Worldwide, a wider understanding of the relationship between mental states and crime has led to an increased utilization of forensic experts in courts of law at different levels of legal action.
On entering into the legal system, three major areas need consideration: fitness to stand trial, insanity regulations and dangerousness applications. The major developments on the issue of fitness to stand trial pertain to rulings that defenders found not fit to stand trial are sent to psychiatric facilities, with the expectation that their competence to be tried is to be restored: the question for clinicians revolves on what parameters to use to predict restore ability of competence, which should be based on an adequate response to treatment. Insanity regulations pertain to legal tests used to decide whether the impact of mental illness on competence to understand or appreciate the nature of a crime could be used to declare an offender “not criminally responsible because of a mental condition”, “not guilty by reasons of insanity” or any other wording used in different countries. Applications to declare a person a “dangerous offender” usually demand a high level of expertise on the part of forensic experts, who are expected to provide courts with technical and scientific information on risk assessment and prediction of future violence.
Once an offender has been adjudicated, a major task for forensic psychiatrists is to gauge the level of systems interface in relation to different types of receiving and treating institutions. Hospitals for the criminally insane, mental hospitals for the civilly committed patients, penitentiary hospitals for mentally ill inmates, as well as hospital wings in local jails, are all part of the mental health system, and their interdependency has to be acknowledged for purposes of system integration and budgeting. How mental patients are managed in prisons is also a major matter of concern. Table shows some of the currently available alternatives.
Finally, on exit from the legal-correctional system, forensic psychiatrists are expected to provide expert knowledge on matters such as readiness for parole, predictions of recidivism, commitment legislation applicable to existing offenders, and the phenomenon of double revolving doors for the mentally ill in prisons and hospitals.
These unfortunate after-effects of deinstitutionalization should be counteracted with the realization that treatment alternatives to custodial care exist in the form of better medications with enhanced efficacy and effectiveness, that are becoming widely available, and psychosocial treatment strategies, that are also providing new proven ways for management of mentally ill persons in the community. In this respect, the development of mental health courts in some countries, diversion alternatives to imprisonment, assertive community treatment and intense case management modalities, as well as the use of community treatment orders, along with better policies in housing, point toward a social move to resolve the inequities of deinstitutionalization in order to stabilize community tenure for the mentally ill. At the same time, evaluations of anti-stigma programs seem to indicate that some of these initiatives are helping in changing public attitudes toward mental illness and increasing awareness about the human rights issues in the treatment and management of the mentally ill in many countries