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.     

Teaching forensic psychiatry to medical students

Are separate courses on forensic psychiatry available for medical students? During the 1985 to 1986 academic year, the authors surveyed all U.S. medical schools to identify courses on forensic/legal psychiatry. A minority of schools included separate courses or practicums on forensic psychiatry or mental health law. In a follow-up telephone survey, instructors of each of these courses were interviewed. Information was obtained on format of course, duration, discipline of instructor or instructors, topics covered, reading materials, institutional settings, and the number of students who took the course. The results are discussed and compared with earlier surveys.     

The concept of free will and forensic psychiatry

This text examines how conceptions of free will impact on legal systems and forensic psychiatry: free will is generally regarded as a prerequisite for responsibility, criminal responsibility included, while forensic psychiatry to a large extent deals with the limits imposed on responsibility by mental disorder. First we discuss the question of whether there is and has been such an impact. The answer is yes: different conceptions of free will have inspired different systems of law and forensic psychiatry, as becomes clear when looking at the accountability doctrine as compared to the unique Swedish system rejecting this doctrine. However, there is no necessary connection between doctrines of responsibility and conceptions of free will, since the former primarily says something about when someone should be held responsible and the latter says something about when someone really is free in a sense relevant to responsibility. This leads to the second question: should conceptions of free will have an impact on law and forensic psychiatry? We argue: that they should not, given the implausibility the normative theory retributivism, which posits a direct connection between free will and punishment. More importantly, questions of free will are complicated and unresolved philosophical issues that are better left out of the everyday decision-making incumbent on the legal and psychiatric systems. Instead, we recommend using an empirically useful and gradual conception of autonomy to facilitate the determination of legal responsibility. This autonomy conception, being neutral on the question of free will, eliminates the need to take a stand on it.     

Russian and Soviet forensic psychiatry: Troubled and troubling

Russian forensic psychiatry is defined by its troubled and troubling relationship to an unstable state, a state that was not a continuous entity during the modern era. From the mid-nineteenth century, Russia as a nation-state struggled to reform, collapsed, re-constituted itself in a bloody civil war, metastasized into a violent “totalitarian” regime, reformed and stagnated under “mature socialism” and then embraced capitalism and “managed democracy” at the end of the twentieth century. These upheavals had indelible effects on policing and the administration of justice, and on psychiatry's relationship with them. In Russia, physicians specializing in medicine of the mind had to cope with rapid and radical changes of legal and institutional forms, and sometimes, of the state itself. Despite this challenging environment, psychiatrists showed themselves to be active professionals seeking to guide the transformations that inevitably touched their work. In the second half of the nineteenth century debates about the role of psychiatry in criminal justice took place against a backdrop of increasingly alarming terrorist activity, and call for revolution. While German influence, with its preference for hereditarianism, was strong, Russian psychiatry was inclined toward social and environmental explanations of crime. When revolution came in 1917, the new communist regime quickly institutionalized forensic psychiatry. In the aftermath of revolution, the institutionalization of forensic psychiatry “advanced” with each turn of the state's transformation, with profound consequences for practitioners' independence and ethical probity. The abuses of Soviet psychiatry under Stalin and more intensively after his death in the 1960s–80s remain under-researched and key archives are still classified. The return to democracy since the late 1980s has seen mixed results for fresh attempts to reform both the justice system and forensic psychiatric practice.     

Biological factors and crime: implications for forensic psychiatry

To summarize, we can say that (1) Criminal behavior, especially chronic criminal behavior, seems to be partly genetically predisposed; (2) An important task at this point is to attempt to determine the biological factors which predispose people to crime; and (3) We have related some tentative initial steps being taken in the study of the autonomic nervous system as one possible heritable, biological basis for the failure of normal social learning forces in inhibiting criminal behavior. Early in this paper we discussed the tenability of asserting criminal responsibility on individuals whose criminal behavior has a partly genetic etiology. But this special consideration seems to set biological factors apart as being in some unique causal category. In fact, genetic, physiological, and biochemical factors are causal agents in the same sense as family, social class, or neighborhood factors. Of course, criminal behavior (like all other behavior) must be caused; one class of causal variables is the biological category. The legal doctrine of responsibility is not challenged by identifying biological factors as partially determining crime any more than it is by findings of social causation. Only in cases in which abnormal biological factors are exceptionally powerful influences might responsibility be challenged. Such cases will be quite rare.     

Violence prevention in psychiatry: an umbrella review of interventions in general and forensic psychiatry

Relative risks of violence in psychiatric patients are high compared to the general population and existing evidence in non-psychiatric populations may not translate to reductions in violence in psychiatric populations. We searched 10 databases including Medline, EMBASE, CINAHL and Scopus, from inception until August 2015 for systematic reviews and meta-analyses of violence prevention interventions in psychiatry. Reviews were included if they used a hard outcome measure (i.e. police or hospital recorded violence, or reincarceration) and contained randomized or non-randomized controlled studies. Five reviews met our inclusion criteria (n = 8876 patients in total), of which four received a GRADE rating of ‘low’ or ‘very low’. Three randomized studies (n = 636) reported that therapeutic community interventions may reduce reincarceration in drug-using offenders with co-occurring mental illness (‘moderate’ GRADE rating). The lack of intervention research in violence prevention in general and forensic psychiatry suggests that interventions from non-psychiatric populations may need to be relied upon.     

Patient perceptions of schizophrenia in forensic and general adult psychiatry

This study explores the illness perceptions of patients with schizophrenia in forensic settings and contrasts their views with those of a general adult psychiatry sample. It was hypothesised that forensic psychiatric patients would have more negative illness beliefs than general adult patients. A cross-sectional survey was used. Forty forensic patients and 32 general adult patients with schizophrenia were recruited. They completed the Illness Perception Questionnaire for Schizophrenia (IPQS), a valid and reliable measure of illness perceptions in mental health problems. Forensic patients perceived their illness to be less chronic, less cyclical, and had a lower negative emotional response to illness. Our results did not support our original hypothesis and possible reasons are explored. Acknowledging patient’s views when formulating management plans could permit more effective individually tailored treatment.