Career Focus

Forensic psychiatry

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7215.2 (Published 09 October 1999) Cite this as: BMJ 1999;319:S2-7215
  1. John J Sandford, specialist registrar in forensic psychiatry
  1. Langdon Hospital, Dawlish EX7 0NR

    Career prospects are strong in the specialty whose job it is to assess and treat mentally abnormal offenders. John Sandford reports

    Criminally insane people have long been a source of fear and fascination for public and doctors alike. Tell people at a dinner party that you are a forensic psychiatrist, and they will either bombard you with questions about infamous criminals or shy away, fearful that doctors become like their patients. Contrary to the popular Hollywood stereotype, little time is spent analysing the internal mental processes of serial killers. In reality, the working day is spent travelling between prison, hospital, and community to provide assessments, opinions, and treatment for a variety of mentally disordered people who exhibit antisocial behaviour.

    The first special hospital was established in 1863, but it was not until the 1970s that forensic psychiatry developed as a distinct specialty. Concern over the limited psychiatric input into prisons and problems with discharging patients from special hospitals led to the establishment of regional forensic psychiatrists and secure psychiatric units. The numbers of consultants and beds have slowly expanded since.Forensic psychiatry is an applied rather than theoretical specialty. It is the application of a part of medical knowledge to legal and custodial settings. As psychiatry is a diverse branch of medicine, so this diversity is reflected in its forensic aspect (box B1). The core skill is the treatment of mentally abnormal offenders, be this in secure hospital, prison or under supervision in the community.

    What do forensic psychiatrists do?

    Most forensic psychiatrists are based in medium secure units located near major towns or cities. These provide a highly staffed environment where potentially dangerous patients can be assessed and treated. Patients generally come from prison, high secure hospitals, or general psychiatric wards. The inpatient work of consultant forensic psychiatrists involves planning and overseeing patient care, an important emphasis being the balance between treatment and security needs. Outpatient work, in prisons and the community, centres on assessing offenders for the court, prison medical service, general psychiatrists, or other agencies. As well as advising on suitability for formal psychiatric treatment, reports often address wider issues such as risk to the public, mitigation, and medicolegal conundrums.

    Some forensic psychiatrists work in one of the four high secure hospitals in Britain (Ashworth, Broadmoor, Rampton, and Carstairs). This work is more focused on inpatient work, although consultants will still be involved in assessing potential admissions. A few consultants work in low secure or community teams, and work in subspecialties such as forensic psychotherapy, forensic learning disability, and forensic adolescent psychiatry. Most forensic work is in the NHS, but about 40%of secure psychiatric beds are in the private sector. This provides a substantial opportunity for employment.

    Politics, law, and medicine

    Forensic psychiatry is a medicolegal specialty. Practitioners require a working knowledge of the law, as many of the questions they are asked are about legal rather than medical definitions (such as intent or diminished responsibility). It is not just legal knowledge but legal skills and mindset that are important. Forensic psychiatry inhabits a strange legalistic world where attention to detail, due process, and considered opinions are as important as evidence based medicine. Legal and ethical, as well as medical, dilemmas occur regularly. In such an atmosphere it is important to be proactive, to think through decisions, and to consult freely with colleagues. Second opinions should be valued not feared.

    What is less recognised is that forensic psychiatry is a highly political area of medicine. As with cancer screening programmes, research on embryos, and heart operations on children, it has a highly visible public face. Adverse outcomes are noticed, and the public and media like to know what is going and to criticise liberally. Furthermore, activities in parliament have a more direct effect on forensic psychiatry than is the case for many other medical specialties. In the past two years, two pieces of legislation1 2 and one green paper3 have appeared that will have important effects on practice.

    Despite the competing interests of politicians, lawyers, and the media, it is important to remember that the core training is a medical one and that all patients have a right to confidentiality, dignity, and humane treatment.

    Clinical governance

    Clinical governance may be a hot topic for many doctors, but it is nothing new for forensic psychiatrists. While “clinical governance” through the Department of Health may be new, forensic psychiatrists have been inspected for years by the Mental Health Act Commission (MHAC), the criminal justice system, and the Home Office.

    Practically all the patients of forensic psychiatrists are detained under the Mental Health Act, many come via the courts, and about half are subject to Home Office restriction. This means that doctors have regular visits by the MHAC to inspect their facilities and practice, by the Mental Health Review Tribunal (MHRT) to scrutinise the detention and treatment of individual patients, and by the Home Office to oversee restricted patients (who cannot be transferred, discharged, or given leave from hospital without the permission of the home secretary). Patients” files quickly grow with the numerous MHRT, home office, and court reports. This level of clinical governance really becomes oppressive when something goes wrong. Inquiries are the currency of forensic psychiatry; the all powerful “retrospectoscope” sees all mistakes. Inquiries are compulsory in the case of a homicide and common after other “critical incidents”. The multiagency nature of forensic work means that one incident can lead to several inquiries.

