid 1800s professional special expertise
  was acknowledged by the court while in 1760 the
  psychiatrists appeared in only 1 out of 10
  insanity trials.

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Development

• In the 1700s, England applied the death penalty
  to a wide range of personal and property
  offenses.
• Bethlem (originally Bethlehem Hospital) was
  established in 1247, but it did not admit the
  mentally ill until the year 1400.
• The first hospital to care for the mentally ill
  in colonial America was the Public Hospital for
  the Insane (opened in 1773 in Williamsburg,
  Virginia).
• The earliest American asylums for the treatment
  of the insane opened in 1810 and 1820.
• From 1825-1865, the number of asylums grew from
  only nine to 62.

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Roles and Responsibilities of Forensic
Psychiatrists

• To describe the mental attributes, define the
  issues (criminal, civil), answer legal questions
  (consultation).
• Source of information defined in state laws,
  cases, books.
• Provide the court with information based on
  knowledge, research, and training.

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Civil Commitments

• Involuntary confinement of a person judged to be
  a danger to himself/herself or others, even
  thought the person has not committed a crime.
• Procedures differ by state however most states
  enable physicians to commit an individual for a
  period of time (24 hours-several day) before
  formal court proceedings.

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Civil Commitment

• Greek philosophers recommend that people with
  mental illness be cared for in a comfortable,
  sanitary, well-lighted place.
• The Roman appointed a curator (guardian) to
  safeguard the property of these people.
• During the first third of the 20th century, most
  changes in civil commitment law were developed.
• By 1970, 31 states provided hospitalization based
  simply on the certification of one or two
  physicians that the individual suffered from
  mental illness and needed treatment.

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Criteria for Commitment

• Mental illness
• Impaired capacity and competency to make
  treatment decisions.
• Danger to others
• Danger to self
• Inability to care for self
• Need for treatment
• Least restrictive alternative

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Least Restrictive Alternative

• Meeting criteria is not enough, if a less
  restrictive alternative exists.
• State hospital is most restrictive environment.
• Community-based services and outpatient clinic
  are less restrictive.

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Inpatient Commitment

• Two stages of commitment.
• 1. Emergency commitment to prevent harm to
  self or others.
• In California, police officers or clinician may
  authorize this commitment up to 72 hours.
• In New York, a clinician or community director of
  mental health can authorize this commitment up to
  15 days if a second physician has examined the
  patient within 48 hours.
• 2. Long term commitment usually following the
  first and it is the formal commitment hearing.
  It varies from state to state.
• In California, up to 7 days, 14 days, second 14
  days, 180 days.
• In New York, 15 days, 60 days.
• In Missouri, 96 hours, 21 days, 90 days, one year.

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Patients Rights

• Written notice of the fact that the patient faces
  a commitment proceeding.
• A right to counsel and to have counsel appointed
  if necessary.
• The right to call witnesses and cross examine
  witnesses.
• The right to request a jury trial.
• The right to have a judge rather than a clinician
  make the ultimate decision.
• The right to have the state prove its cases by
  clear and convincing evidence.

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Criminal Commitment

• Confinement of a person who has committed a
  crime. Confinement in a mental institution
  occurs for determination of competency to stand
  trial or after acquittal by reason of insanity.

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The Concept of Criminal Responsibility

• In order to be guilty of an offense, it is
  necessary for the prosecution to prove all the
  required elements of the charge to the required
  standard of proof. This standard is proof
  beyond all reasonable doubt. The prosecution
  must prove not only that the accused committed
  the act described, but also had the required
  state of mind or mens rea.

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The Insanity Defense

• Refers to mental state at the time of crime.
• Not Guilty by Reason of Insanity is a legal
  argument that a defendant should not be held
  responsible for an illegal act. It applies if
  the act is attributable to a mental illness that
  interferes with rationality or that results from
  some other excusing condition, such as not
  knowing right from wrong.

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The Insanity Defense

• Criminal law rests on the assumption that people
  have free will and that if they do wrong, they
  have chosen to do so, are blameworthy, and should
  therefore be punished. The insanity defense
  applies to individuals who are assumed to have
  less fee will, or responsibility for their
  actions, because of a mental defect.

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Legal Precedents/Considerations in the Insanity
Defense

• M'Naghten Test Did the person know right from
  wrong?
• Applies if reasoning was so defective that the
  person didnt know what she or he was doing, or
  if she or he was unable to comprehend that the
  act was wrong.
• Problems Just cognitivefails to take
  emotional, volitional factors into account.

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Legal Precedents/Considerations in the Insanity
Defense

• Irresistible Impulse Test Did the person lack
  the willpower to control his/her actions?
• Problems What is the difference between an
  irresistible impulse and an unresisted impulse?

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Legal Precedents/Considerations in the Insanity
Defense

• American Law Institute Test A person is not
  responsible for criminal conduct if at the time
  of such conduct as a result of mental disease or
  defect he lacks substantial capacity either to
  appreciate the criminality of his conduct or to
  conform his conduct to the requirements of the
  law.
• Problems expert witnesses and jury must define
  substantial, appreciate.

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Legal Precedents/Considerations in the Insanity
Defense

• Insanity Reform Act of 1984 focuses on
  cognitive definition of insanity (i.e., was
  doing) requires defense to prove insanity
  (instead of prosecution proving insanity)
• Guilty but Mentally Ill verdict assumes
  personal responsibility but ensures treatment.

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Competency to Stand Trial

• Refers to mental state after arrest/before trial.
• Does the defendant have a factual understanding
  of the proceedings?
• Rational understanding of the proceedings.
• Can the defendant rationally consult with counsel
  in presenting his or her own defense.

