International Review of Psychiatry, October 2014; 26(5): 607–614

Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK

ALI AJAZ1,2, JOHN OWITI2 & KAMALDEEP BHUI2 1Department of Forensic Psychiatry, East London NHS Foundation Trust, London, and 2Centre for Psychiatry, Queen Mary College, University of London, UK

Abstract Healthcare inequalities for black and minority ethnic (BME) patients in forensic mental health services in the UK are stark. Despite the level of attention given to this over the last 15 years there has been little progress to address disparities. There is a great deal of confusion over what is understood by culture, and what aspects of culture signal specific needs of BME patients. In addition, we have a lack of empirical research demonstrating what it means for psychiatrists to be culturally competent. These are all important barriers against progress in this area. Using a homicide case study that illustrates the typical issues encountered in practice, we explore how to use a cultural formulation in order to assess the role of culture within a forensic psychiatry setting. Finally, practical advice is offered to assist expert witnesses in preparing court reports that adequately consider the significance of defendants’ cultural beliefs and practices.

Introduction The ethical underpinnings of medicine differ from those of law. The fundamental purpose of law is to deliver justice, whereas medicine is primarily concerned with human health and welfare. Despite this tension there is an important and necessary relationship between psychiatric and legal practice. An example of this is contained in the UK Homicide Act 1957, which first introduced ‘diminished responsibility’ as a new and specific defence for murder. This permitted the law to consider abnormal mental states (which fell below the high threshold required for an insanity defence) as mitigation in homicide cases and thus resulting in a lesser conviction of manslaughter. A recent revision to the law through Section 52 of the Coroners and Justice Act 2009 made significant changes to this defence (Ormerod, 2011), primarily to provide clarity for psychiatric assessments (see Table 1). It is this relationship between psychiatry and the law that is at the heart of forensic psychiatry. Homicide is the act of taking the life of another human being, an execrable act which is universally condemned. In the field of forensic psychiatry it is arguably the most serious offence for which a psychiatrist is required as an expert witness. The law related to homicide takes into consideration the suspect’s mental state at the material time and crucially whether mens rea, the intention to harm and commit

the act of homicide, was influenced by this in any way. In England and Wales it is estimated that 10% of convicted homicide perpetrators have symptoms of mental illness at the time of homicide, with most having no active contact with mental health services (Oram et al., 2013). The role of the psychiatrist (as an expert witness) is to present any relevant mental health issues concerning the accused to be taken into consideration as part of the due legal process. According to the National Confidential Inquiry into Suicide and Homicide annual report (2012), between 1999 and 2009 there were a total of 6,332 homicide convictions in the UK. A psychiatric assessment was conducted in 38% of these cases for either defendants with a known history of mental health problems or for those whose behaviour or beliefs had caused sufficient concerns to warrant a psychiatric opinion. This figure is likely to be much higher as there will be a number of completed psychiatric reports that legal counsels declined to submit to the courts. The interplay between psychiatry and the law is already complex. Explaining how mental states can influence offending behaviour in terms that are understood by judges, juries, and legal teams is challenging. There is already considerable guidance for expert witnesses and forensic psychiatrists regarding this. However, a further influence that is now receiv-

Correspondence: Ali Ajaz, MBBS, BSc, MRCPsych, Centre for Psychiatry, Old Anatomy Building, Charterhouse Square, EC1M 6BQ, London, UK. E-mail: [email protected] (Received 4 August 2014 ; accepted 12 August 2014 ) ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry DOI: 10.3109/09540261.2014.955085

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Table 1. Legal criteria for diminished responsibility (Omerod, 2011; pp. 529).

mination of the level of culpability and therefore serve as a more fitting guide to appropriate sentencing.

1. 2. 3.

Culture, ethnicity and pathways to care

4.

An ‘abnormality of mental functioning’ Arising ‘from a recognized medical condition’ The defendant’s ‘mental responsibility’ must be substantially impaired, meaning the inability to: i. understand the nature of their conduct ii. form a rational judgement iii. exercise self-control The abnormality of mental functioning must be a cause or contributory cause in the killing

