Transcript Forensic Psychiatry

FORENSIC PSYCHIATRY
DR MARTIN LAWLOR
CONSULTANT IN INTENSIVE CARE AND
FORENSIC PSYCHIATRY
HSE-SOUTHERN AREA
CARRAIGMOR UNIT &
MERCY UNIVERSITY HOSPITAL
CORK
LEARNING OBJECTIVES
•UNDERSTAND THE NATURE OF
FORENSIC PSYCHIATRY & LEVELS OF
SECURITY
•UNDERSTAND THE SIGNIFICANT
LEGAL CONCEPTS FOUND IN
PRACTICE
•DESCRIBE HOW RISK ASSESSMENT
OCCURS IN CLINICAL PRACTICE
FORENSIC PSYCHIATRY
•ASSESSMENT, TREATMENT AND
MANAGEMENT OF MENTALLY DISORDERED
OFFENDERS
•PATIENT AT THE INTERFACE OF LEGAL
AND PSYCHIATRIC SYSTEMS
•THERAPEUTIC USE OF SECURITY
(PHYSICAL/RELATIONAL/PROCEDURAL)
•ADVISE COLLEAGUES REGARDING
MANAGEMENT OF PATIENTS WITH
CHALLENGING/RISKY BEHAVIOURS
FORENSIC PSYCHIATRY
THERAPY Vs SECURITY
•RESPECT FOR RIGHT OF PERSON TO
DIGNITY, INTEGRITY, PRIVACY AND
AUTONOMY
•EQUIVELENCE OF CARE
•RECOVERY ORIENTATED
• LEAST RESTRICTIVE ENVIROMENT
(EXPERT GROUP ON MENTAL HEALTH
POLICY)
FORENSIC PSYCHIATRY
UK
TREAT MENTALLY DISORDER OFFENDERS IN
A RANGE OF PSYCHIATRIC SERVICES THESE
INCLUDE THE SPECIAL HOSPITALS:
(BROADMOOR, ASHWORTH, RAMPTON)
INPATIENT - CONDITIONS OF MAXIMUM
SECURITY
THESE ARE INDIVIDUALS WHO ARE SO
DANGEROUS THAT THEY WOULD CAUSE
GRAVE CONCERN IF MANAGED ELSEWHERE
VERY HIGH PHYSICAL / PROCEDURAL AND
RELATIONAL SECURITY
FORENSIC PSYCHIATRY
•MEDIUM SECURE UNITS
-BUTLER REPORT 1975
LESS THAN SPECIAL GREAT UNLOCK WARD
LESS PHYSICAL THAN SPECIAL HOSPITAL/VERY HIGH
PROCEDURAL AND RELATIONAL SECURITY
•LOW SECURE (LESS PHYSICAL SECURITY / GREATER
RELATIONAL SECURITY/HIGH PROCEDURAL SECURITY
REHABILLITATION EMPHASIS
MAY INCLUDE HOSTELS
•DISTRICT HOSPITALS
OFFENDERS MENTALLY DISORDERED WHO ARE NOT A
RISK TO THE PUBLIC
•EXCEPTION IS PSYCHIATIC INTENSIVE CARE UNIT WHERE
PATIENTS ARE ACUTELY
DISTURBED AND MAY
PRESENT A RISK TO OTHERS OR
TO THEMSELVES-UK
6 WEEKS LIMIT ON STAY
LEGAL ISSUES-FITNESS TO BE INTERVIEWED
FITNESS TO BE INTERVIEWED:
DEEMED FIT TO BE INTERVIEWED ON THE
BASIS OF CLINICAL ASSESSMENT
Based on my examination, I have formed
the opinion that xx is fit to be interviewed by
the Gardai in relation to YYY
-IN CLEAR CONSCIOUSNESS
-FULLY ORIENTED
-DID NOT APPEAR TO BE SUGGESTIBLE OR
ABNORMALLY ACQUIESCENT
LEGAL ISSUES-FITNESS TO PLEAD
FITNESS TO PLEAD( BE TRIED):
DEEMED UNFIT TO BE TRIED BY
REASON OF MENTAL DISORDER
NOT ABLE TO UNDERSTAND THE
NATURE AND COURSE OF
PROCEEDINGS
LEGAL ISSUES
UNFIT TO PLEAD:
AS EVIDENCED BY BEING UNABLE
-TO PLEAD TO A CHARGE
-TO INSTRUCT THEIR LEGAL
REPRESENTATIVE
-TO MAKE A PROPER DEFENCE
-CHALLENGE A JUROR
- UNDERSTAND THE EVIDENCE.
