Forensic Psychiatry_Prof. Soewadi

7/30/2019 Forensic Psychiatry_Prof. Soewadi

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FORENSIC PSYCHIATRY

Prof. Dr. dr.H. SOEWADI MPH, SpKJ (K)

DEPARTEMENT OF PSYCHIATRY

SCHOOL OF MEDICINE

GADJAH MADA UNIVERSITY

2005


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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


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Forensic Psychiatry

Is a general term that denotes the interface between law

and psychiatry. The field of forensic psychiatry:

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


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FORENSIC PSYCHIATRY

ABOUT 30 % OF MEN IN PRISON HAVE A PSYCHIATRICDISORDER OF A SEVERITY REQUIRING TREATMENT

THE COMMONEST DIAGNOSES ARE SOCIOPATHY ANDALCOHOLISM;

THERE IS ALSO AN EXCESS OF MENTAL SUBNORMALITY ,FUNCTIONAL PSYCHOSIS, ORGANIC BRAIN DISEASE, ANDEPILEPSY AMONG PRISONERS.

HOWEVER , SOCIAL AND CULTURAL FACTORS ARE MOREIMPORTANT THAN PSYCHIATRIC ILLNESS IN CAUSINGCRIME


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FORENSIC PSYCHIATRY

MALE PRISONERS OUTNUMBER FEMALE ONES 30-FOLDS

CULTURAL FACTORS PROBABLY ACCOUNT FOR MOST OFTHIS DISCREPANCY, BUT THE INCREASED FREQUENCY OFCRIMINAL BEHAVIOUR AMONG MEN WITH THE XYY

GENOTYPE SUGGESTS THAT BIOLOGICAL FACTORS ALSOCONTRIBUTE

FEMALE PRISONERS HAVE MORE MENTAL AND PHYSICALDISEASE THAN MALE ONES


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MURDER

THERE ARE 400-500 MURDERS PER YEAR INENGLAND 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


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THE MAIN PSYCHIATRIC CONDITIONS WHICH

CAN LEAD TO MURDER ARE :

1. PSYCHOSES : A SEVERELY DERPESSED PERSON MAYMURDER CHILDREN OR OTHER RELATIVES BECAUSE OFA DELUSION THAT THEY ARE GOING TO SUFFER AWORSE FATE.

2. SCHIZOPHRENICS MAY COMMIT MURDER UNDER THEINFLUENCES OF PARANOID DELUSIONS.

3. PUERPERAL PSYCHOSIS ACCOUNTS FOR SOME, BUTNOT ALL, CASES OF INFANTICIDE.

4. SOCIOPATHICPERSONALITY DISORDER5. DRUG-INDUCED STATES


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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 RARECAUSE , AND THERE IS NO SIGNIFICANT

ASSOCIATION BETWEEN MURDER ANDEPILEPSY


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ABNORMAL EEG

ABOUT 75 % OF MURDERERSWHOSE CRIME WASAPPARENTLY MOTIVELESS HAVEAN ABNORMAL EEG


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UNFIT TO PLEAD

LESS OFTEN, A MENTALLY ABNORMALOFFENDER ACCUSED OF MURDER OROTHER SERIOUS CRIME IS FOUND UNFIT TO

PLEAD, AND IS SENT DIRECTLY TO APSYCHIATRIC HOSPITAL.

IF HE RECOVERS HE MAY BE REQUIRED TOSTAND TRIAL


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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


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PLEA IN MURDER

A RARE PLEA IN MURDER CASES ISNOT GUILTY BY REASON OF INSANITY,WHEN THE OFFENDER FULFILS THE

MCNAUGHTEN RULES , THAT IS HEEITHER DID NOT KNOW THE NATUREAND QUALITY OF HIS ACT, OR DID NOTKNOW THAT IT WAS WRONG


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PLEA IN MURDER

A DELUDED PATIENT IS ASSUMED TO BE UNDER THESAME DEGREE OF RESPONSIBILITY AS HE WOULDBE IF THE DELUSIONS WERE TRUE.

IF THIS PLEA IS SUCCESFUL, THE ACCUSED IS SENT

TO A SPECIAL HOSPITALABOUT HALF THOSE ACCUSED OF MURDER CLAIM

AMNESIA FOR THE EVENT, BUT THIS IS NOT ANADEQUATE DEFENSE , NOR IS DRUNKENNESS


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RAPE

Rape is sexual intercourse with a

woman without her consent

About 400 rapes are reported annuallyin England and Wales , but most cases

are probably not reported


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The following types or rapist are

described :

1. Inhibited men who are unable to form normalsexual relationship

2. Aggressive violent men with contempt for

women3. The psychiatrically ill or mentally handicapped

4. Group rape, by gangs of youth whose memberswould probably not commit the crime

individually


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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 libidinaldrugs

Centres for counseling rape victims have

been set up in some cities


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SHOPLIFTING

Women shoplift more often than men, andshoplifting is the most common crime amongfemale prisoners

A minority of shoplifting episodes are organized

crimesAbout two-thirds of female shoplifters are

depressed middle-aged women

In Londons West End, about a third are young

foreign women without psychiatric disturbance


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SPECIAL HOSPITALS

Special hospitals exist for the treatment ofpsychotic, sociopathic, or mentally handicappedpatients who have committed violent crimes

They include broadmoor , Rampton , Moss Side

and Park Lane in England , and Carstairs in ScotlandAll patients are compulsorily admitted and

detained under the Mental Health Act, the majorityfrom the courts, some from prisons or psychiatric

hospitals


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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


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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 HealthAct


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Criminal Responsibility

It is established principle of English law that man isresponsible for his own actions-that is to say that heintends 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 illnesscommitting a crime, it has been for many years argued thatthe mans state of mind must impair his responsibility forhis acts.


