● Assessment of offenders who may have a mental dis-order.
● Advice to the police when they are deciding whether to proceed with charges against mentally disordered offenders.
● Fitness to plead. To be fit to plead, a person must be able to understand the nature of the charge and the difference between a plea of guilty and a plea of not guilty, instruct lawyers and challenge jurors, and fol-low evidence presented in court. A person can suffer from severe mental disorder and still be fit to plead. A person judged unfit to plead is not tried but detained in a hospital until fit to plead, at which time (if it comes) the case is tried.
● Assessment of responsibility; providing evidence and/
or an opinion as to whether the defence of insanity or diminished responsibility is appropriate.
● Giving evidence in court, or writing a formal report for the criminal court.
● Treatment of offenders whilst in custody or prison, in hospital, or in the community.
● Providing risk assessments of offenders anywhere within the criminal legal system.
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serious crime. They are an alternative to sending the patient to prison whilst awaiting trial.
● Section 37 is a treatment order (similar to Section 3) which can be used for mentally disordered offenders who have been convicted of a serious crime and sentenced to imprisonment. After 6 months, the patient may request an MHRT in the usual way, but if the patient is found to have recovered from the mental disorder they are transferred to prison rather than discharged home.
● Patients who pose an extremely high risk to others may have a Section 41 added to their Section 37. This imposes further restrictions, most importantly that only the Home Secretary can decide that the person can leave hospital.
● Section 47 allows for prisoners to be transferred from a prison to a psychiatric hospital for treatment.
In the UK, there are three tiers of secure psychiatric hospitals; high-, medium-, and low-security facilities.
There are five high-security hospitals in the UK:
1 England: special hospitals at Broadmoor, Rampton, and Ashworth;
2 Scotland: the state hospital at Carstairs;
3 Northern Ireland: the central mental hospital at Dundrum.
These facilities take patients who pose grave imminent danger to the public, and are extremely secure. There are at least two high perimeter fences outside the hospital walls, and maximal security within. The ratio of staff to patients is very high. The average stay in Broadmoor is 8 years, and contrary to popular belief, most patients who receive treatment in a high-security facility are eventually BOX 12.3
Preparing a medical report for criminal proceedings
When a doctor is asked for a written medical report on a person it is sensible to (as far as possible) avoid technical language, explain any technical terms that are essential, and not use jargon. The report should be concise, have a clear structure, and be limited to matters relevant to the rea-son for the report. The following headings are recommended:
1 The doctor’s particulars: full name, qualifications, and present appointment.
2 When the interview was conducted and whether any third person was present.
3 Sources of information, including any documents that have been examined.
4 Relevant points from the family and personal history of the defendant.
5 The accused person’s account of the events of the alleged offence, whether they admit to the offence or have another explanation of the events, and if they admit to it, their attitude and expressed degree of remorse.
6 Other relevant behaviour such as the abuse of alcohol or drugs, the quality of relationships with other people, general social competence, and personality traits or behaviour indicating ability to tolerate frustration.
7 Mental state at the time of the assessment, mentioning only positive findings or specifically relevant negative ones.
8 A decision as to whether or not the person has a mental disorder as defined by the Mental Health Act. A more specific diagnosis can be added (such as dementia or schizophrenia) but the court is unlikely to be helped by the finer nuances of diagnosis.
9 Mental state at the time of the alleged offence. As explained above, this question is highly important in law but difficult to answer on medical evidence. A judgement is made from the present mental state, diagnosis, the accused person’s account, and accounts from any witnesses. If the person has a chronic mental illness (such as dementia) it is less difficult to infer his mental state at the time of the alleged offence than it is if he has a depressive disor-der, which could have been more or less severe at the former time than it was at the assessment. To add to the difficulty, the court does not simply require a gen-eral statement about the mental state at the time, but a specific judgement about the accused person’s intentions.
10 Fitness to plead is referred to when this is relevant.
11 Assessment of criminal responsibility. For most offences, a person is not regarded as culpable unless they were able to choose whether or not to perform the unlawful action, and unless they were able to control their behaviour at the time. Again a judgement has to be made on the available evidence, and may not be clear cut. This is especially important in cases where a defence of insanity or diminished responsibility is being made.
12 Advice on further treatment is likely to be particularly helpful to the court. It is not the doctor’s role to advise the court about sentencing, although sometimes it is helpful to indicate the likely psychiatric consequences of different forms of sentence that might be considered by the court (e.g. custodial vs. non-custodial).
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rehabilitated sufficiently to move back into the commu-nity. In the UK, there are now also special high-secure units for patients with dangerous severe personality dis-orders (DSPD), encompassing 300 beds. Two of these are located on the sites of high-security hospitals, and two at high-security prisons. A large part of the treatment in these units is targeted at rehabilitation, and helping the patient towards moving back into the community.
Medium-secure facilities fall somewhere between the
‘escape-proof ’ secure facilities and locked wards. The majority of patients in these facilities move there due to behaviour that is unmanageable in lower-security envi-ronments. The length of stay is much shorter—2 years on average—and then most patients are well enough to return to a less restrictive environment. There are several facilities in the UK that take adolescents needing a medium level of security.
Low-security units are mainly based in large general psychiatric hospitals or on the same site as a medium-secure facility. They are essentially locked wards, with similar security to that which is provided in intensive care units for patients who have not offended. Most patients
are admitted for a relatively short time, until their illness is under better control and they are able to return to a non-secure environment.
Community treatment
As in the rest of psychiatry, treating a mentally disordered offender has two parts: managing the acute psychiatric dis-turbance and then rehabilitating the patient to life in the community. Once a mentally disordered offender is deemed fit for discharge from hospital, and has completed their mandatory sentence, it is essential they receive appropriate community follow-up. This is provided in a similar way to that in the general services, with community psychiatric nurses, social workers, occupational therapists, and many other professionals providing input. For a patient to be successfully reintroduced into society and to reduce the chance of reoffending it must be clear that their mental state is appropriate, and that they have the skills required for community living. This includes help finding somewhere to live, employment, hobbies, financial assis-tance, and reintegration with family. The latter can be extremely difficult, and family therapy plays a vital role.
Further reading
Fazel, S. & Grann, M. (2006). The population impact of severe mental illness on violent crime. American Journal of Psychiatry 163: 1397–1403.
Stone, J. H., Roberts, M., O’Grady, J., Taylor, A. V., & O’Shea, K. (2000). Faulk’s Basic Forensic Psychiatry. Blackwell, Oxford.
www.dh.gov.uk/en/Healthcare/Mentalhealth/DH_078743.
UK Department of Health website; a useful summary of the
changes in the Mental Health Act 2007 (accessed April 2011).
www.legislation.gov.uk/ukpga/2005/9/contents. UK Department of Health website page covering the Mental Capacity Act (accessed April 2011).
Further reading 109
CHAPTER 13
Chapter contents
General considerations 110
Review of drugs used in psychiatry 113 Other physical treatments 127 Prescribing for special groups 128 Further reading 129