FORENSIC PSYCHIATRY

Prof. Dr. dr.H. SOEWADI MPH, SpKJ (K)

DEPARTEMENT OF PSYCHIATRY SCHOOL OF MEDICINE GADJAH MADA UNIVERSITY 2005

PSYCHIATRY:
THE MEDICAL SPECIALTY CONCERNED WITH THE STUDY, DIAGNOSIS, TREATMENT, AND PREVENTION OF BEHAVIOR DISORDERS OR MENTAL DISORDERS

PSYCHIATRIST IS :
A PHYSICIAN WHO HAS HAD ADVANCED TRAINING IN THE DIAGNOSIS AND TREATMENT OF MENTAL DISORDERS

Forensic Psychiatry
Is a general term that denotes the interface between law and psychiatry. The field of forensic psychiatry:
the psychiatric expert witness criminal law and psychiatry insanity the guilty but mentally ill offender diminished capacity competency to stand trial involuntary hospitalization and conservatorship the right of patients, informed consent the right to treatment and the right to refuse treatment confidentiality and privileged communication

FORENSIC PSYCHIATRY
ABOUT 30 % OF MEN IN PRISON HAVE A PSYCHIATRIC DISORDER OF A SEVERITY REQUIRING TREATMENT THE COMMONEST DIAGNOSES ARE SOCIOPATHY AND ALCOHOLISM; THERE IS ALSO AN EXCESS OF MENTAL SUBNORMALITY , FUNCTIONAL PSYCHOSIS, ORGANIC BRAIN DISEASE, AND EPILEPSY AMONG PRISONERS. HOWEVER , SOCIAL AND CULTURAL FACTORS ARE MORE IMPORTANT THAN PSYCHIATRIC ILLNESS IN CAUSING CRIME

FORENSIC PSYCHIATRY
MALE PRISONERS OUTNUMBER FEMALE ONES 30-FOLDS CULTURAL FACTORS PROBABLY ACCOUNT FOR MOST OF THIS DISCREPANCY, BUT THE INCREASED FREQUENCY OF CRIMINAL BEHAVIOUR AMONG MEN WITH THE XYY GENOTYPE SUGGESTS THAT BIOLOGICAL FACTORS ALSO CONTRIBUTE FEMALE PRISONERS HAVE MORE MENTAL AND PHYSICAL DISEASE THAN MALE ONES

MURDER
THERE ARE 400-500 MURDERS PER YEAR IN ENGLAND AND WALES , IN 75 % OF CASES THE VICTIM IS WELL KNOWN TO THE MURDERER, MOST OFTEN THE SPOUSE. ABOUT 50 % OF MURDERERS HAVE A SERIOUS PSYCHIATRIC ABNORMALITY MANY COMMIT SUICIDE AFTER THEIR CRIME

THE MAIN PSYCHIATRIC CONDITIONS WHICH CAN LEAD TO MURDER ARE :

1. PSYCHOSES : A SEVERELY DERPESSED PERSON MAY MURDER CHILDREN OR OTHER RELATIVES BECAUSE OF A DELUSION THAT THEY ARE GOING TO SUFFER A WORSE FATE. SCHIZOPHRENICS MAY COMMIT MURDER UNDER THE INFLUENCES OF PARANOID DELUSIONS. PUERPERAL PSYCHOSIS ACCOUNTS FOR SOME, BUT NOT ALL, CASES OF INFANTICIDE. SOCIOPATHIC PERSONALITY DISORDER DRUG-INDUCED STATES

2. 3. 4. 5.

