Specialist training in forensic psychiatry: the UK experience

BACKGROUND

Training pathways and structures in forensic psychiatry differ between European Union countries, and perspective may differ between trainees and trainers.

AIM

To describe the context of forensic psychiatry training in the UK, with a particular emphasis on England and Wales, as well as some details of core psychiatry and specialist forensic training.

INFORMATION AND DISCUSSION

Forensic psychiatry in the UK takes place in the context of general medical training guidance and regulation. In the last decade, it has changed to be in line with the European working directive and to take account of opinions from outside medicine. The specialist component is typically during the last 3 years of post-graduate training and is based on an apprenticeship/competency model.

Teaching forensic psychiatry in Europe

BACKGROUND

Forensic psychiatry was long regarded as sufficiently defined by the laws of a country to be restricted by national boundaries in all but a few areas. European Union (EU) employment rights and travel facilities have changed that within the EU.

AIMS

The goal of this research is to explore the role and development of a network of teachers and trainees in forensic psychiatry.

INFORMATION AND DISCUSSION

European Union countries differ widely in the extent to which they recognise forensic psychiatry as a specialty and thus also in the amount of training clinicians receive before they present themselves as expert witnesses in court, or develop or run services, or manage and treat individual offender patients. Nevertheless, a summer seminar for practicing clinicians, who also present evidence to court and for bodies considering discharge of potentially dangerous patients, has proved a useful forum for joint 'European learning'. Participants have left with a sense of improved understanding of their own law and practices as well as new perspectives on what works for offenders with mental disorder.

Formal training in forensic mental health: psychiatry and psychology

The field of forensic mental health has grown exponentially in the past decades to include forensic psychiatrists and psychologists serving as the primary experts to the court systems. However, many colleagues have chosen to pursue the avenue of serving as forensic experts without obtaining formal training and experience. This article discusses the importance of formal education, training and experience for psychiatrists and psychologists working in forensic settings and the ethical implications that befall those who fail to obtain such credentials. Specific aspects of training and supervised experience are discussed in detail.

[Training in forensic psychiatry: comparative issues towards a rethinking of the Portuguese model]

BACKGROUND AND AIMS

Forensic psychiatry has experienced a significant development in the last few decades. Several mechanisms underlie this shift, including deinstitutionalization of mental health patients and extraordinary progress in neurosciences, imaging technologies and psychology, just no name a few. This development has put in evidence specific needs for training and education. A review and comparison of forensic psychiatry training in several European countries, U.S.A. and Brazil is made.

METHODS

A mixed approach was used, including a) systematic literature review (Pubmed search, 1989-2009) and cross-reference search and inclusion; b) specific online sites search (e.g. medical associations or scientific societies responsible for forensic psychiatry training); c) direct contact with psychiatrists and forensic psychiatrists.

RESULTS AND CONCLUSIONS

Forensic psychiatry training is still a heterogeneous field. While not all countries have specialization, subspecialization or competency certification in forensic psychiatry, there has been, however, a definite shift towards its individuation as a specific technico-scientific area. This contributes to an improvement in quality standards and promotes research. Notwithstanding, forensic training in general adult and child psychiatry's residencies should continue to be strengthened as it is likely that most forensic activities will remain at their care in the near future.

Practising forensic psychiatry: creating awareness amongst psychiatry residents

Forensic psychiatry is still obscure a discipline amongst the practising psychiatrists; so awareness should be created in the young residents pursuing this stream. It is prudent of setting a curriculum for the general psychiatry residents to learn the relevant topics of forensic psychiatry through didactic lectures, seminars, case-discussions and witnessing case proceedings. This topic could enable budding psychiatrists to acquire the skills of the legal aspects of psychiatry. This challenging yet little known branch of medicine can rejuvenate trainee psychiatry residents to specialise further orconduct research activities.

