Forensic Psychiatry Explained

Forensic psychiatry is a specialised branch of psychiatry which deals with the assessment and treatment of mentally disordered offenders in prisons, secure hospitals and the community. It requires sophisticated understanding of the interface between mental health and the law.

Nature of the work

Forensic psychiatrists must balance the needs of each person assessed and/or treated with the risks of harm to others, including the person’s own family and associates, criminal justice or health service staff or the wider public. They most commonly provide treatment in a secure hospital environment, but may deliver services to prisons or deliver specialist community services. Generally, their patients are subject to legal restrictions.

Forensic psychiatrists need expertise in assessing and limiting further harm to the patient or others and also need highly developed multidisciplinary clinical and inter-agency skills. The work requires an ability to work effectively with other psychiatric specialties. Forensic psychiatrists also contribute to the design of treatment facilities and programmes, to their evaluation and provide expert advice to other health and social care professionals.

Knowledge of relevant legislation is central to the work as there is regular involvement with criminal justice agencies and the courts. Forensic psychiatrists need an in-depth understanding of criminal, civil and case law as it relates to (alleged) offenders with (suspected) mental disorder. Almost all patients have had previous health service assessment and treatment - many have also had previous contact with the criminal justice system. Most are referred from the criminal justice system but other health service facilities are an important source of referral when a patient is perceived as posing a risk – often to staff or other patients - which cannot be safely managed in a less secure environment.

An important part of the work is assessment of risk of harm to others as well as to the patient themselves. This task is only complete when a resultant management strategy has also been documented, even when that strategy is an argued case for disowning any risk. Where risk management is assumed in whole or in part by the forensic mental health team, the forensic psychiatrist must ensure appropriate, regular review of the assessment and strategy.

Forensic psychiatrists also provide specialist advice to the courts, the probation service, the prison service and other psychiatric colleagues. They also prepare reports for mental health review tribunals, hospital managers’ hearings, other practitioners and criminal justice agencies. Forensic psychiatry is in a state of continuing development according to need. Since 2000, for example, there has been specialist medium secure service development for women, for people with intellectual disabilities and for people with personality disorders

Forensic psychiatry has also seen development of forensic low security hospital beds, distinct from psychiatric intensive care unit (PICU) beds, which fill a recognised gap in the treatment pathway for patients working towards discharge and recovery. The same period has also seen a reduction in the number of high security hospital beds in the UK. It is likely that that there will be further expansion in low security hospital services and fuller development in community forensic services

Common procedures/interventions

Court work

Forensic psychiatrists regularly provide expert witness evidence to courts at all levels. Psychiatrists in other specialties may also have sufficient training to do this, but, more commonly forensic psychiatrists are called to the higher courts – including crown courts or the Court of Appeal in more serious criminal cases such as homicide, other serious violence and sex offending. They may also be asked for expertise in the family court or on other civil matters, such as compensation after major trauma or disaster. Areas of expertise required include:

• defendant’s fitness to plead and fitness to stand trial
• capacity to form intent
• advice to the courts on the available psychiatric defences
• appropriateness and circumstances required for an individual’s admission to hospital for
  assessment
• appropriateness of a mental health disposal at the time of sentencing
• nature of a particular mental disorder and link to future risks
• prognosis and availability of “appropriate treatment”
• level of security required to treat a patient and manage risk

Consultation work

When advising colleagues in the care of patients deemed to be a risk to others, forensic psychiatrists will need to be competent to provide a detailed assessment including advice on:

• risk of harm to others, including use of structured risk assessment/professional and judgement tools
• risk management
• expertise on pharmacological and psychological treatment approaches to violent
  behaviours associated with mental disorders
• psychodynamic formulation of the case, including psychotherapeutic strategy
• therapeutic use of security

Community forensic work provides opportunities to assess and to work with mentally disordered offenders in facilities run by HM Prison and Probation Service and/or third sector organisations. In addition, although all psychiatrists should have a basic understanding of the system of Multi-Agency Protection Panels, in practice forensic psychiatrists must be very experienced in such work. Ethical issues, such as information sharing, differ under such working arrangements from usual clinical practice. Skills needed include knowledge of when and what otherwise confidential information must be shared with others in these circumstances, clarity of understanding of role in the arrangements and appropriate confidence in requiring information from other agencies when necessary for good and safe care.

Forensic psychiatrists must participate in regular audit within and outside the specialty, thus helping to improve the quality of the service offered to patients. They must understand clinical governance procedures, attend meetings and investigate complaints and serious incidents alongside colleagues in the multi-disciplinary team. Teaching and training is also an important part of the work. This includes weekly supervision of specialist higher trainees in forensic psychiatry, but also more junior trainees in any specialty. With recruitment and retention in mind, it is important to engage with undergraduate medical trainees too. Given the multi-professional nature of the work, a contribution to the teaching and training of people from other relevant disciplines is also expected.

Super-specialties

People with needs relevant to the whole psychiatric spectrum may offend or become dangerous to others. In some areas this is so common that joint training has been set up to allow those who complete the training to be able to claim expertise in both (or more) areas. There is a growing need for old-age forensic psychiatry, and most offender patients have problems with substance misuse, but the three recognised combinations to date are:

• adolescent forensic psychiatry
• forensic learning disability psychiatry
• forensic psychotherapy