THE MAIN PSYCHIATRIC CONDITIONS WHICH CAN LEAD TO MURDER ARE : MORBID JEALOUSY MENTAL HANDICAP , IN WHICH FRUSTRATION MAY BE EXPRESSED BY VIOLENCE EPILEPTIC AUTOMATISM : THIS IS A RARE CAUSE , AND THERE IS NO SIGNIFICANT ASSOCIATION BETWEEN MURDER AND EPILEPSY

ABNORMAL EEG
ABOUT 75 % OF MURDERERS WHOSE CRIME WAS APPARENTLY MOTIVELESS HAVE AN ABNORMAL EEG

UNFIT TO PLEAD
LESS OFTEN, A MENTALLY ABNORMAL OFFENDER ACCUSED OF MURDER OR OTHER SERIOUS CRIME IS FOUND UNFIT TO PLEAD, AND IS SENT DIRECTLY TO A PSYCHIATRIC HOSPITAL. IF HE RECOVERS HE MAY BE REQUIRED TO STAND TRIAL

UNFIT TO PLEAD
THE GROUNDS FOR BEING UNFIT TO PLEAD, ARE : INABILITY
TO INSTRUCT COUNSEL, TO APPRECIATE THE SIGNIFICANCE OF PLEADING, TO CHALLENGE A JUROR, TO EXAMINE A WITNESS, OR TO UNDERSTAND THE EVIDENCE OR COURT PROCEDURE

PLEA IN MURDER
A RARE PLEA IN MURDER CASES IS NOT GUILTY BY REASON OF INSANITY, WHEN THE OFFENDER FULFILS THE MCNAUGHTEN RULES , THAT IS HE EITHER DID NOT KNOW THE NATURE AND QUALITY OF HIS ACT, OR DID NOT KNOW THAT IT WAS WRONG

PLEA IN MURDER
A DELUDED PATIENT IS ASSUMED TO BE UNDER THE SAME DEGREE OF RESPONSIBILITY AS HE WOULD BE IF THE DELUSIONS WERE TRUE. IF THIS PLEA IS SUCCESFUL, THE ACCUSED IS SENT TO A SPECIAL HOSPITAL ABOUT HALF THOSE ACCUSED OF MURDER CLAIM AMNESIA FOR THE EVENT, BUT THIS IS NOT AN ADEQUATE DEFENSE , NOR IS DRUNKENNESS

RAPE
Rape is sexual intercourse with a woman without her consent About 400 rapes are reported annually in England and Wales , but most cases are probably not reported

The following types or rapist are described :

1. Inhibited men who are unable to form normal sexual relationship 2. Aggressive violent men with contempt for women 3. The psychiatrically ill or mentally handicapped 4. Group rape, by gangs of youth whose members would probably not commit the crime individually

the aggressive type

Of those convicted, 90 % do not repeat the crime , but the aggressive type may do so as well as committing other violent crimes , and may required secure care and anti libidinal drugs Centres for counseling rape victims have been set up in some cities

SHOPLIFTING
Women shoplift more often than men, and shoplifting is the most common crime among female prisoners A minority of shoplifting episodes are organized crimes About two-thirds of female shoplifters are depressed middle-aged women In Londons West End, about a third are young foreign women without psychiatric disturbance

SPECIAL HOSPITALS
Special hospitals exist for the treatment of psychotic, sociopathic, or mentally handicapped patients who have committed violent crimes They include broadmoor , Rampton , Moss Side and Park Lane in England , and Carstairs in Scotland All patients are compulsorily admitted and detained under the Mental Health Act, the majority from the courts, some from prisons or psychiatric hospitals

Violence
Violence to others, violence to self , damage to property, and sex offences are the most frequent reasons for admission The length of stay is several years but about half the patients are eventually fit for discharge or transfer to conventional psychiatric hospitals

other topics with forensic implications

Some other topics with forensic implications are dealt with in other parts of the book : sexual deviations , juvenile delinquency and baby battering , and the Mental Health Act

Criminal Responsibility
It is established principle of English law that man is responsible for his own actions-that is to say that he intends their result Therefore is follows that in the eyes of the law he must bear the responsibility for them In the case of serious offences, responsibility is the more likely to be questioned In the case of an individual suffering from mental illness committing a crime, it has been for many years argued that the mans state of mind must impair his responsibility for his acts.

test of insanity
This has, however , not been easy to establish in a court of law since the law assumes everyone is sane , and insanity has to be proven Since the law assumes everyone is sane , and insanity has to be proven Since 1843 the courts have used the MacNaughten Rules as a test of insanity .

