Medicine meets law:forensic psychiatry

Undergraduate placements in forensic psychiatry enrich general medical training and help us face our prejudices, say Elisabeth Cottrell and Adrian Grounds

Forensic psychiatry is an unknown specialty to many medical students. And if you are aware of the field, you may not be clear about what it involves. All undergraduate medical courses contain student selected components - projects, placements, and the medical student elective. A placement in forensic psychiatry may be an option for any of these.

What is it?

Forensic psychiatry became a specialty in its own right only in the 1970s. It is unusual because it embraces both the med ical and legal worlds: knowledge of both is essential for fair and appropriate management of patients. Patients who have personality disorders or mental illnesses and have offended or are thought likely to offend in the future. Such offending does not have to result directly from mental illness. A minor ity of forensic psychiatry patients have neither committed an offence nor are thought likely to offend. The United King dom's health service, rather than the criminal justice system, refers patients who are too challenging or unmanageable in general psychiatry settings. These patients may have exhausted local resources or may need higher security care.

Forensic psychiatry differs to many other subspecialties. Firstly, forensic psychiatry does not focus on particular disorders, but on patients within a particular situation - offenders or likely offenders. And, secondly, many of these patients do not want or feel a need for treatment and are detained against their will.

Less of the attitude

Judgmental or discriminatory attitudes can exist towards the patients encountered in forensic psychiatry. All healthcare professionals, including medical students, have a duty to remain professional at all times. Forensic psychiatry provides a good opportunity to tackle any preexisting stigma and discriminatory attitudes. If you can shift your focus away from the often serious crimes to the patients' past psychiatric, medical, and social histories, these become hugely more interesting and complex.

Medical students may feel sadness and hopelessness for some patients. This often takes over from the possible anxiety associated with managing "a murderer" or "a rapist." Many patients seem vulnerable and misled. Patients are often victims of horrific backgrounds, and many, especially inpatients, are isolated, at least temporarily, from their "normal" way of living. Medical students can learn how to manage their own feelings of hopelessness and helplessness, and they can establish skills in dealing with patients with criminal backgrounds.

Detective development

The instinctive reaction when faced with such extraordinary patients is to try to comprehend how their histories and psychiatric morbidity have led to their situation.

Although discussion and contemplation of these points is fascinating, conclusions may never be reached. This is a good lesson for future practising clinicians; patients' problems or situations in any specialty may not always have an answer. Indeed, relevant and sometimes crucial information may be elusive. Some patients with serious psychiatric illness have no contactable family or friends or obtainable past documentation. Therefore, a general history about childhood and premorbid personality and functioning cannot be determined. In fact, psychiatric symptoms may not be visible: establishing the precise nature of the psychiatric diagnosis may sometimes be impossible.

Working with such uncertainty - barriers to adequate and effective management - is a difficult and sometimes frustrating lesson in itself. Methods of obtaining even small pieces of information can amount to full blown detective work, and this is the opportunity to refine clinical skills, including increased patience and persistence and taking patients' histories from third parties. This situation emphasises the importance of questioning everything and using and evaluating every piece of evidence available.

Doctor-patient interactions in forensic psychiatry may be more challenging than in any other specialty. Patients' accounts of symptoms are less reliable due to lack of insight, hostility due to detention, or a longing for increased freedom. This unreliability may be unintentional, but intentional misrepresentation of mental state also is all too common. This presents a huge problem when trying to assess not only the psychiatric condition but also the risk the patient poses. It is difficult to think of another specialty in which such significant numbers of patients think they are not ill; try persistently to convince you they are well; and are admitted and detained against their will. The dissonance between patients' goals and healthcare goals can be immense: "Why should I take my antipsychotics, which make me feel more and more uncertain, when my voices have always instructed me what to do?"

Assessment of competence can be critical to appropriate, fair, and effective management, therefore. These rare experiences may provide insights into developing skills in managing difficult patients in more general settings and effectively eliciting relevant information from uncooperative patients.

Controlled settings

On university based community psychiatric placements, many of the patients whom medical students encounter are well controlled with minimal active symptoms. Settings such as forensic psychiatry inpatient wards, as well as prison clinics, provide experience of acutely psychotic and relapsing patients. Medical students may witness the speed at which severe relapses can occur. Retrospectively, early warning signs of relapses can be identified. This provides a lesson in earlier detection of relapses in the future.

At times, the hostility or delusional beliefs of forensic psychiatry patients may provoke anxiety. In some situations, they may represent a danger. Medical students gain experience of management and care provision to (potential) offenders. This may be of use in many future careers. Threatening, hostile, and (potentially) criminal behaviour, perhaps alcohol or drug induced, can be encountered in an emergency department as a junior doctor or in a general practitioner's surgery. In such situations not only may levels of security be lower but also management of such patients may not be instinctive unless it has been previously observed.

