FORENSIC PSYCHIATRY:FORENSIC PSYCHIATRY:A State of MindA State of Mind

Marilou Patalinjug Tyner, M.D., Marilou Patalinjug Tyner, M.D., FAPAFAPA

Highland Behavioral Health ServicesHighland Behavioral Health Services

Charleston, WVCharleston, WV

FORENSIC PSYCHIATRYFORENSIC PSYCHIATRY

Subspecialty of Psychiatry in which Subspecialty of Psychiatry in which scientific and clinical expertise is scientific and clinical expertise is

applied to legal issues in legal applied to legal issues in legal contextscontexts

Private practicePrivate practice ClinicClinic InpatientInpatient Forensic HospitalForensic Hospital CorrectionsCorrections AcademeAcademe

Areas of ConcernAreas of Concern

CivilCivilcontracts, testamentary capacity, negligence & malpractice, contracts, testamentary capacity, negligence & malpractice, disability determination, child abuse & neglect, custody issues, disability determination, child abuse & neglect, custody issues, etc. etc.

CriminalCriminalfitness to stand trial, insanity defense, sentencing fitness to stand trial, insanity defense, sentencing considerations, issues in correctional settings, etc. considerations, issues in correctional settings, etc.

Legal RegulationLegal Regulationcivil involuntary commitment, confidentiality, right to refuse civil involuntary commitment, confidentiality, right to refuse treatment, informed consent, ethical guidelines, etc.treatment, informed consent, ethical guidelines, etc.

CompetencyCompetency

Definition: Definition:

Having the mental capacity to Having the mental capacity to understand the nature of an actunderstand the nature of an act

CompetencyCompetency

UnderstandingUnderstanding

AppreciatingAppreciating

ChoosingChoosing

ReasoningReasoning

CompetencyCompetency

Decisional capacity is preferred term Decisional capacity is preferred term for assessment of specific for assessment of specific competencies competencies

Declaring a person incompetent is a Declaring a person incompetent is a legal matter and is decided by a legal matter and is decided by a judgejudge

Civil CompetenciesCivil Competencies

Civil CompetenciesCivil Competencies

Testamentary capacityTestamentary capacity

Work ability/DisabilityWork ability/Disability

Family related issuesFamily related issues

Guardianship/conservatorshipGuardianship/conservatorship

Civil CompetenciesCivil Competencies

Is there a mental disorder?Is there a mental disorder? Does the disorder impair the capacity Does the disorder impair the capacity

to carry out the specific civil function to carry out the specific civil function in question?in question?

Will the disorder be likely to respond Will the disorder be likely to respond to treatment or intervention?to treatment or intervention?

Testamentary CapacityTestamentary Capacity

Assess the ability to know and understand Assess the ability to know and understand that:that:

The person is making a willThe person is making a will The natural objects of their bounty The natural objects of their bounty

and claims upon themand claims upon them The general nature and extent of The general nature and extent of

their propertytheir property

Work ability/DisabilityWork ability/Disability

Assessment includes thorough evaluation Assessment includes thorough evaluation of:of:

Activities of daily livingActivities of daily living Social functioningSocial functioning Concentration and memory functioninConcentration and memory functionin Ability to keep up paceAbility to keep up pace Ability to tolerate stress/changesAbility to tolerate stress/changes Evidence of deterioration of symptoms in Evidence of deterioration of symptoms in

work-like settingswork-like settings

Parenting capacity in Abuse casesParenting capacity in Abuse caseso Are there specific legal tests in this jurisdiction that Are there specific legal tests in this jurisdiction that

must be addressed? must be addressed? o What mental health issues/factors gave rise to the What mental health issues/factors gave rise to the

abuse or neglect? To what extent have these been abuse or neglect? To what extent have these been treated? What interventions are needed to improve or treated? What interventions are needed to improve or maintain the parentmaintain the parent’’s functioning? s functioning?

o What is the likelihood of relapse? What is the likelihood of relapse? o What is the likelihood of recurring abuse or neglect?What is the likelihood of recurring abuse or neglect?o What are the parenting need of the particular child?What are the parenting need of the particular child?o Can the parent meet the childCan the parent meet the child’’s needs? How will the s needs? How will the

parent carry out essential functions like providing for parent carry out essential functions like providing for childchild’’s safety, basic needs, medical care, discipline, s safety, basic needs, medical care, discipline, education, and emotional needs?education, and emotional needs?

