FORENSIC PSYCHIATRY

1. FORENSIC PSYCHIATRY DR MARTIN LAWLOR CONSULTANT IN INTENSIVE CARE AND FORENSIC PSYCHIATRY HSE-SOUTHERN AREA CARRAIGMOR UNIT & MERCY UNIVERSITY HOSPITAL CORK

2. LEARNING OBJECTIVES UNDERSTAND THE NATURE OF FORENSIC PSYCHIATRY & LEVELS OF SECURITY UNDERSTAND THE SIGNIFICANT LEGAL CONCEPTS FOUND IN PRACTICE DESCRIBE HOW RISK ASSESSMENT OCCURS IN CLINICAL PRACTICE

3. FORENSIC PSYCHIATRY ASSESSMENT, TREATMENT AND MANAGEMENT OF MENTALLY DISORDERED OFFENDERS PATIENT AT THE INTERFACE OF LEGAL AND PSYCHIATRIC SYSTEMS THERAPEUTIC USE OF SECURITY (PHYSICAL/RELATIONAL/PROCEDURAL) ADVISE COLLEAGUES REGARDING MANAGEMENT OF PATIENTS WITH CHALLENGING/RISKY BEHAVIOURS

4. FORENSIC PSYCHIATRY THERAPY Vs SECURITY RESPECT FOR RIGHT OF PERSON TO DIGNITY, INTEGRITY, PRIVACY AND AUTONOMY EQUIVELENCE OF CARE RECOVERY ORIENTATED LEAST RESTRICTIVE ENVIROMENT (EXPERT GROUP ON MENTAL HEALTH POLICY)

5. FORENSIC PSYCHIATRY UK TREAT MENTALLY DISORDER OFFENDERS IN A RANGE OF PSYCHIATRIC SERVICES THESE INCLUDE THE SPECIAL HOSPITALS: (BROADMOOR, ASHWORTH, RAMPTON) INPATIENT - CONDITIONS OF MAXIMUM SECURITY THESE ARE INDIVIDUALS WHO ARE SO DANGEROUS THAT THEY WOULD CAUSE GRAVE CONCERN IF MANAGED ELSEWHERE VERY HIGH PHYSICAL / PROCEDURAL AND RELATIONAL SECURITY

6. FORENSIC PSYCHIATRY MEDIUM SECURE UNITS -BUTLER REPORT 1975 LESS THAN SPECIAL GREAT UNLOCK WARD LESS PHYSICAL THAN SPECIAL HOSPITAL/VERY HIGH PROCEDURAL AND RELATIONAL SECURITY LOW SECURE (LESS PHYSICAL SECURITY / GREATER RELATIONAL SECURITY/HIGH PROCEDURAL SECURITY REHABILLITATION EMPHASIS MAY INCLUDE HOSTELS DISTRICT HOSPITALS OFFENDERS MENTALLY DISORDERED WHO ARE NOT A RISK TO THE PUBLIC EXCEPTION IS PSYCHIATIC INTENSIVE CARE UNIT WHERE PATIENTS ARE ACUTELY DISTURBED AND MAY PRESENT A RISK TO OTHERS OR TO THEMSELVES-UK 6 WEEKS LIMIT ON STAY

7. LEGAL ISSUES-FITNESS TO BE INTERVIEWED FITNESS TO BE INTERVIEWED: DEEMED FIT TO BE INTERVIEWED ON THE BASIS OF CLINICAL ASSESSMENT Based on my examination, I have formed the opinion that xx is fit to be interviewed by the Gardai in relation to YYY -IN CLEAR CONSCIOUSNESS -FULLY ORIENTED -DID NOT APPEAR TO BE SUGGESTIBLE OR ABNORMALLY ACQUIESCENT

8. LEGAL ISSUES-FITNESS TO PLEAD FITNESS TO PLEAD( BE TRIED): DEEMED UNFIT TO BE TRIED BY REASON OF MENTAL DISORDER NOT ABLE TO UNDERSTAND THE NATURE AND COURSE OF PROCEEDINGS

9. LEGAL ISSUES UNFIT TO PLEAD: AS EVIDENCED BY BEING UNABLE -TO PLEAD TO A CHARGE -TO INSTRUCT THEIR LEGAL REPRESENTATIVE -TO MAKE A PROPER DEFENCE -CHALLENGE A JUROR - UNDERSTAND THE EVIDENCE.

