Int J Psychiatry Clin Pract 2015; 19: 80–83. © 2014 Informa Healthcare ISSN 1365-1501 print/ISSN 1471-1788 online. DOI: 10.3109/13651501.2014.967700
REVIEW ARTICLE
Forensic psychiatry in Europe: The perspective of the Ghent Group
informahealthcare.com/ijpcp
Norbert Nedopil1, Pamela Taylor2 & John Gunn3 1
Abteilung für forensische Psychiatrie, München, Germany, 2Institute of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, School of Medicine, Cardiff University, Cardiff, UK, and 3Institute of Psychiatry, King’s College London, London, UK
Abstract Objective. The Ghent Group was established in 2004 as a forum for forensic psychiatrists from different countries in Europe in order to bridge the gaps in knowledge, experience, practice and care which exist between them due to their different legal traditions and constitutions in dealing with people having mental disorders who come into conflict with the law. Methods. The Ghent Group considers itself as a loosely organised think tank to which all interested and invited professionals can contribute without statutory restraints. Its aim is to facilitate communication with mentally disordered offenders appearing in court, to understand the procedures of our neighbouring countries and to find common ground between clinicians. Results. The major focus of the Ghent Group is on teaching and training both at a national level, where one can learn about the methods of training from each other, and at a European level. The group of trainees from different countries experiment in seminars in solving medico-legal cases considering European Human Rights issues and their respective national procedures and institutions. Conclusions: This helps not only to understand the differences between the national medico-legal procedures but also to deepen the understanding of the principles and practice in one’s own country. Key words: Forensic psychiatry, Europe, teaching, training, mentally disordered offenders (Received 31 March 2014; accepted 16 September 2014)
Introduction: Forensic psychiatry is practiced differently in each EU country Forensic psychiatry has long been thought to be restricted to national and jurisdictional confines by the legislation of individual countries. While clinical aspects of assessment and treatment are more similar between countries, the ways in which services are provided differ considerably. There are also sufficient differences in mental health law and in the way in which people with a major mental disorder are dealt with in court; hence, it can be difficult to consult across national boundaries with any confidence. International exchange of knowledge and experience by scientists and experts is limited to certain topics; some consider it to be without boundaries such as risk assessment or the management of aggression and sexual deviance, although here we even probably need more information about demographics and social context of offending to make truly valid exchanges (SWANZDSAJCS 2009). On the other hand, people with recognised professional training, including forensic psychiatrists, from the countries of the European Union (EU) are allowed to practice in all member countries and to cross those national confines if they exercise their right to choose a workplace outside their home country. Also, many criminals or forensic psychiatric patients may also move freely within the European
Correspondence: Professor Dr. Norbert Nedopil, Abteilung für forensische Psychiatrie Klinik für Psychiatrie und Psychotherapie der LMU München, Nußbaumstr. 7, D-80336 München, Germany. E-mail: [email protected], www.forensik-muenchen.de
Union, and it is important that they can be assessed and treated by forensic psychiatrists outside their home country. Therefore, it is vital that we have opportunities for training together and understanding each other. Problems and attempts to resolve legal and practical differences between EU countries The systems which work at the interface between criminal justice and health care have been differently developed across the 28 member states of the EU. From this starting point, a number of issues have to be considered, in particular the following questions: –
– – –
–
How can we facilitate communication between European countries about mentally disordered offenders appearing in the courts? How can we facilitate transfer of patients between countries if/when this becomes appropriate? How difficult is it to reconcile any differences between us in practice? How extensive are the special knowledge and skills required to deal with the clinical issues under the different criminal or civil laws? To what extent should there be common ground between clinicians throughout Europe on how to teach and train in the specific knowledge and necessary skills for practitioners in this field?
