Forensic Psychiatry

KELVIN INSIGNE
CHENIE MAY SUMANDE
 What is forensic psychiatry?
• Forensic psychiatry is a branch of medicine which
focuses on the interface of law and mental health and
with the flow of mentally disordered offenders along a
continuum of social systems.
• Modern forensic psychiatry has benefited from four key
developments: the evolution in the understanding and
appreciation of the relationship between mental illness
and criminality; the evolution of the legal tests to define
legal insanity; the new methodologies for the treatment
of mental conditions providing alternatives to custodial
care; and the changes in attitudes and perceptions of
mental illness among the public.
 Continuation……
• It may include psychiatric consultation in a
wide variety of legal matters
– expert testimony
– clinical work with perpetrators and victims.
Two main interactions
• Psychiatry as applied to the law, i.e. criminal
responsibility, competency to stand trial
evaluations, testamentary capacity,
malpractice, disability
• The law as applied to psychiatry, i.e. laws that
affect psychiatric practice and confidentiality.
THREE MAJOR SUBGROUPINGS

•Criminal forensic psychiatry: competence to

stand trial, assess criminal responsibility
(insanity), sentencing considerations/capital
mitigation, risk/dangerousness, etc.
•Civil forensic psychiatry: contracts,
testamentary capacity, negligence &
malpractice, disability determination, psychic
injury, child abuse & neglect, custody issues,
etc.
•Legal/Regulatory/Admin forensic psychiatry:
Ethics (involuntary treatment), risk
assessment, dangerousness, special issues in
correctional settings, etc.
ASSESSMENT OF MENTAL STATUS

•Current Mental Status: Decision-making

capacity, Competency to stand trial
•Past Mental Status: Criminal responsibility
(insanity)  
•“Future” Mental Status: Dangerousness
COMPETENCY OR CAPACITY?

•Capacity is a CLINICAL determination

that addresses the integrity of mental
functions.
•Competency is a LEGAL determination
that addresses societal interest in
restricting a person’s rights.
•Despite the distinction, many use the
terms interchangeably.
FOUR COMPONENTS OF CAPACITY TO
MAKE MEDICAL DECISIONS

•Communicate a choice—needs to be clear

and consistent
•Understand relevant information  
•Appreciate the nature of situation and illness
and the consequences, risk/benefits of
treatment
•Reason rationally – ability to weigh different
factors rationally and understand cause/effect
of decision
 What is a forensic psychiatrist?
• A psychiatrist is a medical doctor
who has completed several years of
additional training in the
understanding, diagnosis, and
treatment of mental disorders.
• A forensic psychiatrist is a
psychiatrist who has additional
training and/or experience related to
the various interfaces of mental
health (or mental illness) with the law.
 Forensic psychiatrist vs Forensic
psychologist
• Psychiatrists are physicians with specialty
training in the understanding, diagnosis, and
treatment of mental disorders.
• This includes:
– biological evaluations and treatments
• (such as laboratory tests and medications)
– psychotherapy, and family & social issues.
• Doctoral-level psychologists do not go to
medical school,
– Have special expertise in topics not usually studied in
detail by psychiatrists (such as psychological testing).
 How is forensic psychiatry useful
to the legal process?

• When legal matters involve issues

outside law (general public)
expertise, lawyers and judges
regularly seek consultation from
professionals in a wide variety of
fields, including medical specialties.

• Such professionals are often called

"experts" or "expert witnesses."
 Continuation ……
• Forensic experts usually are truly
knowledgeable, the criteria for "expert"
designation in such cases are legal ones,
and not necessarily scientific.

• Sometimes the expertise is sought in an

effort to provide the best possible
information to judges or juries, but there
are many other situations in which a
prudent attorney, judge, or other party
may request consultation.
 Are forensic psychiatrists "advocates"
for one side or the other in legal
matters?

• Usually not.
• Ethical forensic psychiatrists try
to avoid bias.
• They focus on the data or
evidence within their areas of
expertise, and comment
objectively on the information as
they see it.
 Continuation…..
• Are often consultants to advocates (lawyers) or
courts, and at other times may participate in
advocacy strategy, but consider it unethical to
combine our expert opinions (testimony,
reports, or affidavits, for example) with
advocacy per se.

• Ethical forensic psychiatrists do not accept

contingency fees or otherwise conduct
themselves in ways that may interfere with, or
imply, a lack of professional objectivity.
 Doesn’t the expert have an incentive to
agree with the lawyer, so he or she can
testify and make money?

• In most cases, no.

