Danish Forensic Psychiatry

19-11-2009

The Danish Penal Code comprises two paragraphs about the legal status of mentally ill or retarded offenders (§§ 16 and 69) and one concerning the appurtenant judicial measures (§68). § 16 states: “Persons who at the time of the act was irresponsible due to psychosis or quite similar conditions or a pronounced mental retardation are not punishable. If the person as a result of consumption of alcohol or other psychoactive substances temporarily was in a state of psychosis or a similar condition, he may however be punished if certain pre-conditions are present”. § 69 concerns persons with less severe degree of mental illness or retardation.   A forensic psychiatric evaluation should be requested by the judicial system if there are reasons to assume that the offender suffers from any of the conditions comprised in § 16 - and often also for the more heterogeneous conditions comprised in § 69. For offenders charged with crimes that seriously endangers other persons – homicide, serious violence, rape, and arson without financial motive – a forensic report will also usually be performed. The only exceptions of more recent date from this rule are members of different biker gangs as these categorically refuse to participate in psychiatric evaluation. The forensic evaluation always takes place before the trial – i.e. the person is only on charge and not yet found guilty - in the form of a written report. Two key questions must be dealt with in the conclusion of the forensic psychiatric report: which of the §§ 16 or 69 are relevant in the specific case, AND the kind of judicial measure suggested to the court. As the population under forensic psychiatric evaluation is already highly selected it is rare that a person is found completely mentally healthy, i.e. neither comprised by § 16 nor § 69.   The suggestions to judicial measures, may differ depending on the paragraph in action: for § 16, always a special penal measure - either psychiatric treatment or social placement - for § 69 often ordinary sentence, unless a psychiatric or social sentence is regarded MORE SUITABLE than ordinary sentence to prevent the offender from committing future similar crime.   The second condition for being not-punishable – being irresponsible due to the mental abnormality – is solely for the judge to decide upon; however, it is very rare that the court finds a psychotic or retarded offender responsible. Very seldom, if a person has been in a state of psychosis at the time of the act but not at the time of the trial AND psychiatric treatment is not found necessary /suitable the court can decide that no measures whatsoever shall be taken.   The forensic psychiatric expert is only rarely asked to witness before the court. The concepts of fitness to plead or competence to stand trial do not exist in Danish jurisdiction.   The provision of forensic psychiatric evaluations and treatment in Denmark A psychiatrist, usually with some kind of forensic expertise, is responsible but often gets help from psychologists and social workers. A forensic report is rather long - usually 10-20 pages – and follows a preconceived structure. Within the last 15years the greater part of the Danish counties – presently 5 – has developed special forensic psychiatric services that are obliged to deliver evaluations to the court system. The Danish Medico-legal Council strives to secure a high and consistent standard of the forensic reports. No formal demands exist on training or education for psychiatrists or psychologists in forensic psychiatry – however in 2003 the Section of Forensic Psychiatry under Danish Psychiatric Association initiated a training course in forensic psychiatry that has received financial support from the Danish government.   The psychiatric forensic services are embedded within the public mental health care system and do evaluations for the court as well as treatment of the most severely ill patients. Denmark holds only one high secure forensic psychiatric hospital (“Sikringen” at Nykøbing Sjælland) with 30 beds. The majority of forensic patients are treated within general mental health care. A sentence to psychiatric treatment (usually) implies the opportunity of compulsory admission but no further coercive measures per se. Besides a regional forensic psychiatric service the metropolitan area of Copenhagen is also provided with the Clinic of Forensic Psychiatry under the Ministry of Justice. The Clinic delivers the majority of forensic psychiatric reports in greater Copenhagen besides directing research and education but only has a very limited treatment capacity. The approximate annual number of forensic reports in the whole of Denmark is 600. The number of mentally ill offenders sentenced to psychiatric treatment is constantly on the rise – from 300 persons in 1980 to the actual 2054 in 2008.   Mette Brandt-Christensen

