Forensic psychiatry in China

This article reviews the legal basis for the development of forensic psychiatry in China, the organization of clinical assessments, and training of forensic psychiatrists. Regulations for the management of patients in Ankang hospitals and the role of forensic psychiatrists within the Criminal Justice system are described. The primary role of forensic psychiatrists is to provide expert opinions on competence to stand trial and criminal responsibility in criminal cases. They are increasingly involved in civil court proceedings and tribunals at the request of a range of official agencies. The clinical cases assessed by Chinese forensic psychiatrists are very similar to those of their counterparts in Western countries, but the organizational and legal framework for these assessments reflects a very different system that has evolved independently.     

The forensic psychiatrist of the future

The rate of change in scientific knowledge and the growing psychiatric sophistication of attorneys and courts have made it increasingly difficult for forensic psychiatrists to retain proficiency in the full spectrum of potential professional activities. As the consumers of forensic services become more sophisticated, forensic psychiatrists have an increasing need to become scientifically informed and a decreasing need to become legally informed. Traditional training in forensic psychiatry, which emphasizes clinical, legal, and institutional knowledge and experience, gives short shift to behavioral science and other technical knowledge that can enhance the validity of forensic assessments and their value to the legal system and society. Forensic psychiatrists can best respond to these changes and maximize the value of their assessments by narrowing their focus to some subset of the four branches of the discipline: criminal behavior, mental disability, forensic child psychiatry, and legal aspects of psychiatric practice. Maximal proficiency in each of these four branches requires a greater depth of knowledge and experience than was once sufficient among those who practiced in all four areas. Fellowship training programs and professional organizations should lead forensic psychiatry into the twenty-first century by organizing their efforts along these four parallel tracks.     

Who's afraid of forensic psychiatry?

Forensic psychiatry has come under mounting criticism from the press and other medical professionals, largely for its participation in the insanity defense. The author argues that the expertise available from the specialty is of increasing importance to psychiatry as a whole, as more and more legal issues become relevant to the practice of general psychiatry, and should be actively encouraged and legitimized rather than ostracized. All psychiatrists should be exposed to forensic principles and practices during their training, and the ability of forensic psychiatrists to serve as transducers between the clinical and the legal/judicial should be increasingly used to present the clinical viewpoint effectively in courts and legislatures.     

Crime and multiple personality disorder: a case history and discussion

The application of the concept of multiple personality disorder (MPD) is one of the most complex and controversial issues facing forensic psychiatrists. The case presented is one in which a diagnosis of multiple personality disorder is not only well documented, but was so diagnosed at least 10 years before the ultimate homicide. Nonetheless, consideration of the legal issues was difficult. Other cases, particularly the Bianchi case, reflect the clinical difficulties in diagnosis. Subsequent cases have reflected a judicial review of the issues and a trend to disallow the concept of MPD as a defense; the author suggests that forensic psychiatrists incorporate these opinions in their future judgments.     

Insanity, methamphetamine and psychiatric expertise in New Zealand courtrooms

The use of methamphetamine in New Zealand has increased significantly over the last decade. Due to the potential of methamphetamine to induce, exacerbate and precipitate psychotic symptoms, this drug has also taken centre stage in several criminal trials considering the sanity of defendants. Highly publicised and often involving contested expert evidence, these criminal trials have illustrated the limits of using psychiatric expertise to answer legal questions. This article considers the implications of such cases in light of material from a qualitative study that aimed to generate insights into the difficulties forensic psychiatrists and their instructing lawyers face when providing expert evidence on the relationship between methamphetamine, psychosis and insanity. It reports material from 31 in-depth interviews with lawyers and forensic psychiatrists and observation of one criminal trial that considered the relationship between methamphetamine and legal insanity. The findings are correlated with the clinical and medico-legal literature on the topic and subjected to scrutiny through the lens of "sanism". The article concludes that the continued use of forensic psychiatry to meet the legal objectives of insanity, where methamphetamine is involved, has the potential to reinforce sanist attitudes and practices.     

