INTRODUCTION
Psychiatry is a specialty within medicine. Its practitioners, as in other specialties, are trained to see their role as identifying sick individuals (diagnosis), predicting the future course of their illness (prognosis), speculating about its cause (etiology), and prescribing a response to the condition, to cure it or ameliorate its symptoms (treatment)
[1]. Consequently, it would be surprising if psychiatrists did not think in terms of illness when they encounter variations in conduct which are troublesome to people (be they the identified patient or those upset by them). Those psychiatrists who have rejected this illness framework, in whole or in part, tend to have been exposed to and have accepted, an alternative view derived from another discourse (psychology, philosophy, or sociology).
As with other branches of medicine, psychiatrists vary in their assumptions about diagnosis, prognosis, etiology, and treatment. This does not imply, though, that views are evenly spread throughout the profession, and as we will see later in the book, modern Western psychiatry is an eclectic enterprise. It does, however, have dominant features. In particular, diagnosis is considered to be a worthwhile ritual for the bulk of the profession and biological causes are favored along with biological treatments.
The illness framework is the dominant framework in mental health services because psychiatry is the dominant profession within those services. However, its dominance should not be confused with its conceptual superiority. The illness framework has its strengths in terms of its logical and empirical status, but it also has weaknesses. Its strengths lie in the neurological evidence: Bacteria and viruses have been demonstrably associated with madness (syphilis and encephalitis). Such a neurological theory might be supported further by the experience and behavior of people with temporal lobe epilepsy, who may present with anxiety and sometimes florid psychotic states. The induction of abnormal mental states by brain lesions, drugs, toxins, low blood sugar, and fever might all point to the sense of regarding mental illness as a predominantly biological condition.
The question raised is: What has medicine to do with that wide range of mental problems that elude a biological explanation? Indeed, the great bulk of what psychiatrists call "mental illness" has no proven bodily cause, despite substantial research efforts to solve the riddle of a purported or assumed biological etiology. These "illnesses" include anxiety neuroses, reactive depression, and functional psychoses (the schizophrenias and the affective conditions of mania and severe or endogenous depression). While there is some evidence that we may inherit a vague predisposition to nervousness or madness, there are no clear-cut laws evident to biological researchers as yet. Both broad dispositions run in families, but not in such a way as to satisfy us that they are biologically caused. Upbringing in such families might equally point to learned behavior, and the genetic evidence from twin studies remains contested.
HEALTH
The word health is derived from hal, which means "hale, sound, and whole"
[2]. When it comes to the health of people, the word health has been defined in a number of different ways - often in its social context, as when a parent describes the health of a child or when an avid fan defines the health of a professional athlete. The most widely quoted definition of health was the one created by the World Health Organization (WHO) in 1946, which states "health is a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity". Further, the WHO has indicated that "health is a resource for everyday life, not the object of living, and is a positive concept emphasizing social and personal resources as well as physical capabilities". Others have stated that health cannot be defined as a state because it is ever changing. Therefore, we have chosen to define health as a dynamic state or condition of the human organism that is multidimensional (i.e. physical, emotional, social, intellectual, spiritual, and occupational) in nature, a resource for living, and results from a person's interactions with and adaptations to his or her environment. Therefore, it can exist in varying degrees and is specific to each individual and his or her situation. "A person can have a disease or injury and still be healthy or at least feel well. There are many examples, but certainly, Olympic wheelchair racers fit into this category".
A person's health status is dynamic in part due to the many different factors that determine one's health. It is widely accepted that health status is determined by the interaction of five domains: Gestational endowments (i.e., genetic makeup), social circumstances (e.g., education, employment, income, poverty, housing, crime, and social cohesion), environmental conditions where people live and work (e.g., toxic agents, microbial agents, and structural hazards), behavioral choices (e.g., diet, physical activity, substance use, and abuse), and the availability of quality medical care. "Ultimately, the health fate of each of us is determined by factors acting not mostly in isolation but by our experience where domains interconnect. Whether a gene is expressed can be determined by environmental exposures or behavioral patterns. The nature and consequences of behavioral choices are affected by social circumstances. Our genetic predispositions affect the health care we need, and our social circumstances affect the health care we receive".
