Forensic psychiatry and the law

In the famous M’Naghten’s case, the judge asked: ‘why could not any person form an opinion from the circumstances whether a person was sane or not’. The forensic witness answered: ‘because it seems to require a careful comparison of particular cases, more likely to be looked by medical men, especially experienced in cases of unsoundness of mind’.

The court asked: ‘what is the limit of responsibility?’ The expert answered: ‘that is a very difficult point. It is scarcely a medical question.’

The recent judgement of the Supreme Court on the case of Imdad Ali, a mentally ill prisoner, highlights a blind spot amidst the two disciplines of forensic psychiatry and the law. Internationally, the criminal justice system relies on psychiatric input, including assessments of a defendant’s competence to stand trial, criminal responsibility, and less common assessments such as determination of a prisoner’s competence to be executed.

Forensic psychiatry is not a well-established career in Pakistan. Generally adult psychiatrists placed at government hospitals are expected to perform the highest level of forensic assessments as a routine matter. With very few psychiatrists in Pakistan, this is a Herculean task. The factors determining a proper evaluation of a mentally ill prisoner are poorly controlled due to the lack of any forensic setting to date.

Imdad’s fault is that he belongs to a country where health and education are accorded least priority. And interest and investment in mental health is far from satisfactory. We have a propensity to invest in cardiac, eye and cancer units but mental rehabilitation is a foreign term to us as yet. The Mental Health Ordinance 2001, which stands now as the Punjab Mental Health Act 2014, is far from implementation.

Forensic assessment needs to be unbiased. Unfortunately, cases concerning controversial, racial or prejudiced issues invite mob anger and public resentment. As a result, certain cases linger on for years without any solution.

There has been gross neglect in utilising the services of forensic psychiatry in legal matters. Psychiatrists refrain from getting involved in cases with legal implications; and the legal community is also not fond of psychiatric assessments. No one is more mistrusted than a witness who comes with no hard facts. Psychiatry has its limitations but its findings cannot be rejected. The two disciplines have not befriended each other.

Only those professionals who have an immediate experience of a mentally ill person, usually in the family, seem to understand these issues. So, simply put, the role of a forensic psychiatrist is to translate the illness of a mentally ill person for the lawyers or the courts. There are very subtle but crucial differences between the duty of a forensic psychiatrist and a general psychiatrist. The ultimate right resides with the court to take a decision.

If only a few mental health professionals, psychiatrists and psychologists are going to practise exclusively as forensic experts, they should all be trained to a degree that they can perform the duties assigned to them. This makes training bodies responsible to devise and introduce new training systems and guidelines to train the existing workforce in forensic psychiatry.

Similarly, lawyers being inadequately familiar with forensic psychiatry’s language leads to pitfalls. This results in a deficient cross examination and lack of characteristic rigour seen otherwise. At times the ignorance is such that lawyers are even unfamiliar with basic manuals such as DSM V and ICD 10, without which no psychiatric diagnosis is possible.

It is not difficult to imagine the frustration experienced lawyers or judges face if they believe they can themselves diagnose the case.

Efforts are underway to start a series of educational workshops for law-related professionals by the Punjab Psychotrauma Centre created at King Edward Medical University & Mayo Hospital after the APS Peshawar attack.

A revised curriculum of both disciplines would be a good start. The closed-mindedness that exists between the two disciplines can only be overcome if pre- and postgraduate courses are initiated for doctors and lawyers alike. A deep mutual understanding needs to be developed among law and psychiatry.

The writer is assistant professor of psychiatry at the King Edward Medical University.