    Personal qualities

    While an interest in criminal matters and a sense of humour are beneficial, they are not compulsory. Nonetheless, not all doctors are constitutionally disposed to this specialty— it has its cons as well as pros (see box 2).

    As a forensic psychiatrist, you will meet people who have committed a variety of crimes, and some will have committed unspeakable offences. You will meet sex offenders, murderers, arsonists, and kidnappers. You will have to discuss the details of their offending with them. It is important to maintain a balanced, objective approach and to avoid being overly punitive or becoming too emotionally involved. Many perpetrators are also victims. It is necessary to be level headed, a realist rather than a rescuer, and to possess a “robust emotional constitution”.Forensic psychiatrists are rarely able to abolish the risk that their patients present; they reduce and manage it. They have to tolerate a level of uncertainty that cannot be removed by a blood test or scan. They are paid to absorb society's anxiety. While not a specialty for risk takers, forensic psychiatry is not for those who are adverse to risks or intolerant of anxiety.Other important personal attributes include common sense, proactive thinking, the ability to present clear and reasoned opinions, and leadership skills-combined with modesty, a thick skin, and an ability to tolerate criticism. Court appearances may seem glamorous, but your report will be subject to the scrutiny of lawyers trained to dissect and criticise in full public view.Doctors who obtain much of their self esteem through the praise of their patients should consider carefully whether forensic psychiatry is a suitable career.

    Constant exposure to the dark side of the human condition, regular scrutiny of your work, living with risk, and the fear of inquiries takes its toll over the years. All doctors need to have advanced strategies to prevent and deal with stress. Forensic psychiatrists have no formalised system of support and supervision to help them do this. Supportive colleagues, a stable personal life, and outside interests are important, as is the ability to switch off when you get home and to have insight into your strengths and weaknesses.

    Training and job opportunities

    Forensic psychiatry is a distinct medical specialty recognised by the specialist training authority. Admission to a higher training programme is possible after successful completion of general professional training and possession of the Membership of the Royal College of Psychiatrists. Higher professional training takes three years in dedicated forensic posts (box 3).

    Some schemes undertake all this training in medium secure units; others offer a year in a high secure hospital, low secure unit, or specialist area (such as forensic learning disability). Good training schemes allow exposure to a wide variety of work and should cover the areas listed in box 1. Trainees with a strong interest in one of the subspecialties may choose to obtain a dual accreditation with another psychiatric specialty (such as child and adolescent psychiatry). The perceived failure of care in the community, the rising prison population, the decreasing number of psychiatric beds, and public concern about mentally disordered offenders have led to an increase in the number of beds in general and specialist forensic units. In turn, the number and range of opportunities open to forensic psychiatrists are also increasing. It is reasonable to project that, for the foreseeable future, job opportunities in forensic psychiatry are good.

    Summary

    While not a large specialty, forensic psychiatry continues to grow and diversify. It provides a career that is intellectually rigorous, diverse, and multifaceted. Its practice requires patience, open mindedness, humanity, and realism. Many patients prove challenging, but their treatment is generally rewarding. Although perhaps not as glamorous as the Hollywood stereotype, it remains a fascinating, stimulating, and curiously addictive specialty. Most who work in the area would do nothing else.

    Recommended readingChiswick D, Cope R. Seminars in practical forensic psychiatry. London: Royal College of Psychiatrists, Gaskell Publications, 1995.

    Box 1: Diversity of forensic psychiatry

    High secure hospital

    • Medium secure units

    • Low secure units

    • Specialist units

    • Forensic community psychiatry

    • Prison psychiatry

    • Court diversion

    • Probation liaison

    • Forensic psychotherapy

    • Forensic learning disability

    • Forensic adolescent psychiatry

    • Expert witness

    Box 2: Pros and cons of forensic psychiatry

    Advantages

    • Variety

    • Limited acute work

    • Contact with non-medical professionals

    • Public interest

    • Sitting on inquiries

    Disadvantages

    • Paperwork

    • Slow patient turnover

    • Driving and travel

    • Poor press

    • Subject of inquiry

    Box 3: Training in forensic psychiatry

    • General psychiatric training at senior house officer level (3-5 years) Posts in general adult, old age, child and adolescent, learning disability, and other subspecialties Leads to MRCPsych

    • Higher psychiatric training at specialist registrar level (3 years) Dedicated forensic posts No exit exam

    References

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