To put clinical responsibility into context, it is important for the health professional to understand the many different factors that have an effect on them
[3]. These include how accountability is discharged, the court process, the components of a legal claim for compensation, the duty of care, how this duty is measured and also how issues such as waiting lists, lack of resources, and following orders will affect them. This will help to put clinical responsibility in context.
Health professionals may become involved in the court process when an issue of their accountability arises. The discharge of accountability rests ultimately with the court. A health professional may have to give evidence in court, for example, when there has been a serious untoward incident. The kind of court proceedings in which a health professional may become involved can include an inquest, civil proceedings for compensation, criminal proceedings for gross negligence, professional conduct hearing, or employment tribunal for breach of contract.
MENTAL HEALTH
There can be few areas in medicine where the conflict of ethical principles is exposed so starkly as it is in respect of the management of mental ill health
[4]. Yet, by definition, the person with mental disorder cannot make ordered decisions and, in the extreme position, someone must act on his or her behalf - this is, in short, paternalism, a concept which is now generally regarded as both outmoded and undesirable but which returns, in this context, as an acceptable, and in some cases an unavoidable, option.
The solution to the resulting problem is not, however, of the all or nothing variety. A person's mental disorder may be permanent, temporary or fluctuating; it may be severe, or it may be minor; it may interfere with one form of mental activity but not with another. Put another way, mental disorder will interfere with the patient's capacity to make autonomous decisions to a variable extent, and the degree of acceptable paternalistic intervention on his or her behalf varies directly with the degree of incapacity.
Mental disorder prevention aims at reducing the occurrence, frequency, and relapses, the time spent with symptoms, or the risk for mental illness, preventing or delaying their occurrence and decreasing their impact in the affected person, their families, and society
[5]. Recently, there has been a wider acceptance and recognition of the importance of prevention in mental disorders.
Many of the effective preventive measures are harmonious with principles of social equity, equal opportunity, and care of vulnerable groups in society. Examples of these interventions include improving nutrition, ensuring primary education, access to the labor market, removing discrimination based on race and gender, and ensuring basic economic security. A particularly potent and unfortunately common threat to mental health is conflict and violence, both between individuals and between communities and countries. The resulting mental distress and disorders are substantial. Preventing violence requires larger societal efforts, but mental health professionals may be able to ameliorate the negative impact of these phenomena by implementing some specific preventive efforts and making humanitarian assistance more mental health friendly.
MENTAL DISORDER
Mental disorder represents the main point of contact between psychiatry and the law
[1]. The early days of psychiatry in the 19
th century were heavily influenced by eugenic considerations - it was assumed that a variety of deviant conducts could be explained by a tainted gene pool in the lower social classes. This degeneracy theory, which characterized early biological psychiatry, linked together the mad, the bad, and the dim. However, during the First World War and its aftermath, such an underlying assumption began to falter. In the forensic field, there emerged a resistance to the old eugenic ideas of degeneracy, which accounted for criminality in terms of an inherited disposition to bad conduct. This was replaced by an increasing interest in environmental or psychological explanations for law-breaking. Since that time, psychiatric experts have played a major role in identifying and explaining criminal conduct. Moreover, once there was that shift away from biogenetic determinism, then this opened up questions, still pertinent today, about psychological explanations. Given that the latter contain elements of determinism as well as assumptions about human agency, the case by case the balance allotted to each is always open to consideration and varying perspectives. The norms of the criminal justice system permit this ambiguity. For example, mental illness may be considered as a reason to exculpate criminal action in a context, in which usually intention, and therefore intentionality, is the focus of interest to judges and juries.
MENTAL ILLNESS
Mental illness is one of the major health issues facing every community
[2]. It is the leading cause of disability in North America and Europe and costs the United States more than half a trillion dollars per year in treatment and other expenses. Mental disorders are associated with smoking, reduced activity, poor diet, obesity, and hypertension and also contribute to unintentional and intentional injury. Mental disorders reduce average life expectancy, in some cases (involving substance use disorders, anorexia nervosa, schizophrenia, and bipolar mood disorder) by the same amount as does smoking >20 cigarettes a day. Clearly, there is "no health without mental health". Approximately 20% of American adults (about 45 million people) have diagnosable mental disorders during a given year, and about 5% of adults in the United States have a serious mental illness, that is, illness that interferes with some aspect of social functioning. Only 38% of those diagnosed with a mental disorder receive treatment. Some of these people require only minimal counseling, followed by regular attendance of supportive self-help group meetings to remain in recovery, while others suffer repeated episodes of disabling mental illness. These individuals require more frequent medical treatment and more significant community support. Finally, there are the most severely disturbed individuals, who require repeated hospitalization.