Treatment as punishment: Forensic psychiatry in The Netherlands (1870–2005)

This article provides an overview of the development of forensic psychiatry in the Netherlands from the late nineteenth to the early twenty-first century. The first part addresses the ways forensic psychiatry established itself in the period 1870–1925 and focuses on its interrelatedness with forensic practice, psychiatry's professionalization, the role of the government, the influence of the so-called New Direction in legal thinking and (Italian and French) anthropology of crime, and the debates among physicians as well as between psychiatrists and legal experts on the proper approach of mentally disturbed offenders. From the mid-1920s on the so-called ‘psychopaths laws’ anchored forensic psychiatry in the Dutch legal system. The second part zooms in on the enactment of these laws, which formalized special measures for mentally disturbed delinquents. These implied a combination of sentencing and forced admission to and treatment in a mental institution or some other form of psychiatric surveillance. The article deals with the meaning, reach and consequences of this legislation, its debate by psychiatrists and legal experts, the number of delinquents affected, the offenses for which they were sentenced and the (therapeutic) regime in forensic institutions. The goal of the Dutch legislation on psychopaths was ambiguous: if it was designed to protect society against assumed dangerous criminals, at the same time they were supposed to receive psychiatric treatment to enable their return to regular social life again. These legal and medical objectives were at odds with each other and as a result discussions about collective versus individual interests as well as about the usefulness and the effects of this legislation kept flaring up. To this day the history of this legislation is characterized by the intrinsic tension between punishment and security on the one hand and treatment and re-socialization on the other. Whether at some point one or the other prevailed was largely tied to the social climate with respect to law, order and authority.     

New perspectives in the legal psychiatry of cocaine-related crimes.

The legal criteria for the insanity defense as it applies to cocaine-related crimes remains elusive because of cocaine's unique spectrum of effects on human thought and action. This paper discusses the literature relevant to cocaine and forensic psychiatry/psychology, and summarizes the results of a survey of forensic psychiatrists on the topic of drug-induced psychosis. A conceptual framework is posited for the expert witness to distinguish the separable effects of cocaine on human behavior and to clarify their relationship to criminal responsibility.     

Forensic mental health assessment in France: Recommendations for quality improvement

The quality of forensic mental health assessment has been a growing concern in various countries on both sides of the Atlantic, but the legal systems are not always comparable and some aspects of forensic assessment are specific to a given country. This paper describes the legal context of forensic psychological assessment in France (i.e. pre-trial investigation phase entrusted to a judge, with mental health assessment performed by preselected professionals called “experts” in French), its advantages and its pitfalls. Forensic psychiatric or psychological assessment is often an essential and decisive element in criminal cases, but since a judiciary scandal which was made public in 2005 (the Outreau case) there has been increasing criticism from the public and the legal profession regarding the reliability of clinical conclusions. Several academic studies and a parliamentary report have highlighted various faulty aspects in both the judiciary process and the mental health assessments. The heterogeneity of expert practices in France appears to be mainly related to a lack of consensus on several core notions such as mental health diagnosis or assessment methods, poor working conditions, lack of specialized training, and insufficient familiarity with the Code of Ethics. In this article we describe and analyze the French practice of forensic psychologists and psychiatrists in criminal cases and propose steps that could be taken to improve its quality, such as setting up specialized training courses, enforcing the Code of Ethics for psychologists, and calling for consensus on diagnostic and assessment methods.     

The role of the defense psychiatrist in workmen's compensation cases

Tomorrow's psychiatrist should be more cognizant, competent, and comfortable in forensic science matters. Psychiatric cases are increasingly the subjects of litigation, but justice in the court depends on able advocacy by all parties. Advocacy for patient-plaintiffs is more similar to customary clinical roles than is advocacy for defendant insurance companies, which nevertheless are as needful of competent psychiatric experts as patient-plaintiffs if justice is to be done. Ironically, defense psychiatrist can do much to help patient-plaintiffs if they understand their roles correctly. Since legal systems are designed to produce justice, not therapy, the forensic competence of future psychiatrists will help to make litigation more therapeutic and just for patients. This paper describes the peculiarities of psychiatric work in litigated workmen's compensation cases, focusing on the role of the defense psychiatrist. We will highlight the constructive and therapeutically gratifying potentials of this work. Greater familiarity with the process will help to enlist the interest and participation of psychiatrist in workmen's compensation cases for the ultimate benefit of the patients and improvement of the legal system.     

