Civil arena

Many forensic psychiatrists work in the private sector and provide medico-legal opinions, predominantly relating to civil matters. These include insurance—mainly workers’ compensation and traffic accidents—as well as providing psychiatric reports for other jurisdictions such as professional registration boards.

There are a range of psychiatric consequences which may develop from workplace or traffic accidents (see Box 18.1). But moreover, premorbid personality and mental disorder may affect the development of psychiatric illness, and forensic psychiatrists are involved in assisting the trier of fact (court, tribunal or insurer) to determine what was preexisting and what someone else is liable for.

Children and family

Issues of child sexual abuse, neglected children and psychiatric issues related to the breakdown of relationships are the specialty of some forensic psychiatrists, often with child and adolescent psychiatric training, who provide opinions to assist the court in determining how to regulate relationship breakdowns and look after the welfare of children.

Criminal jurisdictions

Most people think of forensic psychiatrists as working in criminal jurisdictions. In these areas, forensic mental health services are involved in many stages of the care of mentally disordered offenders. Such offenders may be diverted from police custody into psychiatric units. The prevalence of mental disorder in people remanded in custody is greatly increased compared to the general community, as is the proportion of people with troublesome substance use. Court liaison services assess and divert some mentally disordered offenders.

Once imprisoned, mental disorders are assessed and managed by forensic mental health staff, although it should be noted that compulsory treatment is not permitted in prisons. Overall, well over half of all people remanded in custody have significant substance abuse problems; personality disorders are massively increased; and the prevalence of psychotic illnesses is approximately eight times that of the general population and possibly more for women. In the United States, some prisons have so many mentally disordered people that they qualify as the largest psychiatric institutions in the country.

Some people with mental disorders are not able to be managed in the prison system. Typically, they have severe mental health problems and refuse treatment. Most mental health legislation provides for the involuntary transfer of prisoners to secure psychiatric facilities for treatment.