TRAUMA
Experiencing violence and crime creates a sense of turmoil for the survivor and her loved ones
[6]. Trauma is a personal and often horrific event that profoundly affects a person and redefines her life. The experience of trauma has the potential to change ones' perceptions, worldview, and behavior. Trauma often leaves behind physical injury, emotional trauma, financial loss, and changes to the routines of daily life.
Violence and crime can also produce a crisis for the victim. Crisis is an intolerable situation in which one's usual coping strategies are not effective. It upsets the usual order of one's life, and often, after healing, a new sense of order and balance is created. Being unable to solve a problem can result in increased tension, anxiety, emotional unrest, and an inability to function.
PSYCHIATRISTS
The establishment of the doctor-patient relationship is the legal predicate to the recognition of a professional duty of care owed to a patient
[7]. Since a medical malpractice claim demands proof that a doctor breached the duty he or she owed to a patient, the existence of a doctor-patient relationship and the duty of care it demands is a core issue in every malpractice claim. As a general rule, a psychiatrist in private practice is not required to accept anyone who seeks treatment and may choose whomever he or she wishes to treat. Similarly, psychiatrists have no legal obligation to provide emergency medical care to someone with whom they do not have a preexisting doctor-patient relationship, absent any contractual or statutory obligation (e.g., emergency department [ED]). Once a psychiatrist has agreed (explicitly or implicitly) to accept a patient; however, tort law anticipates continuity of care until the relationship is appropriately terminated.
The expanded opportunities for forensic psychiatrists to be heard in judicial proceedings have resulted not just from the judicial and legislative recognition of substantive and procedural rights of individuals with mental health problems
[8]. While that evolution is the essential context within which psychiatry may play a role, the necessary prerequisite for forensic psychiatrists to indeed participate is the recognition that expert witnesses should be heard in the adversary legal process. Adjudication requires the presentation of evidence to support claims and defenses, be the issues criminal or civil or administrative, and attorneys are utilitarian: They seek persuasive and admissible evidence wherever it may be found. Beyond the traditional direct and circumstantial evidence, testimonial and documentary, and expert testimony have become a critical element of proof in many cases.
NURSES
Nursing is a clinical practice that includes systematic problem solving (the nursing process) and nursing management of identified patient needs
[9]. In planning patient care, the nurse makes countless decisions concerning nursing diagnoses, construction and implementation of nursing care plans, and evaluation of patients' progress toward health. Each decision requires that the nurse combine a wide range of facts (or data) with a set of values to determine what ought to be done to help the patient fulfill his or her health needs. The facts are drawn from many different types of information about the patient: His or her medical and psychosocial histories, physiological status, economic status, and esthetic, and religious orientations. However, collection and analysis of the facts alone can never lead to a conclusion that a particular nursing intervention is morally justified. To reach a conclusion about what is morally justified in nursing practice, the nurse must combine relevant facts with a set of values. Thus, the first task in nursing ethics is to identify the many evaluations that take place in nursing practice and to separate the moral from the non-moral components in these evaluations.
ED nurses, as well as trauma team nurses, are often the first to encounter a patient with forensic issues
[10]. Patients who have been assaulted or who are victims of any type of violence or negligence, and perpetrators with various types of injuries or psychological problems present with unique needs. Nurses can no longer focus on treatment of physical injuries alone. Essential evidence that is highly perishable and fragile such as DNA evidence is often the most essential evidence linking the perpetrator to the crime. Nurses must know when and how to collect evidence and how to preserve the chain of custody of that evidence. Assessing the patient for the possibility of being a victim, collecting the proper evidence as indicated, taking photographs, and properly informing the patient are all elements of proper care. These tasks are not difficult, but nurses need training to complete them properly. In addition, the nurse has an ethical responsibility to advocate for all patients, both victims and offenders. It is not the nurse's role to determine guilt or innocence. The nurse must provide holistic nursing care for each patient while being unbiased and an advocate for truth and justice.