Assessment of mentally disordered offenders in Sweden

30-12-2009

Swedish law does not have the legal concept of accountability. If a court finds a person guilty of the crime, the offender will be held responsible regardless of the mental state at the time of the crime. However, according to the Swedish Penal Code, a person who has been found guilty of a criminal act, must not be sentenced to prison if the crime has been committed under the influence of a severe mental disorder. All psychotic states, severe depression with strong intention to commit suicide and severe personality disorders or neuropsychiatric disorders combined with marked compulsiveness or impulsivity with psychotic features, are considered to be a severe mental disorder according to the legislation.   In order to assess the degree of mental disorder, the offender is referred to a forensic psychiatric assessment, minor and/or major. The minor assessment is a forensic psychiatric screening procedure performed by a (forensic) psychiatrist. The report is to advise the court whether there is a need for a major assessment.     Approximately 600 major forensic psychiatric assessments are performed every year in Sweden. The assessment is performed by a team comprising a forensic psychiatrist (in charge of the assessment), a psychologist, a medical social worker and nursing staff from the ward.   Marianne Kristiansson

Current status of forensic psychiatry in Iceland.

30-12-2009

Iceland does not have a special mental act legislation.   A short summary on civil legislation for psychiatry as a background for legislation of forensic psychiatry in Iceland Psychiatric and forensic psychiatric institutions in Iceland Psychiatric assessments in association to trials of persons with psychiatric illnesses Training and education of forensic psychiatrists/psycholo-gists Psychiatric treatment in prisons  Maria Sigurjonsdottir