ing more attention is the role of culture in the psychiatric assessment (Fabrega Jr, 2004; Tseng & Streltzer, 2006). Culture affects both individual and organizational level practices between the legal and health systems. How then can specialist psychiatrists (and all expert witnesses) produce informed court reports, which formulate how cultural beliefs and practices may help understand and possibly explain offending behaviour and vulnerability to mental distress and mental disorders? The role of cultural defences (asking the courts to consider the cultural imperatives motivating people to commit acts that transgress the law) is an area of contention and debate in many countries (Van Broeck, 2001). There are some legal systems which are more inclined to embrace cultural pluralism, and consider cultural defences; for example, South Africa (Carstens, 2010). Given the burgeoning evidence regarding the complex and significant relationship between culture and mental illness (e.g. Tseng & Streltzer, 2006) and culture and offending behaviour (Boehnlein et al., 2005; Hicks, 2004; Silva et al., 2000; Tseng et al., 2004), legal systems should be more cognizant of avoiding injustice in outcomes due to a neglect of culture. Regarding homicide, Fabrega Jr. (2004) asserts that to consider culture and what it entails is not only necessary for the proper adjudication of homicide, but also to understand homicide as a meaningful social act, within a cultural context. It is somehow assumed that the psychiatrist has developed an informed perspective about social life and behaviour, and increasingly about culture, as well as the causes and treatment of mental disorders (Kirmayer et al., 2007). The inclusion of a cultural perspective helps to contextualize actions and experiences and should therefore be considered in forensic psychiatric assessments and court reports. Cultural beliefs and background influence an individual’s capacity to form intent, as well use cultural and social resources to contain risk behaviours. Accounting for culture in psychiatric assessments can add essential depth about pre-offending personality, achievements, child development and educational experiences, and the likelihood of offending being due to mental illness. Ultimately this approach will lead to a better deter-

Although culture is often identified as an area of importance in the healthcare for black and minority ethnic (BME) people, culture is a poorly understood concept and often mistakenly used synonymously with the terms race and ethnicity. This can misleadingly imply that culture refers exclusively to something relating only to people from more exotic parts of the world and not to all people in all societies. A useful definition is offered by Helman (2007), who described culture as a set of explicit and implicit laws that are inherited by members of a particular society. These provide the individual with a particular view of the world, telling them how to experience it emotionally and how to behave in relation to other people, to supernatural forces and to the natural environment. Different cultures have unique systems for classifying illness based on perceived symptoms. These are some of the reasons why an evaluation of culture in the psychiatric assessment process is so fundamental, especially considering the reliance of psychiatric practice on phenomenology, and the fact that culture shapes what people think and how they believe, and influences the emergence of and expression of mental distress (Tseng & Streltzer, 2008). In the UK, mental health patients from BME backgrounds continue to have more admissions via the criminal justice system, are over-represented in secure and forensic services, and are disproportionately admitted more frequently under the Mental Health Act (Sewell, 2008). The 2010 ‘Count me in’ national census of psychiatric inpatients in England and Wales (Care Quality Commission, 2010) showed that both admission and detention rates under the Mental Health Act for BME groups (especially for black and white/black mixed groups) were higher than average. This trend is magnified if detention rates under the criminal sections of the Mental Health Act are considered. Among men detained under Section 37/41, the rate of detention for the white British group was 16% lower than average, and it was higher than average in the white/black Caribbean mixed group by 77%, the black Caribbean group by 100%, the black African group by 27% and the ‘other black‘ group by 52%. Regarding those transferred from prison to a psychiatric hospital for treatment, there was a 107% higher than average detention rate among men from the white/black African mixed group. For admission via the criminal justice system, white/Asian mixed prisoners were 86% higher than average, black groups ranged from 36% to 56%

Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK higher, and for white/black Caribbean this figure was 33% higher. Over the last six years this health inequality has persisted, with no discernible improvement. These disparities might be explained as simply reflecting illness and risks of violence, but an alternative analysis is that they arise due to unfair assessment and pathways through criminal justice agencies; thus, unfair processes have been demonstrated at police encounter, recall about offenders, processing and disposal by courts, remand and sentencing decisions, and then in diversion schemes for returning people to health rather than criminal justice agencies (Banerjee et al., 1995; Coid et al., 2002; Independent Commission on Mental Health and Policing, 2013). The latest data from the Statistics on Race and the Criminal Justice report (Ministry of Justice, 2013) show that in the majority of homicide cases in the UK, although victims are more likely to be killed by someone from the same ethnic group; there is a disparity between the proportion of homicides perpetrated by BME groups. The average annual rate for black people is three times greater than the white group and one and a half times greater for Asians. Over the last ten years in the UK, there have been a number of significant publications (e.g. Department of Health, 2005; Norfolk, Suffolk and Cambridgeshire SHA, 2003) that have emphasized the importance of training in cultural competency for mental health professionals as a way of removing or reducing health disparities. However, although most service providers and practitioners would now not consider cultural needs of patients as an optional extra, there is little evidence-based information about what it means to do so effectively (Sewell, 2008). For the most part, there has remained a dearth of research regarding which type of cultural training is successful (Brach & Fraser, 2000), and there has been a further failure to assess the impact of such cultural competence training on patient outcomes and staff skills (Dogra et al., 2010; Vega, 2005). In contrast, during this same period, interest by researchers on the importance and role of culture in the criminal justice system has been gaining momentum (Del Valle Bustos, 2013; Renteln, 2004). There is an ongoing debate where the proponents of a cultural defence argue that it is intrinsically unjust to judge someone by the values of a society to which they are alien. Opponents to this are concerned that this may compromise the integrity of long-established legal systems. Kirmayer et al. (2007) argue that this dilemma is embodied in the field of forensic psychiatry, where cultural, ethnic and race disparities are the subject of fierce controversy. Unfortunately, this level of interest has not materialized into empirical research evaluating the integration of cultural evaluations into forensic psychiatric practice.