o What is the nature of the relationship between parent What is the nature of the relationship between parent and child?and child?-Peter Ash. M.D. in Textbook of Forensic Psychiatry by Robert Simon, M.D. and Lisa Gold, M.D. (editors), 2004-Peter Ash. M.D. in Textbook of Forensic Psychiatry by Robert Simon, M.D. and Lisa Gold, M.D. (editors), 2004

Criminal CompetenciesCriminal Competencies

To stand trialTo stand trial To defend oneTo defend one’’s self (s self (pro sepro se)) To be a witnessTo be a witness To be sentencedTo be sentenced To receive death penalty To receive death penalty

Criminal ResponsibilityCriminal Responsibility

Knowledge of act committedKnowledge of act committed

Differentiate between right and Differentiate between right and wrongwrong

Psychiatry in Correctional SettingsPsychiatry in Correctional Settings

Census: 15,000-17,000Census: 15,000-17,000 30% homeless prior to 30% homeless prior to

incarcerationincarceration 75% drug-related crimes75% drug-related crimes 25% have been treated 25% have been treated

for mental disordersfor mental disorders 75% of those released 75% of those released

will re-offend and will be will re-offend and will be back in a yearback in a year

Rikers Island: NYRikers Island: NY’’s largest jail facilitys largest jail facility

Psychiatry in Correctional SettingsPsychiatry in Correctional Settings

Shift from long term psychiatric hospital care to Shift from long term psychiatric hospital care to community based treatment has contributed to community based treatment has contributed to the increase in population of seriously mentally ill the increase in population of seriously mentally ill in the jail/prison systemsin the jail/prison systems

Civil CommitmentCivil Commitment

Dangerous to self or othersDangerous to self or others Presence of mental illnessPresence of mental illness Presence of addictionPresence of addiction Presence of both mental illness and Presence of both mental illness and

addictionaddiction

Civil CommitmentCivil Commitment

Police Power of the StatePolice Power of the Stateto protect societyto protect society

issue of dangerousnessissue of dangerousness

Parens Patriae PowerParens Patriae Powerto address needs of the individualto address needs of the individual

issue of treatmentissue of treatment

MalpracticeMalpractice

D amagesD amages injuryinjury

D irect CausationD irect Causation causal relationship causal relationship

D erelictionD ereliction negligencenegligence

D utyD uty standard of practicestandard of practice

Treatment refusalTreatment refusal

Informed ConsentInformed Consent Risks and benefits of treatmentRisks and benefits of treatment Alternatives to proposed treatment and Alternatives to proposed treatment and

their risks and benefitstheir risks and benefits Risk of no treatmentRisk of no treatment

Assessment of decision making Assessment of decision making capacitycapacity

Becoming a Forensic PsychiatristBecoming a Forensic Psychiatrist

Degree in Medicine (M.D. or D.O.)Degree in Medicine (M.D. or D.O.)

Residency in PsychiatryResidency in Psychiatry

Subspecialty training in Forensic Subspecialty training in Forensic PsychiatryPsychiatry

Practice devoted to doing forensic Practice devoted to doing forensic psychaitric workpsychaitric work

Some concerns in the practice of Some concerns in the practice of Forensic PsychiatryForensic Psychiatry

Delineating clinical work from Delineating clinical work from forensic workforensic work

Time issuesTime issues Billing issuesBilling issues Question of truthsQuestion of truths

Helpful websitesHelpful websites

www.lawandpsychiatry.com

www.reidpsychiatry.com

www.aapl.org

The Four-Step Conceptual The Four-Step Conceptual FrameworkFramework

What is the specific What is the specific psychiatric-legal issuepsychiatric-legal issue to be to be considered?considered?

What are the legally defined terms and What are the legally defined terms and criteriacriteria that that will be used to resolve the specific psychiatric-legal will be used to resolve the specific psychiatric-legal issue?issue?

What information obtained from What information obtained from clinical examinationclinical examination is pertinent to the legal criteria that will be used to is pertinent to the legal criteria that will be used to resolve the psychiatric-legal issue?resolve the psychiatric-legal issue?

How can the available How can the available relevant data be appliedrelevant data be applied to to the legal criteria so as to yield a rationally convincing the legal criteria so as to yield a rationally convincing psychiatric-legal opinion? psychiatric-legal opinion?

Rosner, Principles and Practice of Forensic Psychiatry, Rosner, Principles and Practice of Forensic Psychiatry, 20032003