Forensic psychiatry and other areas of medical practice

Comparing forensic psychiatry with other areas of medical practice may seem a strange thing to do. This article is stimulated by reflection upon the author’s appraisals by the following appraisers: breast surgeon, haematologist, psychiatrists, anaesthetist. The appraisals have all been of good quality. The author of this post has been trained as appraiser as well.

Non-psychiatrist appraisers at times seemed to struggle with understanding the nature of psychiatry and the overall chaos involved in psychiatric work. It became apparent that psychiatry is such a ‘different world’ that it is not something that they could easily fathom. Forensic psychiatry is probably even more difficult to fathom. It is a subspeciality of psychiatry that contains other micro-specialties with it e.g. Prison Psychiatry, Female Mental Disorders, Community Forensic Psychiatry, Personality Disorders. This article follows on from What is Forensic Psychiatry?

Table of Contents

Comparisons

The accordions below can be toggled and are optional. They represent deep thought in finally drawing out some core features of forensic psychiatry.

Anaesthesiology is picked for comparison, because it seems to represent a discipline that is quite remote from the world of psychiatry i.e. anaethetists have quite sound level of control when serving their patients. Note these table is about broad generalisations and cannot include every variance or exception.

Table 1: Broad differences between psychiatry and anaesthesiology
ParameterPsychiatryAnaesthesiology
Primary FocusMental health and behaviour, protection of risk to self, others and mental health, physical health in mental disorders. Consciousness and pain management during medical procedures
Scope of PracticeBiopsychosocial model, hence complex structure. Often involved in giving much advice to patients and teams. Primarily biological model when treating patients. No lingering roles in giving advice to patients. May have roles advising service development.
Duration of InterventionOften acute or long-term cases, revolving door cases. Short-term, procedure-specific
Team StructureLarge multidisciplinary teams with no hierarchy involving medical practice. Liaison with extended teams, social services, care homes etc. Smaller teams, clearer hierarchy of responsibilities.
AuthorityNot in authority (suprising to most outside of psychiatry). In prescribing ECT or medications psychiatrists are in authority but not in psychosocial domains of treatment. The latter they can be advisory. In authority due to specific nature of skills applied in biological domain. Other than circumscribed psychological support for a procedure, anaesthetists will not have on going roles in psychosocial support or interventions.
Decision MakingOften collaborative, involving patient and family, carers, social services, care homes, Primarily doctor-driven due to nature of specific procedures.
Immediate FeedbackLimited, effects of psychiatric interventions in the richness of the biopsychcosoical model are often delayed. Few instruments or equipment to give information.Almost immediate, real-time monitoring, instruments and equipment can give information.
Objectivity of MeasuresOften subjective, based on patient report and observationMuch more objective, based on physiological measurements
Tools and EquipmentMostly intangible (therapeutic techniques, medications)Tangible (medical devices, monitoring equipment, drugs)
Patient State During TreatmentTypically conscious and participatoryConcious initially until underoing GA. For some procedures patients may be awake e.g. epidural or with various nerve blocks.
Typical Treatment SettingVaried (outpatient clinics, inpatient wards, patients’ homes, care homes.) Loss of locus of control through the above.Controlled (operating rooms, procedure suites).
Predictability of OutcomesOften variable and long-term. Difficult to estimate risks with the noise arising in from the biopsychosocial model. Generally more predictable and immediate
Patient InteractionExtensive, various forms core of treatment, psychosocial factors may predominate. Limited, primarily pre- and post-procedure
Legal and Ethical ConsiderationsComplex, often involving issues of autonomy and capacity. Mental Health Act and related issues. Psychiatrist whilst having the law on their side in many situations like detention, will have to be proportionate according to law and behave very ethically in their practice. Cultural factors have to be at the forefront of their minds, not just for patients but as cultures of work vary from location to location. Focused on informed consent and procedural safety, except in emergency situations.
Emergency InterventionsLess frequent, may involve managing acute behavioural crises, detention under the MHA 1983.More frequent, managing sudden physiological changes.
Follow-up CareExtensive, often long-termUsually short-term, focused on procedure recovery
Influence of Patient’s EnvironmentHighly significant, considerations of social care/support, limited or no control outside of hospitals. Limited significance
Research MethodologiesMix of qualitative and quantitativePredominantly quantitative