Fitness in paradise: quality of forensic reports submitted to the Hawaii judiciary

This paper examined quality of forensic reports submitted to the Hawaii Judiciary. Hawaii utilizes a three panel system for assessing fitness to proceed, where two psychologists and one psychiatrist submit independent reports to the Court. Utilizing a survey instrument based on previous research and nationally-derived quality standards, 150 competency to stand trial (CST) reports were examined. Reports demonstrated pervasive mediocrity with respect to quality (Mean QC=68.95, SD=15.21). One quarter (N=38) of the reports scored at or above 80% of the maximum possible score. Levels of CST agreement between evaluators and evaluators and judges were high. Report quality did not differ as a function of evaluator professional identity. Full-time employed evaluators submitted a greater number of reports above the quality criterion. For those evaluators who attended the March training, reports demonstrated significantly improved quality. Suggestions for enhancing report quality are offered with a special attention to inclusion of report elements, focus on inclusion of historical elements, and clearly described rationales supporting forensic opinions. (7664 words. Competency to stand trial, inter-rater agreement).

Learning to collaborate: the teaching legacy of Howard Zonana in forensic psychiatry

The teaching legacy of Howard Zonana in forensic psychiatry has been in educating psychiatric fellows and law students to collaborate in advocacy on behalf of individuals whose problems exist at the intersection of the law and mental health. The author describes more than three decades of collaborative teaching with Dr. Zonana in Yale Law School legal clinics serving mental hospital patients, prisoners, children, and immigrants. In those clinics, law students and forensic psychiatry fellows have worked collaboratively in representing clinic clients and advocating for their legal and medical rights. The article reports three examples of this interdisciplinary collaboration: a project conducted at a state hospital shortly after the Supreme Court's decision in O'Connor v. Donaldson; a class action on behalf of individuals with developmental disabilities inappropriately subjected to long-term confinement in a state hospital; and an asylum case on behalf of a severely traumatized African woman fleeing persecution in her home country. The author concludes that Dr. Zonana's legacy reflects not only his contributions to medical and legal education, but also his profound commitment to effective and humane medical practice and to justice.

The effect of a forensic fellowship program on general psychiatry residents' in-training examination outcomes

This article describes how the establishment and existence of a forensic psychiatry fellowship program was associated with improvements in general psychiatry residents' scores on the Psychiatry Resident In-training Examination (PRITE). Four consecutive years of general psychiatry residents' PRITE scores spanning 2 years before and 2 years after implementation of the forensic fellowship program at our institution were compared. Mixed-model statistical analyses accounting for repeated measurements of individual residents across the periods indicated statistically significant improvement in forensic content scores and several other subspecialty areas in which our institution offers educational fellowship programs. External indicators of program outcomes such as standardized examination scores may provide a useful indication of the effects that an educational fellowship program can have on general psychiatry education.

The field of forensic psychology in Israel--the state of the discipline

The process of the establishment of forensic psychology in Israel begins in the eighties; while at the past 6 years after the creation of the Department of Psychology, Law and Ethics--The International Center for Health, Law and Ethics at Haifa University, the field continues to grow rapidly. Today, the development of forensic psychology is reflected in the scientific practice at Haifa University as at others (academic courses for different graduate levels and research concerning professional and ethical issues); as well as in the practical professional development of professional organizations, practice standards and training programs. Now as a specialty, forensic psychology must continue to make an effort to enrich in science and in professional practice, its aid in the administration of justice by assisting legal decision-makers.

Delivering mental health awareness training to police officers

Police officers regularly come into contact with people with mental health problems but receive relatively little training on the issue. This article outlines an initiative to deliver awareness training to officers, and explores the benefits of such programmes. It also gives details of the evaluation carried out.

Commentary: evidence-based practice and forensic psychiatry

A diverse sampling of articles was considered as a landscape against which evidence-based practice has been and should be a part of forensic psychiatry. Caveats were identified, limitations suggested, and recommendations made as to how such a marriage might work.

Forensic psychiatry, neuroscience, and the law

The rise of modern neuroscience is transforming psychiatry and other behavioral sciences. Neuroscientific progress also has had major impact in forensic neuropsychiatric practice, resulting in the increased use of neuroscientific technologies in cases of a psychiatric-legal nature. This article is focused on the impact of neuroscientific progress in forensic psychiatry in relation to criminal law. Also addressed are some emerging questions involving the practice of forensic neuropsychiatry. These questions will be reframed by providing alternative perspectives consistent with the objectives of forensic neuropsychiatric practice. The last part of the article is a discussion of potential developments that may facilitate the integration of neuroscientific knowledge in forensic neuropsychiatric practice.