There have been several attempts to answer these questions. An early idea was to harmonise criminal law and forensic
Forensic psychiatry and the Ghent Group 81
DOI: 10.3109/13651501.2014.967700
practice across the different countries of the EU (Casselman et al. 1992). This proposal was quickly dropped, but was followed by resignation and stagnation. Forensic psychiatry in Europe had little international exchange and few European platforms to further transnational discussions. Within European psychiatric organisations, like the European Psychiatric Association (EPA), forensic psychiatry played only a marginal role. Forensic psychiatrists have taken the initiative to overcome this stagnation and to build networks of professional exchange within the European framework only around 2003 (Gunn and Nedopil 2005). The Ghent Group: Networking in European forensic psychiatry The ‘Ghent Group’ is probably the most important European network for forensic psychiatrists. It focuses mainly on teaching, training and providing specialist education in forensic psychiatry in different countries of Europe, with a focus on EU countries but routinely including Norway and Switzerland. The name ‘Ghent Group’ resulted from its first meeting held at Ghent, Belgium in 2004 (www. ghentgroup.eu). Since then, the group has held yearly meetings in several places including Scandinavia, Germany, Belgium, The Netherlands, the UK and Spain, with Hungary scheduled for 2015 and Italy in the early stages of planning. The aims of the group were not to work towards harmonisation of laws or practices in the field, or even to collaborate in research, but to further understanding of the ways in which our European neighbours deal with medicolegal matters, to create awareness of what is going on in Europe and to explore ways of communicating the differences – and similarities – in practice through teaching and training. The group started with an analysis of the situation of forensic psychiatry in the different countries by exploring, e.g. how many forensic experts were known as specialists for the courts, whether there is a recognised speciality of forensic psychiatry in the different countries and, where so, the degree to which training is structured and ‘official’. Learning from each other: Specialisation in forensic psychiatry Currently, five countries offer accredited training in forensic psychiatry which offers a European certificate of completion of training (CCT) in the specialty – these are Germany, Ireland mostly in association with the UK, Sweden, Switzerland and the United Kingdom. In addition, we have been advised that the EU’s newest member – Croatia – already has a substantive training programme (Turcin and Goreta 1984). In most of the other European countries, universities or other official medical bodies run a diploma course in forensic psychiatry and psychology, e.g. Austria, Belgium, Denmark, Finland, the Netherlands, Norway and Spain. In some countries, there are fears that if forensic psychiatry becomes too specialised it will be separated from general psychiatry. On this basis, the group tried to examine the possibilities of common ground and the reasons why the development of forensic psychiatry went in different directions in the different legal systems. The group very quickly established that
the methods and even the ideas behind the procedures and institutions of forensic psychiatry are so greatly influenced by the historical background of legal systems in the different countries, the beliefs about judicial truth finding and even about the purposes of the criminal law, the traditions of court systems and also of the extent to which the legal system seeks to involve psychiatrists, hence it is sometimes difficult to find common ground. Considering the historical background of some countries, the Ghent Group was aware that psychiatry, and especially forensic psychiatry, has been in danger of being misused for political purposes, and has to fight for its reputation as a healing and caring medical discipline in several countries, some of which are newcomers into the EU [see also chapter 5, (Gunn and Taylor 2014)]. Working through the historical background of participating countries had not only learning benefits with regard to better understanding of our neighbours’ positions but also benefits of avoiding errors and mistaken developments in one’s own country. Examples for learning from experience would include the law reforms of 1998–2011 in Germany, which were regarded as violations of the European Convention of Human Rights by the European Court of Human Rights in 2009 and unconstitutional by the Federal Constitutional Court in 2011, and the Dangerous and Severe Personality Disorder experiment in the UK, which was opposed by many in the profession but ultimately fell because of its cost (Duggan 2011). Definition and ethical guidelines One of the first tasks of the Ghent Group was to agree on a definition of forensic psychiatry. This had to capture – –
–
–
the range of knowledge required; its medical roots and ethics (including but not confined to psychological medicine in all its aspects), relevant law, criminal and civil justice systems, mental health systems, the relationships between mental disorder, antisocial behaviour and offending; the aims and purpose of the work, including the assessment, care and treatment of mentally disordered offenders; and to achieve this, highly qualified specialist with the skills – including risk assessment and management and the prevention of victimisation – is required.
The Group emphasised the medical model as a sound overarching approach, because this provides a transparent and well-tried framework for delivering services within a complex field filled with potential conflict. This model has been adapted in countries which have introduced a specialisation certified by their respective medical associations. Occasional, but regular reminders of the importance of this basic premise arise when forensic psychiatrists have to give expert evidence in the face of explicit arguments about evildoing. A recent example of the bad–mad debate extending to forensic psychiatrists was the Breivik case, in Norway, with evidence from those who chose to focus exclusively on the mental disorder issues being set aside in favour of that from those who considered the case from a wider perspective (Haller 2012).