Similarities among psychiatry and anaesthesiology

Both require extensive medical knowledge, careful patient assessment, and management of risk

Both fields require strong communication skills and ability to manage stress

Both involve pharmacological interventions and understanding of drug interactions

Table 2 -Broad differences between forensic psychiatry, dermatology and A&E medicine
ParameterForensic PsychiatryDermatologyAccident & Emergency Medicine
Primary FocusMental health and behaviour in legal contexts, risk assessment and management for offendersDiagnosis and treatment of skin, hair, and nail disordersRapid assessment and management of acute illness and injury
Scope of PracticeBiopsychosocial model with legal overlay. Complex structure involving legal system, prisons, and secure hospitalsPrimarily biological model with some psychosocial aspects in chronic conditionsBroad scope covering all acute presentations, triage, and initial management
Duration of InterventionOften long-term, potentially lifelong in some forensic casesMix of acute and chronic cases, some lifelong conditionsShort-term, focused on immediate stabilisation and referral
Team StructureLarge multidisciplinary teams including legal professionals, prison staff, and social servicesSmaller teams, may include specialist nurses and plastic surgeonsLarge, dynamic teams with clear hierarchies, including various specialties and paramedics
AuthoritySignificant authority in secure settings and the courts, but often advisory in psychiatric hospitals. Flatening of any supposed medical hierarchy was influenced in part by the Mental Health Act 2007. Authority in dermatological interventions, may advise other specialtiesHigh authority in acute situations, directs initial management of various conditions
Decision MakingCollaborative, involving legal system, multidisciplinary team, and sometimes patientsPrimarily doctor-driven, may involve patient in treatment choicesRapid, often unilateral decisions required in emergencies
Immediate FeedbackLimited, effects of interventions often delayedVaries, some immediate (e.g., cosmetic procedures), others delayedImmediate, real-time monitoring and response to interventions
Objectivity of MeasuresOften subjective, based on clinical judgment and risk assessment toolsMix of objective (e.g., biopsy results) and subjective (patient-reported symptoms)Highly objective, based on vital signs and immediate clinical findings
Tools and EquipmentRisk assessment tools, psychological tests, some basic medical equipment (neurological equipment often not available). Dermatoscopes, biopsy tools, lasers, phototherapy equipmentExtensive range of diagnostic and interventional equipment
Patient State During TreatmentTypically conscious and participatory, unless acutely disturbedConscious, often ambulatoryVaries widely, from fully conscious to critically ill or unconscious
Typical Treatment SettingSecure hospitals, prisons, outpatient clinicsOutpatient clinics, specialised inpatient unitsEmergency department, resuscitation rooms, ambulances
Predictability of OutcomesOften variable and long-term, influenced by multiple factorsGenerally predictable for acute conditions, variable for chronic diseasesVariable, ranging from highly predictable to very uncertain
Patient InteractionExtensive, forms core of assessment and treatmentModerate, focused on specific skin concernsBrief but intense, focused on immediate needs
Legal and Ethical ConsiderationsHighly complex, involving mental health law, criminal law, and issues of capacityFocused on informed consent, some ethical issues in cosmetic proceduresComplex, involving consent in emergencies, child protection, and medicolegal aspects of trauma
Emergency InterventionsManagement of acute behavioural disturbances, suicide riskRare, mainly for severe drug reactions or infectionsFrequent, core aspect of practice
Follow-up CareExtensive, often long-term, involving multiple agenciesRegular for chronic conditions, limited for acute issuesUsually short-term, often handed over to other specialties
Influence of Patient’s EnvironmentHighly significant, considering secure settings and community riskLimited, mainly relevant in occupational skin diseasesModerate, considering circumstances of injuries and social factors in emergencies

Psychiatry as a whole

Psychiatric practice in the UK stands apart from other medical specialties in its fundamentally collaborative and multidimensional approach to patient care. Unlike most other branches of medicine, where a doctor’s expertise and decision-making often take centre stage, psychiatrists frequently find themselves as part of large multidisciplinary teams. This may include mental health nurses, psychologists, social workers, occupational therapists, and even car support workers, each bringing their unique perspective and experience to the table. The psychiatrist, while holding specific authority in areas such as medication management and certain medical procedures like ECT, often does not have the final say in many aspects of a patient’s overall treatment plan. This diffusion of authority and decision-making power is a stark contrast to specialties like surgery or anesthesiology, where the consultant’s word is typically final and directs the course of treatment.

