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Forensic psychiatry and general psychiatry: re-examining the relationship

  • Trevor Turner (a1) and Mark Salter (a2)
Extract

Something is going wrong with forensic psychiatry, as a concept and as a service. Beds in medium secure units are logjammed, and relations with general adult services increasingly fraught with disputes over resources and responsibilities. Despite a remarkable investment in buildings, and the 300% growth of the forensic specialty (Goldberg, 2006), offending behaviour by individuals with mental illness shows no sign of decline, either in terms of prison numbers (at record high levels in the UK) or the countless demands for risk assessment (Duggan, 1997; Moon, 2000).

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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BJPsych Bulletin
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  • EISSN: 1472-1473
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Forensic psychiatry and general psychiatry: re-examining the relationship

  • Trevor Turner (a1) and Mark Salter (a2)
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eLetters

Any re-examination of forensic psychiatry should include a proper examination of the alternatives

Andy Bickle, SpR in Forensic Psychiatry
05 February 2008

Turner & Salter’s re-examination of the relationship between forensic and general psychiatry was provocative and rehearsed the criticisms from generalists towards their forensic colleagues (2008). No doubt it is important for forensic psychiatrists to consider external views in reflecting on their own practise. However, I feel it necessary to highlight the fallacy of simply adopting the United States’ system, as was suggested by the authors.

The U.S. approach of effectively separating the treatment of mentallydisordered offenders from the contribution of psychiatry to the courtroom brings with it serious ethical problems which should not be overlooked. One line of U.S. thinking, as advanced by Stone (1984), argues that clinicians should not act as expert witnesses as they cannot help but use their therapeutic skills at interview which may induce disclosures used bycourts for non-medical purposes. However, this raises the unedifying prospect of participants in the legal process unused to delivering psychiatric treatment being responsible for advising the court on mental health disposals. This does not seem to me in the interests of the justice or the best way to ensure treatment needs are met. An alternativeview, expressed by Appelbaum (1997), argues that psychiatric testimony falls outside traditional medical practice and therefore is not subject totraditional medical ethics, meaning that psychiatrists need not feel boundby medical ethics when acting as expert witnesses. However, it is difficult to see how a trained psychiatrist would not, unwittingly or otherwise, use their specialist interviewing skills in obtaining evidence from a defendant. For this reason they should be bound, at least in part,by the ethics of their profession.

In my view, the most appropriate approach to be taken in the UK was explained by O’Grady (2002) who incidentally responded to this article, but not on this point. O’Grady earlier argued that forensic psychiatristsshould adhere to both justice ethics (truthfulness, respect for autonomy, and respect for the human rights of others) as well as medical ethics (beneficence and non-maleficence). This type of theory of ‘mixed duties’ was approved by the Royal College (2004) and encourages forensic psychiatrists to be highly sensitive to the ethical dilemmas inherent in their subspeciality. I acknowledge the brief nature of Turner & Salter’s article, but feel their suggestion that the problems they perceive could be resolved simply by adopting U.S. practice is overly simplistic and should have been accompanied by a description of the limitations of this approach.

References

Appelbaum P.S. (1997) A theory of ethics for forensic psychiatry. JAm Acad Psychiatry Law, 25(3), 233-247.

Royal College of Psychiatrists (2004) The psychiatrist, courts and sentencing: the impact of extended sentencing on the ethical framework of forensic psychiatry. Council Report CR 129.

O’Grady J. (2002) Psychiatric evidence and sentencing: ethical dilemmas. Criminal Behaviour and Mental Health, 12, 179-184.

Stone A.A. (1984) The Ethical Boundaries of Forensic Psychiatry - A View from the Ivory Tower Bulletin of the American Academy of Psychiatry and Law, 12(3), 209-219.

Turner T & Salter M (2008) Forensic psychiatry and general psychiatry: re-examining the relationship. Psychiatric Bulletin, 32, 2-6.
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