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The forensic psychiatrist must be equipped to make full allowance for such dilemmas in practice. In addition, s/he is explicitly required, as is any other doctor, to remain up-todate and to work within the limits of his/her competence. In this field, failure to do so may lead to serious miscarriage of justice (examples of this can be seen in several countries, e.g. in the UK: Clark; Aitken et al. 2010) in addition to any adverse clinical effects. The Ghent Group, after a long and sometimes controversial discussion, adopted the position that the general ethical guidelines of medicine would also apply for forensic psychiatry (see also Nedopil 2004) and did not agree with the position of the American Academy of Psychiatry and the Law (AAPL), which adopted special ethical guidelines for the practice of forensic psychiatry in 2005 (http://www.aapl. org/ethics.htm), which suggested that somehow a duty to the Court may override the medial ethic. Some think that the latter approach may be helpful in Europe too (Grounds et al. 2010), but a robust defence of the adequacy of the medical ethic, even when duties include medico-legal reports, has been mounted from both Europe (Gunn 2010, see Grounds et al. 2010) and the USA (Myers 2010, see Grounds et al. 2010). We have found the Ghent Group to not just be a useful forum for exploring together particular medico-legal challenges within the EU, such as the extent to which the professional treating a patient can also be an expert witness to the court in relation to that patient (Taylor et al. 2012), and that this may promote discussion outside Europe too (BarryWalsh and Norris 2013). All but 5 (Bulgaria, Czech Republic, Lithuania, Slovakia and Slovenia) of the then 27 EU countries contributed to the 2012 expert witness paper, the gaps arise because we did not then have good enough contacts with those countries. That has now been remedied. In such discussion, we can more readily recognise where the knowledge base ends, and consensus – or lack of it – takes over. Based on these considerations, the Ghent Group agreed on a definition of forensic psychiatry as ‘a specialty of medicine based on detailed knowledge of relevant legal issues, criminal and civil justice systems, mental health systems and the relationship between mental disorder, antisocial behaviour and offending. Its purpose is the assessment, care and treatment of mentally disordered offenders and others requiring similar services; risk assessment and management and the prevention of further victimization are core elements of this’. Teaching and training The Ghent Group has also considered the interrelationship between treatment and assessment, and the question of how essential it is to understand and possibly treat victims of childhood abuse and/or adult trauma and the potential advantages of incorporating skill development in this area of forensic psychiatric training. Forensic psychiatry, then, holds clinical skills in common with general medicine and psychiatry, and is perhaps distinguished from them in degree rather than nature by the range and depth of other knowledge and skills required. It follows that if some level of forensic psychiatric skill may be needed by all medical practitioners as, for example, all may be called to provide expert evidence in court and all will at some stage have to make judgements at some level about a patient’s risk of harm to others as well as to him/herself, then
Int J Psychiatry Clin Pract 2015;19:80–83
forensic psychiatry training should be a core part of any medical curriculum – at both undergraduate and post-graduate level. The higher specialist skills required would then include running specialist health facilities with different kinds of security that must be used therapeutically, the capacity for long-term treatment of treatment-refractory patients and, for the most serious and persistent offenders, decisions on the timing and conditions for release, taking account of victim needs. These would require a higher level of training. At best, fully trained forensic psychiatrists should be those who are the most committed beyond the more routine to continuing education, to regular peer review and to reflective practice. To take this idea one step further, we reflected on the skills and competencies needed in forensic psychiatry. They include – – – – – –
– –
–
medicine and psychological medicine in all its aspects; organisation of mental health systems; criminology and criminal psychology; methods of offender treatment; legal concepts of competency and responsibility; the legal statutes and the principles outlined in the Conventions of the United Nations and the European Council; organisation of the court system and Code of Conduct in the Court; communication not only within and outside the medical profession, especially with jurists, but also with the press; and interdisciplinary and multiagency work.
If these topics are valid, one has to come to the following conclusions: –
–
–
–
If there are distinct qualities in the skills and competencies of forensic psychiatrists, then there must be distinct training to ensure that those are in place. If there are some tasks for which forensic psychiatrists are uniquely well qualified, then completion of a specialist training ought to lead to specialist recognition. Anyone who delivers treatment services for offender patients would consider the task to be possible only in the context of sound multidisciplinary practice. This, however, is only possible if each contributing discipline recognises and is trained for, although not necessarily confined to, specific roles within the team. Unless the roles are clear, it is difficult to ensure that the training is sufficient for the task. Given the breadth of knowledge and skill required to become a specialist in forensic psychiatry, and the number of other specialties it touches, it may be important from the very earliest stages of career planning – even while people are still in secondary education – to be clear about the career pathway.