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Instead, much of the available research has highlighted the inadequate nature of secure facilities to meet the needs of mentally disordered offenders from BME groups and the fault lines in the assessment process leading to an over-prediction of dangerousness in black people (Fernando et al., 1998; Hicks, 2004). Sadly, these publications often omit practical recommendations for improving the forensic psychiatric assessment and practice. It is also disappointing that reputable texts in forensic psychiatry (Gunn & Taylor, 2014) often fail to acknowledge the significance of a cultural formulation (CF) in addressing the obvious health inequalities in forensic psychiatry. Instead, references to culture are inexplicably restricted to a discussion of rare (and controversial) culture-bound syndromes. To compound the matter further, important publications from the Royal College of Psychiatrists also fail to acknowledge the value of cultural considerations in psychiatric assessments for legal cases (Rix, 2008a, 2008b; Royal College of Psychiatrists, 2008). This is in contrast to the criminal justice system, for example, in the Practice Direction (Ministry of Justice, 2011) for medical experts in the family courts, which reminds psychiatrists that it is the duty of experts to consider all relevant factors arising from ethnic, cultural, religious or linguistic contexts in their assessment reports.

Cultural consultation and formulation The authors of this paper are members of a cultural consultation service (CCS) based in East London. Established in 2010, it was designed and commissioned to improve the delivery of culturally capable mental healthcare by mainstream services catering for a culturally diverse urban population of innerLondon boroughs. In our experience with the CCS, care provided by community mental health services was less personalized and less accommodating of cultural issues, and frontline healthcare professionals were unable to see or consider cultural influences in assessment, care planning and recovery (Ascoli et al., 2012; Owiti et al., 2013). In addition, we found that the teams’ ‘culture of care’ and the culture of healthcare settings were both an impediment to any meaningful change. In fact, the main reasons for referral to the service were for an exploration of patients’ experience of racism and discrimination and an evaluation of the possible impact of this on their current clinical presentation and level of engagement, and also their propensity for violence and involvement in the criminal justice system. Through the CCS model we demonstrated how the incorporation of a CF can enhance the psychiatric assessment process (and subsequent clinical treatment) for BME

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patients suffering from severe psychiatric illness and also those who may encounter forensic psychiatry. Our outcomes also provided some evidence that the CCS model might be an effective method of training clinicians in cultural competence (Owiti et al., 2013). As part of the wider remit of the service, we provided court reports as expert witnesses, and so developed guidance on preparing psychiatric court reports for homicide cases; specifically, we considered ways of incorporating a CF. See Box 1 for a case study example. Our CF in relation to the case study was based upon the ‘Outline for cultural formulation’ in DSM-IV which covered four categories: cultural identity, cultural explanations of illness, cultural factors in the psychosocial environment, and functioning and cultural elements in the relationship between individual and clinician. The questions built a patient-centred narrative, which incorporated language capabilities, ethnic reference group, acculturation process, illness meanings, expectations towards treatment, partners, family, religion and social support, and attitude towards treatment. Case history In the instructions from Mr E’s legal team, we were requested to evaluate whether his belief in spirits and the unusual experiences he reported around the time of the offence might be explained on the basis of cultural and religious beliefs, more precisely in the formation of intent; and we were asked to consider whether these beliefs might be expressions of mental disorder. Given there is no precedent for a cultural