Opinions by AAPL forensic psychiatrists on controversial ethical guidelines: a survey.

A survey was conducted of a sample of AAPL members to determine their opinions on the inclusion of controversial ethical guidelines for forensic psychiatry. Members appear to appreciate the need to consider traditional Hippocratic values as at least one consideration in their functioning as forensic psychiatrists. They appear to balance their duties to an evaluee with duties to society and the legal system and to appreciate the responsibilities of multiple agency. Support was shown for interpreting ambiguities in AAPL's current guidelines in the directions indicated by most of this survey's proposed guidelines.     

Physicians' confusion demonstrated by competency requests

A study was performed at a Veteran's Administration (VA) Hospital of the requests for competency evaluations made by medical and surgical services to a psychiatric consultant service. Since less than half the requests were found to be appropriate and specific, this study emphasizes the need for forensic psychiatrists to educate our nonpsychiatric colleagues about the problems engendered by confusion regarding competency. To do so, psychiatrists as well as other physicians and mental health professionals must be trained in discriminating between different types of competencies and the criteria appropriate for each. Because of continuing legal developments, it is becoming increasingly essential to be precise not only about the specific purpose for a competency request but also about the criteria necessary for evaluating different types of competencies. Forensic psychiatrists could play an important role in the education process to clarify the confusion. This study highlights the need for clarity and education concerning competency issues.     

Cybersex with minors: forensic implications.

This paper is designed to assist forensic psychiatrists/psychologists who evaluate adults who commit sexual crimes against children on the Internet. The typical offender is an adult male who logs onto the Internet and enters a chat room in which children congregate. Unbeknownst to the offender, undercover police officers are posing as minors in the chat rooms. The undercover officer (pretend kid) and offender engage in increasingly explicit, sexual conversation; the offender may transmit erotic photographs to the undercover officer and/or arrange to meet at a motel in order to have sexual intercourse. The authors will discuss the relevant legal, clinical, and ethical aspects of examining these offenders, and describe specific cases that the author (2) evaluated.     

Psychiatric aspects of sexual abuse

Sexual abuse of children and adolescents has become an increasingly publicized phenomenon. Psychiatrists and other mental health professionals are often called upon to evaluate and treat children and adolescents who may have been sexually abused, to provide counseling or treatment to the families of such children, and to provide reports and testimony for proceedings about such cases in the child protection system, the criminal justice system, and in custody disputes. Clarity regarding the medical, psychiatric, and legal aspects of sexual abuse is essential in carrying out such professional activities and in evaluating and formulating research on sexual abuse. In this paper current knowledge regarding these aspects of sexual abuse is summarized, and the role of psychiatrists in clinical and forensic work involving allegations of sexual abuse is discussed.     

Forensic pitfalls

The lives of forensic psychiatrists are complicated and subject to stressful experiences because they have elected to interact with a social system very different from their own. This article presents discussion of these frequently troublesome areas commonly encountered by forensic psychiatrists in trying to respond to the law's requests and needs without sacrificing their medical integrity: (1) legitimate definition of expertise; (2) reasonable medical certainty; (3) generally accepted standard of care. They are explored with emphasis on the exercise of self-assessment by the involved forensic psychiatrists lest their incautious application of knowledge and expertise become pitfalls of their own making.     

