How forensic psychiatry evolved: physicians and crimes

From its beginning, psychiatry did not restrict itself to “insanity” but strived to explain human behaviour more generally, extrapolating knowledge from the “mad” persons confined to asylums into everyday life phenomena, such as anxiety or shyness, sexuality, and schooling, norm transgressions in general, and criminal law in particular. Thus, psychiatry was a central player in the expansion of the “triumphalistic” medical paradigm (Le Fanu, 1999), which saw modern medicine as the royal road to understanding and alleviation of man’s ailments and sufferings.

The area of crime and punishment has always attracted human curiosity and imagination. Psychiatrists, being no exception, have contributed their expertise, often with a humanistic stance against harsh punishments and penal law retributivism. The psychiatric approach was long opposed by hard-line moralists and conservatives. Eventually, as the task of exerting societal control over undesired behaviours to an increasing extent was assigned to psychiatry, confrontations flared up on a new frontier, namely with radicals opposed to control structures.

Psychiatry’s perspective on mental disorder as the cause of crime has thus been one of a “scientific” approach to crime and punishment as opposed to the legalistic or retributionistic models that came to be characterized as “moralistic” or even “transcendental”. However, as experimental settings for testing a causal connection between mental disorder and crime are virtually impossible to design, there has never been much of an empirical basis to back the psychiatric stance. 

A long time was to elapse before the question of causation was actually examined beyond the mere identification of mental problem constellations among subjects who had committed criminal acts. Today, the notion of a causative role for mental disorders behind crimes rests mainly on probabilistic inferences from epidemiological studies (identifying male gender, substance abuse, early-onset disruptive behaviour disorders, especially conduct disorder, and, behind these problems, ADHD, personality disorders and genetic effects as main risk factors). But we have previously discussed the problems in interpreting risk as causation here (for genetic risk, but applicable to all the different types of risk factors listed). More on the results of such studies in the Intro to this thesis, on the theoretical models for such studies here, more on the history of forensic psychiatry here.

Doctors are reluctant to scale down their claims of expertise. Forensic psychiatry is thus a history of overstated expertise and claims to have scientific proofs for very diverse opinions about criminality. Nevertheless, today we know that mental health care needs among offenders are very high and, tragically, often unmet. This is the true challenge for forensic psychiatry.

(This blogpost is partly excerpted from this paper. If you have troubles accessing full-text versions of references, don't hesitate to contact directly for a copy, henrik.anckarsater@neuro.gu.se or in the comment section of this blog).