[Burden on designated hospitals when they receive inpatients from distant places in accordance with the Medical Treatment and Supervision Act]

OBJECTIVE

The current Medical Treatment and Supervision Act places a burden on designated psychiafric hospitals with forensic wards. We aimed to clarify the rate of discharge beyond the jurisdictional catchment area, for which overnight training becomes quite cost-ineffective, as hospital staff must accompany the patients home.

SUBJECTS

On September 30, 2008, there were 16 designated hospitals in Japan, and 447 inpatients in these hospitals. They were the subjects of this study.

METHOD

We collected information on the 447 subjects regarding the postdischarge administrative division, the nearest railway station to the postdischarge residential location, "treatment stage", "overnight training" at the postdischarge residential location, and trouble during "overnight training". We analyzed the collected data using the "designated bed sufficiency ratio". We divided the 447 subjects into three groups: (1) Home inpatient group (home group); the administrative division of his/her postdischarge residential area is the same administrative division as the designated hospital. (2) Inpatient within a jurisdiction group (within group) ; the administrative division of his/her postdischarge residential area is not the same as the designated hospital but is in any administrative division within a jurisdiction of the Japanese Regional Bureau of Health and Welfare. (3) Inpatient outside a jurisdiction group (outside group) ; the administrative division of his/her postdischarge residential area is not the same as the designated hospital but is any administrative division outside a jurisdiction of the Japanese Regional Bureau of Health and Welfare. We compared: (1) the time required to travel to the railway station nearest the postdischarge residential location (time required), (2) traveling expenses, and (3) the distance from the railway station nearest the designated hospital to that of the postdischarge residential location (distance) between the three groups. We also analyzed staff comments regarding "overnight training".

RESULTS

The lack of designated beds was a serious problem in two jurisdictions of Kinki and the Hokkaido Regional Bureau of Health and Welfare, with a "designated bed sufficient ratio" of 0.08 and 0.00, respectively. Twenty-four Japanese administrative divisions had no designated beds, while 37 administrative divisions had less than 10 inpatients at the time of the survey. The numbers of people in the "home group", "within group", and "outside group" were 125 (28.0%), 166 (37.1%), and 145 (32.4%), respectively. The "time required", traveling expenses, and distance were 1: 00, Yen 735, and 29.8 km in the "home group", 2: 51, Yen 5,764, and 165.3 km in the "within group", and 4: 14, Yen 20,565, and 694.6 km in the "outside group". Seventy-nine (59.4%) of 133 subjects who were at the "return to community stage" had already experienced "overnight training". No difference was found in the rate of "overnight training" between the "home group", "within group", and "outside group". Staff comments included difficulties in providing staff for "overnight training", responsibilities during "overnight training", and difficulties in finding places of residence in the inpatients' hometowns.

DISCUSSION

Because of the lack and maldistribution of designated beds in Japan, many patients are reluctantly admitted to designated hospitals far from their postdischarge residential areas, burdening not only hospital staff but also families and the inpatients themselves. Increasing the number of designated beds will solve this problem. An effective way would be to set up a ward with a small-scale designated unit (less than 15 beds) in the 24 administrative divisions where there are no designaed beds at present.

Position and role of forensic psychiatry in integrative psychiatry

The integrative approach to psychiatry has gained more importance in recent years. Is it justified or not, does it improve theory or practice, those are only some of the questions to which we are looking for answers, but in this paper we shall underline the necessity of enrolling forensic psychiatry into integrative, modern psychiatry. The reason and the motive for that integration is the fact that nowadays the content and the activities of contemporary forensic psychiatrists are totally reduced to executing the tasks given by courts. It is therefore entirely right to say that current forensic psychiatry finds itself in the passive role of executing orders of the court. Our aim is to point out how important it is that forensic psychiatry becomes an interdisciplinary profession in interaction with psychiatry but also with other medical branches just as with judiciary, educational institutions, moral-ethical institutions and religious institutions in producing preventive programmes and by participating in individual decision making process likewise. Our primary goal is to present the status and the position of contemporary forensic psychiatry and to specify the necessary improvements and its place in integrative psychiatry. It should be better, more meaningful and more ethical, both for the individual and the society in total. We want forensic psychiatry to include a protective and therapeutic role for each individual forensic examinee, i.e. a person who has already been in forensic examination and for whom one evaluates mental competence because of a mental disorder. We also want it to get a far larger and more active general role in society in terms of preventing criminal acts among the mentally ill and in society in total.