LEGAL ISSUES-INSANITY
GUILTY BUT INSANE
1843 MC NAUGHTON RULES
“EVERY MAN IS PRESUME TO BE SANE, UNLESS THE
CONTRARY BE PROVED"
'' IN ORDER TO ESTABLISH A DEFENCE ON THE GROUND OF
INSANITY IT MUST BE CLEARLY PROVED THAT AT THE TIME
OF COMMITTING THE ACT THE ACCUSED PARTY WAS
LABOURING UNDER SUCH A DEFECT OF REASON, FROM
DISEASE OF THE MIND, AS NOT TO KNOW THE NATURE OR
QUALITY OF THE ACT HE WAS DOING, OR IF HE DID KNOW IT
THAT HE DID NOT KNOW THAT WHAT HE WAS DOING WAS
WRONG''
1974 DOYLE Vs WICKLOW COUNTY COUNCIL
-UNABLE TO STOP HIMSELF DUE TO MENTAL DISORDER
LEGAL ISSUES-INSANITY
INSANITY (CLIA 2006)
-PERSONS DID NOT KNOW THE NATURE AND
QUALITY OF THE ACT OR
-DID NOT KNOW WHAT HE OR SHE WAS DOING
WAS WRONG OR
-WAS UNABLE TO REFRAIN FROM COMMITTING THE
ACT.
-SPECIAL VERDICT NOT GUILT BY REASON OF
INSANITY
-CHARGED WITH MURDER BUT REDUCED TO
MANSLAUGHTER ON GROUNDS OF DIMINISHED
RESPONSIBILITY.
LEGAL ISSUES
CRIMINAL LAW INSANITY ACT 2006
MENTAL DISORDER=
-MENTAL ILLNESS
-MENTAL HANDICAP OR
-ANY DISEASE OF THE MIND WHICH DOES
NOT INCLUDE INTOXIFICATION OR WITHIN
THE MEANING OF THE MENTAL HEALTH
ACT 2001.
PATIENT IS SENT TO DESIGNATED CENTRE.
RISK ASSESSMENT
IN CLINICAL PRACTICE RISK
ASSESSMENT REQUIRES A BALANCE OF
BOTH RISK AND PROTECTIVE
FACTORS
Combination of methods:•CLINCAL JUDGEMENT
•ACTUARIAL (VRAG)
•HYBRID-STRUCTURED CLINICAL
JUDGEMENT-HCR-20
RISK ASSESSMENT
•MULTI DISCIPLINARY TEAM
•KNOWLEDGE OF THE PATIENT
•EXAMINE MULTIPLE SOURCES OF INFORMATION
•-MEDICAL NOTES
-COLLATERAL HISTORY
-VICTIM STATEMENTS
-WITNESS STATEMENTS
-CRIMINAL RECORD
RISK ASSESSMENT
•SUMMARISE CIRCUMSTANCES OF PAST
VIOLENCE AND RECENT CHANGE
•DESCRIBE NATURE & CONTEXT OF PAST
RISKS
•IDENTIFY FACTORS THAT INCREASED RISK
•RECOMMEND / PRIORITISE RISK
MANAGEMENT STRATEGRIES
ASSESSING RISK
•HISTORY
-PREVIOUS VIOLENCE
-SOCIAL RESTLESSNESS
-POOR COMPLIANCE
-POOR ENGAGEMENTS
-DISINHIBITORY FACTORS
-SOCIAL CONTEXT
•ENVIROMENT
-ACCESS TO VICTIM
•DYNAMIC FACTORS
-SEVERE STRESS
RISK DOMAINS
•1. RISK TO SELF-SUICIDAL BEHAVIOUR
•2. RISK OF SELF NEGLECT
•3. RISK OF ALCOHOL AND SUBSTANCE MISUSE
•4. RISK OF NON COMPLIANCE WITH MEDS/AFTERCARE
•5. RISK OF VIOLENCE
•6. OTHER RISKS-ARSON/RISK TO CHILDREN/SEXUAL
OFFENDING
•7. PHYSICAL HEALTH
PROTECTIVE FACTORS
•Engagement with team/rapport
•Previous achievements
•Compliance with Care Planning
-Medication
-OPD
-Community Visits
•Family Support/Close relationships
•Preferred Future (Hope)
•Appropriate use of leave
•Access to Community Resources
•Appropriate Living/Coping Skills
RISK ASSESSMENT
•WHICH RISKS ARE PRESENT?
•HOW OFTEN ARE THEY PRESENT?
•IN WHAT CIRCUMSTANCES?
•WHAT IS THE CHARACTER OF THE RISK?
•WHAT CAN WE DO WITH IT?