The nature of psychiatric interventions also sets the field apart from its medical counterparts. While a cardiologist might prescribe a clear-cut treatment for hypertension, or an orthopedic surgeon might set a broken bone, psychiatric treatments are often less straightforward and more open-ended. Psychiatrists must navigate a complex interplay of biological, psychological, and social factors, often without the benefit of clear-cut diagnostic tests or imaging that other specialties rely upon. Treatment outcomes in psychiatry are frequently subjective and can take weeks or months to manifest, unlike the more immediate and measurable results seen in many other medical fields. This uncertainty and the need for patience and persistence in treatment are unique challenges that psychiatrists face daily.

Perhaps most strikingly, psychiatric practice in the UK is deeply embedded in a framework of legal and ethical considerations that are far more pervasive and complex than in most other medical specialties. The Mental Health Act, which allows for the detention and treatment of individuals against their will under certain circumstances, places an enormous ethical burden on psychiatrists that is virtually unparalleled in other fields of medicine. Psychiatrists must constantly balance respect for patient autonomy with the need to prevent harm and provide necessary care, often under intense scrutiny from both legal and ethical perspectives. This legal dimension, coupled with the stigma still associated with mental health issues, creates a practice environment for psychiatrists that is uniquely challenging and distinct from that of their colleagues in other medical specialties. The need to navigate these complex legal and societal landscapes, while still providing compassionate and effective care, truly sets psychiatric practice apart in the medical world.

Forensic Psychiatry

Forensic psychiatry, as a subspecialty within psychiatry, stands out as a uniquely complex and multifaceted field, even more so than general psychiatry. Operating at the intersection of mental health, criminal justice, and legal systems, forensic psychiatrists navigate a labyrinth of interconnected domains that demand an exceptional breadth of knowledge and adaptability. Unlike their counterparts in other medical specialties or even in general psychiatry, forensic psychiatrists must seamlessly transition between roles as clinicians, legal consultants, and expert witnesses, sometimes within the same working week. This constant shifting of gears requires not only a deep understanding of psychiatric principles but also a firm grasp of legal concepts, criminology, and the intricacies of the prison system. The forensic psychiatrist’s workplace might range from secure hospitals and prisons to courtrooms and police stations, to a car in a carpark or field – each environment presenting its own set of challenges and ethical considerations.

The collaborative nature of forensic psychiatric practice is particularly striking in its scope and complexity. Forensic psychiatrists frequently find themselves as integral members of multi-agency protection teams, working alongside professionals from diverse backgrounds such as probation officers, social workers, police officers, and lawyers. These teams, often tasked with managing high-risk individuals in the community, require forensic psychiatrists to communicate complex psychiatric concepts to non-medical professionals and to synthesise information from various sources to inform risk assessments and management plans. This level of inter-agency collaboration is rarely seen in other medical specialties and demands exceptional communication skills, as well as the ability to balance multiple, sometimes conflicting, professional perspectives and priorities.

Perhaps most distinctively, forensic psychiatrists operate within a framework where clinical decisions can have far-reaching legal and societal implications. Unlike in general psychiatry, where the primary focus is on the individual patient’s well-being, forensic psychiatrists must constantly balance the needs of their patients with public safety concerns and legal obligations. This might involve making recommendations about an offender’s fitness to stand trial, fitness to plead [both legal matters], assessing the risk of future violence, or determining the appropriate level of security for a mentally disordered offender. The weight of these decisions, which can significantly impact an individual’s liberty and the safety of the public, places an enormous ethical burden on forensic psychiatrists. Furthermore, their work often comes under intense scrutiny, not just from medical peers, but from legal professionals, the media, and the public. This unique position at the crossroads of medicine, law, and public safety sets forensic psychiatry apart as a field that demands not only clinical expertise but also a robust ethical framework, diplomatic skills, and the ability to thrive under pressure in highly complex and often contentious situations.

