The nature of the alliance an anthropological look at the practice of forensic psychiatry

Publication Date10 Dec 2002
AuthorDena Plemmons
Dena Plemmons*
This anthropological research concerns the relationships between and
among mental illness, criminality, medicine and the law, when each
become, both separately and as one manifestation in the practice of
forensic psychiatry, radically transformed by differing needs to assess
responsibility and construct comprehensibility. The work of forensic
psychiatry deals with these needs, and encompasses the professional,
moral, and social concerns that inform these needs. This is an
ethnographic look at the practice of criminal responsibility assessment.
Madness is not initially a fact but a judgment - even if that judgment becomes itself a
(Sheridan, 1980)
* At the time of the writing of this chapter, Dena Plemmons was a NASMHPD post-doctorai
fellow at the Center for Mental Health Services Research, Department of Psychiatry, University of
Medical School.
Community-Based Interventions for Criminal Offenders with Severe Mental Illness,
Volume 12, pages 123-141.
Copyright © 2003 by Elsevier Science Ltd.
All rights of reproduction in any form reserved.
ISBN: 0-7623-0972-5
At the far edge of traditional mental health services is the field of forensic
mental health, where it is the skills of assessment and evaluation, not treatment,
which are valued and pressed into service. Forensic practitioners are called
upon, in criminal matters, to evaluate, and perhaps testify about, a person's
competence in many different arenas - competence to plead guilty, to be
executed, to waive rights, and most commonly, competence to stand trial.
Forensic clinicians are also asked to assess a person's criminal responsibility
vis&-vis mental illness and criminality, and it is this aspect of forensic
psychiatric practice that will concern us here. The practice of psychiatry in this
instance becomes a different proposition when both the client (the court) and
the service (not treatment, but assessment) alter the traditional goals of clinical
mental health practice, and also, in some way, illuminate the moral premises
upon which psychiatric practice is predicated. In a usual clinical situation, the
clinician diagnoses for the purpose of treating the patient. In the forensic
situation, the clinician evaluates for the purpose of assisting the court in
adjudication - it is then up to a jury to decide if the psychiatric evaluation of
the person has any bearing on subsequent legal determinations about the
offense. Illness in this arena is not medical but legal, and the "fact" of the
illness is produced legally, after a judge or jury's consideration of clinical
information. The forensic clinician, then, is not the final arbiter of "sickness,"
either of what it is, or whether it exists at all, or in sufficient quantity, in relation
to a criminal act.
The person being assessed for criminal responsibility is, in this situation,
dealt with in both the medical and legal arenas, but fully in neither. The
processes of making a medical assessment of some necessary degree of
impairment and a legal adjudication of criminal responsibility involve
judgment - the medical about normalcy and the legal about guilt. Both, in some
final analysis, are concerned with issues of criminality and dangerousness - the
medical to discern its presence, the legal to confine it. In the practice of forensic
psychiatry, what is the nature of the alliance between and among mental illness,
criminality, medicine and the law? What happens when each - medicine and
law - becomes transformed by differing needs to assess responsibility and
construct comprehensibility? How do we describe the forensic process, this
rendering of expert medical opinion written for and then relinquished to experts
in law?
In the early nineties, I began what would become a 41/2-year research
endeavor investigating the practice of forensic psychiatry. As a medical
anthropologist, I wanted to undertake an ethnographic examination of the
process of forensic evaluation and consider how medical conceptions of mental
illness are both implicated in and opposed to legal conceptions of insanity and

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