MacNaughten rules
These rules arose following the trial for murder of Daniel MacNaughten who killed Sir Robert Peels private secretary MacNaughten had paranoid delusions and was acquitted on the direction of the judge Subsequently judges formulated the rules as they have been know ever since, as a of answers to questions put to them by the house of lords .

In practice the rules seek the answer to the questions

1. Regarding the offence, did the accused know the nature and quality of the act? 2. If he did, did he know he was doing wrong ? 3. If he knew the nature and quality of the act, was he labouring under a delusion ?

responsibility
Despite their apparent simplicity, the rules can be difficult to apply and make for only a limited acknowledgement of impaired responsibility For years they have been the subject of controversy, both here and in the USA . Nevertheless they are still widely applied as tests of insanity in capital cases

diminished responsibility
Since the homicide Act of 1959 the law in England and Wales has acknowledged the concept of diminished responsibility, which can be invoked if an accused person is shown to be suffering from such abnormality of mind ..as substantially to impair his responsibility.

diminished responsibility
The concept of diminished responsibility has not been accepted without reserve, and it has been pointed out that once allowance is made for diminished responsibility one is calling into question the whole idea of criminal responsibility at any level. A question that remains unresolved

ARSON
About 40 % of serious fires are started deliberately. Types of arsonist include : 1. Those with a criminal motive , e.g. obtaining insurance money or concealing evidence of crime . They usually have sociopathic personalities 2. Psychotic patients motivated by delusions 3. Those with abnormal personality or low intelligence who start fires for excitement or revenge. They often repeat the office and require secure detention

Testamentary capacity
The ability to make a valid will depends on the possession of sound diposing mind . This is not defined in law but the concept is derived from the notion that the person concerned should fulfill the following criteria : he should understand the implications of the act of making a will, have a good idea of the extent of the estate and know who are the likely beneficiaries

Testamentary capacity
Mental illness, whether through psychosis or organic cerebral disease, does not automatically debar someone from making a valid will, since even in chronic schizophrenia and in dementia there are often well-preserved areas of lucidity and contact with reality A doctor should never witness a will irrespective whether or not he is a beneficiary

THE PSYCHIATRIC EXPERT WITNESS

THERE ARE TWO KINDS OF PSYCHIATRIC/PHYSICIAN TESTIMONY (EXPERT WITNESSES): A PSYCHIATRIST/PHYSICIAN WHO HAS EXAMINED OR TREATED A PATIENT MAY BE CALLED AS A WITNESS AND ASKED TO PROVIDE INFORMATION ABOUT THE PATIENTS CONDITION AND TREATMENT, INCLUDING, AT TIMES, OPINIONS ABOUT CAUSATION, AND PROGNOSIS A DIFFERENT SITUATION EXISTS WHEN A PSYCHIATRIST/PHYSICIAN IS ASKED TO PERFORM AN EXAMINATION OR TESTIFY AS AN EXPERT SPECIFICALLY FOR LEGAL PURPOSES.

Psychiatrist/Physicians testify
The psychiatrist/Physician called on to present clinical testimony should be willing to testify if the patient wishes the psychiatrist/physician to do so, or if the privilege of confidentiality has been waived by the patient, or if the psychiatrist is legally required to testify.

Psychiatrist/Physicians testify
The psychiatrist should maintain adequate records and properly prepare to give testimony. Preparation should include close familiarity with the details of the patients clinical condition and treatment and some knowledge of the pertinent legal issues. A preliminary conference with the attorney acting for the patient is often useful. The attorney may wish a written report before the court appearance

COMMON REASONS FOR INCOMPETENCE TO STAND TRIAL

LOW INTELLIGENCE OR DEMENTIA THAT IMPAIRS THE DEFENDANTS UNDERSTANDING OF THE TRIAL PROCESS DEPRESSION AND SELF-DEFEATING BEHAVIOR THAT LIMIT THE DEFENDANTS MOTIVATION FOR THE BEST OUTCOME AT TRIAL MANIA THAT IMPAIRS THE DEFENDANTS ABILITY TO ACT APPROPRIATELY IN THE COURTROOM

