Criminal Forensic Psychiatry ACGME Requirement Treatment Court Competency to Stand Trial

1. Criminal Forensic Psychiatry ACGME Requirement Treatment Court Competency to Stand Trial Forensic Report

2. Quick Links Forensic experience materials: http://forensicpsychiatry.stanford.edu/Seminars/materials.htm California PenalCode: http://www.leginfo.ca.gov/calaw.html

3. Law of Crimes • Protective purpose • Restrain, rehabilitate, deter, vindicate law • Penal Code • Crime is union of actus reus and mens rea

4. Link Between Mental Illness and Crime Impaired executive functions Delusions and hallucinations Overwhelming emotion Overreaction to “threat” Substance abuse TBI Personality disorder

5. The Forensic Psychiatrist • Answer legal question in legal arena • No “best interests” • No “do no harm” • Need to know law as well as psychiatry • Must understand legal reasoning • Must consider malingering in every case • Need good writing skills • Need to adapt to adversarial system

6. Ethics • Honesty, objectivity, neutrality, competence • Duty to law and to truth • Must respect patient’s “personhood” • Consent and non-disclosure statement • Consider all evidence • Explicate reasoning process

7. Percipient vs. Expert Testimony • Evidence must be relevant, probative • Judge decides admissibility • Jury decides weight to be given • Percipient vs. expert witness • Rule against admissibility of junk science • Frye: special expertise, general acceptance • Daubert: special expertise, general acceptance, focus on methodology (peer reviewed, known error rates, etc.)

8. Forensic Questions • Is defendant mentally ill now? • If so, is he currently incompetent to stand trial? • Was defendant mentally ill at time of crime? • If so, was he insane under California law? • Did illness impair ability to form legal intent? • What are the treatment options? • What is risk to community if not incarcerated?

9. Forensic Assessment • Fact heavy • Answer legal question • Consider all the evidence plus malingering • Write for legal as well as medical audience • Explicate scientific and legal reasoning • Expose limits of certainty

10. Reasoning Process Scientific Legal Legal question Legal rule Relevant facts Reasoning process Major premise Minor premise Logical conclusion • Scientific question • Focus on methodology • Empirical • Quantitative • Reproducible • Statistical reliability

11. Treatment Court Movement • Decrease jail time / cost • Law as first responder • Therapeutic sentencing • Reduce risk to community • Drug, mental health, veterans courts

12. Forensic Experience Rotation • Pathways Program • Assess applicants for mental health court • Prepare report to Pathways team • Third Thursday of month • Maguire Jail or Probation Dept., Redwood City • Supervision by ACF forensic psychiatrist • Write report • Meet with supervisor • Other opportunities

13. San Mateo “Pathways” Program • Joint Program – Probation and Mental Health • Misdemeanor defendants who are Axis I SMI • Reduce recidivism / protect community • Modify sentence to community treatment • Progressive sanctions • Therapeutic sentencing

14. Pathways Forensic Questions • Is the defendant seriously mentally ill? • Is there a link between illness and crime? • Is there community treatment? • Would sentence modification to community treatment decrease the likelihood of reoffending without exposing the community to undue risk of harm?

15. Therapeutic Sentencing Outpatient psychotherapy Medication management / psychotherapy Residential care / supportive housing AA, NA, CBT, anger management Monitoring substance use, med compliance Rehabilitation / reintegration programs Intensive case management

16. Generic Forensic Report • Identify referral source • Identify forensic question and relevant law • Consent / statement of non-confidentiality • Case facts • Identify and analyze relevant documents • Clinical and forensic examination • Diagnosis • Diagnostic and forensic discussion • Medical and Legal Conclusions

17. The Forensic Report for Pathways • Two parts: • The mental health court report • The competency to stand trial report • The online report template

18. Competency to Stand Trial (1) • Fundamental fairness – 5th, 6th, 14th Amendments • Defined at Cal Penal Code Section 1367 • Principle case law – Dusky and Sell • Critical phases of trial: • confess, waive Miranda, plead guilty, testify, represent self, be executed

19. Competency to Stand Trial (2)Dusky vs. US • “whether he has sufficient present ability to • consult with lawyer with a reasonable degree of rational understanding and • whether he has a rational as well as factual understanding of the proceedings against him.“ • If incompetent, remand to hospital for restoration of competency

20. Competency to Stand Trial (3)Sell vs. US Involuntary drugs to restore competency Defendant must be facing serious charge Drug must be medically appropriate Side effects unlikely to undermine fair trial

21. Competency to Stand Trial (4)Assessment Mental status examination Case related motivation / knowledge Quality of relating to attorney Capacity to engage legal needs at all critical points in the case