Forensic Psychiatry

This book is the third in the new Oxford Specialist Handbooks in Psychiatry series; earlier volumes covered child and adolescent and geriatric psychiatry. Handbook is something of a misnomer for the volume that Eastman et al. have written. The print is small and the paper thin, meaning that, although the result is small enough to fit in a pocket, its 691 pages contain more material than most texts. One consequence of Oxford's handbook style is that there are no references, but the text has an authoritative tone that means that, in most instances, the reader does not thereby lose confidence in what is being said.

For readers of the Journal, the book will provide a window into the different ways in which forensic psychiatry is defined by its practitioners on the two sides of the Atlantic. Compare, for instance, Howard Zonana's U.S. definition, “the use of psychiatric expertise to help resolve legal questions,” (see http://lawandpsychiatry.yale.edu/index.aspx) with the division of forensic psychiatry by Eastman et al. into “clinical forensic psychiatry” and “legal psychiatry” (p 7). Clinical forensic psychiatry they define as, “The assessment and treatment of mental disorder where that disorder appears to be associated (not necessarily causally) with offending behavior” (p 7). Legal psychiatry is defined as, “All law relating to mental disorder, and to the treatment and care of those suffering from mental disorder” (p 7).

This attempt to address the problems of defining one subspecialty of psychiatry by creating two sub-subspecialties has to be seen in context. The differences in the historical relationship between law and psychiatry in different countries has made it difficult to arrive at a definition that applies across national boundaries. Even legal psychiatry, as defined by Eastman et al., has a more clinical flavor than do most North American definitions. The authors detect a change in recent years in the attitude of U.K. psychiatrists toward the legislation that regulates some of what they do and that affects so many of their patients. They note that the law was once widely regarded by mental health practitioners as, “an irritating intrusion into the proper exercise of medical paternalism” (p vi).

Of course, the differences between U.K. and U.S. forensic psychiatry are not restricted to the definitions that their practitioners develop to describe what they do. Some U.S. forensic psychiatrists will feel misunderstood by certain of the book's assertions, including one that U.S. forensic psychiatrists see their sole obligation as to the court, rather than to the person being evaluated. The authors state also that this obligation derives from the duty of all citizens to assist in the administration of justice (p 225).

In fact, as the Ethical Guidelines of the American Academy of Psychiatry and the Law, helpfully included by Eastman et al. in an Appendix, make clear, a U.S.-based forensic psychiatrist has numerous duties to the person being evaluated. Examples include explaining to the person the purpose of the evaluation and, to the extent that this is consistent with reporting the results of the evaluation to the person who asked for it, maintaining the confidentiality of what is said. Those duties are usually held to derive, not from any general duty of citizens to assist justice, but from a much more concrete one, to respect the person in front of them. Nor in 11 years in the United States did I meet a “forensicist,” a species that Forensic Psychiatry tells me is endemic. It is time to put this neologism to rest. The term was coined, I suspect to his lasting regret, by Paul Appelbaum in an analysis of the ethics of forensic evaluation (Ref. 1, p 252). That analysis has spawned several valuable theoretical developments but, as yet at least, no new species. The principle use of the term now seems to be as a stick with which to beat people with whom one disagrees.

The Oxford University Press style for the Handbook series, of which this book is a part, includes the extensive use of lists set apart by bullet points. Some complicated topics turn out to be amenable to this approach. I particularly appreciated the clarity of the descriptions of the differences between community forensic services and assertive outreach and of the book's treatment of confidentiality. One consequence of writing without references is that some interesting assertions cannot be checked easily. The authors assert, for instance, that schizophrenia alone increases the odds of violence as much as cigarette smoking increases the odds of lung cancer. Since smokers who have smoked without quitting successfully have an approximate 20-fold increase in lung cancer risk,² this statistic implies a rate of violence in schizophrenia that is much higher than that reported by birth cohort studies.^3,4 The assertion is also inconsistent with meta-analyses, one of which found odds ratios for violence in schizophrenia compared with the general population to lie between 2 and 4, depending on which statistical model was used to pool the data from the studies.⁵ Of course, the situation is often complicated by substance use and substance use varies, like much else in forensic psychiatry, across treatment settings and jurisdictions. I would have liked to know where to find out more.

The index is good and the Table of Contents comprehensive. Because the book is authored, not edited, it has a coherence of outlook and a consistency of style that is often lacking in books of this scope. The restricted number of people writing the text has not adversely affected its quality. Whatever the size of your pocket, the book deserves a place on your shelf.

• © 2014 American Academy of Psychiatry and the Law