A special seminar Our European context has given us special opportunities in that respect. One of the recurrent themes was the practice of teaching and training for the specialisation. Recognising that assessment and treatment of mentally disordered offenders are multidisciplinary tasks, the group set out to explore the
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best possibilities for multi- and inter-disciplinary teaching and learning. The group came to the conclusion that talking about the issues of teaching and training forensic psychiatry only among experienced professionals would not be fruitful, if the trainees and young professionals were not reached and involved too, and decided to develop a training seminar for experienced trainees and consultants in forensic psychiatry. The first seminar was held in 2010 in collaboration with the Kloster Irsee educational programme in a renovated monastery close to the Bavarian Alps and has become a yearly event. Trainers came from five different European countries and included a law professor who provided the theoretical foundation for the legal discussions. The seminar programmes are available online (www.ghentgroup.eu). The format of the seminar is a combination of lectures and small group work, including case work on the topics outlined above. By making constant comparisons between national positions, the participants follow the paths of the offenders from the moment they committed a serious crime, through the criminal justice systems of each country, their committal to the relevant institutions and onto consideration of their release back into the wider community. Participants first worked in groups of six on the case vignettes provided (Nedopil et al. 2012). From this interdisciplinary exchange, the pathways of the convicted person into the criminal justice system and the involvement of the forensic psychiatrist were outlined for each country. Two of these have been enhanced and published (Hillier et al. 2012). These seminars provide a forum not only for hearing how others manage typical cases, but also for recognising how we may have become too comfortable with our more locally shared assumptions and shorthand communications. One’s native language may be used to obfuscate in the native land. A frequent comment at the end of each case was that participants had not only learned about other systems, but also understood their own legal system much better. Being required to explain it to people without any related experience at all, while being used to managing the core offending or psychiatric problems, meant that no one could shelter under the cover of assumptions of knowledge. Also, participants discovered new ways of dealing with perpetrators that are potentially applicable within their national context and how to better understand the interaction between themselves, the perpetrator and the court. As participants got quite involved in the role-playing which was part of their presentations, they learned how to distance themselves from those feelings, prejudices and disappointments that they encounter from all parties involved in criminal proceedings, and how to withstand challenges caused by them. During five days and four nights of teaching and guided discussion, fellow seminarians lead us beyond an understanding of what they do to a better understanding of our own actions and systems. This is indeed forensic psychiatry in action. Key points –
Forensic psychiatry is being practiced differently in different European countries according to the respective national laws.
–
–
–
–
International exchange between the specialists is more difficult than in clinical psychiatry and has almost been neglected for a long time. The Ghent Group has been founded in 2004 as a network of specialists to bridge this information gap and to improve European cooperation in teaching and training forensic psychiatry. Annual meetings of leading forensic psychiatrists (since 2004) as well as a summer school or trainees and young consultants (since 2010) have been organised and proved to be successful. The activities of the Ghent Group have greatly improved the knowledge and understanding of common principles and national differences in forensic psychiatry in European countries and thereby increased the understanding of the respective national particularities.
