With increasing litigation and strong links between crime and mental health, forensic psychiatry is a growth industry in America. Tim Cornwell reports.

Forensic psychiatry, the mingling of psychiatry and law, has enjoyed a minor boom in American universities. Ever more litigation, a record number of people behind bars and a steady flow of death penalty cases where the mental condition of the defendant is an issue have fed the demand for qualified practitioners. So, too, have child custody cases, head injury lawsuits and cases where demonstrably sick people refuse medical treatment. In the United States, all of these may require the services of a psychiatrist familiar with the workings of a court.

In 1980, the American Academy of Psychiatry and the Law, known by its acronym Aapl, had only 860 members. The membership is about 2,500, after a dramatic increase through the 1990s. Both Harvard and Yale universities boast law and psychiatry divisions. Other major centres are run at the University of California campus in Davis and the University of South Carolina. Many leading forensic psychiatrists are medical scholars who double up as expert witnesses in court.

The swelling of Aapl's ranks, according to members, results in part from the squeeze on US health spending for routine psychiatric care.

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At the recent Aapl meeting in Vancouver, topics covered ranged from love and hate on the internet to schoolyard harassment and the treatment of paedophilia with voluntary orchiectomy (the polite word for castration).

It is not many years since the field was shaken by so-called recovered memories of child sexual abuse. Long-buried "memories" led to a number of sensational court cases, first brought against the alleged abusers and then, as the pendulum swung, against the medical professionals accused of encouraging people to invent them.

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These days, forensic psychiatrists are more likely to deal with risk assessment in releasing prisoners, particularly as many US states have laws allowing indefinite incarceration of those declared "sexual predators". Predictions of future violence - whether in hardened criminals or troubled adolescents - is a long-time focus of the profession. Also, psychiatrists are typically involved at several stages in death penalty cases - deciding if defendants are competent to stand trial, if they are eligible for an insanity defence and if they are fit to be executed.

Keith Caruso is a psychiatrist in private practice in Nashville, Tennessee, as well as an assistant professor at the city's Vanderbilt University. He conducts examinations of criminal defendants, some facing the death penalty, for both defence and prosecution. At the Aapl conference, Caruso offered his findings on dissimulation in forensic evaluations. These did not involve criminals trying to fake mental illness, as the US public believes is commonly the case, but mentally ill defendants trying to deny or conceal their condition.

Caruso was consulted by the FBI on the case of the Una-bomber, Theodore Kaczynski, the former university mathematician who portrayed his one-man bombing campaign as a battle to save humanity from technology. At first, Kaczynski angrily rejected the suggestion that his actions were not entirely sane: he believed, however, that airlines had purposely routed their jets over his remote Montana cabin.

Caruso was consulted in the case of one patient who for years believed he was under government surveillance 24 hours a day, and that a car accident on a Texas back road was an attempt to kill him. He mailed his mental health records to a number of prominent figures in an attempt to expose the conspiracy, "but people began to behave as if he was crazy, so he stopped telling them," Caruso says. Caruso was brought in to examine him after he was convicted of four killings in a series of fast-food restaurant robberies. To hide his difficulty in expressing himself, the defendant had even memorised a list of vocabulary.

"This was a guy that really could not accept what he had done," Caruso says. "He had reached the point that not only had he not committed the crimes, but there was nothing wrong with him."

The murder rate in the US is at its lowest in 33 years, but crime and punishment is still a healthy industry. Last year, there were 17,000 homicides, and the US jail population was at the 2 million mark. In the state of South Carolina, about 1,000 people have been charged with murder over the past five years. About a third of these defendants find their way to the secure William Hall Psychiatric Institute in Columbia, referred by the courts for a week-long evaluation of their mental condition by the state's Department of Mental Health.

The hospital staff include 12 psychiatrists, who double as faculty members at the University of South Carolina and train students in psychiatry, psychology, social work and medicine. The defendants who pass through their hands have become part of the largest reported USstudy of people charged with murder.

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Richard Frierson, who heads the forensic psychiatric fellowship programme at USC, reported some of the survey's early findings at the Aapl meeting. The age of the 0 murder defendants examined ranged from 17 to 79, with an average age of 32.8 and an average IQ of 83. They were 88 per cent male, 62 per cent African-American and 85 per cent single (including widowed or divorced). Some 59 per cent had guns (others killed with bricks, fists and even a hairbrush). Almost all were convicted, but of the 13 cases in which prosecutors sought a death sentence, only seven were sent to death row.

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A third were diagnosed with mood or anxiety disorders, and 29 per cent had impaired intelligence, mental retardation or borderline intellectual function. And 63 per cent met diagnostic criteria for abuse or dependence on alcohol, marijuana or cocaine, while 82 percent had a history of significant use. According to the psychiatrists, 10 per cent were faking mental illness in an attempt to get off the hook.

Gregor Lande, a member of the faculty, is leading a separate research project. He has enrolled ten out of a proposed 40 subjects in a study of levels of cholesterol, blood sugar and the neurotransmitter serotonin in murder defendants. In the controversial search for biological and genetic sources of crime, low levels of cholesterol and serotonin have been linked to impulsive, violent behaviour.

Paul Mullen, a professor of forensic psychiatry at Monash University in Melbourne, Australia, spoke at the Aapl meeting about his research on stalkers.

Mullen, author of Stalkers and their Victims (Cambridge University Press), described how stalking appears to have a cut-off point of two weeks; stalkers who continue beyond that time are likely to move into a pattern of harassment and intimidation that lasts on average a year.

Case management of stalkers is vital, Mullen says. "The best way to help victims is to help stalkers. No one is sympathetic to them, but if you can't work with them and treat them, you can't relieve the distress of the victim."

About 15 to 20 per cent of women have suffered a stalking experience, Mullen's research shows. "You may not be harmed in the short term, but you could be frightened, harassed, intimidated and ultimately damaged by the constant drip, drip, drip," he said.

Douglas Mossman, who teaches classes on law and the mentally disabled at the University of Dayton, Ohio, spoke to the Aapl meeting on the subject of those few defendants who shake off their lawyers and represent themselves in court. In a study of 49 cases, Mossman found the defendant-cum-attorney succeeded about a third of the time in having charges dismissed or reduced.

"When you represent yourself, you can directly confront and cross-examine your accusers," Mossman says, giving some defendants, particularly professional people, a potential advantage. However, eight were given sentences of more than 30 years and five received the death penalty.

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Several defendants in the study showed mental symptoms ranging from the comic to the tragic. They included a 75-year-old retired man who had represented himself in three prosecutions for public nudity and one for murder. He asked for the death penalty "as a fitting end to a ruined life".