This may be used as a guide to ensure comprehensive coverage of psycho-legal matters relevant for training in forensic psychiatry. Priority should be placed on criminal matters, which are the subject of the topic summaries. 

Developing Clinico-legal Skills

Alongside developing clinical skills during higher forensic psychiatric training, it is necessary to develop clinico-legal capabilities;[1] that is, skills at the interface between clinical decision making and law; accompanied by the capacity to analyse the ethical implications, and justification, of any decision taken. Such skills include, but go far beyond, presenting ‘expert reports’ to courts and tribunals. Since the interface between clinical and legal constructs is ‘ever present’ in everyday clinical practice.

The purpose of this syllabus is to lay out the combinations of clinical and legal issues that, by the end of their training, the trainee should be capable of addressing. Trainees can use it to ‘tick off’ combinations as they cover them throughout their training; and may wish to keep a ‘log-book’ to evidence this training. Column A lists core legal constructs and Column B clinical ones. Where each item in Column B might potentially be ‘mapped onto’ each item in Column A.[2] Such mapping will also expose ethical issues which trainees should be able to reflect on (aside from ethical issues which solely relate to clinical decision making unrelated to legal matters). The aim of the training should be for the trainee to develop generic clinico-legal capabilities that are transferable to any UK domestic or other common law jurisdiction.[3]

Clinico-legal skills will naturally be developed through supervised ‘real-life’ clinical and clinico-legal work. However, adopting this approach alone risks leaving gaps in the trainee’s knowledge. Both because serendipity will dictate the combinations of clinical and legal constructs that the trainee comes across within their clinical training, and because they may be denied access to expert witness practice in many legal domains.

As regards ‘real experience’ of expert witness practice during training, this will be pursued, of course, in concert with the trainees’ various supervisors; albeit aided by guidance on the ‘boundaries’ between the roles of supervisee and supervisor where the trainee writes expert witness reports.[4] However, a useful route towards filling serendipitous gaps in supervised training is offered by psycho-legal workshops[5] (aside from self-directed learning using a ‘case book’[6]). And these can offer a route to achieving comprehensive clinico-legal capabilities.

Psycho-legal Workshops

Psycho-legal workshops offer the trainee the opportunity to consider in detail clinical, legal, clinico-legal and ethical issues that arise in relation to a clinical case or a case requiring an expert witness report; so as to cover ‘scenarios’ they may not happen to address in ‘real-practice’. They may be conducted either with a supervisor alone or within a trainee group (either facilitator or trainee led) and should focus on a particular combination of legal constructs (Column A) and clinical constructs (Column B). This combination may be illustrated by a ‘real’ (anonymised) expert report provided by the facilitator or trainee or a ‘fictional’ case[7] (see example in Appendix).

If the case is a ‘real’ expert report, then it is suggested that the trainee(s) be provided with an anonymised version which excludes the ‘Opinion/Recommendations’ section of the report; and poses ‘questions’ (or ‘instructions’ from lawyers) to be answered by the trainee(s) during the workshop. Whether ‘real’ or ‘fictional’, the case should be provided to the trainee(s) in advance, to allow them to consider what issues the case raises and to form their own opinion, or expert opinion. Toward the end of the workshop, or afterwards, the facilitator’s opinion/recommendations may be provided to the trainee(s) (although facilitators may not be expected to provide written ‘answers’ in respect of real cases).   

During the workshop, the facilitator should guide the discussion so as to stimulate critical thinking and debate between trainees. This should be addressed in terms of the clinical, legal, clinico-legal and ethical issues that arise in the case. Subdivision of the issues in this manner should allow the trainees to distinguish the ‘stages’ it is necessary to go through in order to come to a clinico-legal opinion. That is, to appropriately clinically assess the patient/defendant/litigant; to know the relevant law; to ‘map’ the patient’s/defendant’s/litigant’s mental state onto the relevant legal test clinico-legally; and to consider the relevant ethical aspects across the process.

Some workshops will need to draw upon identified experts in a specific clinical or clinico-legal field as facilitator. Facilitators with particular expertise may therefore come from within or outside forensic psychiatric services.

Approaches to Ethical Issues

Forensic psychiatrists need daily to make complex clinical and clinico-legal judgements in the context of conflicting ethical demands (e.g. non-maleficence vs. confidentiality). There are many ways to approach ethical analysis and ethical justification (listed below). Note, in a tribunal[8] or court context, the primary duty is unequivocally to the tribunal or court, and to ‘justice’.

Alternative ethical approaches:

• Four principles plus scope (autonomy, beneficence, non-maleficence, justice);
• Consequentialist framework, with consideration of future effects of possible courses of action;
• Duty framework, with focus on duties and obligations one has;
• Virtue framework, with consideration of one’s motivations.
• Values-based practice

Psycho-legal Case Types

Column A addresses legal constructs, and Column B clinical constructs. Each construct in Column B may potentially be ‘mapped onto’ each construct in Column A; where each ‘mapping’ represents a ‘case type’.