Forensic psychiatry deals with some of the most disturbed and difficult to manage patients in psychiatric practice. Its focus is the assessment and treatment of mentally disordered offenders, and other patients presenting with severe mental disorder in association with significant behavioural disturbance.
Forensic psychiatrists work in hospitals, whether high, medium or low secure or hospitals that are not designated as secure, in prisons and other custodial settings and in the community. Forensic psychiatrists commonly carry out liaison work, with criminal justice agencies and with non-forensic mental health services. They deliver treatment and manage care for their own patients and they provide expert advice and support to other professionals. Patients of forensic services tend to suffer from severe mental illnesses, but they often have co-morbid personality pathology, addiction problems and other criminogenic needs.
A truly holistic and multidisciplinary approach is essential; trainees often cite this as what attracts them to the specialty:
“When working in forensic psychiatry as a core trainee, I found that the patients we admitted were at the lowest point they could possibly be. Not only had they developed a serious mental illness but they had committed an act of violence, often against a loved one. Seeing them recover from such depths was incredibly rewarding and managing the complexity of that recovery process such an invigorating therapeutic challenge. That’s why I chose to pursue forensic psychiatry as a career.”
Forensic psychiatry has diversified greatly over the years. While it is always concerned with the criminal law and patients who are involved with the criminal justice system, there are now distinct services for women, adolescents and older adults; for patients with personality disorder (often run by forensic psychotherapists), learning disabilities, autism spectrum disorders, head injuries and other brain disorders. Some services have a short term focus, aiming for quick recovery from acute illnesses; some provide acute treatment followed by forensic rehabilitation; and others provide longer term care for those who need it. Some provide forensic community care after discharge and some support existing community mental health teams to follow up patients who have been discharged from secure care. So a CCT in forensic psychiatry is a gateway to a very broad specialty.
A forensic psychiatrist needs to have an excellent knowledge of mental health law and some knowledge of other aspects of law. Many, though not all, forensic psychiatrists work regularly as expert witnesses and this aspect of practice is an essential part of training. Ethical dilemmas are common in clinical practice - around restrictive practices, confidentiality or sharing of information and issues of autonomy and risk management. The complexity of the pathology and of the clinical teams means that a high capacity for self-awareness is crucial, both at an individual and team level; personal reflection and clinical supervision are essential to effective practice.
If you want to be a forensic psychiatrist, you will need:
- Good clinical skills with sound experience in general psychiatry
- Natural curiosity about unusual behaviour and willingness to examine it in a multi-dimensional manner
- Tolerance for difficult patients and a capacity to accept - without condoning - anti-social behaviour.
- Clarity of thought and of expression, both written and oral
- Thoroughness and attention to detail
- To understand and value the importance of the multidisciplinary team and the capacity to provide leadership to it.