10. LEGAL ISSUES-INSANITY GUILTY BUT INSANE 1843 MC NAUGHTON RULES “EVERY MAN IS PRESUME TO BE SANE, UNLESS THE CONTRARY BE PROVED" '' IN ORDER TO ESTABLISH A DEFENCE ON THE GROUND OF INSANITY IT MUST BE CLEARLY PROVED THAT AT THE TIME OF COMMITTING THE ACT THE ACCUSED PARTY WAS LABOURING UNDER SUCH A DEFECT OF REASON, FROM DISEASE OF THE MIND, AS NOT TO KNOW THE NATURE OR QUALITY OF THE ACT HE WAS DOING, OR IF HE DID KNOW IT THAT HE DID NOT KNOW THAT WHAT HE WAS DOING WAS WRONG'' 1974 DOYLE Vs WICKLOW COUNTY COUNCIL -UNABLE TO STOP HIMSELF DUE TO MENTAL DISORDER

11. LEGAL ISSUES-INSANITY INSANITY (CLIA 2006) -PERSONS DID NOT KNOW THE NATURE AND QUALITY OF THE ACT OR -DID NOT KNOW WHAT HE OR SHE WAS DOING WAS WRONG OR -WAS UNABLE TO REFRAIN FROM COMMITTING THE ACT. -SPECIAL VERDICT NOT GUILT BY REASON OF INSANITY -CHARGED WITH MURDER BUT REDUCED TO MANSLAUGHTER ON GROUNDS OF DIMINISHED RESPONSIBILITY.

12. LEGAL ISSUES CRIMINAL LAW INSANITY ACT 2006 MENTAL DISORDER= -MENTAL ILLNESS -MENTAL HANDICAP OR -ANY DISEASE OF THE MIND WHICH DOES NOT INCLUDE INTOXIFICATION OR WITHIN THE MEANING OF THE MENTAL HEALTH ACT 2001. PATIENT IS SENT TO DESIGNATED CENTRE.

13. RISK ASSESSMENT IN CLINICAL PRACTICE RISK ASSESSMENT REQUIRES A BALANCE OF BOTH RISK AND PROTECTIVE FACTORS Combination of methods:- CLINCAL JUDGEMENT ACTUARIAL (VRAG) HYBRID-STRUCTURED CLINICAL JUDGEMENT-HCR-20

14. RISK ASSESSMENT MULTI DISCIPLINARY TEAM KNOWLEDGE OF THE PATIENT EXAMINE MULTIPLE SOURCES OF INFORMATION -MEDICAL NOTES -COLLATERAL HISTORY -VICTIM STATEMENTS -WITNESS STATEMENTS -CRIMINAL RECORD

15. RISK ASSESSMENT SUMMARISE CIRCUMSTANCES OF PAST VIOLENCE AND RECENT CHANGE DESCRIBE NATURE & CONTEXT OF PAST RISKS IDENTIFY FACTORS THAT INCREASED RISK RECOMMEND / PRIORITISE RISK MANAGEMENT STRATEGRIES

16. ASSESSING RISK HISTORY -PREVIOUS VIOLENCE -SOCIAL RESTLESSNESS -POOR COMPLIANCE -POOR ENGAGEMENTS -DISINHIBITORY FACTORS -SOCIAL CONTEXT ENVIROMENT -ACCESS TO VICTIM DYNAMIC FACTORS -SEVERE STRESS

17. RISK DOMAINS 1. RISK TO SELF-SUICIDAL BEHAVIOUR 2. RISK OF SELF NEGLECT 3. RISK OF ALCOHOL AND SUBSTANCE MISUSE 4. RISK OF NON COMPLIANCE WITH MEDS/AFTERCARE 5. RISK OF VIOLENCE 6. OTHER RISKS-ARSON/RISK TO CHILDREN/SEXUAL OFFENDING 7. PHYSICAL HEALTH

18. PROTECTIVE FACTORS Engagement with team/rapport Previous achievements Compliance with Care Planning -Medication -OPD -Community Visits Family Support/Close relationships Preferred Future (Hope) Appropriate use of leave Access to Community Resources Appropriate Living/Coping Skills

19. RISK ASSESSMENT WHICH RISKS ARE PRESENT? HOW OFTEN ARE THEY PRESENT? IN WHAT CIRCUMSTANCES? WHAT IS THE CHARACTER OF THE RISK? WHAT CAN WE DO WITH IT?