Acknowledgement None. Statement of interest None of the authors reports conflicts of interest. References Aitken C, Roberts P, Jackson G. 2010. Communicating and interpreting statistical evidence in the administration of criminal justice. I Fundamentals of probability and statistical evidence in criminal proceedings. Royal Statistical Society: London. http://www.rss.org. uk/uploadedfiles/userfiles/files/Aitken-Roberts-Jackson-Practitioner-Guide-1-WEB.pdf. Accessed 80 07 2014. Barry-Walsh J, Norris J. 2013. Separation of the role of treating clinician and expert. Crim Behav Mental Health 23:72–73. Casselman J, Bobon D, Cosyns P, Wilmotte J, Arteel P, Depreeuw W, et al. (Hrsg). 1992. Law and Mental Health. Leuven. Duggan C. 2011. Dangerous and severe personality disorder. Br J Psychiatry 198:431–433. Grounds A, Gunn J, Myers WC, Rosner R, Busch K. 2010. Contemplating common ground in the professional ethics of forensic psychiatry. Crim Behav Mental Health 20:307–322. Gunn J, Nedopil N. 2005. European training in forensic psychiatry. Crim Behav Mental Health 15:207–213. Gunn J, Taylor PJ. (eds). 2014. Forensic psychiatry – Clinical, legal and ethical issues. Oxford: CRC Press (Taylor & Francis). Haller R. 2012. Amok, Massaker, Terror - forensisch psychiatrische Aspekte. In: Yundina E, Stübner S, Hollweg M, Stadtland C editors. Forensische psychiatrie als interdisziplinäre Wissenschaft. Berlin: Medizinisch-Wissenschaftliche Verlagsgesellschaft, pp 89–101. Hillier B, Lambourne C, Larsen TG. 2012. Mapping offender-patient pathways in the different jurisdictions of the European Union. Crim Behav Mental Health 22:293–296. Nedopil N. 2004. The boundaries of courtroom expertise: ethical issues in forensic psychiatry. Dir Psychiatry 24:107–120. Nedopil N, Gunn J, Thomson L. 2012. Teaching forensic psychiatry in Europe. Crim Behav Ment Health 22:238–246. SWANZDSAJCS. 2009. Offenders with mental disorder on five continents: a comparison of approaches to treatment and demographic factors relevant to measurement of outcome. Int J Forensic Ment Health 8:81–96. Taylor PJ, Graf M, Schanda H, Vollm B, et al. (2012) The treating psychiatrist as expert in the courts: is it necessary or possible to separate the roles of physician and expert? Crim Behav Mental Health 22:271–292. Turcin R, Goreta M. 1984. Ausbildung in forensischer Psychiatrie fur Psychiater, Juristen und Spezialisten anderer Fachgebiete. Forensia 5:127–134.iUS
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REVIEW ARTICLE
Forensic psychiatry in Europe: The perspective of the Ghent Group
informahealthcare.com/ijpcp
Norbert Nedopil1, Pamela Taylor2 & John Gunn3 1
Abteilung für forensische Psychiatrie, München, Germany, 2Institute of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, School of Medicine, Cardiff University, Cardiff, UK, and 3Institute of Psychiatry, King’s College London, London, UK
Abstract Objective. The Ghent Group was established in 2004 as a forum for forensic psychiatrists from different countries in Europe in order to bridge the gaps in knowledge, experience, practice and care which exist between them due to their different legal traditions and constitutions in dealing with people having mental disorders who come into conflict with the law. Methods. The Ghent Group considers itself as a loosely organised think tank to which all interested and invited professionals can contribute without statutory restraints. Its aim is to facilitate communication with mentally disordered offenders appearing in court, to understand the procedures of our neighbouring countries and to find common ground between clinicians. Results. The major focus of the Ghent Group is on teaching and training both at a national level, where one can learn about the methods of training from each other, and at a European level. The group of trainees from different countries experiment in seminars in solving medico-legal cases considering European Human Rights issues and their respective national procedures and institutions. Conclusions: This helps not only to understand the differences between the national medico-legal procedures but also to deepen the understanding of the principles and practice in one’s own country. Key words: Forensic psychiatry, Europe, teaching, training, mentally disordered offenders (Received 31 March 2014; accepted 16 September 2014)
Introduction: Forensic psychiatry is practiced differently in each EU country Forensic psychiatry has long been thought to be restricted to national and jurisdictional confines by the legislation of individual countries. While clinical aspects of assessment and treatment are more similar between countries, the ways in which services are provided differ considerably. There are also sufficient differences in mental health law and in the way in which people with a major mental disorder are dealt with in court; hence, it can be difficult to consult across national boundaries with any confidence. International exchange of knowledge and experience by scientists and experts is limited to certain topics; some consider it to be without boundaries such as risk assessment or the management of aggression and sexual deviance, although here we even probably need more information about demographics and social context of offending to make truly valid exchanges (SWANZDSAJCS 2009). On the other hand, people with recognised professional training, including forensic psychiatrists, from the countries of the European Union (EU) are allowed to practice in all member countries and to cross those national confines if they exercise their right to choose a workplace outside their home country. Also, many criminals or forensic psychiatric patients may also move freely within the European
Correspondence: Professor Dr. Norbert Nedopil, Abteilung für forensische Psychiatrie Klinik für Psychiatrie und Psychotherapie der LMU München, Nußbaumstr. 7, D-80336 München, Germany. E-mail: [email protected], www.forensik-muenchen.de
Union, and it is important that they can be assessed and treated by forensic psychiatrists outside their home country. Therefore, it is vital that we have opportunities for training together and understanding each other. Problems and attempts to resolve legal and practical differences between EU countries The systems which work at the interface between criminal justice and health care have been differently developed across the 28 member states of the EU. From this starting point, a number of issues have to be considered, in particular the following questions: –
– – –
–
How can we facilitate communication between European countries about mentally disordered offenders appearing in the courts? How can we facilitate transfer of patients between countries if/when this becomes appropriate? How difficult is it to reconcile any differences between us in practice? How extensive are the special knowledge and skills required to deal with the clinical issues under the different criminal or civil laws? To what extent should there be common ground between clinicians throughout Europe on how to teach and train in the specific knowledge and necessary skills for practitioners in this field?