Perceptions of forensic psychiatrists

The author recalls many perceptions of forensic psychiatrists before becoming a forensic psychiatrist. Thereafter perceptions and reactions from others seemed to cohere as follows:

  1. Legalistic approach: Forensic psychiatrists must operate within a complex legal framework, necessitating a precise understanding and application of relevant laws and regulations. This can manifest as a seemingly legalistic approach to clinical situations.
  2. Pedantic and hair-splitting: The need for extreme precision in forensic work, particularly when providing Expert Witness Evidence or writing reports for courts and tribunals, can be interpreted as pedantry. However, this attention to detail is crucial in a field where small distinctions can have significant legal and clinical implications. The latter may well spill over into other areas of medical and non-medical life.
  3. Rule-oriented: The strict protocols and guidelines governing work in secure settings and interactions with the legal system necessitate a strong adherence to rules and procedures. People tend to judge personality based on what they see in particular domains.
  4. Attention to detail: What might be perceived as obsession with minutiae is often a professional necessity, given the potential consequences of overlooking seemingly small details in risk assessments or legal proceedings.

These characteristics, while sometimes viewed negatively, serve important functions in forensic psychiatry:

  1. They ensure compliance with legal and ethical standards in a highly scrutinised field.
  2. They protect patient rights and public safety in complex, high-stakes situations.
  3. They maintain the credibility and reliability of forensic psychiatric assessments and expert evidence.
  4. They help navigate the intricate intersection of mental health, criminal justice, and societal expectations.

It is worth noting that these traits, which may seem exaggerated in forensic settings, are to some extent present across other medical specialties. All doctors must pay close attention to detail, follow protocols, and navigate complex systems. In forensic psychiatry, these aspects are amplified due to the unique demands of the specialty.

Recognising these perceptions can be beneficial for forensic psychiatrists in several ways:

  1. It can inform communication strategies with colleagues from other specialties, helping to explain the rationale behind forensic approaches.
  2. It can guide interactions with patients and their families, balancing necessary precision with empathy and clear communication.
  3. It can contribute to professional development, encouraging reflection on when these traits are essential and when they might be moderated.

Ultimately, while these characteristics may lead to certain perceptions about ‘personality’ as conceptualised in a lay sense, they are often necessary adaptations to the demanding and precise nature of forensic psychiatric work.

Key differentiating features

Several key differences emerge that distinguish forensic psychiatry from most other areas of medical practice in the uk:

  1. Legal system integration: Forensic psychiatry is uniquely positioned at the intersection of medicine and law. Unlike most medical specialties, it routinely involves engagement with the criminal justice system, courts, and prisons.
  2. Risk assessment focus: While risk assessment is part of all medical practice, in forensic psychiatry it takes on a broader societal context, focusing on potential risks to public safety as well as to the patient.
  3. Long-term interventions: Forensic psychiatric care often involves extended periods of treatment and follow-up, sometimes lasting years or even lifelong, which is less common in many other specialties.
  4. Multidisciplinary collaboration: The range of professionals involved in forensic psychiatry is particularly diverse, including legal professionals, prison staff, and social services, extending well beyond the typical healthcare team.
  5. Involuntary treatment: Forensic psychiatrists more frequently deal with scenarios involving involuntary treatment and detention under mental health legislation.
  6. Ethical complexities: The specialty faces unique ethical challenges in balancing patient rights, public safety, and legal obligations.
  7. Expert witness role: Providing Expert Witness Evidence in court is a core part of forensic psychiatric practice, not as commonly encountered in other medical fields.
  8. Secure settings: Work often takes place in highly secure environments like prisons or secure hospitals, settings uncommon in other areas of medicine.
  9. Influence of social factors: While all medicine considers social determinants of health, forensic psychiatry places particular emphasis on how social and environmental factors contribute to both mental health issues and offending behaviour.
  10. Limited immediate feedback: Unlike many medical interventions, the effects of forensic psychiatric treatment are often not immediately apparent and can take considerable time to manifest.
  11. Objectivity challenges: Assessment and treatment outcomes in forensic psychiatry often rely more heavily on subjective measures and clinical judgment compared to specialties with more readily quantifiable outcomes.
  12. Scope of authority: Forensic psychiatrists often have significant authority in secure settings but may play more advisory roles in other contexts, a duality not typically seen in other specialties.

These distinguishing features highlight the unique nature of forensic psychiatry within the broader landscape of UK medical practice, emphasising its complex interplay between mental health care, legal considerations, and public safety concerns.