What about forensic psychiatry as a career? Undergraduate and early post-graduate medical perspectives

BACKGROUND

Medical students in the UK are encouraged to plan their career earlier than ever before. What do they need to do that?

AIM

To explore the roles of the undergraduate curriculum and the foundation programme from the perspective of a foundation trainee looking towards a career in forensic psychiatry, and to conduct a pilot survey of undergraduates and early trainees about their knowledge and wishes with respect to forensic psychiatry.

FINDINGS

A fifth of those given a questionnaire responded. Among 36 responders, 14 were considering a career in forensic psychiatry. Some of the remainder did not know about the option at all; no one felt that they had sufficient information about this career option.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This was a pilot study with a low response rate, and confined to Wales, so the findings must be regarded with caution. Nevertheless, it does appear that a concerted effort by medical schools and relevant professional bodies to provide more information and encouragement to trainees at an early stage would be likely to support recruitment to the specialty of forensic psychiatry.

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.