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FORENSIC PSYCHIATRY
Prof. Dr. Dr.H. SOEWADI MPH, SPKJ (K)
Departement of psychiatry
School of medicine
Gadjah mada university
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:
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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.
2.
3.
4.
5.
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
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 London’s 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 man’s 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 Peel’s
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 PATIENT’S 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/Physician’s 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/Physician’s testify
• The psychiatrist should maintain adequate records and
properly prepare to give testimony.
• Preparation should include close familiarity with the details
of the patient’s 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 DEFENDANT’S UNDERSTANDING OF THE
TRIAL PROCESS
• DEPRESSION AND SELF-DEFEATING BEHAVIOR
THAT LIMIT THE DEFENDANT’S MOTIVATION FOR
THE BEST OUTCOME AT TRIAL
• MANIA THAT IMPAIRS THE DEFENDANT’S ABILITY
TO ACT APPROPRIATELY IN THE COURTROOM
COMMON REASONS FOR INCOMPETENCE TO
STAND TRIAL
• PARANOID DELUSIONS THAT IMPAIR THE DEFENDANT’S
ABILITY TO WORK WITH DEFENSE COUNSEL
• DISORGANIZED THINKING THAT IMPAIRS THE
DEFENDANT’S 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
DEFENDANT’S PRESENT MENTAL FUNCTIONING
• IN EVALUATING SANITY, FOCUS ON THE DEFENDANT’S
MENTAL STATE AT THE TIME OF THE OFFENSE
• ASSESS THE IMPACT OF THE DEFENDANT’S 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
DEFENDANT’S 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
• M’NAGHTEN RULE (MCNAUGHTAN’S 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 doctor’s 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 patient’s 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 psychiatrist’s 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 patient’s 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.
THANK YOU