Criminal Behavior · Forensic Psychiatry · Medicine · mental health · psychiatry · Psychosis · Schizophrenia

A Primer on the Nebulous Field of Forensic Psychiatry

As a medical student, I’ve had the opportunity to experience vastly different areas of medicine, from delivering babies to Personality Disorders to removing gallbladders to electroconvulsive therapy. One particularly interesting field of study I undertook was  Forensic Psychiatry. In medical school, we are allowed to take elective rotations, which are somewhat comparable to options in a traditional University or College degree.

Early on, I took a liking to the field of Psychiatry. I remember my first patient. He was a middle-aged man admitted to a locked psychiatric ward due to an acute psychosis. He did all sorts of strange things. He was disheveled, smelled like he hadn’t showered in weeks, was talking to people that weren’t there and made no sense at all when he was talking. I will not describe exactly how he was admitted to protect his identity, but suffice it to say he had put himself in a very precarious position that could have resulted in severe injury and even death. Up until that point, I knew very little about psychotic disorders and I was amazed what mental illness could do to one person. I was fascinated that the human brain, while malfunctioning, was capable of such bizarre thinking and behaviour.

Over the six weeks of my rotation, I watched that man go from the one I first observed in such a state that night to one who I could converse with normally and to one who could play piano beautifully.

To say the least, I was hooked. It seemed like I had witnessed a small miracle. It also made me appreciate the power of the antipsychotic medications we have at our disposal today.

I entered into several psychiatric medical electives at that point and one in particular, Forensic Psychiatry.

Most people I have spoken with often confuse psychiatrists with psychologists, and they sure as heck don’t have a clue what Forensic Psychiatry entails. In fact, even a few doctors I’ve met don’t realize that such a field even exists in Medicine.

So, what is Forensic Psychiatry? Forensic Psychiatry deals mostly with those who have entered the criminal justice system and suffer from a mental disorder.

A Forensic Psychiatrist might evaluate a patient for a mental disorder in what is known as an NCR defense (in Canada). An NCR defense means the defendant is Not Criminally Responsible on account of mental disorder. The criminal code defines not criminally responsible on account of mental disorder as follows “No person is criminally responsible for an act committed or an omission made while suffering from a mental disorder that rendered the person incapable of appreciating the nature and quality of the act or omission or of knowing that it was wrong.” Essentially, this means that two criteria must be met:

1. The defendant must have suffered from a mental disorder at the time of the offense;
2. The mental disorder rendered the defendant incapable of understanding the wrongness of his or her actions.

The example I always use is that of the tragic death of Tim McLean at the hands of Vince Li on a Greyhound bus in Alberta, Canada in 2008. I remember that even I was appalled that this man had been determined not criminally responsible by reason of mental disorder for such a heinous act. Of course, that was before I understood just what depths of madness a mental disorder like schizophrenia could drive a person to, a madness so deep that one loses all awareness and beliefs about ones’ self, the world around them and their relationship to it.

Many people were outraged by the verdict. That said, what many may not realize is that an NCR court ruling may, in fact, keep the perpetrator institutionalized even longer than the traditional prison system… it may even keep them incarcerated in a mental institution for life. This is an interesting tidbit of information about the criminal justice system in Canada where we do not have life sentences. (Note: That said, we do have a dangerous defender status which can keep a prisoner incarcerated for life).

The reason is thus; a perpetrator institutionalized in a psychiatric facility will only be released when they are no longer considered a harm to the public. If their mental disorder keeps them in a perpetual state of danger (no matter how small) to the public, then quite simply, they stay institutionalized.

Forensic Psychiatrists also assess the ability to stand trial. The criminal code states that if a defendant cannot understand the basic criminal proceedings of a trial, then they are not fit to undergo trial.

I have seen patients who are not fit to stand trial – for example, an elderly man accused of assaulting his common-law wife – who become perpetually incarcerated in psychiatric facilities. The man suffered from severe alcohol-related dementia and was not capable of understanding the court proceedings. He probably never would. It was a real eye-opener for me because cases like this happen all the time, and our Forensic Psychiatric wards are sorely underfunded. Patients such as these eventually end up going to facilities designed for elderly patients with dementia.

These are probably the better-known roles of a Forensic Psychiatrist. Others include treating incarcerated patients for their mental disorders (even if their mental disorder did not cause them to commit a crime), following up with them in the community after release, and sitting on release boards that determine whether a patient incarcerated in a forensic psychiatric facility should be released back into society.

An interesting civil case was once shared during a lecture. The Forensic Psychiatrist was required to assess and present at a hearing on behalf of a woman who suffered PTSD after a horrific car accident where she saw her friend beheaded. The insurance company did not want to pay out for a non-physical ailment. But indeed, pay they did, and so they should – just because one walks away from a car accident physically unharmed, does not mean they remain unscarred.

So, there you have it. Forensic Psychiatry in a nutshell. I hope it was an eye-opening and interesting read for you!

~ ThePinkLady

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