The Current Status of Norwegian Forensic Psychiatry

30-12-2009

Basic Principles for Accountability: From 1929 the absolute biological (medical) principle has been ruling in the General civil penal code. Section 44 says that an offender who at the time of the crime was either psychotic, unconscious or severe mentally retarded is forensically irresponsible. He/she will either have to be released or, on particular condition, given a sort of compulsory mental health. However, between 1902 -1929 the psychological principle was practiced, meaning that there should be causality between the crime and the psychotic ideation before the offender is to be set free. In medieval time the “district penal legislation” guaranteed that an insane person could not be given an ordinary sentence for his or her crime. The biological principle has recently been criticized, mainly by representatives from the court of justice and by influential prosecutors, increasingly also by psychiatrists.   The Provision of Forensic Psychiatric Services in Norway The forensic psychiatric work is in all individual cases almost exclusively done by two private psychiatrists (sometimes one psychiatrist together with one private psychologists), appointed by the court on an ad hoc-basis. Annually Norwegian forensic psychiatrists produce some 250 - 400 forensic reports (2008: 350). There are no public institutions (hospital or clinic) which are established for the purpose, or obliged to provide forensic psychiatric services upon a decision made by a court of justice. In special occasions, a hospital can decide whether or not to receive a criminal offender in order to carry out forensic examinations and evaluations, after a court decision. At the moment, there are no concrete plans for financing and establishing public forensic institutions for these purposes, but the need for it is under evaluation, and a project for its planning is probably in its very beginning.   Forensic Psychiatrists/Psychologists – Education and Training: So far there has been no formal demand on training or education for psychiatrist or psychologists doing forensic psychiatric work. The recruiting of specialists within this field seems to be accidental. For some years specialists that take an interest in forensic psychiatry have been offered some training courses, on a voluntary basis. Recently a group within the three Centres for forensic psychiatry (Oslo, Bergen and Trondheim) has started to prepare for the development of an education that in the longer term will form the basic for the creation of a professional expertise group of forensic psychiatrists and psychologists, who have all passed these required courses.   The Norwegian Medical Forensic Board (MFB): This public service reports to the Ministry of Justice and was founded in 1900. Very soon it was extended to include forensic psychiatry. It controls all the forensic reports, sees to that the two specialists have done the examination and evaluation thoroughly, and that there are reasonable connections between description of symptoms and conclusions regarding accountability and other main topics. No Norwegian court of law will accept any forensic report as a foundation of its verdict, unless it is accepted by the MFB. The position of the MFB within the forensic field is rather strong, and it is reasonable to state that in the lack of formal forensic institutions, the MFB has played an essential role in developing a good culture for what is the “gold standard” within forensic psychiatry.   The Concept of Forensic Psychiatry in Norway Being mainly a service of giving expert opinion to the court, the concept of forensic psychiatry in Norway has traditionally been a narrow one, compared to what is seen in most western European countries. Norwegian forensic psychiatry is traditionally an activity restricted to present to the court an opinion of expert before and under the trial, and has so far not included the management of ordinary security wards or the psychiatric services given to the prisoners. The old “criminal asylum” Reitgjerdet was closed down in the early 1980’s and replaced by three regional security departments (RSA) in Oslo, Bergen and Trondheim, and smaller local units in almost all counties. The two levels are supposed to share the public task of giving adequate treatment for those who combine severe mental illnesses with a potential of violent or dangerous behaviour. The patients are referred to the hospital partly from the ordinary psychiatric services, partly as a consequence of a court decision or a verdict of cumpulsory mental health care. The health authorities have stated some distinct goals for increased capacity as well as improved professional competence in the security wards, but the number of bed are strikingly reduced. All security wards are managed as part of the health system, controlled by the Ministry of Health. The general health services for prisoners are given within the prison by the local community, whilst the psychiatric services come from the local psychiatric hospital. During severe mental brake downs the prisoners will be transferred to the local psychiatric hospital and thereafter returned to the prison.   “Particular Reactions” Linked to Reduced/Lost Accountability or Severe Personality Disorders: In 2002 a new legislation divided the mentally disturbed that commit severe crimes (violence, murder, rapes, arson etc.) in to three categories: Those who at the time of the crime were psychotic or “unconscious”, those who are severe mentally retarded, and those who have severe conduct disorders or personality disorders. If deemed necessary for the protection of society, these groups are likely to receive the following verdicts: The first group will regularly be transferred to a psychiatric hospital for compulsory mental health care. The second group will be transferred for examination and evaluation to a central expert unit, established for the purpose, and further on transferred to his or her local community, taken care of by means of special measures. For the third group a sentence of preventive detention in an institution under the correctional services will be imposed. For all groups the sentence can be continued by a court decision, in case there have been no real progress and there is a danger that a crime of the same kind can be repeated.   Lately, there has been some pressure from the political and public opinion that compulsory mental health care should be imposed as a “particular reaction”, even on those psychotic (unaccountable) offenders that are doing economic crimes or are behaving just annoyingly. The Ministry of Justice considers at the moment a new legislation for this purpose, but many instances and professionals have warned against it. There are reasons to believe that the annoying behaviour at stake results from the fact that a lot of mentally ill people are not sufficiently taken care of within the psychiatric services, mainly due to incomplete capacity in the wards designed especially for this group of patients. From this point of view, the prevailing legislation is robust enough to solve the problems without an extension of the “particular reactions” as described.   Standard of Academy and Research: Compared to ordinary psychiatric services, the academy of Norwegian forensic psychiatry doesn’t have a strong position. Traditionally the academic “needs” have been taken care of by scientific staff within the general psychiatry. “Clinical” research within forensic psychiatry has been sparse, but is now increasing. There are expectations that the three regional Centres for security, prison and forensic psychiatry (Oslo, Bergen and Trondheim) will boost research within forensic psychiatry and pave the way for a new academic development. For this purpose the three centres should be even more closely linked to the Faculty of Medicine at the three universities than they are today.   Current Norwegian Ideological and Political Debate on compulsory mental health care: There are allegations that Norwegian psychiatric services employ too much of compulsory mental health care, by admitting patients to the hospital by force “when not necessary”, as well as putting too much restraints on them during their stay in the hospital. The country has a fairly well developed data basis for analysis of what is going on within the services. Yet the legislation and the health care systems differ a lot between the countries, even between the Nordic ones. Direct comparison between them is for that reason rather difficult or risky, and it is hard to say whether or not the allegations are correct. In the media there has been for some five - ten years a rather importunate debate on this topic, with a strong ideological conviction that the opportunity to employ force or compulsory measures should to be substantially reduced. To some extent the professionals within the psychiatric services regard the health authorities as being absent from the debate scene, thus giving legitimacy to the forming idea that a lot of psychiatric patients are badly treated victims.     Yngve Ystad, senior consultant, specialist in psychiatri Leader of the Working Committee on Forensic Psychiatry, under the Board of The Norwegian Psychiatric Association