The legal decision on whether a defendant can fairly take part in a criminal trial in England and Wales is currently based on the leading case of R v Pritchard (1836), which despite subsequent case law updates does not embrace the concept of mental capacity or effectively identify defendants who are unable to meaningfully participate. Further to an extensive consultation process, the Law Commission published recommendations for reform in 2016, with a proposed new test of capacity to participate effectively in a trial and detailed suggestions for statutory reform of court procedures for managing defendants found unable to participate. Here we review the proposals and consider practical implications and suggestions regarding their implementation.

The severe dissociative disorders of dissociative identity disorder (DID) and dissociative disorder not otherwise specified (DDNOS) are complex, not uncommon presentations associated with severe symptoms, high rates of comorbidity, high service use compared with other psychiatric disorders, and high suicidality. They exact high personal and socioeconomic burdens and show poor response to standard treatments, with high levels of treatment attrition and ‘revolving-door’ out-patient and in-patient service use; patients are often misdiagnosed or labelled ‘untreatable’. DID and DDNOS diagnoses remain controversial, but they have been repeatedly validated internationally over the past 20 years and the disorders can be accurately identified using screening tools and structured clinical interviews. Neurobiological understanding of the disorders is increasing; findings are consistent with a trauma origin and have commonality with features seen in other trauma-related disorders. Specialist treatment that addresses the dissociative symptoms alongside their trauma origins shows promise in early evidence. Working knowledge of these disorders among non-specialist psychiatrists and psychologists in the UK remains poor, resulting in long delays before diagnosis and treatment.

This article offers a selective review of memory and of issues relevant for a psychiatrist thinking about memory in a forensic context. It considers the development of our knowledge of memory, some of the ways in which memory can be erroneous and some evidence that this fallibility may sometimes be overstated. It concludes with a section on good practice in psychiatric assessment and in medico-legal work, looking at memory assessment, malingering/exaggeration and guidance for expert witnesses.

Malingering is the dishonest and intentional production of symptoms. It can cause considerable difficulty as assessment runs counter to normal practice, and it may expose clinicians to testing medicolegal situations. In this first part of a two-article review, we explore types of psychiatric malingering and their occurrence across a range of common and challenging scenarios, discussing presentations that may help delineate true from feigned illness. A framework is provided for undertaking an assessment where malingering is suspected, including recommendations on clinician approach, the use of collateral information, and self-evaluation of biases. The uses, and limitations, of psychometric tests are discussed, including ‘general’, malingering-specific and ‘symptom validity’ scales.

Psychiatrists called on to assess the reliability of witness testimony in the courts enter an arena fraught with uncertainties. This commentary discusses Commane & Kopelman's exploration of both the ‘normal’ fallibility of memory and disordered memory and considers the unavoidable limitations of their guidance on memory assessment and medico-legal work.

The expert witness practice of psychiatrists is under constant scrutiny by the courts and, in the UK, the General Medical Council, as well as within appraisal and revalidation as part of a doctor's overall practice. Regulation and appraisal of expert witness practice must address not only technical competence, including demonstration of a real understanding of the interface between medicine and law, but also ethical probity, including in respect of bias, which is the most challenging appraisal focus. In psychiatry, there is much room for ‘values expression’, and therefore bias, in the offering of expert opinion. This article first describes various legal and psychological definitions of bias; then addresses the sources and routes to expression of bias within expert witness practice, viewed legally, psychologically and neuroscientifically. Finally, it proposes ways in which inevitable bias can be minimised by the individual practitioner.

This article outlines the rationale for dedicated specialist services for high-risk young people about whom there may be family or professional concerns in relation to mental disorder. It provides an overview of the development and remit of such services and emphasises the need for them to form part of overall service provision for children and young people.

This article describes how the M'Naghten Rules, which govern the law of insanity in England and Wales, came into existence. In relation to knowledge of the wrongfulness of the alleged act, the article reveals how the Court of Appeal has sought to limit the defence, whereas the courts of first instance, and a number of other jurisdictions, have adopted interpretations of the Rules that accord more closely with the law of insanity as it existed at the time of Daniel McNaughtan's trial and that the Rules were probably meant to formulate. Three cases are used to illustrate the difficulties resulting from the position adopted by the Court of Appeal. It is suggested that in cases where the insanity defence is raised, justice is likely to be better served by addressing specifically and separately the accused's understanding or appreciation of the moral wrongfulness of the alleged act and their knowledge as to whether the alleged act is contrary to the law of the land.

Although the older adult population makes up only a small percentage of mentally disordered offenders, there is a clear need for forensic mental health services for older people. However, these services to date have developed ad hoc and with no coordination. In this article we discuss the evolution, current provision, future direction and therapeutic implications of such services. Although the epidemiology, criminology and clinical characteristics of older people are sufficiently different from those of younger people to warrant such service specificity, we suggest that the provision of care should be geared to services based on older people's multiple and complex needs, rather than on arbitrary age cut-offs.

Forensic psychiatry services have grown and become more complex in structures, processes and pathways. Legacy customs, practices and changing policy are now organised into formal models of care. These are written accounts of how a health service is delivered, outlining best practice and services for patients progressing through the stages of their condition and the care and treatment available. This article explores the four key elements of a model of care: goals; pathways and processes; treatment programmes; and systematic evaluation. It describes the most common model of care in forensic services, which builds on structures of stratified therapeutic security. It also considers variations on this basic or standard model matched to needs arising from the complex interrelationship with other parts of the mental health service for the population served and with criminal justice, primary care and physical health, housing and welfare agencies.