PSYCHIATRIC PATIENTS
The therapeutic role involves a traditional doctor-patient relationship, with all the demands of consent and confidentiality inherent in this relationship
[11]. The ethical principles involved will be familiar to any doctor working in primary care or hospital medicine. Information obtained should normally be kept confidential but may be shared with others in the healthcare team, in this case, other forensic physicians who may take care of the patient, a custody or forensic nurse, or any doctor to whom the patient is referred. The extent to which this information is shared depends entirely on a judgment as to what constitutes the best interests of the patient in terms of safe detention. Treatment must be given on the basis of fully informed consent. If this is absent, as in the case of incapacity due to alcohol, drugs, or illness, then the doctor proceeds on the basis of the patient's best interests or implied consent.
Legalism has played an important role in the field of mental health
[1]. It has set certain limits on medical power and discretion. It has also codified two separate social processes which are at odds with one another: The rights of patients to exercise choice and the rights of professionals to impose their actions against the wishes of patients. Psychiatric patients have also had special legal provision when they commit criminal offenses. The legal rules applied to them have been different from those of other offenders, highlighting the special (arguably discriminatory) way in which people with mental health problems are treated. This special treatment also applies to self-injurious behavior. Although suicide itself is not illegal, suicidal intent detected in people with mental health problems can trigger peculiar forms of lawful control.
The etiology of psychiatric emergencies involves the classic triad of brain, mind, and behavior
[12]. Often a patient presents with an alteration in his or her behavior manifested as a change in mental state, level of functioning, mood, or personality. The emergency physician must distinguish between those patients needing medical treatment for an organic problem affecting the brain (e.g., delirium or dementia) and those individuals who would benefit from psychiatric treatment for a functional problem of the mind (e.g., thought disorder, mood disorder, or personality disorder).
Traditional psychiatry involves the diagnosis and treatment of functional entities. The psychiatric emergency, however, is an acute, undifferentiated presentation of altered behavior that may result from either functional or organic conditions. In fact, sometimes both types of problems coexist in the same patient. The emergency physician must consider all these possibilities, first ruling out organic conditions before diagnosing functional entities that may require psychiatric care. This is often referred to as "medical clearance".
Many patients present to psychiatric facilities with acute altered behavior. Emergency physicians often provide the first and possibly only medical evaluation the acute psychiatric patient is likely to receive. In addition, psychiatric facilities may not be equipped with either appropriate staff or equipment to provide comprehensive medical evaluation and/or treatment. ED personnel is tasked with excluding a medical etiology for the patient's symptoms. Unfortunately, the term "medical clearance" can imply different things to psychiatric staff and emergency staff. Emergency staff must determine the appropriate evaluation based on a focused history and physical. No agreed on standard exists, and therefore emergency physicians must use the patient presentation to determine the appropriate evaluation.
MENTAL HEALTH PROFESSIONALS IN THE COURTROOM
In the courtroom setting, the question of what makes an expert witness is more complex
[13]. A reductionistic answer is this: An expert is anyone whom a court accepts or whom it stipulates (grants without challenge) as an expert.
The concept of a psychiatric expert witness, clinically defined, is a psychiatrist who uses particular skills, both clinical and nonclinical, to provide information and understanding relevant to the legal system's concerns. This essentially didactic functioning - more closely resembling teaching than anything else - often requires intellectually bridging the gap between two widely divergent realms of discourse and thought: Psychiatry and law. Indeed, this intellectual challenge is one of the features that make forensic work so exciting and interesting to its practitioners.
More narrowly, the expert is distinguished from the ordinary or "fact" witness by an essential attribute: The fact witness is limited to testimony about what can be discerned by the five senses by direct observation or experience; in contrast the expert is entitled by the role to draw conclusions, even if those conclusions are based on others' observations. For example, an expert witness may review a chart filled with other clinicians' observations and provide the court with an opinion as to whether the care so recorded was negligent. Other conclusions in the form of opinions might involve whether a particular person met various legal criteria, such as competence or insanity.