American forensic psychiatrists who work in state institutions

The authors surveyed a sample of American forensic psychiatrists who work in state institutions. As a group, their respondents tended to be middle-aged, white men, who had little formal training in forensic psychiatry, felt somewhat alienated from their peers, yet who were Board certified in general psychiatry. They tended to be involved primarily in the direct treatment of patients, and most often expressed concerns about the care-and prominent lack of aftercare--received by forensic patients. They also perceived a sense of patient futility in the institutional forensic setting. The authors conclude by recommending that AAPL take a more active role in appealing to and representing such forensic psychiatrists.     

Accountability and psychiatric disorders: How do forensic psychiatric professionals think?

Swedish penal law does not exculpate on the grounds of diminished accountability; persons judged to suffer from severe mental disorder are sentenced to forensic psychiatric care instead of prison. Re-introduction of accountability as a condition for legal responsibility has been advocated, not least by forensic psychiatric professionals. To investigate how professionals in forensic psychiatry would assess degree of accountability based on psychiatric diagnoses and case vignettes, 30 psychiatrists, 30 psychologists, 45 nurses, and 45 ward attendants from five forensic psychiatric clinics were interviewed. They were asked (i) to judge to which degree (on a dimensional scale from 1 to 5) each of 12 psychiatric diagnoses might affect accountability, (ii) to assess accountability from five case vignettes, and (iii) to list further factors they regarded as relevant for their assessment of accountability. All informants accepted to provide a dimensional assessment of accountability on this basis and consistently found most types of mental disorders to reduce accountability, especially psychotic disorders and dementia. Other factors thought to be relevant were substance abuse, social network, personality traits, social stress, and level of education.     

Forty-five revolutions per minute: a qualitative study of Hybrid Order use in forensic psychiatric practice

Psychiatrists who recommend a Hybrid Order (Section 45A) as a disposal option at the point of sentencing accept that the convicted individual, as well as being mentally disordered and in need of treatment, is also culpable and deserving of criminal punishment. Ethical and clinical concerns have typically limited its clinical use. However, in 2015 the Court of Appeal specified in R v Vowles and others that the Hybrid Order disposal should be considered first in terms of potential mental health disposals. This judgement sets a high threshold for the use of the hospital order which has been the bedrock of inpatient forensic psychiatric practice since 1983. This study sought to explore the attitudes of consultant forensic psychiatrists towards the use of the Hybrid Order in the wake of the Vowles judgement. We interviewed 12 consultant forensic psychiatrists with longstanding experience of psychiatric sentencing recommendations. We found that the majority of consultants considered the Hybrid Order to be a valuable disposal option when used under specific circumstances. However, significant concerns were raised about its use in those with an enduring psychotic illness. Community aftercare arrangements for Hybrid Order disposals were viewed as inferior to community aftercare arrangements for Section 37/41 patients.     

Medical malpractice in the absence of a doctor-patient relationship: the potential liability of psychiatric examiners in New York State

In New York, psychiatrists (and all physicians) have a duty, in every circumstance with respect to such functions as they are required to undertake, to conduct themselves and all their examinations in a thorough and proper manner. Especially in a forensic setting, psychiatrists must bear in mind that they have a legal duty to perform a competent examination before they render an opinion. It is well established that malpractice liability does not require the preexistence of a doctor-patient relationship based on an undertaking for the purpose of treatment. The author discusses a long line of cases in New York State which holds that psychiatric examiners are potentially liable in malpractice for any breach of duty with respect to those functions that are undertaken. Failure to conduct a proper, careful, and competent examination may result in liability in a variety of areas: competency examinations, commitment proceedings, workers' compensation claims, and so on. Limitations on such malpractice liability are discussed. Unlike some jurisdictions, New York does not accord judicial immunity to psychiatric examiners.     

《精神卫生法（草案）》浅析——以司法鉴定为视角

以司法鉴定为视角,对精神疾病司法鉴定的规定是否应纳入精神卫生法等问题进行探讨,并详细分析精神卫生法草案的立法精神,肯定了将司法鉴定作为重要协助手段是此次立法的亮点之一,提出了明确关于危险精神病人有关规定的立法建议。