CRIME AND MENTAL DISORDER
??? INDEPENDENT EFFECTS OF-POVERTY / SCHOOL FAILURE / FAMILY HISTORY / POOR
PARENTING
IS THE EXCESS OFFENDING BEHAVIOUR IN THE MENTALLY
ILL DUE TO POVERTY AND FAMILY PROBLEMS?
THERE IS STILL A LINK WITH PSYCHOSIS AND IN
ADDITIONAL ALCOHOL AND DRUG MISUSE.
KEY ISSUES ARE ACTIVE SYMPTOMS AND FAULTY
REASONING WHICH DISTURB PERCEPTIONS FAR MORE
THAN THE DIAGNOSIS
VIOLENCE IS ASSOCIATED WITH MENTAL ILLNESS (CLINICAL
FACTORS) AND BACKGROUND FACTORS SUCH AS AGE,
GENDER, EDUCATION AND SOCIO-ECONOMIC GROUP
CRIME AND MENTAL DISORDER
•ANTISOCIAL PERSONALITY DISORDER (ICD10) THERE IS
GROSS DISPARITY BETWEEN THE INDIVIDUAL’S BEHAVIOR
AND PREVAILING SOCIAL NORMS
U.K. MENTAL HEALTH ACT 1983
•PSYCOPATHIC DISORDER THAT IS A DISABILITY OF MIND
WHICH RESULTS IN ABNORMALLY AGGRESSIVE OR
SERIOUSLY IRRESPONSIBLE CONDUCT ON THE PART OF THE
PERSON CONCERNED.
•COMBINATION OF IMPULSIVE BEHAVIOUR AND DEFICIENT
EMOTIONAL RESPONSES WHICH LEAD TO FAILURE TO
RESTRAIN FROM ANTI SOCIAL BEHAVIOUR
•THE LIKELY KEY AREAS: VENTRO-MEDIAL PRE FRONTAL
CORTEX AND THE AMYGDALA
VIOLENCE
•VIOLENCE = ACTUAL, ATTEMPTED OR
THREATENED PHYSICAL HARM THAT IS
DELIBERATE AND NOT CONSENTING
•DECISION TO ACT VIOLENTLY CAN
DEPEND ON ORGANIC, PSYCHOTIC OR
LEARNING HISTORY (VIOLENT SOCIAL
MODELS)
DIFFERENTIAL DIAGNOSIS
•ORGANIC-Delirium/Dementia
•PSYCHOTIC
•SUBSTANCE MISUSE-Intoxication/Withdrawal
•AFFECTIVE-BPAD/AGITATED DEPRESSION
•PERSONALITY DISORDER
•LOW IQ
VIOLENCE
•VIOLENCE IS A RESULT OF A
RESPONSE TO SITUATIONS WHICH
HOWEVER MISTAKINGLY ARE
BELIEVED TO BE SUFFICENTLY
PROVOCATIVE
Case study
M. A 47 YEAR OLD SEPARATED WOMAN
DATE OF ADMISSION 29.07.06
ALLEGED STABBING OF 22 YEAR OLD
DAUGHTER TO DEATH
LOCAL TAXI RANG 12 MONTH OLD
GRANDSON TO A&E CUH TO CARRAIGMOR
COMMAND HALLUCINATIONS THAT HER
DAUGHTER WAS 'DEVILISH'
Case study
PERSONAL HISTORY
2 SONS 24 AND 15, 1 DAUGHTER (RIP), SEPARATED
PAST PSYCHIATRIC HISTORY
1ST CONTACT WITH SERVICES OCT. 00
ATTENDED OPD FOR 12 MONTHS AFTER THIS.
1ST ADMITTED NOVEMBER 01. DEPRESSION WITH PSYCHOTIC SYMPTOMS
TREATED WITH ECT
ATTENDED OPD FOR ONE YEAR.
2ND ADMISSION SEPTEMBER 03
7 MONTH HISTORY OF ALTERED MENTAL STATE
PARANOID DELUSIONS BIZZARE BEHAVIOR
DIAGNOSIS SCHIZO AFFECTIVE DISORDER
JAN 2005 ADMITTED TO CUH
HEARING VOICES SINCE 03
Case study
‘SHE SAID SHE WOULD DIE IF SHE DID NOT
DIVULGE WITH THE DEVIL THIS MEANT TO
WORSHIP THE DEVIL’
SHE STATED THAT AT 3.30 A.M OUR LADY
SPOKE TO HER VIA WATER DRIPPING FROM
THE TOILET “YOU KNOW WHAT YOU HAVE
TO DO
“YOU WANT ME TO KILL J.”
‘I HAVE ONLY GOT ONE SHARP KNIFE (THAT
WILL DO)’