Forensic psychiatry

DEFINITION: Branch of medical practice at the interface of psychiatry and law that involves the application of medical expertise and research findings in legal contexts.

SIGNIFICANCE: Physicians who work in forensic psychiatry assume a wide range of responsibilities that are essential to decision making in the criminal and civil justice systems.

Forensic psychiatrists focus on legal principles and evidentiary rules when assisting the courts on matters that require specialized knowledge and experience regarding mental disorders and cognitive capacities. In the field of forensic psychiatry, physicians typically serve as consultants and expert witnesses in criminal or civil litigation. As consultants, forensic psychiatrists educate attorneys and defendants about science-validated techniques for diagnosing and treating mental illness and the relevance of these techniques to the cases at hand. As expert witnesses, forensic psychiatrists testify on a variety of probative issues that advance court cases and are beyond the understanding of laypersons (such as jurors) and legal professionals (such as attorneys and judges). Expert witnesses generally do not proffer about a defendant’s guilt in a criminal trial or liability in a civil trial, nor do they testify as fact witnesses regarding the alleged criminal or negligent act. Instead, their answers complicated legal questions through the expression of informed medical opinions that help the fact finders (judges and jurors) arrive at those ultimate decisions. Therefore, the participation of forensic psychiatrists in the court system can be instrumental in the determination of legal cases and clearly promotes the pursuit of justice.

Treatment Techniques and Settings

Psychiatrists treat mental illness largely through the prescription of medications that target the brain chemicals believed to be responsible for the causes and symptoms of mental disorders. They also treat patients with psychotherapeutic techniques (talk therapy) as well as other medical interventions, such as electroconvulsive therapy, which is an effective treatment for severe depression.

Forensic psychiatrists use the same treatment regimens as other psychiatrists. They differ from other psychiatrists mostly with respect to the settings in which they administer treatment and the types of patients they treat. Forensic psychiatrists engage in clinical practices in correctional settings, such as jails, prisons, departments of forensic services, and other venues that are under legal and control. All the patients evaluated or treated by forensic psychiatrists are involved in different stages of the legal process. Due to the nature of forensic psychiatry as a part of criminal justice investigations, the American Psychological Association issued separate guidelines for forensic psychiatrists in 1991. Some of these guidelines differ from those used by psychiatrists in standard practices, especially in relation to privacy and patient confidentiality.

Competency to Stand Trial

Forensic psychiatrists are probably best known for their work in the criminal justice system. In criminal courts, they perform assessments and deliver testimony on two major issues: to stand trial and the insanity defense. In the case of Dusky v. United States (1960), the US Supreme Court declared that the prohibition against trying a mentally incompetent is a fundamental principle of the American justice system. Competency to stand trial is a legal question that demands the expertise of a forensic psychiatrist because it hinges on a defendant’s mental or cognitive capacity to comprehend and process information and to communicate rational choices. An evaluation of competency to stand trial can be requested by a or by an attorney.

Competency is a defendant’s ability to participate meaningfully in his or her own defense in consultation with legal counsel. It also presumes that a defendant has a factual understanding of the charges and legal proceedings. The right to due process guaranteed under the Sixth Amendment to the US Constitution stipulates that both of these conditions must be met before a person can be tried for an alleged criminal offense. In assessing competency or fitness to stand trial, the forensic psychiatrist examines, among other areas of functioning, the “McGarry criteria,” which are concerned with the defendant’s appreciation of the possible penalties in the case, capability to testify, and willingness and ability to communicate effectively with in order to develop a basic defense plan. When conducting competency evaluations, forensic psychiatrists use psychological tests, structured interviews, and observations. They also perform mental status examinations during which they evaluate the individuals’ insight, judgment, mood, thinking, alertness, and speech.

If a forensic psychiatrist deems a defendant incompetent to stand trial and the judge declares the defendant to be such, trial is delayed until the defendant can be restored to competency. (The judge’s ruling on competency elevates the forensic psychiatrist’s opinion to a court finding.) The competency restoration process consists of standard psychiatric care in a correctional psychiatric facility. Other types of criminal court decisions involving forensic psychiatrists include evaluations to determine competency to testify, to refuse medical treatment, to be executed, and to be a juror.