There have been several attempts to answer these questions. An early idea was to harmonise criminal law and forensic
Forensic psychiatry and the Ghent Group 81
DOI: 10.3109/13651501.2014.967700
practice across the different countries of the EU (Casselman et al. 1992). This proposal was quickly dropped, but was followed by resignation and stagnation. Forensic psychiatry in Europe had little international exchange and few European platforms to further transnational discussions. Within European psychiatric organisations, like the European Psychiatric Association (EPA), forensic psychiatry played only a marginal role. Forensic psychiatrists have taken the initiative to overcome this stagnation and to build networks of professional exchange within the European framework only around 2003 (Gunn and Nedopil 2005). The Ghent Group: Networking in European forensic psychiatry The ‘Ghent Group’ is probably the most important European network for forensic psychiatrists. It focuses mainly on teaching, training and providing specialist education in forensic psychiatry in different countries of Europe, with a focus on EU countries but routinely including Norway and Switzerland. The name ‘Ghent Group’ resulted from its first meeting held at Ghent, Belgium in 2004 (www. ghentgroup.eu). Since then, the group has held yearly meetings in several places including Scandinavia, Germany, Belgium, The Netherlands, the UK and Spain, with Hungary scheduled for 2015 and Italy in the early stages of planning. The aims of the group were not to work towards harmonisation of laws or practices in the field, or even to collaborate in research, but to further understanding of the ways in which our European neighbours deal with medicolegal matters, to create awareness of what is going on in Europe and to explore ways of communicating the differences – and similarities – in practice through teaching and training. The group started with an analysis of the situation of forensic psychiatry in the different countries by exploring, e.g. how many forensic experts were known as specialists for the courts, whether there is a recognised speciality of forensic psychiatry in the different countries and, where so, the degree to which training is structured and ‘official’. Learning from each other: Specialisation in forensic psychiatry Currently, five countries offer accredited training in forensic psychiatry which offers a European certificate of completion of training (CCT) in the specialty – these are Germany, Ireland mostly in association with the UK, Sweden, Switzerland and the United Kingdom. In addition, we have been advised that the EU’s newest member – Croatia – already has a substantive training programme (Turcin and Goreta 1984). In most of the other European countries, universities or other official medical bodies run a diploma course in forensic psychiatry and psychology, e.g. Austria, Belgium, Denmark, Finland, the Netherlands, Norway and Spain. In some countries, there are fears that if forensic psychiatry becomes too specialised it will be separated from general psychiatry. On this basis, the group tried to examine the possibilities of common ground and the reasons why the development of forensic psychiatry went in different directions in the different legal systems. The group very quickly established that
the methods and even the ideas behind the procedures and institutions of forensic psychiatry are so greatly influenced by the historical background of legal systems in the different countries, the beliefs about judicial truth finding and even about the purposes of the criminal law, the traditions of court systems and also of the extent to which the legal system seeks to involve psychiatrists, hence it is sometimes difficult to find common ground. Considering the historical background of some countries, the Ghent Group was aware that psychiatry, and especially forensic psychiatry, has been in danger of being misused for political purposes, and has to fight for its reputation as a healing and caring medical discipline in several countries, some of which are newcomers into the EU [see also chapter 5, (Gunn and Taylor 2014)]. Working through the historical background of participating countries had not only learning benefits with regard to better understanding of our neighbours’ positions but also benefits of avoiding errors and mistaken developments in one’s own country. Examples for learning from experience would include the law reforms of 1998–2011 in Germany, which were regarded as violations of the European Convention of Human Rights by the European Court of Human Rights in 2009 and unconstitutional by the Federal Constitutional Court in 2011, and the Dangerous and Severe Personality Disorder experiment in the UK, which was opposed by many in the profession but ultimately fell because of its cost (Duggan 2011). Definition and ethical guidelines One of the first tasks of the Ghent Group was to agree on a definition of forensic psychiatry. This had to capture – –
–
–
the range of knowledge required; its medical roots and ethics (including but not confined to psychological medicine in all its aspects), relevant law, criminal and civil justice systems, mental health systems, the relationships between mental disorder, antisocial behaviour and offending; the aims and purpose of the work, including the assessment, care and treatment of mentally disordered offenders; and to achieve this, highly qualified specialist with the skills – including risk assessment and management and the prevention of victimisation – is required.