A question of risk

Risk assessment and management underlie significant portions of the work done by all medical, surgical, and psychiatric professionals. But in forensic psychiatry, risk assessments and their use in management are crucial in terms of the safety of patients, staff, and public. The focus must be shifted away from patients' offending behaviour to gain a deeper understanding of the underlying factors in their disorder, but their criminal behaviour must not be forgotten. Patients are capable of violent or criminal acts, given the right circumstances. Risk assessment involves the identification of what the "right circumstances" are for each patient. Consideration must be given to environment, management, concordance with management, current mood, current and past symptoms, previous triggers for offending behaviour, and the patient's insight into their condition. Interviews and medical and legal documentation can help identify potential risk factors for future violent or criminal behaviour.

Rigorous risk assessment techniques importantly show not only the value of adequately assessing risk but also the breadth of factors to consider. This can be relevant whatever specialty you choose.

Medicine meets law

People working in forensic psychiatry must have an understanding of mental health legislation, the criminal justice system, and how these relate to each other. Forensic psychiatrists must be aware of the criteria for being found guilty and legal definitions of responsibility, diminished responsibility, and fitness to plead, because professional assessments may be used to inform the judge's decisions about such issues.

In addition, the options for what to do with offenders brought to court must be understood in order to reach medical and criminal justice goals. For example, patients may be prisoners found guilty in court and in need of care in prison or in a forensic psychiatry hospital - this may be temporary or long term. The options for offenders found not guilty because of insanity or who are unfit to plead must be understood by forensic psychiatry teams. Offenders may be sentenced to forensic psychiatry inpatient care for example, people for whom unfitness to plead is due to a mental rather than physical disorder. Or they may be provided with a supervision order for example, people who need support and treatment to prevent the disorder that led to the offence. Or they may be given an absolute discharge for example, if the alleged offence was trivial. The criteria for each of these options differ, and forensic psychiatry reports, assessments, and management of the patient may influence the decision on which criteria are fulfilled.

The interaction between medicine and law can present interesting problems. For example, the ethical problems inherent in prison consultations, during which prison officers or prison healthcare staff, there for safety, may overhear all that is said. In addition, forced detention, either in prison or in a forensic psychiatry hospital, imposed by the criminal justice system, may undermine the medical treatment of psychiatric disorders. Patients may undertake treatment, aimed at reducing their symptoms and risk, in the belief that it will hasten their release, consequently patients and doctors may be working towards different goals. You can learn to critically evaluate the effects of situation, environment, and reasons for concordance with management plans on recovery, reporting of symptoms, and the patient's satisfaction with care.

Not just in hospital

Forensic psychiatry provides many opportunities to experience settings in high, medium, and low security forensic hospital units. Assessments of alleged offenders and prisoners and provision of professional opinions on psychiatric patents are commonly sought from all members of the forensic psychiatry team. Therefore, courts, prisons, general psychiatric institutions, and the community are regular haunts for people working in forensic psychiatry. Working within a forensic psychiatry team, which includes nurses, social workers, and consultants, you can expect to visit all these settings within a week.

Patients may have drug or alcohol problems, which gives students exposure to the treatment of addiction. A placement in forensic psychiatry may open your mind to careers in general psychiatry, prison medicine, substance misuse rehabilitation, or even medical law.

Freedom

As with most undergraduate placements, they are more varied experience than the work in postgraduate post. The latter often involves administration and sometimes little patient contact. Medical students have the luxury of being able to cherry pick the exciting, interesting, or thought provoking experiences.

Multidisciplinary teams allow sometimes heated discussion on patients' management and enables a more open minded view of and exposure to the roles of other professionals and approaches to care. Multidisciplinary teams also ensure that at least one member of the team is doing something of interest at any one time. Experience of multidisciplinary teams is invaluable in medical school exams and future job applications. Knowing the roles and approaches to care of many types of healthcare professional on a multidisciplinary team helps logical and thorough planning of management. Educational and self help groups and services give an insight into the non-doctor-patient relationships of forensic psychiatry patients. Such groups highlight the issues that are important to patients and their carers. And patients and carers are often more open about their illness and crimes with others than they are with doctors.

BSIP, LAURENT/SPL
Neither mad, nor bad

And finally

Forensic psychiatric patients are complex, challenging, and fascinating, perhaps not uniquely. They provide great scope and opportunity for medical students to research unusual and criminal cases; to gain deeper understanding on how psychosocial backgrounds interact with mental health; to present interesting cases; and to produce publications. With so many social, political, ethical, legal, and medical concerns surrounding these patients, most medical students will meet at least one exciting case. Forensic psychiatry may lead to a career that you've previously thought little about, whether it is forensic psychiatry or one of the associated areas of medicine and law. After a placement, you might find yourself with fewer judgmental attitudes toward people with a criminal past, questioning any remaining discriminatory beliefs, and having a greater understanding of generally stigmatised patients. This is undoubtedly of benefit to a practising clinician.

Competing interests: None declared.

Elisabeth Cottrell, final year medical student, Manchester/Keele Medical School
Email: elizabethcottrell@hotmail.co.uk
Adrian Grounds, senior lecturer in forensic psychiatry, Institute of Criminology, Cambridge



studentBMJ 2006;14:309-352 September ISSN 0966-6494