Insanity Defense

The insanity defense is a widely misunderstood, rarely invoked, and controversial criminal defense. Insanity is a legal concept that dates back to the twelfth century. In order for a behavior to constitute a crime, two elements must be present to establish criminal responsibility: voluntary conduct (actus reus) and willful and malicious intent (mens rea). The raises questions about the defendant’s intentionality, which is evaluated by a forensic psychiatrist, who then testifies to the court about whether the defendant could control his or her behavior and understood the wrongfulness of his or her actions at the time of the crime.

Several tests or rules have evolved to determine criminal responsibility and have served as legal touchstones for forensic psychiatrists when they must gather and interpret clinical information to render opinions to the courts. These include the M’Naghten rule of 1843, which states that defendants are not criminally responsible (not guilty by reason of insanity) if, at the time of their crimes, they suffered from diseases of the mind that rendered them unable to discern the difference between right and wrong or caused them to harbor delusions that, if true, would have justified their criminal behavior as legitimate self-defense.

The two-prong test of criminal responsibility of the American Law Institute’s Model Penal Code is somewhat similar to the M’Naghten rule. It states that persons are not criminally responsible (are insane) if, at the time of their alleged criminal conduct, a mental disease or defect (a legal term) prevented them from having the substantial capacity to appreciate the wrongfulness of their behavior (cognitive prong) and to conform their conduct to the law (volitional prong). A forensic psychiatrist’s opinion about insanity is formulated, in part, on the basis of the psychiatrist’s assessment of the nexus of the defendant’s mental illness and the crime; the defendant’s thinking and behavior before, during, and after the offense; the defendant’s criminal record; and the defendant’s or justification for the crime. In most criminal cases that invoke the insanity defense, two or more psychiatrists are asked to testify for the defense and for the prosecution in an adversarial proceeding, sparking a debate about the defendant’s state of mind during the commission of the crime.

Civil Courts

Forensic psychiatrists testify in a wide range of civil court proceedings. For example, in medical malpractice litigation, they are called to present in cases where patients or others (such as patients’ family members) sue psychiatrists for negligence (these may involve prescription errors, failure to warn victims of patients’ stated intention to harm them, failure to take precautions with suicidal patients, or inflicting harm on patients through irresponsible or unethical conduct). In such cases, forensic psychiatrists must show that the physician defendants deviated from standards of care and that these actions directly resulted in patient harm or damages.

In child-custody cases, forensic psychiatrists advise the court on parental rights based on the standard of the best interests of the child. In personal injury cases, forensic psychiatrists must ascertain the nature and extent of the psychological trauma sustained by plaintiffs following accidents and rule out the possibility of plaintiff malingering.

Bibliography

Barsky, Allan E., and Jonathan W. Gould. Clinicians in Court: A Guide to Subpoenas, Depositions, Testifying, and Everything Else You Need to Know. Guilford Press, 2002.

Heilbrun, Kirk, et al. Forensic Mental Health Assessment: A Casebook. Oxford UP, 2002.

Martone, Christine. “The Role of a Forensic Psychiatrist.” Missouri Medicine, vol. 119, no. 3, May–June 2022, 198–201, www.ncbi.nlm.nih.gov/pmc/articles/PMC9324712/. Accessed 14 Aug. 2024.

Rogers, Richard, and Daniel W. Shuman. Fundamentals of Forensic Practice: Mental Health and Criminal Law. Springer, 2005.

Rosner, Richard, editor. Principles and Practice of Forensic Psychiatry. Oxford UP, 2003.

Simon, Robert and Liza Gold, editors. Textbook of Forensic Psychiatry. American Psychiatric Publishing, 2004.

“Specialty Guidelines for Forensic Psychology.” American Psychological Association, 2024, www.apa.org/practice/guidelines/forensic-psychology. Accessed 14 Aug. 2024.