The Group emphasised the medical model as a sound overarching approach, because this provides a transparent and well-tried framework for delivering services within a complex field filled with potential conflict. This model has been adapted in countries which have introduced a specialisation certified by their respective medical associations. Occasional, but regular reminders of the importance of this basic premise arise when forensic psychiatrists have to give expert evidence in the face of explicit arguments about evildoing. A recent example of the bad–mad debate extending to forensic psychiatrists was the Breivik case, in Norway, with evidence from those who chose to focus exclusively on the mental disorder issues being set aside in favour of that from those who considered the case from a wider perspective (Haller 2012).
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The forensic psychiatrist must be equipped to make full allowance for such dilemmas in practice. In addition, s/he is explicitly required, as is any other doctor, to remain up-todate and to work within the limits of his/her competence. In this field, failure to do so may lead to serious miscarriage of justice (examples of this can be seen in several countries, e.g. in the UK: Clark; Aitken et al. 2010) in addition to any adverse clinical effects. The Ghent Group, after a long and sometimes controversial discussion, adopted the position that the general ethical guidelines of medicine would also apply for forensic psychiatry (see also Nedopil 2004) and did not agree with the position of the American Academy of Psychiatry and the Law (AAPL), which adopted special ethical guidelines for the practice of forensic psychiatry in 2005 (http://www.aapl. org/ethics.htm), which suggested that somehow a duty to the Court may override the medial ethic. Some think that the latter approach may be helpful in Europe too (Grounds et al. 2010), but a robust defence of the adequacy of the medical ethic, even when duties include medico-legal reports, has been mounted from both Europe (Gunn 2010, see Grounds et al. 2010) and the USA (Myers 2010, see Grounds et al. 2010). We have found the Ghent Group to not just be a useful forum for exploring together particular medico-legal challenges within the EU, such as the extent to which the professional treating a patient can also be an expert witness to the court in relation to that patient (Taylor et al. 2012), and that this may promote discussion outside Europe too (BarryWalsh and Norris 2013). All but 5 (Bulgaria, Czech Republic, Lithuania, Slovakia and Slovenia) of the then 27 EU countries contributed to the 2012 expert witness paper, the gaps arise because we did not then have good enough contacts with those countries. That has now been remedied. In such discussion, we can more readily recognise where the knowledge base ends, and consensus – or lack of it – takes over. Based on these considerations, the Ghent Group agreed on a definition of forensic psychiatry as ‘a specialty of medicine based on detailed knowledge of relevant legal issues, criminal and civil justice systems, mental health systems and the relationship between mental disorder, antisocial behaviour and offending. Its purpose is the assessment, care and treatment of mentally disordered offenders and others requiring similar services; risk assessment and management and the prevention of further victimization are core elements of this’. Teaching and training The Ghent Group has also considered the interrelationship between treatment and assessment, and the question of how essential it is to understand and possibly treat victims of childhood abuse and/or adult trauma and the potential advantages of incorporating skill development in this area of forensic psychiatric training. Forensic psychiatry, then, holds clinical skills in common with general medicine and psychiatry, and is perhaps distinguished from them in degree rather than nature by the range and depth of other knowledge and skills required. It follows that if some level of forensic psychiatric skill may be needed by all medical practitioners as, for example, all may be called to provide expert evidence in court and all will at some stage have to make judgements at some level about a patient’s risk of harm to others as well as to him/herself, then
Int J Psychiatry Clin Pract 2015;19:80–83
forensic psychiatry training should be a core part of any medical curriculum – at both undergraduate and post-graduate level. The higher specialist skills required would then include running specialist health facilities with different kinds of security that must be used therapeutically, the capacity for long-term treatment of treatment-refractory patients and, for the most serious and persistent offenders, decisions on the timing and conditions for release, taking account of victim needs. These would require a higher level of training. At best, fully trained forensic psychiatrists should be those who are the most committed beyond the more routine to continuing education, to regular peer review and to reflective practice. To take this idea one step further, we reflected on the skills and competencies needed in forensic psychiatry. They include – – – – – –
– –
–
medicine and psychological medicine in all its aspects; organisation of mental health systems; criminology and criminal psychology; methods of offender treatment; legal concepts of competency and responsibility; the legal statutes and the principles outlined in the Conventions of the United Nations and the European Council; organisation of the court system and Code of Conduct in the Court; communication not only within and outside the medical profession, especially with jurists, but also with the press; and interdisciplinary and multiagency work.
