Principles & Practice of Forensic Psychiatry (Psychiatry & Law)

Principles & Practice of Forensic Psychiatry

Forensic Psychiatry is a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment. Forensic psychiatry deals with issues at the interface of penal or criminal law as well as with matters arising in evaluations on civil law cases and in the development and application of mental health legislation.

Because of its dual role in psychiatry and in law, the practice of forensic psychiatry is fraught with ethical dilemmas worldwide. A forensic psychiatrist is first of all a clinician with theoretical and practical knowledge of general psychiatry and forensic psychiatry, and experience in making rational decisions from a clearly stated scientific base. In law, forensic psychiatrists must know the legal definitions, the legal policies and procedures, the legal precedents relating to the question or case at hand.

Ethical medical practice and treatment in psychiatry are based on the concept of first do no harm. However, this cannot, and does not, apply to forensic cases where there is no doctor–patient relationship and the forensic psychiatrist may indeed cause harm to the examinee.

Psychiatrists who take on a forensic assessment role for patients with whom they have a therapeutic relationship face competing ethical principles that must be acknowledged and managed. Treating psychiatrists who have conducted a risk assessment on their patient and provide forensic opinion regarding the results in court, or at a Review Board or other tribunal, may provide opinions that may reflect negatively on their patient, thereby potentially damaging the therapeutic relationship. The adversarial nature of legal proceedings where the psychiatrist acts in this dual role must be accepted and managed in a professional manner. Further, the potential for bias in the psychiatrist’s opinion stemming from the nature of the therapeutic relationship must be accepted and
acknowledged. As such, treating psychiatrists are especially cautious when acting as an expert witness for their patients. When acting in this dual role, the dual role should be highlighted including educating the trier of fact about the potential for bias in their opinions so that appropriate weight can be given to the opinion.

Honesty, objectivity and the adequacy of the clinical evaluation may be called into question when an expert opinion is offered without a personal examination of the evaluee. Forensic psychiatrists refrain from making public statements regarding direct diagnosis of or conclusions about public figures in the absence of formal assessment. If such an assessment is conducted, any public disclosure would require informed consent.

Forensic psychiatrists must have knowledge of courtroom activity and must possess an ability to communicate their findings clearly and to the point and to do so under the difficult situation of cross examination. The double knowledge in psychiatry and law defines the subspecialty of forensic psychiatry and provides the ethical foundations for its practitioners. This double knowledge should be reflected from the very beginning in the way the forensic psychiatrist first agrees to get involved in an evaluation, the way the forensic psychiatrist approaches the person to be evaluated, and the caveats that have to be provided. At this stage, the most important issue for the forensic psychiatrist is to make sure that the person subject of the evaluation is not misled into believing that, because the psychiatrist is a medical doctor, the relationship to be unfolded is one of physician-patient, in which the doctor is expected to do the best for the patient and always to act to maximize the patient's benefit, while reassuring the patient that privacy and confidentiality are protected. In forensic psychiatry the relationship is one of evaluation, where the foundation of neutrality demanded from the evaluator, and the fact that the evaluator is in no position to reassure the person on matters of confidentiality or privacy could mean that negative findings will endanger the interests and cause harm to the person being evaluated, regardless of this person's health and the evaluator being a physician. Because of this, forensic psychiatrists may even be implicated in the criminalization of mentally ill persons