Forensic reports and reports written for other clinical purposes differ in several important ways
[14]. Understanding these differences is key to writing good forensic reports. Forensic reports summarize forensic evaluations that are conducted to inform a legal decision maker (or other person involved in the legal process) about psychological or psychiatric issues that impact the legal issue in dispute. In contrast, therapeutic reports are generally conducted to facilitate care or treatment.
These distinctions result from the differences in the role of treating mental health professionals and forensic examiners. In forensic contexts, referral questions are more specific, evaluations focus on psycholegal abilities, and reports are prepared for legal professionals, who view them as evidence. These varying purposes necessitate differences in the content of the reports. Clinicians who prepare therapeutic reports have considerable latitude regarding the content they include. In contrast, forensic examiners always tailor their reports to address narrow referral questions. Therapeutic reports are typically written for mental health and other health-care professionals, who are likely to be familiar with clinical jargon and complicated concepts surrounding emotional, behavioral, and cognitive functioning. Forensic reports are authored for laypersons (i.e. attorneys, judges, hearing officers, and insurance adjusters), who typically have a much more limited understanding of these concepts. As a result, forensic examiners must explain clinical issues in a manner that laypersons will understand.
Mental health professionals are increasingly called on to serve the legal process
[15]. Sometimes clinicians are called as ordinary or "fact" witnesses to testify about occurrences they have perceived themselves (e.g., an assault by one patient on another). Other times, however, mental health professionals are called to the stand as "expert" witnesses, which allow them to serve in a different role. The function of an expert witness may be voluntarily assumed, as in the case of those forensic clinicians whose practice is almost entirely devoted to evaluations and courtroom testimony; however, sometimes clinicians are unwillingly drawn into the adversarial process. This may occur when a patient requires commitment or when the contact that a clinician had with a patient and the opinions that he formed become relevant to non-mental health litigation, such as a child custody case or a suit for psychic damages after a negligent act. Thus, all clinicians are susceptible to unexpected subpoenas and ought to be aware of the formal and informal rules governing their participation in courtroom proceedings.
Mental health professionals are called on by the legal system to provide testimony in a wide variety of cases, criminal, and civil. In the criminal area, forensic clinicians may be asked to comment on the competence of a person to make decisions throughout all the phases of the criminal investigation, trial, and punishment
[15]. These include the competence to waive one's rights (e.g., the right not to be searched without a warrant, the right not to answer investigators' questions or make a confession), to stand trial, to plead guilty, to be sentenced, to waive appeal (especially in capital cases), and to be executed. The most well known and controversial role that mental health professionals play in the trial process is considered: Evaluating defendants criminal responsibility.
On the civil side, clinicians perform a similarly broad range of functions. They may assess a number of civil competences, including competence to make a will or contract, to make decisions about one's person and property, and to marry. Clinical experts are also called on to testify about a person's mental impairments insofar as they relate to the ability to work or could have been caused by an allegedly negligent act (emotional harms).
Clinicians who work with children are frequently involved in evaluations and testimony concerning juvenile delinquency, child custody, termination of parental rights, and newer issues, such as competence of the child to testify and how she may be protected in the courtroom.
CONCLUSION
The psychiatric examination is needed when psychological disorders that hurt the experience of good mental health and communication with other people prevent people in achieving of the desired success. Most often, it is about states that most people can recognize in themselves and others such as tension, anxiety, worry, anxiety, panic attacks, fears, thoughts, and actions that people are not able to control themselves, a pronounced feeling of tiredness, apathy, inability to feel happiness and satisfaction, disinterest for events in the environment, disturbance of concentration, difficulty remembering and recalling, faster mental fatigue, diminishing total intellectual ability, potentially increased need for medication, cigarettes, alcohol, or other psychoactive substances. In a small number of cases it is about more severe psychiatric disorders in which some people are unable to recognize their psychological difficulties or deny the existence of obvious psychological difficulties, which are often manifested in a disrupted experience of reality, strange ideas, possible hearing or visual hallucinations or deceptions, loss of control over the procedures, dependence on various psychoactive substances, severe disorders of work and social functioning, illegal behavior, and so on forth.
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