COMMON REASONS FOR INCOMPETENCE TO STAND TRIAL

PARANOID DELUSIONS THAT IMPAIR THE DEFENDANTS ABILITY TO WORK WITH DEFENSE COUNSEL DISORGANIZED THINKING THAT IMPAIRS THE DEFENDANTS CONCENTRATION AND ATTENTION IRRATIONAL DECISION MAKING ABOUT THE DEFENSEAS THE RESULT OF DELUSIONS, DISORGANIZED THINKING, LOW INTELLECT, OR DEMENTIA HALLUCINATIONS THAT DISTRACT THE DEFENDANT FROM ATTENDING TO THE TRIAL

COMMON ERRORS IN COMPETENCY AND SANITY EVALUATIONS

EQUATING PSYCHOSIS WITH INCOMPETENCE TO STAND TRIAL CONFUSING COMPETENCY TO STANDTRIAL WITH INSANITY EQUATING PSYCHOSIS AT THE TIME OF THE ACT WITH INSANITY CONCLUSORY REPORTS THAT FAIL TO STATE THE BASIS FOR THE OPINION PSYCHODYNAMIC EXPLANATION FOR THE OFFENSE GIVEN AS AN EXCUSE, RATHER THAN FOCUSING ON THE LEGAL STANDARD FOR SANITY

COMMON ERRORS IN COMPETENCY AND SANITY EVALUATIONS

FAILURE TO READ RELEVANT MEDICAL RECORDS FAILURE TO INTERVIEW THE DEFENDANT DESIRE FOR JUST OUTCOME, INFLUENCING THE ACCURACY OF THE REPORT FAILURE TO ADDRESS THE CORRECT COMPETENCY OR SANITY STANDARD IN THAT PARTICULAR JURISDICTION EVALUATING COMPETENCY IN THE PAST RATHER THAN THE PRESENT EVALUATING SANITY IN THE PRESENT RATHER THAN AT THE TIME OF THE CRIME

PRACTICE GUIDELINES
IN ASSESSING COMPETENCY TO STAND TRIAL, FOCUS ON DEFENDANTS PRESENT MENTAL FUNCTIONING IN EVALUATING SANITY, FOCUS ON THE DEFENDANTS MENTAL STATE AT THE TIME OF THE OFFENSE ASSESS THE IMPACT OF THE DEFENDANTS MENTAL ILLNESS ON THE AREAS OF FUNCTIONING ADDRESSED BY THE COMPE-TENCY AND SANITY STANDARDS

PRACTICE GUIDELINES
A DEFENDANT MAY BE SERIOUSLY MENTALLY ILL BUT STILL BE COMPETENT TO STAND TRIAL OR LEGALLY SANE THE CRITICAL ISSUE IS THE IMPACT OF THE DEFENDANTS MENTAL ILLNESS ON THE AREAS OF FUNCTIONING ADDRESSED BY THE COMPETENCY AND SANITY STANDARDS.

PRACTICE GUIDELINES
GENERAL PSYCHIATRISTS WHO AGREE TO PERFORM A COMPETENCY OR SANITY EVALUATION MUST KEEP IN MIND THAT THEIR OPINION WILL BE HIGHLY INFLUENTIAL WITH THE COURT AND WILL CARRY SERIOUS CON- SEQUENCES. FORENSIC PSYCHIATRISTS ROUTINELY PERFORM A COMPETENCY AND SANITY EVALUATION

SUMMARY OF INSANITY STANDARDS

WILD BEAST TEST (REX V. ARNOLD 1724) -- A
MAN MUST BE TOTALLY DEPRIVED OF HIS UNDERSTANDING AND ME- MORY SO AS NOT TO KNOW WHAT HE IS DOING, NO MORE THAN AN INFANT, A BRUTE, OR A WILD BEAST