If these topics are valid, one has to come to the following conclusions: –
–
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If there are distinct qualities in the skills and competencies of forensic psychiatrists, then there must be distinct training to ensure that those are in place. If there are some tasks for which forensic psychiatrists are uniquely well qualified, then completion of a specialist training ought to lead to specialist recognition. Anyone who delivers treatment services for offender patients would consider the task to be possible only in the context of sound multidisciplinary practice. This, however, is only possible if each contributing discipline recognises and is trained for, although not necessarily confined to, specific roles within the team. Unless the roles are clear, it is difficult to ensure that the training is sufficient for the task. Given the breadth of knowledge and skill required to become a specialist in forensic psychiatry, and the number of other specialties it touches, it may be important from the very earliest stages of career planning – even while people are still in secondary education – to be clear about the career pathway.
A special seminar Our European context has given us special opportunities in that respect. One of the recurrent themes was the practice of teaching and training for the specialisation. Recognising that assessment and treatment of mentally disordered offenders are multidisciplinary tasks, the group set out to explore the
Forensic psychiatry and the Ghent Group 83
DOI: 10.3109/13651501.2014.967700
best possibilities for multi- and inter-disciplinary teaching and learning. The group came to the conclusion that talking about the issues of teaching and training forensic psychiatry only among experienced professionals would not be fruitful, if the trainees and young professionals were not reached and involved too, and decided to develop a training seminar for experienced trainees and consultants in forensic psychiatry. The first seminar was held in 2010 in collaboration with the Kloster Irsee educational programme in a renovated monastery close to the Bavarian Alps and has become a yearly event. Trainers came from five different European countries and included a law professor who provided the theoretical foundation for the legal discussions. The seminar programmes are available online (www.ghentgroup.eu). The format of the seminar is a combination of lectures and small group work, including case work on the topics outlined above. By making constant comparisons between national positions, the participants follow the paths of the offenders from the moment they committed a serious crime, through the criminal justice systems of each country, their committal to the relevant institutions and onto consideration of their release back into the wider community. Participants first worked in groups of six on the case vignettes provided (Nedopil et al. 2012). From this interdisciplinary exchange, the pathways of the convicted person into the criminal justice system and the involvement of the forensic psychiatrist were outlined for each country. Two of these have been enhanced and published (Hillier et al. 2012). These seminars provide a forum not only for hearing how others manage typical cases, but also for recognising how we may have become too comfortable with our more locally shared assumptions and shorthand communications. One’s native language may be used to obfuscate in the native land. A frequent comment at the end of each case was that participants had not only learned about other systems, but also understood their own legal system much better. Being required to explain it to people without any related experience at all, while being used to managing the core offending or psychiatric problems, meant that no one could shelter under the cover of assumptions of knowledge. Also, participants discovered new ways of dealing with perpetrators that are potentially applicable within their national context and how to better understand the interaction between themselves, the perpetrator and the court. As participants got quite involved in the role-playing which was part of their presentations, they learned how to distance themselves from those feelings, prejudices and disappointments that they encounter from all parties involved in criminal proceedings, and how to withstand challenges caused by them. During five days and four nights of teaching and guided discussion, fellow seminarians lead us beyond an understanding of what they do to a better understanding of our own actions and systems. This is indeed forensic psychiatry in action. Key points –
Forensic psychiatry is being practiced differently in different European countries according to the respective national laws.
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International exchange between the specialists is more difficult than in clinical psychiatry and has almost been neglected for a long time. The Ghent Group has been founded in 2004 as a network of specialists to bridge this information gap and to improve European cooperation in teaching and training forensic psychiatry. Annual meetings of leading forensic psychiatrists (since 2004) as well as a summer school or trainees and young consultants (since 2010) have been organised and proved to be successful. The activities of the Ghent Group have greatly improved the knowledge and understanding of common principles and national differences in forensic psychiatry in European countries and thereby increased the understanding of the respective national particularities.
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