Forensic mental health assessment in France: recommendations for quality improvement

Impact of Legal Traditions on Forensic Mental Health Treatment Worldwide

Background

Forensic psychiatry is a subspecialty dealing with the diagnosis and treatment of mentally ill offenders. However, forensic treatment standards vary. Differences arise among forensic treatment standards, due to variations in either the legal framework, the general psychiatric treatment standards, or the forensic training standards. Thus, to date there is no evidence-based pattern for how forensic services should be organized and provided.

Aims

The aim of this article is to compare forensic services in various countries in order to contribute to the current debate on international forensic treatment standards, by informing about existing differences in available policies.

Methods

This scoping review was conducted by reviewing the academic literature regarding forensic treatment around the world. Studies were identified from Pub-Med and Google-Scholar. Keywords for the search included "forensic psychiatry," "mentally ill offenders," "legal framework," "jurisdiction," and the names of geographical regions.

Results

Forensic treatment admission varies significantly around the world. There are countries that do not recognize forensic psychiatry as a subspecialty, whereas other countries apply insufficient forensic training. Most countries provide inpatient treatment for mentally ill offenders. However, service organization varies, including where the services are delivered (prisons, high-security hospitals, and general psychiatric departments). Forensic services are mainly centralized, although the need for outpatient care is emerging.

Discussion

Differences may originate mainly from variations in the legal tradition. These differences combined with the limited evidence on the effectiveness of the intervention imply the need for the optimization of forensic treatment standards on an international level. Therefore, further follow-up studies are needed.

Criminal responsibility evaluations: Benchmarking in different countries

Forensic mental health experts play a crucial role in criminal responsibility evaluations. However, the quality of these assessments has at time come under scrutiny and has been heavily criticized. A literature review revealed significant differences between countries concerning legal frameworks and procedures for conducting these assessments. The findings suggest that although some countries can be seen as a "role model", there still is room for improvement.

Forensic-Psychiatric Risk Evaluations: Perspectives of Forensic Psychiatric Experts and Older Incarcerated Persons From Switzerland

Background: Forensic-psychiatric risk assessments of persons in prisons aim to provide treatment for their mental health disorders to prevent risk of recidivism. Based on the outcomes of such evaluations, it is decided, for instance, whether the person can be released or be assigned to further treatment with or without privileges. A negative evaluation would mean that the assessed person must remain in prison or in a forensic institution until his or her mental health has improved to live safely in the community. This paper highlights the process of forensic-psychiatric evaluations and the challenges faced by the two parties directly involved in this process in Switzerland. Methods: Data for this manuscript are gathered using semi-structured one-to-one interviews. The study participants included a purposive sample of 41 older incarcerated persons under measures (i.e., mandated by court order to psychotherapeutic and psychiatric treatment), and 23 expert participants working in Swiss prisons or forensic institutions. We analyzed data using thematic analysis. Results: Study findings within four themes are reported. First we describe the standards and procedures that expert participants use to carry out adequate risk assessments and conditions under which they refuse to perform such assessments. Thereafter, we present expert participants' concerns associated with predictive risk assessments and highlight the need to be cautious in drawing conclusion from them. We then reveal older incarcerated participants' reports on the inconsistencies with the forensic expertise and their belief that these reports tend to be negative toward them. The final theme concerns older participants' experiences of how these evaluations negatively impact their lives and their perspectives of a different future. Conclusion: The study findings about forensic-psychiatric risk assessments point to the need for a clearer communication on how these evaluations take place and how decisions are taken based on them. As incarceration under measures denotes the necessity to continue therapy and reduce dangerousness, it is important that accused person understands his or her real progress, feel that the decisions are objective and justified, and are aware of the progress needed to achieve the goal of eventual release. Such clarity will not only be valuable for those under measures, but also the justice system.

Mental health and the criminal justice system in France: A narrative review

The treatment of people diagnosed with mental disorders who committed crimes differ greatly in countries around the world because of the long histories of criminal justice and psychiatry specific to each country. As a result, it is often difficult to grasp the specificities of each system. The main objective of this paper is to provide a narrative review of the interactions between the French mental health and judicial systems. Subsequently, we will discuss how the concept of forensic psychiatry does not yet exist in France and how it can be applied.