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Confidentiality

• Confidentiality is an ETHICAL obligation of a
  therapist toward his/her clients.
• Ensures that information divulged within
  professional-client relationship will not be
  disclosed to other individuals or institutions
  without the clients consent.

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Privileged Communication

• Privileged communication is a LEGAL right of a
  client regarding his/her communications with a
  therapist.
• Prevents the disclosure of confidential
  communications without the clients permission.

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Limits to Confidentiality/Privileged Communication

• Client is a danger to self/others.
• Child or elder abuse.
• Some legal proceedings (e.g., evaluations for
  civil/criminal commitments or competency to stand
  trial).
• Infectious disease (duty to warn public
  official).
• Gunshot and knife wounds.
• Impaired automobile drivers (safety of others).

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Duty-to-Warn Principle (Tarasoff Ruling)

• When their clients pose clear and imminent danger
  to another person, mental health professionals
  are obligated to break confidentiality by warning
  the potential victim.

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Informed Consent

• Defined by willing acceptance of a medical
  intervention by a patient after discussion with a
  physician about the nature of intervention,
  indications, risks, benefits, and potential
  alternatives (including no treatment).
• Exceptions include Consent is implied when
  emergency treatment is required, consent can be
  obtained form a surrogate decision maker when
  patients lack decision-making capacity.
• Patients who sign waivers to the right of
  informed consent.

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Competency and Decision-Making Capacity

• Competence is a legal term referring to a
  patients authority to make personal and medical
  choices. Decision-making capacity is a medical
  term referring to a patients capacity to accept
  or refuse treatment.
• All competent patients have the right to refuse
  or discontinue treatment as long as this will not
  harm other parties (e.g. Jehovahs Witnesses can
  refuse blood products). An incompetent or
  decisionally incapacitated (intoxicated, altered
  mental status) cannot refuse treatment.

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Minors

• Parental consent is not required if minors
  requested treatment for pregnancy, STDs, or
  substance abuse and emancipated minors.
• Consent is implied in life threatening situations
  when parents cannot be contacted.

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References

• Textbook of Forensic Psychiatry. Simon, M.D.
• Rappeport 1999
• Eigen 1991, 1995 Eigen Andoll 1986
• Psychological Evaluations for the Courts. Gary
  B. Melton. 1997.
• http//www.forensicmed.co.uk/forensic_psychiatry.h
  tm

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Cases

• Ms. Boggs, aka Ms. Joyce Brown, has lived on the
  public sidewalk in from of a restaurant in New
  York City for the past year. She uses this
  location as her bedroom, toilet, and living room.
  At a proceeding instituted to determine whether
  she should be committed, Ms. Putnam, a social
  worker who works for Project Help (an
  organization that attempts to assist the
  homeless), testifies that she observed Ms. Boggs
  scream racial epithets at delivery men who came
  near her sidewalk, to the point where she thought
  Ms. Boggs might be assaulted Ms. Boggs seemed to
  believe black men treated her as a prostitute.
  Dr. Hess, a psychiatrist with Project Help,
  testifies that, a month after this incident he
  saw Ms. Boggs for the first time he also saw her
  on three subsequent occasions, on each of which
  he felt her condition had progressively worsened.
  On his first visit she exhibited hostility to
  his staffs attempts to help her wore disheveled
  clothing twirled an open umbrella to avoid eye
  contact with him and the persons passing by and
  spoke in rhymes, the content of which was sexual
  and related to his and her genitals. Five days
  later she had become more disheveled and was
  barefoot cursed him and flipped open her skirt
  and exposed her buttocks. Two months later,
  still at the same location, her clothing was
  inadequate for the weather her hair was matted
  she smelled of urine and feces she had torn up
  money and stuck its pieces in the sidewalk. A
  month later, she still smelled, and Dr. Hess
  showed more torn up currency. She repeatedly
  said, What is my name? At that point she was
  taken to the hospital. At the hospital, another
  psychiatrist interviewed Ms. Boggs three times in
  the week before the hearing. He testifies that
  on the first occasion he could not speak with her
  because she was hostile and angry on the second,
  she was less angry and he spoke with her for 30
  minutes on the third occasion, she was bright,
  verbal, and oriented. He diagnoses her with
  chronic schizophrenia. A few days later she was
  examined and found to have no suicidal or
  homicidal ideas and no delusions or
  hallucinations. Ms. Boggs testifies that she
  stays at the street because there is a hot-air
  vent there that she has never been cold the she
  panhandles money for food, and makes eight
  dollars to ten dollars a day, which is more than
  she needs for food that she has friends who can
  supply her with clothes that she uses profanity
  to make the states staff go away that she has
  no delusions about black persons giving her money
  for sex and that she has never hurt or
  threatened anyone. She testifies that she would
  go back to the streets if released.

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Cases

• You are working in the ER. Police officers bring
  a 36-year-old man to the facility and report that
  he became irritated at a group of children and
  shook a small girl. Apparently, the children had
  been playing outside of his apartment and he had
  rushed toward them screaming, among other things
  Youve taken away my childhood. Youll go to
  hell. The children were upset, but a medical
  examination of the girl revealed no significant
  harm, and the officers reported that they would
  not charge the man. The man seems calm now, he
  states that he lives along on social security,
  that he has never been on psychoactive
  medications, and that he hears voices form time
  to time telling him that hes getting old and
  will soon go to hell. He admits that the
  children make him very angry but he cannot
  explain why except that they reminded him of his
  past.