defence in the UK, this had not been considered, although this might be considered relevant in mitigation of the offence, if it was committed in response to symptoms such as hallucinations or delusions. Completing a forensic assessment was necessary in any case; however, the challenge of how to introduce a cultural assessment and explain it to the court as part of an expert witness statement was not a wellestablished process. We relied on a structured CF as a tool in the assessment process; this proved to be invaluable as it set out the criteria in concrete terms under which Mr E was assessed, including identity, causal explanations and explanatory models, psychosocial factors, relationship with the assessor, and an overall conclusion. Each of these required eliciting information, understanding the context and the construction of symptoms and beliefs, forming a judgement about cultural congruence or roots, the level of influence (all, nothing or partial), and at which stages of the offence culture might have influenced behaviour. The CF afforded a platform to generate a more precise understanding of Mr E’s world view, which in turn allowed us to evaluate whether culture influenced his behaviour and explained his abnormal experiences. An important aspect of the assessment involved liaising with Mr E’s friend of 16 years (who was also from Ghana), the pastor of his church, and an expert in West African culture. They were able to explain aspects of cultural beliefs and practices that might be considered normative, and where this was considered inappropriate and might be illness related. This information also enabled a judgement about pre-morbid personality, educational experiences, and patterns of responding to adversity and distress.

Box 1. Case study. Mr E is a middle-aged African man who was charged with murdering his partner of 3 years by stabbing her with a knife over 40 times in their home following an argument. He was born in Ghana and one of seven children and he experienced a materially poor upbringing. His parents subjected him to physical and psychological abuse (e.g. often being told that he was possessed by the devil when he misbehaved) throughout his early years. Having dropped out of school to work on the family farm aged 11 he was subjected to 3 years of sexual abuse by two men from his local community. Mr E followed his parents’ footsteps by becoming increasingly active in the church and eventually became a deacon. This role included performing exorcisms on a regular basis. In his mid 20s he moved to the UK shortly after marrying. His wife was diagnosed with a chronic autoimmune illness and her health deteriorated significantly over the following decade. All of his attempts through the church to find a cure for his wife failed and he became disenchanted with his faith. He then embarked on a number of extra-marital relationships. After the death of his wife, Mr E moved in with his girlfriend (the victim). He was viewed externally by some as being very controlling and physically abusive towards his partner who was many years his junior although he maintained that he was a very devout partner. A number of weeks before the killing Mr E had become increasingly concerned that his girlfriend was spending too much time attending parties and possibly seeing another man. On the morning of her death the victim returned from a party from the previous evening and at that time Mr E described experiencing foul smells which he attributed to her ‘ungodly’ behaviour. He then believed that she had caused evil spirits to enter their home and attack him at that time. Although he had no previous psychiatric history Mr E reported hearing voices commanding him to kill her, despite having no recollection of events after this point until 3 days later. He denied any volitional part in the killing. The only explanation he could suggest was that he blamed the evil spirits who possessed him of carrying out the act. Prior to our assessment Mr E had previously been assessed by three forensic psychiatrists. The two psychiatrists for the prosecution had omitted any reference to culture or religious beliefs in their reports. The psychiatrist for the defence did acknowledge them and recommended a specialist assessment as he did not have the expertise to conduct a cultural formulation.

Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK Our overall opinion in this case was that the defendant did not suffer from a psychotic disorder and was likely to have experienced a dissociative disorder around the material time. His cultural beliefs in spirits were thought to have been used to make sense of the events for himself. So although culture did not have a primary place in the diagnosis that might be seen as mitigating his offence to manslaughter, given the nature of the defendant’s background it was an important exclusion to make. Explaining a psychotic disorder or psychotic symptoms as part of a personality disorder (non-psychotic) or symptoms of dissociation that might seem like psychotic symptoms is not clinically straightforward. Then to explain these to legal experts and place a cultural lens on each of these possibilities required our CCS team to deliberate on each and every possibility, and place all current offence-related and historical information in an overall narrative that explained more of the material facts and assessment findings than other explanations. Strikingly, two forensic psychiatric reports prepared on behalf of the Crown Prosecution Service, did not offer any consideration to the role of culture in Mr E’s case. This again might refer to a lack of adequate training and therefore confidence that forensic psychiatrists have to use CFs in their assessments. Culture can be used to explain intent, or influence symptom presentation such that a psychotic disorder could be explained away as ‘cultural’, and similarly a cultural presentation might be seen as ‘psychotic’.