A decision-making model for pre-sentence evaluations for juveniles

Forensic mental health assessments (FMHAs) are requested by the courts to assist in the sentencing process and can have a major impact upon the life of the person evaluated. Completing these assessments is a core competency for forensic psychologists. However, some FMHAs are undertaken by psychologists who have no forensic training. Despite this, there are no formalised Australian minimum standards to ensure reports are helpful to the courts and reflect sound evaluation methodologies. Drawing upon a critical review of the literature and recent research findings, we propose a 10-step decision-making model for pre-sentence evaluations of juveniles. Our model provides a framework for decision-making and highlights the key elements of an evaluation. The model provides a basis for developing practice guidelines and professional standards. The next step is to test the model in the field to determine its impact on the quality of psychological pre-sentence reports.

What does impartiality mean in medico-legal psychiatry? An international survey

Medico-legal psychiatry is the field of forensic psychiatry that consists of reporting to criminal, civil and administrative authorities and testifying in courts of law. As a forensic science, medico-legal psychiatry is based on the principle of impartiality. However, the notion of impartiality is not clearly defined and can be understood in many different ways. The purpose of this study was to explore the meaning that expert psychiatrists attribute to this notion. Members of the forensic sections of the World Psychiatric Association, the European Psychiatric Association and the American Academy of Psychiatry and the Law were surveyed by e-mail using a vignette and a questionnaire. One hundred and thirty-one responses were received. When commenting on the case presented in the vignette, a large majority of respondents considered that the personal moral convictions of the doctor were the main factor likely to cast doubt on the impartiality of the expert, followed by past personal experience and the fact that the expert was the treating doctor of the examinee. In the answers to the questionnaire, 54% of participants considered that the question of impartiality was similar in both the inquisitorial and adversarial systems. Impartiality was considered by most participants as both an ethical and a legal concept. The main factors considered as likely to affect the impartiality of an expert were past personal experience, personal beliefs and perceptions, and the fact that the expert was the treating doctor of the examinee. Training in forensic psychiatry and past professional experience were considered to be the most important factors that could enhance the impartiality of an expert. When asked about their own definition, 70% of respondents defined impartiality as a choice specific to the expert, and 27% of participants defined impartiality as a result of external factors. The term 'objectivity' was used in 30% of responses. Results revealed a rather unified view of the issue of impartiality by medico-legal psychiatrists, irrespective of their country and practice conditions. The notions of honesty and striving for objectivity, which are emphasized in several guidelines of forensic psychiatry associations, were cited by many participants. Impartiality appears to be considered as a coherent concept in both normative and consequentialist ethics and represents a useful reference in the practice of medico-legal psychiatry.

Reports of recovered memories of childhood abuse in therapy in France

Recovered memories of abuse in therapy are especially controversial if the clients were not aware they were abused before therapy. In the past, such memory recovery has led to legal action, as well as a debate about whether such memories might be repressed, forgotten, or false memories. More than two decades after the height of the controversy, it is unclear to what degree such memories are still recovered today, and to what extent it occurs in France. In our French survey of 1312 participants (M_age = 33; 53% female), 551 reported having done therapy at some point. Of that 551, 33 (6%) indicated they had recovered memories of abuse in therapy that they did not know about before therapy. Sexual abuse was the most commonly reported type that was recovered in therapy (79%). As in past research, discussing the possibility of repressed memories with therapists was associated with reports of recovered memories of abuse. Surprisingly, memory recovery occurred just as much in behavioural and cognitive therapies as it did in therapies focused on trauma. We found recovered memories in a proportion of clients who began therapy recently. Recovered memories in therapy appears to be an ongoing concern in France.

Psychological reports for sentencing juveniles in Australian courts

Psychological reports for use in court must be relevant to the legal issues in dispute, meet professional standards, and reflect evidence-based practice. Using the Delphi method, a high degree of consensus was found among Australian experts in the methodology and knowledge required for conducting forensic mental health assessment (FMHAs) and the content needed in pre-sentence reports. Consensus was absent in two areas, if a pre-sentence report should always include a risk-assessment; and the need for a model to guide the FMHA. Without a model it is difficult for practitioners to justify their decision-making process, and judicial officers have no mechanism to determine if the work provided to the court is of an acceptable standard. Future research should focus on developing a model for presentence reports that includes a decision-making process and minimum standards. Researchers also need to determine judicial officers' views on the helpfulness of presentence reports.