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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 , andinsanity has to be proven

Since 1843 the courts have used the MacNaughten

Rules as a test of insanity .


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MacNaughten rules

These rules arose following the trial for murder ofDaniel MacNaughten who killed Sir Robert Peelsprivate 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 toquestions put to them by the house of lords .


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In practice the rules seek the answer to

the questions

1. Regarding the offence, did the accusedknow 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 ?


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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


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diminished responsibility

Since the homicide Act of 1959 the law inEngland and Wales has acknowledged theconcept of diminished responsibility, whichcan be invoked if an accused person is shownto be suffering from such abnormality ofmind ..as substantially to impair hisresponsibility.


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diminished responsibility

The concept of diminished responsibility hasnot been accepted without reserve, and ithas been pointed out that once allowance ismade for diminished responsibility one iscalling into question the whole idea ofcriminal responsibility at any level.

A question that remains unresolved


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ARSON

About 40 % of serious fires are started deliberately. Types ofarsonist include :

1. Those with a criminal motive , e.g. obtaining insurancemoney or concealing evidence of crime . They usuallyhave sociopathic personalities

2. Psychotic patients motivated by delusions

3. Those with abnormal personality or low intelligencewho start fires for excitement or revenge. They often

repeat the office and require secure detention


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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 shouldfulfill 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


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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 areoften well-preserved areas of lucidity and contact

with reality

A doctor should never witness a will irrespective

whether or not he is a beneficiary


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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 PROVIDEINFORMATION ABOUT THE PATIENTS 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.


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Psychiatrist/Physicians 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.


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Psychiatrist/Physicians testify

The psychiatrist should maintain adequate records and

properly prepare to give testimony.

Preparation should include close familiarity with the details

of the patients 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


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COMMON REASONS FOR INCOMPETENCE TO

STAND TRIAL

LOW INTELLIGENCE OR DEMENTIA THAT IMPAIRSTHE DEFENDANTS UNDERSTANDING OF THE

TRIAL PROCESS

DEPRESSION AND SELF-DEFEATING BEHAVIOR

THAT LIMIT THE DEFENDANTS MOTIVATION FOR

THE BEST OUTCOME AT TRIAL

MANIA THAT IMPAIRS THE DEFENDANTS ABILITY

TO ACT APPROPRIATELY IN THE COURTROOM


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COMMON REASONS FOR INCOMPETENCE TO

STAND TRIAL

PARANOID DELUSIONS THAT IMPAIR THE DEFENDANTS

ABILITY TO WORK WITH DEFENSE COUNSEL

DISORGANIZED THINKING THAT IMPAIRS THE

DEFENDANTS 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


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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 FORTHE OPINION

PSYCHODYNAMIC EXPLANATION FOR THE OFFENSE GIVEN AS

AN EXCUSE, RATHER THAN FOCUSING ON THE LEGAL

STANDARD FOR SANITY


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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 STANDARDIN 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


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PRACTICE GUIDELINES

IN ASSESSING COMPETENCY TO STAND TRIAL, FOCUS ON

DEFENDANTS PRESENT MENTAL FUNCTIONING

IN EVALUATING SANITY, FOCUS ON THE DEFENDANTS

MENTAL STATE AT THE TIME OF THE OFFENSE

ASSESS THE IMPACT OF THE DEFENDANTS MENTALILLNESS ON THE AREAS OF FUNCTIONING ADDRESSED BY

THE COMPE-TENCY AND SANITY STANDARDS


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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 THEDEFENDANTS MENTAL ILLNESS ON THE AREAS OF

FUNCTIONING ADDRESSED BY THE COMPETENCY

AND SANITY STANDARDS.


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SUMMARY OF INSANITY STANDARDS

WILD BEAST TEST (REX V. ARNOLD 1724) --AMAN 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, INTRUTH, THE ACTING POWER WITHIN HIM WHICH HE

COULD NOT RESIST, THEN HE WILL NOT BE HELDRESPONSIBLE


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SUMMARY OF INSANITY STANDARDS

MODEL PENAL CODE (AMERICAN LAW INSTITUTE 1955) -

-A PERSON IS NOT RESPONSIBLE FOR CRIMINAL CONDUCTIF 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)


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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.


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A deposition

A deposition may take place in the doctors ownoffice 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.


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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 producethe patients clinical records, or that the records

be made available to the attorney, in which case a

personal appearance is not required.


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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.


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An Expert

Expert witnesses should be prepared to give

their professional qualifications. A preparedresume 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 psychiatrists credentials as an

expert.

A


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An Expert

In providing forensic psychiatric testimony,

psychiatrist are in quite a different role. Theymay or may not have performed a clinicalexamination of the litigant, or if they did, theexamination was performed solely for legal

purposes. Usually it is not the patient who seeks the

examination, and control over the findings is notretained by either the psychiatrist or the subject

of the examination


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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 forensicspecialist and may assume the existence of a traditional

clinical relationship, believing that the examination is for

the patients benefit or that what the patient and specialist

say is confidential.


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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.


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THANK YOU

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Forensic Psychiatry_Prof. Soewadi

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