Practice guidelines Based upon our experiences within the cultural consultation service and work in forensic psychiatry, we propose some practical guidelines for forensic psychiatrists in evaluating the impact of culture in homicide and other criminal cases. 1. General approach to preparing court reports as an expert witness (from Eastman et al., 2012) The primary objective of a court report is to prepare a legal document with a psychiatric opinion regarding the presence of any mental disorder (current or past), the legal implications of this, and recommendations regarding further investigation and transfer to hospital, if appropriate. It is of paramount importance that the psychiatrist understands that his/her role is to assist the court and not the instructing legal party. Legal professionals within the criminal justice system have a variable (often limited) understanding of mental disorder (and also culture), and therefore it requires advanced psychiatric skills to be able to present psychiatric evidence within legal proceedings

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in a manner which is best suited to assist the court. Simply arriving at a diagnosis is insufficient; the psychiatrist should be able to present a diagnosis in relation to the relevant legal questions. There is no inherent difference in a psychiatric report for court proceedings and that for regular clinical practice; however, the content and format is likely to differ somewhat. In order for the court to evaluate the basis (reliability and validity) of the expert opinion, all information considered in the preparation of the report should be referenced by source. The report should follow a logical structure, with numbered paragraphs and pages, and the reasoning for the opinion should be presented coherently. Such an approach also serves to assist the expert in the event of being required to provide oral evidence based on the report and potentially to be subject to cross examination. 2. Framework for assessment of culture The DSM-5 has recently released the ‘cultural interview’ (CI) (American Psychiatric Association, 2013) (an updated version of the ‘Outline for cultural formulation’ from DSM-IV), which is designed to be used for psychiatric assessments in any clinical setting. Although the CF has been criticized for lacking conceptual relevance between intervention and problem, as well as for ignoring the severity of illness (Aggarwal et al., 2013), the DSM should be commended at the very least for attempting to consider the issue of culture. The CI offers some prompts, but otherwise the process of assessment in CF and CI are similar. Field trials took place in many cultural contexts, and these are currently being prepared for future dissemination. However, in this paper we present our use of CF. The CF offered ethnographic methods of eliciting patient-centred explanatory models. It is also considered as a benchmark for education and the evaluation of cultural competence in psychiatry (Aggarwal, 2012). There have been some attempts to adapt the CF into the psychiatric interview as a method of incorporating the influence of culture on clinical presentation into the assessment process. An example of this is from the work of the CCS at McGill University in Canada (Kirmayer et al., 2003) who suggested exploring a number of cultural domains within a traditional psychiatric interview. These included cultural identity, cultural explanations of the illness, cultural factors related to psychosocial environment and levels of functioning, and cultural elements of the clinician–patient relationship at assessment. Aggarwal (2012) has attempted to adapt a similar CF but specifically for forensic psychiatry, and this is summarized in Table 2. We approve this demonstration of how a CF, as part of a psychiatric assessment,

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Table 2. Adaptation of the cultural formulation for use in forensic psychiatry. Example questions Aspect of CF

Cultural focus

Forensic focus

Cultural identity ‘Where are you and your family from?’ ‘Are there cultural differences between you and your parents?’ ‘Do you feel a strong connection to any groups of people?’

For immigrants and refugees acculturation can be assessed by asking: ‘What foods do you eat?’ ‘What television channels, radio stations, books, magazines, or Internet sites do you like?’ ‘What values of your culture do you share or reject?’ ‘How close do you feel to your community?’ Evaluating understanding of legal process and terms: ‘What language would you like to speak with me?’ ‘Do you understand the legal terms and charges against you?’ ‘Are there similar terms for them in your culture?’

Cultural explanations of illness ‘Do you or anyone else have a name for the problem you are experiencing now?’ ‘Why do you think it is happening to you?’ ‘What will make it better or worse?’ ‘When did it start and when do you think it will get better?’ Note: A family history may elicit household experiences of illness and treatment, and whether these resemble the evaluee’s presentation and understanding of illness Cultural factors relevant to psychosocial environment and functioning ‘Who lives at home with you?’ ‘Can they help with this problem?’ ‘Who else can help you?’ ‘Is anything going on to make this problem better or worse?’ ‘How has this problem affected your life?’ ‘Is it preventing you from working? From moving, grooming, feeding, or sleeping?’ ‘Do people close to you understand how you feel?’ Cultural elements of patient–physician relationship ‘Do your friends and family talk with doctors about problems like the one you have?’ ‘Do you think your friends or family would be upset if you spoke to physicians about your problems?’ ‘Do you have any wishes for or concerns about treatment?’ ‘What are your thoughts about medications or psychotherapy?’

