1. Criminal Forensic Psychiatry Principles and Practices Law of Crimes Forensic Questions Forensic Assessment Treatment Court Movement San Mateo Pathways Program 1

2. Forensic Psychiatry Answer legal questions in legal arena Answer legal questions in legal arena No duty to the client No duty to the client No “best interests” No “best interests” Need to know law as well as psychiatry Need to know law as well as psychiatry Ability to navigate an adversarial system Ability to navigate an adversarial system Always consider malingering Always consider malingering Good writing skills and good courtroom skills Good writing skills and good courtroom skills 2

3. Percipient vs. Expert Testimony  Opinion evidence  Percipient  Expert  Admissibility vs. weight of evidence  Judicial gate keeper function  Fry  Daubert 3

4. Principles Honesty, objectivity, neutrality, abstinence, competence (legal and medical) Honesty, objectivity, neutrality, abstinence, competence (legal and medical) Duty is to patient replaced by duty to law Duty is to patient replaced by duty to law Best interest replaced by respect for autonomy Best interest replaced by respect for autonomy Special consent procedure Special consent procedure Address all evidence / challenge own opinions Address all evidence / challenge own opinions Must explicate reasoning process Must explicate reasoning process 4

5. Law of Crimes Who is subject to punishment? Who is subject to punishment? Penal Code Penal Code Misdemeanor vs. felony Misdemeanor vs. felony Actus Reus plus men rea Actus Reus plus men rea 5

6. Typical Forensic Questions  Was the defendant mentally ill at time of crime?  If so, was he/she insane under California law?  Is the defendant mentally ill now?  If so, is he/she currently incompetent to stand trial  Did the illness impair ability to form requisite intent? 6

7. Legal Reasoning   Question   Rule   Relevant facts   Reasoning process   Conclusion 7

8. Competency to Stand Trial (1) U.S. vs. Dusky "test must be whether he has sufficient present ability to "test must be whether he has sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding and consult with his lawyer with a reasonable degree of rational understanding and whether he has a rational as well as factual understanding of the proceedings against him.“ whether he has a rational as well as factual understanding of the proceedings against him.“ If incompetent, remand to hospital for restoration of competency If incompetent, remand to hospital for restoration of competency 8

9. Competency to Stand Trial (2) SELL v. UNITED STATES Permits involuntary use of antipsychotic drugs solely to restore competency to stand trial Permits involuntary use of antipsychotic drugs solely to restore competency to stand trial Mentally ill defendant must be facing serious charges and drugs are necessary to Mentally ill defendant must be facing serious charges and drugs are necessary to Treatment must be medically appropriate Treatment must be medically appropriate Needed to restore competent to stand trial Needed to restore competent to stand trial Effects substantially unlikely to undermine fair trial Effects substantially unlikely to undermine fair trial Is defendant dangerous Is defendant dangerous 9

10. Not Guilty by Reason of Insanity California Penal Code Section 27(b) 10  “… defense shall be found by the trier of fact only when the accused person proves by a preponderance of the evidence that he or she was  incapable of knowing or understanding the nature and quality of his or her act and [or] of  distinguishing right from wrong at the time of the commission of the offense.

11. Link Between Mental Illness and Crime Judgment Judgment Impulse control Impulse control Content of delusions or hallucinations Content of delusions or hallucinations Overwhelming emotion (overwhelms reason) Overwhelming emotion (overwhelms reason) Over reaction to perceived threat Over reaction to perceived threat Anger Anger Substance use Substance use m-TBI m-TBI 11

12. Treatment Court Movement Law as first responder Law as first responder Decrease jail time Decrease jail time Reduce risk to community Reduce risk to community Evidence based therapeutic sentencing Evidence based therapeutic sentencing 12

13. San Mateo “Pathways” Program  Joint Program – Court, Probation, Mental Health  Misdemeanor defendants who are SMI  Reduce recidivism / protect community  “Modify out to community treatment”  Therapeutic sentencing  Use of progressive sanctions  Special monitoring 13

14. Therapeutic Sentencing Outpatient psychotherapy Outpatient psychotherapy Residential treatment / supportive housing Residential treatment / supportive housing Dual diagnosis treatment Dual diagnosis treatment AA, NA, CBT, anger management AA, NA, CBT, anger management Med management Med management Monitoring of substance use / social activities Monitoring of substance use / social activities 14

15. Forensic Experience Rotation Pathways Program Pathways Program Assess applicants for mental health court Assess applicants for mental health court Primary report to Pathways team Primary report to Pathways team Secondary report for Stanford Program Secondary report for Stanford Program Third Thursday of month Third Thursday of month Maguire Jail or Probation Dept. Redwood City Maguire Jail or Probation Dept. Redwood City Supervision by ACF forensic psychiatrist Supervision by ACF forensic psychiatrist Option to attend Pathways meeting and court Option to attend Pathways meeting and court 15

16. Forensic Assessment  Know which “hat” you are wearing  Answer the legal question  Advocate for your opinion – not the client  Expose the limits of scientific certainty  Avoid too much jargon  Deal with disconfirming data  Consider malingering 16

17. Forensic Report Writing  Identify referral source  State the forensic question and the relevant law  List and analyze documents reviewed  Informed consent  Clinical and forensic examination  Diagnosis  Forensic discussion – data, analysis, reasoning  Conclusion (reasonable medical certainty) 17

18. Quick Links Seminar website: http://forensicpsychiatry.stanford.edu/Seminars/materials.htm Penal Code: http://www.leginfo.ca.gov/calaw.html 18