[Forensic psychiatry]

in France about 700 psychiatrists are licensed to determine criminal responsibility before the courts, in other words to assess whether a criminal was capable of knowing what he or she was doing or of controlling him or herself Criminals who are considered irresponsible are committed to psychiatric hospitals. Criminals who are considered to have diminished judgment or control may nonetheless be prosecuted and jailed Psychiatric experts may also be asked to predict aggressive behaviour, and to identify determinants of crime. Too often the answers are not fully grounded in science, and this is not made sufficiently clear. There are 26 psychiatric wards in French prisons, which only treat inmates who accept to be treated. When prisoners are prescribed compulsory treatment, they are discharged from prison and transferred to a psychiatric ward. This situation is more and more frequent but is not the most convenient: it delays treatment and does not facilitate long-term therapeutic relationships. Responsibility or pragmatism? About 20% of French prison inmates are psychotic, and these individuals are at risk of repetitive violent behaviour if left untreated. The main question is not one of criminal responsibility, but rather the most effective response to antisocial behaviour: is punishment or medical treatment the most effective way of preventing future crimes and protecting society? Ethical aspects: the situation could be improved by a number of measures. For example, training in forensic psychiatry should be obligatory before accreditation before a Court, and psychiatric diagnoses should be based systematically on the ICD10. Psychiatrists have a special duty to inform on advances and uncertainties in their field, in terms of diagnosis, prognosis and treatment.

Teleconferencing model for forensic consultation, court testimony, and continuing education

A medical center-based forensic clinic that provides the necessary comprehensive consultation, continuing education, court testimony, and clinical services through an applied model of teleconferencing applications is addressed. Telemedicine technology and services have gained the attention of both legal and clinical practitioners, examining trends and models of health care for underserved populations, and identifying where consultation with a team of professionals may benefit service providers in rural communities. The contribution offered herein provides an understanding of the history of the development of the clinic, a theoretical model that has been applied to a clinical forensic program that employs telepsychiatry services, and the ethical and malpractice liability issues confronted in using teleconferencing services. This model is examined through a child and adolescent forensic evaluation clinic. The goals of this model are offered, as are a number of applications within the broad spectrum of services utilizing telemedicine. Finally, changing patterns are addressed in clinically based health-care delivery for criminal justice, social services, and forensic mental health.

Ethics education

This article briefly describes the background and status of medical education in the areas of ethics and professionalism. Methods of teaching and assessment are described for medical students, residents, and practitioners within the core competency framework of medical education. Key areas of content for child and adolescent psychiatrists are described.

Die forensisch-psychiatrische Versorgung in Mitgliedstaaten der Europäischen Union - Versorgungskonzepte und Kapazitäten

OBJECTIVE

Internationally, there is a variety of approaches and concepts for placing and treating mentally disordered offenders in forensic-psychiatric care. European overviews are missing. Major indicators have not been standardized yet, which is a serious obstacle for cross-boundary comparisons.

METHODS

Basic concepts, legal frameworks, service provision and prevalences in forensic care of 15 European Union Member States were assessed by an expert evaluation. Administrative data was compared and conclusions for a possible harmonization of approaches were drawn.

RESULTS

The placement and treatment of mentally disordered offenders in the European Union Member States is characterized by a considerable variety of concepts and practice routines. National health reporting standards and the quality of available administrative data is poor. On the basis of available information, models of good practice are hard to choose.

CONCLUSIONS

National and cross-boundary research should be intensified. Defining European quality and training standards in forensic psychiatry seems to be an activity to be started on a short term basis.