IRRESISTIBLE IMPULSE TEST (REGINA V. OXFORD 1840) - IF SOME CONTROLLING DISEASE WAS, IN
TRUTH, THE ACTING POWER WITHIN HIM WHICH HE COULD NOT RESIST, THEN HE WILL NOT BE HELD RESPONSIBLE

SUMMARY OF INSANITY STANDARDS

MNAGHTEN RULE (MCNAUGHTANS CASE 1843) -- A MEN TAL
DISEASE OR DEFECT AT THE TIME OF THE ACT WHICH CAUSED THE DEFENDANT NOT TO KNOW THE NATURE AND QUALITY OR THE WRONGFULNESS OF THE ACT

DURHAM RULE (DURHAM V. UNITED STATE 1954) -- THE

ACCUSED IS NOT CRIMINALLY RESPONSIBLE IF HIS UNLAWFUL ACT IS THE PRODUCT OF A MENTAL DISEASE OR DEFECT

SUMMARY OF INSANITY STANDARDS

MODEL PENAL CODE (AMERICAN LAW INSTITUTE 1955) - 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 TO APPRECIATE THE WRONGFULNESS OF HIS CONDUCT (COGNITIVE ARM) OR TO CONFORM HIS CONDUCT TO THE REQUIREMENTS OF THE LAW (VOLITIONAL ARM)

A deposition
The psychiatrist may be required to give testimony in the form of a deposition a deposition is a device for taking sworn testimony before trial for use at trial. Its purpose is to preserve testimony for later use in case where the witness might not be available at trial for any reason.

A deposition
A deposition may take place in the doctors own office or at any convenient place. Usually only the opposing attorney and a court reporter are present. Witness giving deposition testimony are under oath just as if they were in court.

A subpoena
A subpoena is an order, backed by the authority of a judge, for the witness to appear at a deposition or in court. It usually also requires that the physician produce the patients clinical records, or that the records be made available to the attorney, in which case a personal appearance is not required.

A subpoena
Failure to comply with a subpoena is punishable as contempt of court. A subpoena to appear at a deposition or in court will specify a particular time and place. In the case of depositions, reasonable requests for changes in time and place of appearance will usually be granted by the attorney for the requesting party. The psychiatrist may not have to be subpoenaed if there is an agreement to testify voluntarily. The arrangements for time and place then be agreed on between the attorney and the doctor.

An Expert
Expert witnesses should be prepared to give their professional qualifications. A prepared resume is helpful, including education, postgraduate training, licensing, specialty board certification, membership in professional organizations, publications, honors and awards, and any other information relevant to establishing the psychiatrists credentials as an expert.

An Expert
In providing forensic psychiatric testimony, psychiatrist are in quite a different role. They may or may not have performed a clinical examination of the litigant, or if they did, the examination was performed solely for legal purposes. Usually it is not the patient who seeks the examination, and control over the findings is not retained by either the psychiatrist or the subject of the examination

Perform clinical examination

It is generally preferable to perform an appropriate clinical examination whenever possible. A forensic doctor/psychiatrist may sometimes be called on to provide testimony on purely hypothetical issues or to give opinions about scientific or clinical issues relevant to the legal questions.

Perform clinical examination

Forensic expert testimony requires much more legal knowledge than ordinary clinical testimony. Difficult ethical problems may arise in the practice of forensic psychiatry. A person being examined by a doctor may be confused about the function of the forensic specialist and may assume the existence of a traditional clinical relationship, believing that the examination is for the patients benefit or that what the patient and specialist say is confidential.

Fee for testify

The psychiatrist who testifies as an expert in court or in a deposition or who prepares a report for any legal purpose is entitled to a reasonable fee. In all cases it should be understood clearly how much will be paid, when payment will be made, and who is responsible for payment.

Fee for testify

Although lawyers are permitted to take most civil cases on a contingent fee basis, it is not ethical for doctors to agree to a contingent fee for professional services and testimony. It is not improper, if circumstances warrant, to request partial payment in advance.

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