Can analogously harness an insight of client’s views on the legal system and discover any cultural influences on distinguishing between right and wrong and any motivations for punishable acts. ‘Do you know anyone else who faced similar problems or situations?’ ‘How did they handle the problem?’ ‘How are such situations handled where you come from?

Provide an opportunity to reflect on own cultural identity as a professional. To be aware of unconscious and conscious ethnic, racial and cultural biases by asking whether you have considered potential biases in the diagnosis of the evaluee, whether the psychological or risk assessment tests have been validated for the evaluee’s ethnic or linguistic group, whether potential biases in assessing dangerousness have been considered

CF, cultural formulation.

can have explicit and distinct relevance to forensic psychiatry. This is a much needed approach that needs to be developed further, especially considering the alarming health inequalities for BME patients that continue to exist in forensic mental health services. However, although Aggarwal has helpfully included some example questions for the four cultural domains, it would still be quite difficult for a psychiatrist naïve to the cultural issue to interpret the answers in isolation. The updated version of the

CF in DSM-V provides a more practical framework for approaching the four cultural domains. 3. Collateral sources of information Obtaining a collateral history is already an important part of the psychiatric assessment process. It takes on an even greater importance in the cultural assessment, especially if the psychiatrist does not already possess a competent understanding of the culture in

Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK question. A key part of the cultural investigation is to be able to place the subjective experiences of the defendant in a social context, and this can be achieved with greater confidence the more sources of background information that can be accessed. It is likely that this could involve communicating with friends or relatives of the defendant, with or without an interpreter. The importance of this should be highlighted to the instructing legal team from the outset (to give them the maximum time to arrange for this), and this is paramount when there is a short time frame for submitting a report.

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• The pace at which legal processes progress • The timeframe in which assessments are requested • The concerns about misleading biographies and accounts of the offence, which can only be reconstructed by experts who were not at the scene of the offence • The skills required to present evidence in court and communicate in lay terms the nuanced dissection of culture, crime, personality and psychopathology

Conclusion 4. Training in cultural competence More recently, different approaches have been tried for teaching cultural competency (e.g. Chakraborty et al., 2009), and in our experience we found that the cultural consultation model (using an ethnographic methodology) could be effective in developing the cultural competency skills of clinicians (Owiti et al., 2013). There should be no scepticism regarding the need for all psychiatrists to broaden their understanding of alternative perspectives of health, illness behaviour and treatment. Forensic psychiatrists should consider prioritizing their continued professional development (CPD) to include training in cultural competence. This could include skills in court reports (in general), training including cultural factors in legal report writing and courtroom skills and learning how to explain to jurors what the role of culture is through using straightforward language. There are different types of training that can help with this, ranging from formal postgraduate courses such as a PhD or master’s degree (for example, in transcultural mental health or medical anthropology) to shorter online CPD modules and courses. It is important that these educational endeavours should ultimately inform changes in clinical practices including skills to assess patients’ explanatory models of illness and cultural identity, and develop a better understanding of the impact of psychosocial environments on illness presentation and recovery.

5. Limitations It must be acknowledged that the practicalities of practising in forensic psychiatry may provide specific barriers to implementing these recommendations. For example, the strict time restrictions imposed for forensic assessments in prison may make it difficult to complete a CF interview in addition to the regular psychiatric history in one assessment visit alone. Other elements of the criminal justice system that are important to consider here include:

There is a need in forensic psychiatry to better understand the influence of culture regarding illness behaviour and serious acts of crime. With individuals from BME groups significantly over-represented in both secure mental health services and the criminal justice system, it is incumbent upon the community of forensic psychiatrists to work to address these inequalities within their discipline. However, a major stumbling block for most is their inability to competently evaluate the role of differing cultural beliefs (from that of the dominant culture in society), especially when faced with diverse spiritual belief systems that outwardly appear to clash with pre-existing notions of ‘science’. The CF is a valuable tool, which can be used as part of a more culturally sensitive approach to aid the psychiatric assessment process and in the preparation of court reports by forensic psychiatrists. This more culturally aware mode of practising will continue to take on greater importance for forensic psychiatrists, not least due to their responsibilities in tackling the current health inequalities as well as to changing trends of how the criminal justice system employs forensic psychiatrists as experts, for example the growing number of cases of terrorism and radicalization in the UK that require a psychiatric assessment. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK.

Healthcare inequalities for black and minority ethnic (BME) patients in forensic mental health services in the UK are stark. Despite the level of atte...
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