It is over 40 years since the principle of informed consent was accepted in the USA and it has been long established in other common law jurisdictions. But for decades English law has been constrained by the Sidaway case, which effectively perpetuated a form of medical paternalism. Nevertheless, a patient-centred approach can be traced to one of the judgments in that case, and in the case of Montgomery the Supreme Court has now adopted an approach to consent which is based on self-determination and autonomy and is more closely aligned to professional practice. It calls for a dialogue between doctor and patient, recognition of the patient's right to make a choice and recognition by the doctor of their duty to provide the comprehensible information necessary for the patient to exercise choice, having regard to what a prudent patient, in that patient's circumstances and with that patient's characteristics, would want to know.

The assessment and management of violent behaviour in mentally disordered patients are no longer the sole domain of forensic psychiatrists, but are increasingly part of the day-to-day work of all psychiatrists and mental health professionals. Violence risk assessment has become a huge industry, and although the importance of dynamic, as well as actuarial, risk factors is now recognised, a more systematic approach exploring the psychodynamics in the aetiology, assessment and treatment of violent behaviour is often lacking. In this article I revisit some of the key psychodynamic principles and concepts relevant to an understanding of violence, summarising the historical contributions of key psychoanalytic writers on violence and aggression, and exploring the ideas of more contemporary writers working in the field of forensic psychotherapy. A psychodynamic framework for working with violent patients is introduced, focusing on the setting and containment, specific therapeutic interventions and monitoring countertransference reactions.

When those whom the law terms ‘secondary victims’ – i.e. the passive and unwilling witnesses of injury, or of the threat of it, to others – seek compensation through the courts for the psychiatric injuries that they have suffered (traditionally but confusingly referred to as ‘nervous shock’ claims), there would in theory be the potential for a virtually limitless number of claims. For this reason, the courts have developed and apply a number of, to a large extent, arbitrary ‘control mechanisms’ as floodgates. This article describes these control mechanisms and other relevant law using recent illustrative cases and with particular reference to the assistance that the courts can expect of psychiatrists as to diagnosis and causation.

In this second part of a two-article review on malingering we consider the challenges of presenting clinical and psychometric findings. Numerous clinical and demographic factors are statistically associated with malingering but applying them to an individual case risks challenges to the expert psychiatric witness's evidence. Although psychometric data can usefully help strengthen or challenge a diagnosis, expert witnesses must recognise and report the limitations of these tests. We recommend that psychiatric expert witnesses do not try to look for or to link any external incentives with clinical findings, and indeed we suggest that they should, other than exceptionally, avoid using the term ‘malingering’. It is the job of the court, not the expert witness, to ascertain an individual's credibility and motives. We suggest a framework for presenting expert psychiatric evidence in this area.

When a patient in an in-patient psychiatric setting allegedly commits a crime, psychiatrists are sometimes asked to assess their fitness to be interviewed by the police. This article describes how to conduct this assessment, outlines the criminal justice process leading to police interviews (with particular reference to the legal system in England and Wales) and highlights practical issues to consider when assessing fitness to be interviewed in this context.

In this article three main issues are addressed using anecdotal and anonymised illustrations of situations in which the author has been engaged, during 35 years of medico-legal practice, to assist in the process of obtaining and analysing the evidence of children to facilitate decision-making by various authorities and tribunals. Those issues are: the competence of a child to be a witness in the Crown Court; the process by which a child's evidence has been elicited; and the use of an analytical approach to the content (verbal, behavioural and emotional) of a child's evidence as an aid to jurists who have the task of reaching a decision as to the child's reliability, as distinct from their competence.

Although there is an increasing focus on recovery within mental health services, there has been limited exploration of the applicability of these principles within forensic services. The authors draw on their experiences within forensic rehabilitation services to discuss the potential obstacles to secure recovery, exploring the systemic and risk management aspects of such a setting as well as considering attachment theory within this context. Some proposals based on clinical experience are given on how such obstacles are faced and tackled.

Approaches to assessing violence in clinical practice have been influenced by developments in the field of risk assessment. As a result, there has been a focus on identifying and describing factors associated with violence. However, a factor-based approach to assessing violence in individual cases has limited clinical utility. In response, the benefits of a formulation-based approach have been promoted. This approach is enhanced by an understanding of the specific mental mechanisms that increase the likelihood of violence in the individual case. Although there is an empirical evidence base for mental mechanisms associated with violence, this literature has not been distilled and synthesised in a way that informs routine clinical practice. In this article the authors present the key mechanisms that are known to be associated with violence in a way that is relevant to the clinical assessment of violence and, in turn, can inform clinical and risk management.

The Court of Protection has the legal jurisdiction to make decisions about people who lack capacity to make decisions themselves (in England and Wales). When hearing cases, evidence can be provided to the court by expert witnesses and professionals. The Court of Protection Rules 2017 inform the practice and procedure within the Court of Protection. This article reviews the judgment from a Court of Protection case that analyses the proper role of the expert witness in the court. In doing so the article provides guidance to authors of expert witness reports and reports under section 49 of the Mental Capacity Act 2005 submitted as evidence to the court.

Multi-agency public protection arrangements (MAPPA) have been in operation for around 18 years in England and Wales. The primary purpose is for the sharing of information between agencies regarding the risk management of offenders returning to the community from custodial and hospital settings. The legal framework regarding information by psychiatrists is not dealt with in one single policy or guidance document. Psychiatrists must use their clinical and professional judgement when engaging with the MAPPA process, mindful of guidance available from professional bodies such as the Royal College of Psychiatrists, General Medical Council and British Medical Association.