• Ethical experts are paid for their time,
not their testimony.
• Since the time spent forming the opinion
usually far exceeds time spent testifying,
most payment is received regardless of
whether or not the expert testifies.
• Forensic psychiatrists are similar to
most other professionals in their respect
for their work and their clients. The
minority who "cheat" in some way risk
severe censure and loss of credibility.
 What does a Forensic Psychiatrist
do?
• Most forensic psychiatrists don't specialize in
criminal matters.
• The word "forensic" refers to anything that has to
do with the law.
• Forensic psychiatrists thus may be involved with:
– criminal matters
– civil litigation (such as malpractice lawsuits)
– competence to do things (like make a will, consent to
medical care, or take care of children)
– child custody
– treating and working with mentally ill people who get in
trouble with the law
– helping victims of crimes
– helping lawyers and judges understand the psychological
aspects of their cases.
 Here are three things they are not:

• (1) We're not lawyers. We may work with

lawyers, or try to understand the legal aspects
of the matter we're working on, but our job is
to be good doctors who can translate what we
know into something useful for the legal
system, not to be lawyers ourselves.
– (A few forensic psychiatrists and
psychologists have law degrees as well
as medical ones. In my view, those
folks usually do best when they pick
one role or the other.)
Here are three things they are not:

• We're not judges. We don't interpret the

law or tell judges or juries how they should
rule. Most of the time, psychiatric issues are
only a small part of the entire legal matter
being considered. Sometimes we're asked to
give an opinion about those psychiatric
issues, but that's to help the judge or jury
decide, not to tell them what to do.

• (3) We're not cops. We aren't the folks who

protect the community, deal with dangerous
or criminal situations, or contain the bad
guys. That's not our area of expertise, and
nobody gives us permission to do it anyway.
MCARTHUR COMPETENCY ASSESSMENT
TOOL –CRIMINAL ADJUDICATION (McCAT-
CA)
•Just one of the numerous standardized tools out
there.
•Developed by Bonnie, Monahan, and others in
1997 in association with MacArthur Foundation.
•The MacCAT is a standardized instrument in
which a hypothetical case is presented to the
defendant.
•Competency is rated along three axes:
understanding, reasoning and appreciation.
•Has good reliability but some find working with
the
•hypothetical case difficult.  
INSANITY DEFENSE

•Protects against conviction and punishment

of those individuals who should be excused
because they are morally blameless.
•350 B.C. Aristotle: Confusion over reality
may provide a moral excuse for unlawful acts
 
•Common Law test for criminal responsibility:
“actus non facit reum nisi mens sit rea”
which means "the act does not make a
person guilty unless the mind is also guilty".
• So, for criminal culpability, there must be an
“actus reus” (illegal act) in addition to a
“mens rea” (guilty mind).
 VIRGINIA INSANITY STANDARD
Due to a mental disease or defect, a person
is:

•Unable to understand the nature, character

or consequences of actions
•Unable to distinguish right from wrong
•Unable to control one's impulse to act  

******BUT the standard varies from state to

state.
 Stalking

"Even if I did do this,

it would have to have been because I
loved her very much, right?"
- OJ Simpson
 What is Stalking ?
• a set of "behaviors that last more than two
weeks and involves repeated and
persistent attempts to impose on another
person unwanted contacts and/or
communications which induce fear or
distress."
-Paul Mullen, M.D.

“He always told me he would make me sorry,”

never dreamed he would do it by killing our ch
 Who is doing the Stalking ?

• Who is stalked the most??

– ex-partners professional
relationship, fellow
employees,
customers casual
acquaintances
 Who is doing the Stalking ?
• 79% of the stalkers were male
• 30% of the stalkers were ex partners of the victims
• 86% had some form of relationship with the victim,
– including ex-partners (36%),
– professional relationship (23%)
– fellow employees or customers (11%)
– casual acquaintances (19%)
• 36% (52) of the stalkers attacked their victims, 14
involved sexual assault
• the stalkers who assaulted were most likely to be
rejected ex partners.
• (Mullen, Pathe, Purcell, Stuart, 1999: 1244)
 According to a 1998 study by the
Department of Justice.
• 8% of women will be • 2% of men will be
stalked in their stalked in their lifetime
lifetime
• Men
• Women – ages of 18 and 35 (8%)
– aged 18 to 35 (11%) – aged 36 to 55 (4%)
– aged 36 to 55 (8 %) – aged 56 and older (3%),
– 56 or older (4%)
Professor of forensic
psychiatry at Monash
-Paul Mullen, M.D., at University in Victoria,
APA’s 2001 Australia.
 Do Now: Answers
In what ways can stalkers communicate
with their victims?

• Telephone, e-mail, fax, letters, notes, gifts

• Attempt to be physically close to the
victim by approaching, following,
surveilling, and loitering near that person
How might you describe the stalker’s
profile?
• Usually an isolated and shy person , May be
unemployed

• Social Failure: one who lives alone, lacks any

type of important intimate relationship

• Narcissistic personality disorder and very low

self-esteem.
– The stalker feels that they're the most important
person in the world."