Evaluation of a forensic psychiatric setting to provide a graduate nurse programme

There has been growth in the number and diversity of models of Australian graduate nurse programmes in psychiatric nursing. Programmes have also been established in specialist areas, and evidence is needed regarding best models of graduate nurse programmes and the ability of specialist areas to prepare nurses for psychiatric nursing. This paper reports on a qualitative project that examined the adequacy of a forensic psychiatric hospital to provide a graduate nurse programme. Individual, semistructured interviews were undertaken with nurses participating in the programme, and nurses who had completed the programme and had remained at the hospital or were nursing in other areas. Participants identified that the environment was safe and supportive of professional practice and development, and that skilled nurses were willing to encourage and teach graduates. Processes such as orientation, preceptorship and academic study were appreciated; however, their colleagues' willingness to be available, to teach, and to support were more valued. Participants reported that they felt confident and prepared as psychiatric nurses. Although limitations of undertaking a graduate nurse programme in a forensic setting were identified, the participants from past programmes who had gone on to work in other services did not report that their nursing careers had been disadvantaged. It can be concluded that as long as the context of the programme has adequate resources to support and assist graduates to develop the skills, knowledge and attitudes of psychiatric nursing, then the specialist nature may not be a limitation.

Cognitive-attitudinal aspects of key-worker's talk about their patients in forensic psychiatric institutions

SCOPE

Within an international network study involving four European countries (COMSKILLS), results on clinical-qualitative data are reported and discussed. A total of 103 semi-structured interviews were conducted, representing 45 per cent of the patients involved in the project (N=231).

METHOD

The coding framework represents a means of identifying and measuring aspects of complexity and specificity in the way in which key workers talk about care in relation to individual patients.

RESULTS

Respondents talked about patient care most frequently in terms of coping behavior and working relationships with patients. The commonest method cited for information gathering was observation. Out of three conceptual levels, ranging from complex and specific responses (conceptual level 3), to relatively general and unspecific remarks (level 1), most responses were coded at Levels 1 or 2.

CONCLUSIONS

Taking into account the apparent reluctance of many clinical staff to make use of standardized assessment instruments, systematic treatment-oriented methods able to both allow for valid and reliable assessments and to structure clinical experience is needed. It is expected that complexity and specificity care is referred to will profit from the regular use of such a method (e.g. the BEST-Index).

Authorship in forensic psychiatry: a perspective

Authorship in forensic psychiatry is a life-long commitment to learning, creativity, and professional growth. Forensic psychiatrists are writers, by choice and by necessity. The key concepts to effective writing in forensic psychiatry are "process" and a "workman-like approach." The process of writing is not a dash to the finish line, but is more akin to a leisurely, enjoyable walk. A workman-like approach to writing ensures that the author's writing is a process, not an event. Effective writing enhances clarity of communications with attorneys, judges, and others in the legal system. Writing with clarity and precision is a core competency in forensic psychiatry.

Commentary: authorship and training in forensic psychiatry

This commentary is written in praise of Dr. Simon's Presidential Address with exemplification of certain of his themes. Forensic fellowships have now become the training ground for the next generation of forensic psychiatrists, who need to be encouraged to find their own best way to write. They should also be encouraged to participate in research with senior mentors and researchers, as published research will lead to the challenging of stereotyping and misinformation about the populations served by forensic psychiatry.

The forensic mental health nurse - a literature review

Forensic mental health nursing has developed in the UK since the commissioning of Broadmoor Hospital in 1863. Little has been documented about the role until the early 1990s. There is debate over the usefulness of defining the role. It is suggested here that in order to meet the multifaceted, complex needs of the mentally disordered offender (MDO) patient group, the role of forensic mental health nurses (FMHNs) needs to be further developed, and this process is assisted by understanding its current status. This literature review examines the FMHN role in England and Wales. The literature pertinent to issues of task-orientated competence, knowledge and skills required, and desirable personal qualities that the role demands are examined. The latter of these attributes concerned with attitudes, values and morals is likely to be the most difficult to assess. Being able to isolate the composite elements of the role of FMHNs will enable the development of a competency framework, which will ensure quality assurance in contemporary health care for the thousands of FMHNs in practice and many more thousands of MDOs and other patients that the nurse has the potential to affect.

Forensic psychiatric assessment in European Union member states

OBJECTIVE

To provide a structured description and cross-boundary comparison of legal frameworks and training standards relevant for forensic psychiatric assessment in European Union member states before the extension in May 2004.

METHOD

Information on legislation and practice concerning the assessment of mentally disordered offenders was gathered by means of a detailed, structured questionnaire which was filled in by national experts.