Assessing NGRI and dangerousness: Perspectives from forensic reports in Portugal

In Portugal the expert whose report supports the criminal defence of not guilty by reason of insanity (NGRI) must also consider the defendant's dangerousness. Nevertheless, the concept of dangerousness has received little attention in the Portuguese critical literature. Moreover, there is concern that the concept is often used improperly. We endeavoured to evaluate a sample of Portuguese forensic reports in order to discuss: 1) the prevalence of defendants who were considered guilty, NGRI, and dangerous; 2) which treatments were proposed; and 3) the frequency of technical errors found. We analysed 124 case folders from the year 2006, from both mainland Portugal and the archipelagos of Madeira and the Azores, which included an evaluation of dangerousness of the defendants. These 124 cases were analysed using frequencies, correlations and multiple logistic regressions. The majority of the defendants were male and single. Thirty-nine percent (39%) were considered NGRI. A total of 34% of the defendants were considered dangerous or no dangerousness could be excluded. In 66% of cases treatment was recommended but in only 9% was admission to a forensic hospital recommended. Technical errors in the forensic reports, both of format and content, were identified in 26% of the 124 cases, the incidence of errors being high in reports from certain institutions. The majority of the forensic reports did not discuss the educational background of the defendants or their criminal history/records. We conclude that the experience of the expert is crucial in producing an appropriate report. The establishment of uniform criteria for the preparation of forensic reports and enhanced training of psychiatrists in forensic psychiatry should be considered as possible strategies to improve the accuracy of forensic reporting, particularly when assessing dangerousness.

Forensic psychiatry, one subspecialty with two ethics? A systematic review

Background

Forensic psychiatry is a particular subspecialty within psychiatry, dedicated in applying psychiatric knowledge and psychiatric training for particular legal purposes. Given that within the scope of forensic psychiatry, a third party usually intervenes in the patient-doctor relationship, an amendment of the traditional ethical principles seems justified.

Results

Thus, 47 articles, two book chapters and the guidelines produced by the World Psychiatric Association, the American Association of Psychiatry and the Law, as well as by the Royal Australian and New Zealand College of psychiatrists, were analyzed. The review revealed that the ethics of correctional forensic psychiatry and those of legal forensic psychiatry do not markedly differ from each other, but they are incongruent in terms of implementation.

Methods

In an effort to better understand which ethical principles apply to forensic psychiatry, a chronological review of the literature published from 1950 to 2015 was carried out.

Conclusion

The ethics of correctional forensic psychiatry are primarily deontological. The principle of justice translates into the principle of health care equivalence, the principle of beneficence into providing the best possible care to patients, and the principle of respect of autonomy into ensuring confidentiality and informed consent. The ethics of legal forensic psychiatry are rather consequentialist. In this latter setting, the principle of justice is mainly characterized by professionalism, the principle of beneficence by objectivity and impartiality, and the principle of respect of autonomy by informed consent. However, these two distinct fields of forensic psychiatry share in common the principle of non maleficence, defined as the non collaboration of the psychiatrist in any activity leading to inhuman and degrading treatment or to the death penalty.

Is the French criminal psychiatric assessment in crisis?

The criminal psychiatric assessment in France seems to be facing growing criticism related to disagreements between experts and, on the other hand, a lack of interest of psychiatrists for the assessment. We start by explaining the current framework of the criminal psychiatric assessment in France, which differs from the assessment used in English-speaking countries, where Roman law applies. Then, we will describe the disagreements through a literature review and two clinical vignettes. Finally, we will try to understand the causes of discrepancies between experts and the reasons for a supposed lack of interest of the psychiatrists for the expertise. For this, we conducted a survey among the psychiatric experts. We individually questioned experts on the discrepancies and on their awareness of the expertise. We found that 75% of the experts we surveyed had already faced the divergent opinion of a colleague. In addition, the experts were divided on their conclusions related to the fictional scenario we gave them for an a priori assessment (a person with schizophrenia who was accused of murder), particularly in the specific contexts that we submitted to them. The main cause of disagreement between experts was the various schools of thought that influence the psychiatric experts in the forensic discussion and, therefore, the conclusions of a case. Moreover, the experts believed that the decrease in the number of psychiatric experts could be attributed to the adverse financial situation of the assessment, the considerable workload required, and the extensive responsibility that falls on the expert. Calling on a team of forensic experts to perform assessments seems to be the first solution to this crisis. Furthermore, if the experts were better compensated for the assessments, more people would want to undertake this work.