• Many people stalk someone they have only met

briefly
– Someone they don't really know, or barely know.
Mullen’s Five Categories of
Stalkers
Rejected
Suitor

The
Intimacy
Predatory
Seeker
Stalker Types
of
Stalkers

The The
Resentful Incompetent
Stalker Suitor
 1. The Rejected Suitor

• Sometimes a partner rejected by their

spouse or lover may vacillate between
overtures of reconciliation and revenge.
They have a narcissistic sense of
entitlement and belief this is the only
relationship they are going to have.
• More than 80% of rejected stalkers in
Mullen’s study had personality disorders.
• Therapeutic treatment of the rejected
stalker involves helping him or her come
to terms with the end of the relationship.
 2. The Intimacy Seeker

• The intimacy-seeking stalker intends to

establish a relationship with his "true love"
regardless of her wishes.
• More than half of the intimacy seekers Mullen
evaluated were delusional, believing that
their love was reciprocated, and nearly a third
had a personality disorder and a delusion that
their quest would be ultimately successful.
• Legal actions do not work well with intimacy
seekers, who may justify their behavior with
the belief they must pay a price for true love.
• The court may order treatment, which should
focus on treating their delusions or other
mental disorders.
 3. The Incompetent Suitor

• This type is typically a man who had been

rebuffed after asking a woman for a date.
• He’s often socially inept, and when
rejected, begins to stalk with the hope that
his persistent behavior will change the
woman’s mind.
• The incompetent suitors can be responsive
to judicial sanctions but are also likely to
relapse.
 4. The Resentful Stalker
• These offenders express anger in response
to a perception that they have been
humiliated or treated unfairly by the object
of their obsession.
• They thrive on having a sense of power
and control over the victim, and are hard
to treat because they often see
themselves as the victim.
 5. The Predatory Stalker

• Predator plans their attack, rehearses it, has

lots of sexual fantasies about it.
• Derives pleasure from gathering information
about the target and fantasizing about the
assault.
• Doesn't necessarily know the victim.
• The victim may not know she is being
stalked.
• They often have prior convictions as sexual
deviants.
 Predict which is the most to be
concerned about?
• The rejected and predatory stalkers are
most likely to assault their victims.
 When to Be Concerned

The red flags:

• You immediately start getting several
phone calls or emails right after meeting
this person.
• The person is clingy, controlling, or upset if
you want to spend time with friends and
family.
 How to take action:

• Tell everyone you know that this is going

on -- your employer, friends, family.
• Gently but firmly tell the person you've
decided to move on.
• Don't get drawn into discussions of why.
Just say, "This situation isn't right for me"
or "I'm not ready.." -- whatever you need
to say, but say it gently.
 Treatments for Victims

• Mullen has found that cognitive-behavioral

therapy works well in managing the anxiety
stalking victims experience.
• Medications such as SSRIs for some patients.
• "It is important to inform and educate family
members about the stalking and enlist their
help in managing it," he stated.
 Treatments for Victims
• Stressed that victims of stalking, like victims of
sexual or physical abuse, often blame themselves
for the situation.
– Because they feel shame or misplaced guilt, they
do not share their ordeal with others and become
more isolated and afraid
• Counseling the victim to realize that he or she is not
responsible for the stalking.
• Advises victims to file a complaint with the police if
the stalking episodes continue for more than two
weeks.
– "To prove that the perpetrator is guilty of a crime
and have the court order treatment, evidence is
critical. Do not destroy answering-machine tapes,
notes, letters, e-mails, or gifts in a moment of
distress," he advised
• CRIMINAL RESPONSIILITY
• A PERSON WHO IS PROVED TO BE INSANE IS
NOT RESPONSIBLE FOR HIS ACTIONS AS HE
IS DEVOID OF FREE WILL,INTELLIGENCE
AND KNOWLEDGE OF THE ACT
THE LEGAL TEST
•SOME EVIDENCE OF MENTAL DISEASE
•DISEASE OR DEFECT MUST EXIST AT THE
TIME OF COMMISSION OF THE CRIME
•IT SHOULD BE OF SUCH A DEGREE THAT THE
PERSON IS UNABLE TO UNDERSTAND THAT
THE ACT IS WRONG AND/OR CONTRARY TO
THE LAW
CONCLUSIONS
On the matter of ethics, we have dealt
with the controversies that the enlarged scope
of action of forensic psychiatrists have created
in the understanding of their social functions,
from definitional problems to wavering about
whose ethics they should abide by and on to
the latest concerns about the use of clinical
knowledge for purposes that should be
completely out of their ethical boundaries.
Practitioners of forensic psychiatry
have moved their specialty to a frontal
role in society. They now have an
obligation to make sure that they
remain foremost physicians and that
their ethics and motivations are
beyond reproach and impeachment.
 END!

THANK YOU!