RESULTS

Legal frameworks for the assessment and reassessment of mentally disordered offenders and professional training standards in forensic psychiatry vary markedly across EU member states.

CONCLUSION

Currently a cross-boundary harmonization of legal concepts appears hard to achieve. At least a formal construction and implementation of specialist training standards in forensic psychiatry would appear desirable.

Verbal and social interactions in Swedish forensic psychiatric nursing care as perceived by the patients and nurses

Patients and nurses in a Swedish forensic psychiatric unit filled in a questionnaire Verbal and Social Interactions designed to survey patients' and nurses' views on the frequency and importance of nursing interactions in forensic psychiatric care. The patients perceived the 'supportive/encouraging interactions' and the 'reality orientation interactions' as the most frequent interactions and the 'supportive/encouraging interactions' and the 'social skills training' as the most important interactions. The nurses perceived the 'supportive/encouraging interactions' and the 'practical skills training' as the most frequent and the 'supportive/encouraging interactions', 'interpretative interactions' and the 'practical skills training' as the most important interactions. There were significant differences between patients' and nurses' perceptions about the frequency of all the different groups of interactions, but greater agreement as to the importance. In general, the patients perceived that the interactions occurred less frequently than the nurses. The differences between patients' and nurses' perceptions on the interactions as well as the clinical implications of these differences are discussed.

Use of a routine mental health measure in an adolescent secure unit

We examined the use of a staff-completed measure, the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), to record mental health problems in adolescents in local authority secure accommodation. It proved possible to train staff and implement completion of the HoNOSCA on 64 consecutive admissions. Interrater reliability was high. The HoNOSCA identified high levels of psychological problems on admission (mean 18.5, s.d.=5.5). Follow-up HoNOSCA ratings proved sensitive to change; however, correlation between HoNOSCA and adolescent-completed questionnaires was poor. We concluded that HoNOSCA can be helpful in documenting mental health problems among young people admitted to secure local authority units.

[Current problems in psychiatric health care in Poland (2005)]

The paper is a presentation of the most important and actual psychiatric health care problems in Poland: the financial situation of hospitals, the risk faced by the out-patient psychiatric care,ethical problems related to clinical practice, as well as issues on postgraduate education.

Clinician perceptions of personal safety and confidence to manage inpatient aggression in a forensic psychiatric setting

Inpatient mental health clinicians need to feel safe in the workplace. They also require confidence in their ability to work with aggressive patients, allowing the provision of therapeutic care while protecting themselves and other patients from psychological and physical harm. The authors initiated this study with the predetermined belief that a comprehensive and integrated organizational approach to inpatient aggression was required to support clinicians and that this approach increased confidence and staff perceptions of personal safety. To assess perceptions of personal safety and confidence, clinicians in a forensic psychiatric hospital were surveyed using an adapted version of the Confidence in Coping With Patient Aggression Instrument. In this study clinicians reported the hospital as safe. They reported confidence in their work with aggressive patients. The factors that most impacted on clinicians' confidence to manage aggression were colleagues' knowledge, experience and skill, management of aggression training, use of prevention and intervention strategies, teamwork and the staff profile. These results are considered with reference to an expanding literature on inpatient aggression. It is concluded that organizational resources, policies and frameworks support clinician perceptions of safety and confidence to manage inpatient aggression. However, how these are valued by clinicians and translated into practice at unit level needs ongoing attention.

Assessing decision-making capacity: a survey of psychiatrists' knowledge

We aimed to survey the knowledge of psychiatrists on the assessment of decision-making capacity. Ninety-two psychiatrists of all grades and three other doctors attending a regional conference were marked on their verbal response to the question 'What are the key elements in the assessment of a patient's capacity?' On average, participants mentioned three out of the five elements in testing decision-making capacity. Scores were negatively correlated with age (Pearson's coefficient 0.275, sig 0.007). Section 12 status and grade had no impact on knowledge. Most psychiatrists of all grades have a reasonable knowledge of assessing decision-making capacity. Over a third of participants mentioned two or fewer of the five points, suggesting inadequate knowledge. Assessing decision-making capacity needs to be emphasised in training throughout psychiatrists' careers--not just at the start.