FORENSIC PSYCHIATRY: A State of Mind

1. FORENSIC PSYCHIATRY:A State of Mind Marilou Patalinjug Tyner, M.D., FAPA Highland Behavioral Health Services Charleston, WV

5. FORENSIC PSYCHIATRY Subspecialty of Psychiatry in which scientific and clinical expertise is applied to legal issues in legal contexts

6. Private practice • Clinic • Inpatient • Forensic Hospital • Corrections • Academe

7. Areas of Concern • Civil contracts, testamentary capacity, negligence & malpractice, disability determination, child abuse & neglect, custody issues, etc. • Criminal fitness to stand trial, insanity defense, sentencing considerations, issues in correctional settings, etc. • Legal Regulation civil involuntary commitment, confidentiality, right to refuse treatment, informed consent, ethical guidelines, etc.

8. Competency Definition: Having the mental capacity to understand the nature of an act

9. Understanding Appreciating Choosing Reasoning Competency

10. Competency Decisional capacity is preferred term for assessment of specific competencies Declaring a person incompetent is a legal matter and is decided by a judge

11. Civil Competencies

12. Civil Competencies • Testamentary capacity • Work ability/Disability • Family related issues • Guardianship/conservatorship

13. Civil Competencies • Is there a mental disorder? • Does the disorder impair the capacity to carry out the specific civil function in question? • Will the disorder be likely to respond to treatment or intervention?

14. Testamentary Capacity Assess the ability to know and understand that: • The person is making a will • The natural objects of their bounty and claims upon them • The general nature and extent of their property

15. Work ability/Disability Assessment includes thorough evaluation of: • Activities of daily living • Social functioning • Concentration and memory functionin • Ability to keep up pace • Ability to tolerate stress/changes • Evidence of deterioration of symptoms in work-like settings

16. Parenting capacity in Abuse cases • Are there specific legal tests in this jurisdiction that must be addressed? • What mental health issues/factors gave rise to the abuse or neglect? To what extent have these been treated? What interventions are needed to improve or maintain the parent’s functioning? • What is the likelihood of relapse? • What is the likelihood of recurring abuse or neglect? • What are the parenting need of the particular child? • Can the parent meet the child’s needs? How will the parent carry out essential functions like providing for child’s safety, basic needs, medical care, discipline, education, and emotional needs? • What is the nature of the relationship between parent and child? -Peter Ash. M.D. in Textbook of Forensic Psychiatry by Robert Simon, M.D. and Lisa Gold, M.D. (editors), 2004

17. Criminal Competencies • To stand trial • To defend one’s self (pro se) • To be a witness • To be sentenced • To receive death penalty

19. Criminal Responsibility • Knowledge of act committed • Differentiate between right and wrong

21. Psychiatry in Correctional Settings • Census: 15,000-17,000 • 30% homeless prior to incarceration • 75% drug-related crimes • 25% have been treated for mental disorders • 75% of those released will re-offend and will be back in a year • Rikers Island: NY’s largest jail facility

22. Psychiatry in Correctional Settings • Shift from long term psychiatric hospital care to community based treatment has contributed to the increase in population of seriously mentally ill in the jail/prison systems

23. Civil Commitment • Dangerous to self or others • Presence of mental illness • Presence of addiction • Presence of both mental illness and addiction

24. Civil Commitment • Police Power of the State to protect society issue of dangerousness • Parens Patriae Power to address needs of the individual issue of treatment

25. Malpractice D amages injury D irect Causation causal relationship D ereliction negligence D uty standard of practice

26. Treatment refusal • Informed Consent • Risks and benefits of treatment • Alternatives to proposed treatment and their risks and benefits • Risk of no treatment • Assessment of decision making capacity

27. Becoming a Forensic Psychiatrist • Degree in Medicine (M.D. or D.O.) • Residency in Psychiatry • Subspecialty training in Forensic Psychiatry • Practice devoted to doing forensic psychaitric work

28. Some concerns in the practice of Forensic Psychiatry • Delineating clinical work from forensic work • Time issues • Billing issues • Question of truths

29. Helpful websites • www.lawandpsychiatry.com • www.reidpsychiatry.com • www.aapl.org

30. The Four-Step Conceptual Framework • What is the specific psychiatric-legal issue to be considered? • What are the legally defined terms and criteria that will be used to resolve the specific psychiatric-legal issue? • What information obtained from clinical examination is pertinent to the legal criteria that will be used to resolve the psychiatric-legal issue? • How can the available relevant data be applied to the legal criteria so as to yield a rationally convincing psychiatric-legal opinion? Rosner, Principles and Practice of Forensic Psychiatry, 2003