Working where criminal law meets psychiatry
4 Jun 2022
Day in the life
Ever wondered what it's like to be a psychiatrist? This series explores a day in the life of psychiatrists who work in different areas of psychiatry.
In this article, we hear from Dr Gunvant Patel who is a forensic psychiatrist.
A Day in the Life of a Forensic Psychiatrist
My day begins with emails whilst sipping a latte and scanning the local news ‘just in case’ over a bowl of cereal. I make a mental note of anything I will need to deal with when I get into work or news that occasionally has implications for the service.
Why did I choose forensic psychiatry?
I came into forensic psychiatry in 2001 with no idea of what was involved. I was jumping ship, after seven years in a general adult service. I felt the need to explore new horizons.
Forensic psychiatry has suffered from sensationalist portrayals that give the impression that we are out in the field working alongside detectives profiling serial killers and terrorists. Nothing could be further from the truth; we spend our time like other psychiatrists in hospitals and clinics.
I soon realised that what you develop in forensic work is thoroughness of information gathering and critical thinking to pull it all together into a robust synthesis. Luckily, as a forensic psychiatrist you usually have time to do this without the strain of high workloads and fast turnover: system pressures are measured in weeks not days.
Working in a maximum-security hospital
Mondays start on the rehabilitation unit in our maximum-security hospital. The weekend handover done, I review patients with the registrar. The majority of our patients have been found ‘not guilty by reason of mental impairment’ (the older term being ‘insanity defence’) after taking the life of someone when floridly psychotic.
I review a young man whose elderly neighbour’s ill-fated death resulted from him believing she was a witch who abducted and ate children. Still in the first year after the tragedy, a long difficult road lies ahead of him, and it is too early even to be talking about the trauma of what happened. Recovering from the severe psychosis and coming to terms with what he has done will require time, patience and skilled mental health care whilst ensuring that he remains safe to himself and others.
They say it takes a village to raise a child. It takes a team of professionals to return a forensic patient back to life in the community.
Community clinic work
In the afternoon at the community clinic, I assess a man with a history of child sex offences for antilibidinal treatment for his underlying paraphilia. Understandably, some colleagues find it difficult working in this area; to me, all human acts are fascinating and forensic psychiatry is where we see all things generally hidden from others. I regard this as a special privilege.
At the next appointment I review a man who has been granted extended leave into the community by the courts after spending seven years in the secure hospital. Returning to the outside world is a testing time; he is no longer the same and his family have been changed too. He is particularly anxious today, having returned a positive drug screen for cannabis.
Managing the ongoing relationship and negotiating limits at each stage of recovery tests my clinical therapeutic skills. It is rewarding to journey with them as they gradually settle back into the community and establish connections.
Working with the courts
At the same clinic, I regularly assess people at the request of the courts, following a determination of guilt, in order to provide a psychiatric perspective on the person and hence assist with the determination of an appropriate sentence.
Occasionally, I am called to give oral evidence in court based on the report. I always have a sense of frisson as I enter the witness box knowing that I am going to be questioned and challenged about my opinion. This is a great opportunity to sharpen my critical thinking and I rarely walk out of court without learning something for the next time.
My boss and mentor gave me two pieces of advice when I started: ‘you have to be able to step into their shoes’ and ‘never stray outside what you know in the court’.
Prison outpatient clinic visits
Once a week I work at an outpatient clinic in a high-security men’s prison. The clinical challenges mostly comprise assessment and management of psychosis, anxiety, depression in men with severely damaged personalities and backgrounds of serious trauma. Aside from the clinical aspect, I aim to provide a non-judgemental human presence in a place that reminds them of their supposed wickedness and their estrangement from society.
Private practice work
I have a weekly half-day for private practice. In this session, I see people on behalf of the state-wide workers’ compensation insurance scheme. The claimants generally present with trauma-related conditions in the wake of workplace accidents or bullying. It is a fascinating challenge to integrate often voluminous information derived from previous assessments (often including a range of medical and surgical specialties) with my own psychiatric evaluation, and reach a concluded succinct formulation of the person’s suffering.
Back in 2001 there was no RANZCP Advanced Training program in forensic psychiatry. Now, the subspecialty is vibrant across Australia and New Zealand and training programs are thriving in most jurisdictions.
As I walk home under the cathedral canopy of plane trees I reflect on another workday. How forensic psychiatry practice is varied, the psychopathology is wide-ranging, clinical care and medicolegal assessment work is rewarding. My curiosity about the human condition is constantly stimulated; I can’t now imagine doing anything else.
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