What is Forensic Psychiatry?
Forensic Psychiatry is a specialized branch of psychiatry where the medical and the legal worlds overlap. It is a fascinating sub-specialty that involves the application of medical psychiatric expertise in legal contexts.
Canadian definition of the sub-specialty is very similar to that of our American colleagues but actual practice differs because of the difference in the legal systems. Even within Canada, mental health legislation varies between provinces, although the Criminal Code of Canada is federal legislation. This site focuses on practice within Ontario, using the Ontario Mental Health Act and other legislation.
The forensic psychiatrist practices in a broad multi-disciplinary environment, working with both health care professionals (nurses, social workers, psychologist, other medical specialties) and professionals from legal and/or non-medical arenas (lawyers, courts, correctional officers, parole officers). The work environment is similarly diverse: hospitals, general office practice, correctional facilities, courts. In most cases, traditional hospital practice forms only a small component of the forensic psychiatric practice.
What does Forensic Psychiatry deal with?
The field is comprised of three distinct but overlapping areas that deal with different issues:
- Forensic Psychiatry:
- Expert Witness/Testifying
- Dangerous or Long Term Offender Applications
- Fitness to Stand Trial
- Probation and Parole
- Review Boards
- Divorce & Custody Evaluations
- Negligence & Malpractice
- Personal Injury
- Workman's Compensation Boards
- Workplace Violence
- Clinical Criminology
- Developmental Delay Issues within the forensic mental health framework
- Impulse Control Disorders
- Interpersonal Violence
- Major mental illness within the forensic framework (psychosis, schizophrenia, mood disorders, etc)
- Paraphilias & Sex Offending
- Personality Disorders with the forensic mental health framework
- Substance Abuse within the forensic mental health framework
-Risk Assessment & Risk Management
- Treatment Programming within the forensic mental health framework
- Psychiatry & Law
- Capacity: to consent to treatment, to manage property, to consent to emergency treatment, etc.
- Community Treatment Orders
- Consent - informed, consent to treatment, etc.
- Consent & Capacity Board
- Confidentiality of Patient Records
- Duty of Care
- Duty To Warn
- Involuntary Hospitalization
- Mental Health Act, in general
- Patient Rights under the Mental Health Act
- Substitute Decision Making
Although the area is highly specialized and requires a specific knowledge that transcends the boundaries of general mental health, a solid grounding in general psychiatry and major mental illness is essential for those working in the field.
Who works in Forensic Psychiatry?
A forensic psychiatrist is a fully trained psychiatrist (medical school plus 5 years of psychiatric training followed by a comprehensive specialty examination) who usually has at least one additional year of training & study specifically in Forensic Psychiatry. Forensic Fellowships in Canada can last from one to two years and are offered at a select number medical schools across Canada. Usually there is only one Forensic Fellowship position in each program, although there are exceptions.
A number of other professionals work within the broader scope of Forensic Mental Health, each certified by their own professional governing bodies: forensic psychologists, social workers, nurses, psychometrists, occupational therapists, behavioral therapists, recreational therapists, and others.
Who are Forensic Patients/Clients of the Forensic Mental Health System?
Forensic patients are those who have been referred by the Courts for assessment or who have been declared as Not Criminally Responsible or Unfit to Stand Trial by the Criminal Justice System and admitted to a provincial forensic mental health system. In Ontario, forensic patients are under the jurisdiction of the Ontario Review Board which monitors their progress and reviews their cases on an annual basis.
Some forensic clients, on the other hand, are outside of the hospital system although in most cases, they are in contact at some level with the judicial system. They may be detained in correctional institutions, may be on probation, may be on parole from the correctional system, may be otherwise involved in the criminal legal process (eg charged with a criminal offence, on trial, etc), or they may be involved in the civil legal process (custody & access issues, insurance claims &/or disputes, workplace issues, dispute resolution, competence issues, etc.).
What is the Forensic Mental Health System [in Ontario]?
The forensic mental health system in Ontario is comprised of about 600 designated "forensic" or secure inpatient beds and about 100 "non-designated forensic beds" in 10 designated facilities across the province. As in the correctional system, there are different security levels assigned - minimum, medium, maximum – and patients are placed there according to the level of security that the Ontario Review Board deems they require.
In addition to those in hospital, a number forensic patients who remain under the disposition of the Ontario Review Board live outside the hospital and are managed as outpatients.
There are approximately 1000 registered forensic patients in Ontario.
How is the Forensic Mental Health System Accessed?
(The Relationship between the Community, the Judicial System, the Mental Health System and the Forensic System [in Ontario])
Designated forensic beds cannot be filled by admission from hospital emergency rooms or transfer from other hospital programs. They are for a specific population and accessed via a specific process.
Designated beds in the Forensic Mental Health System in Ontario are accessed almost exclusively by the Court or the Judicial system. Patients are sent to the forensic mental health units by the Courts either for assessment (ie pre-trial) or for rehabilitation/re-integration after a Court finding of Not Criminally Responsible.
The Ontario Review Board is responsible for monitoring the patients placed for rehabilitation/re-integration from the time of their admission until they received an "absolute discharge". This includes their progression through the system from designated beds, usually to non-designated beds and/or to community living.
Outpatient forensic mental health services can often be accessed on a contracted basis by Parole & Probation, lawyers or agencies but these referrals are not admitted to the designated forensic inpatient beds.
References and Further Reading:
Handbook of Psychiatry & The Law in Canada. Bloom, H., Schneider, R. & Hucker, S. J (Eds.). Centre For Addictions & Mental Health: Toronto. forthcoming
Introduction to Psychology and Law, Canadian Perspectives. Regina A. Schuller and James R.P. Ogloff, Eds. University of Toronto Press. Toronto. 2001.
Principles and Practice of Forensic Psychiatry. Richard Rosner, Ed. Chapman & Hall. New York. 1994.
Forensic Psychiatry: Clinical, Legal & Ethical Issues. John Gunn and Pamela Taylor, Eds. Butterworth-Heineman, Oxford. 1993.
Principles and Practice of Forensic Psychiatry. Robert Bluglass and Paul Bowden, Eds. Churchill Livingstone. London. 1990.
Clinical Criminology. Ben-Aron, M. H., Hucker, S. J., & Webster, C. D. (Eds.).Toronto: Clarke Institute of Psychiatry and M & M Graphics.1985.
Basic Forensic Psychiatry. Hucker, S. J. , & Turner R. E. (Eds.). Ottawa: Department of Justice. 1983