20. CRIME AND MENTAL DISORDER ??? INDEPENDENT EFFECTS OF- -POVERTY / SCHOOL FAILURE / FAMILY HISTORY / POOR PARENTING IS THE EXCESS OFFENDING BEHAVIOUR IN THE MENTALLY ILL DUE TO POVERTY AND FAMILY PROBLEMS? THERE IS STILL A LINK WITH PSYCHOSIS AND IN ADDITIONAL ALCOHOL AND DRUG MISUSE. KEY ISSUES ARE ACTIVE SYMPTOMS AND FAULTY REASONING WHICH DISTURB PERCEPTIONS FAR MORE THAN THE DIAGNOSIS VIOLENCE IS ASSOCIATED WITH MENTAL ILLNESS (CLINICAL FACTORS) AND BACKGROUND FACTORS SUCH AS AGE, GENDER, EDUCATION AND SOCIO-ECONOMIC GROUP

21. CRIME AND MENTAL DISORDER ANTISOCIAL PERSONALITY DISORDER (ICD10) THERE IS GROSS DISPARITY BETWEEN THE INDIVIDUAL’S BEHAVIOR AND PREVAILING SOCIAL NORMS U.K. MENTAL HEALTH ACT 1983 PSYCOPATHIC DISORDER THAT IS A DISABILITY OF MIND WHICH RESULTS IN ABNORMALLY AGGRESSIVE OR SERIOUSLY IRRESPONSIBLE CONDUCT ON THE PART OF THE PERSON CONCERNED. COMBINATION OF IMPULSIVE BEHAVIOUR AND DEFICIENT EMOTIONAL RESPONSES WHICH LEAD TO FAILURE TO RESTRAIN FROM ANTI SOCIAL BEHAVIOUR THE LIKELY KEY AREAS: VENTRO-MEDIAL PRE FRONTAL CORTEX AND THE AMYGDALA

22. VIOLENCE VIOLENCE = ACTUAL, ATTEMPTED OR THREATENED PHYSICAL HARM THAT IS DELIBERATE AND NOT CONSENTING DECISION TO ACT VIOLENTLY CAN DEPEND ON ORGANIC, PSYCHOTIC OR LEARNING HISTORY (VIOLENT SOCIAL MODELS)

23. DIFFERENTIAL DIAGNOSIS ORGANIC-Delirium/Dementia PSYCHOTIC SUBSTANCE MISUSE-Intoxication/Withdrawal AFFECTIVE-BPAD/AGITATED DEPRESSION PERSONALITY DISORDER LOW IQ

24. VIOLENCE VIOLENCE IS A RESULT OF A RESPONSE TO SITUATIONS WHICH HOWEVER MISTAKINGLY ARE BELIEVED TO BE SUFFICENTLY PROVOCATIVE

25. Case study M. A 47 YEAR OLD SEPARATED WOMAN DATE OF ADMISSION 29.07.06 ALLEGED STABBING OF 22 YEAR OLD DAUGHTER TO DEATH LOCAL TAXI RANG 12 MONTH OLD GRANDSON TO A&E CUH TO CARRAIGMOR COMMAND HALLUCINATIONS THAT HER DAUGHTER WAS 'DEVILISH'

26. Case study PERSONAL HISTORY 2 SONS 24 AND 15, 1 DAUGHTER (RIP), SEPARATED PAST PSYCHIATRIC HISTORY 1ST CONTACT WITH SERVICES OCT. 00 ATTENDED OPD FOR 12 MONTHS AFTER THIS. 1ST ADMITTED NOVEMBER 01. DEPRESSION WITH PSYCHOTIC SYMPTOMS TREATED WITH ECT ATTENDED OPD FOR ONE YEAR. 2ND ADMISSION SEPTEMBER 03 7 MONTH HISTORY OF ALTERED MENTAL STATE PARANOID DELUSIONS BIZZARE BEHAVIOR DIAGNOSIS SCHIZO AFFECTIVE DISORDER JAN 2005 ADMITTED TO CUH HEARING VOICES SINCE 03

27. Case study ‘SHE SAID SHE WOULD DIE IF SHE DID NOT DIVULGE WITH THE DEVIL THIS MEANT TO WORSHIP THE DEVIL’ SHE STATED THAT AT 3.30 A.M OUR LADY SPOKE TO HER VIA WATER DRIPPING FROM THE TOILET “YOU KNOW WHAT YOU HAVE TO DO “YOU WANT ME TO KILL J.” ‘I HAVE ONLY GOT ONE SHARP KNIFE (THAT WILL DO)’