Differences between British and Japanese perspectives on forensic mental health systems: A preliminary study

Abstract

AIM

To clarify the differences in views on forensic mental health (FMH) systems between the United Kingdom and Japan.

METHODS

We conducted a series of semi-structured interviews with six leading forensic psychiatrists. Based on a discussion by the research team, we created an interview form. After we finished conducting all the interviews, we qualitatively analyzed their content.

RESULTS

In the United Kingdom the core domain of FMH was risk assessment and management; however, in Japan, the core domain of FMH was psychiatric testimony. In the United Kingdom, forensic psychiatrists were responsible for ensuring public safety, and psychopathy was identified as a disease but deemed as not suitable for medical treatment. On the other hand, in Japan, psychopathy was not considered a mental illness.

CONCLUSION

In conclusion, there are considerable differences between the United Kingdom and Japan with regard to the concepts of FMH. Some ideas taken from both cultures for better FMH practice were suggested.

Key Words: Forensic mental health, Medical treatment and supervision act, Psychopathy, International comparison, Qualitative research

Core tip: Several differences regarding the policy and perspective in forensic mental health have found between British and Japanese forensic psychiatrists; psychopathy is deemed as a mental illness in the United Kingdom, but not in Japan; British forensic psychiatrists considered to be responsible for ensuring public safety, whereas Japanese do not think so.

INTRODUCTION

Forensic psychiatry is a sub-branch of psychiatry that deals with patients and problems at the interface of the legal and psychiatric systems[1]. Therefore, it follows that forensic psychiatric practice will vary from country to country. Many countries have established how to deal with mentally disordered offenders (MDOs), and this involves different disciplines[2].

Japan established the Forensic Mental Health (FMH) scheme, which coincided with the enforcement of the Medical Treatment and Supervision Act (MTSA; the Act on Medical Care and Treatment for the Persons Who Had Caused Serious Cases under the Condition of Insanity) in 2005[3]. For the establishment of the forensic psychiatric care scheme in Japan, the government referred to their English counterpart to a considerable extent. On the other hand, there are many differences between countries with regard to the cultural background and history of FMH and with regard to the criminal justice system.

Considering these facts, it is hypothesized that there are differences between the United Kingdom and Japan in basic perspectives on and the level of awareness with regard to forensic psychiatry. The aim of the present study was to clarify these differences by conducting a series of semi-structured interviews.

MATERIALS AND METHODS

We created an interview form, using which we conducted the semi-structured interviews. The items on the interview form were formulated by means of a discussion (among the authors) that was based on a relevant literature search. The interview included questions concerning people’s opinions on various issues pertaining to the current systems of and context surrounding FMH in the United Kingdom and Japan.

The interviewees were forensic psychiatrists who were engaged in FMH practice or research in either Japan or the United Kingdom. For our preliminary study, we used convenience sampling to select three participants from each country.

All participants provided written informed consent for participation in the study. The first author conducted the semi-structured interview with each participant. Each interview lasted for approximately forty-five minutes. We digitally recorded the interviews and examined their content after they had been conducted. We transcribed and qualitatively analyzed each comment made by the participants.

The study protocol was approved as an international comparison study of forensic psychiatry by the ethics committee of the Graduate School of Medicine of Chiba University on June 19, 2015.

RESULTS

All six participants answered all the questions that they were asked during the interview, and no questions were omitted.

The participants comprised the following individuals: One British and one Japanese professor of a department of FMH, one British and one Japanese clinical psychiatrist, each of whom was working in a forensic ward, and one British and one Japanese postgraduate student who had each worked in a forensic ward. The length of time for which the participants had worked as a medical doctor (mean, 27.7 years; 12-43) and for which they had worked in the area of FMH (mean, 16.2 years; 5-40) differed.

All three British participants identified psychopathy as a mental disorder, whereas the participants from Japan were neutral to or skeptical of this view. Notwithstanding this, almost all participants were opposed to treating psychopathic patients in a psychiatric ward. The British participants emphasized that there was a lack of evidence suggesting that treatment outcomes for psychopaths were desirable.

In the United Kingdom, seclusion and restraint were rarely implemented, except in the case of psychiatric emergency wards. In Japan, inpatients in general psychiatric wards were occasionally secluded and/or restrained, whereas those in MTSA inpatient facilities were seldom secluded and/or restrained. The British participants felt that seclusion and restraint should be a last resort for managing patients’ aggressive acts. In contrast, the Japanese participants felt that secluded circumstances could be beneficial for patients, for example, those who were bothered by auditory hallucinations, as it would help them become more aware of their psychotic symptoms.

Only one Japanese participant had been involved in masked medication. The Japanese participants were rather accepting of masked medication and considered it a necessary evil, except for one participant, who was absolutely against it; furthermore, all the British participants were against masked medication.

All three British participants stated that forensic psychiatrists should be responsible not just for patients’ treatment but also for public safety to some extent, whereas only one Japanese participant supported this view.

The British participants believed that the core competencies of forensic psychiatrists should be risk assessment and the management and understanding of the psychiatric basis of violent behaviors. In contrast, the Japanese participants felt that the core specialties of forensic psychiatrists should be the understanding of criminal responsibility and psychiatric testimony skills.

In the United Kingdom, the term of hospitalization is six months to two years in medium secure units (MSU), and five to seven years in high secure units (HSU), and in Japan, the MTSA usually requires MDOs to be hospitalized for two to three years in inpatient facilities.

All participants supported the policy that forensic psychiatric care should be funded by the government. Furthermore, the British participants supported the idea that forensic psychiatric services should be covered by the private sector as well; however, the Japanese participants’ opinion regarding this matter was divided.

DISCUSSION

We conducted a series of semi-structured interviews with forensic psychiatrists from the United Kingdom and Japan. The results revealed some significant differences between the opinions of psychiatrists from the two nations.

The British specialists seemed to consider risk assessment, while focusing on MDOs’ aggressive behaviors, as the key areas that should be addressed by FMH. This would imply that psychopaths and substance abusers are at the center of forensic psychiatric treatment, because they are highly relevant to violence and crimes[4]. This view also places a sense of obligation on forensic psychiatrists to maintain public safety through the risk management of MDOs.

However, the British psychiatrists seemed to be ambivalent with regard to the paradox that psychopathy as a form of mental impairment is unsuitable for the psychiatric treatment setting. Since 2001, England has been prepared for the treatment of the so-called “dangerous and severe personality disorders”[5]. However, there continues to be considerable skepticism about the efficacy and cost-effectiveness of this treatment for such disorders[6,7].

On the contrary, the Japanese psychiatrists believed that forensic psychiatric practice should involve engaging in tasks related to people who have to give psychiatric testimony and who are involved with FMH legislation. In other words, they believed that forensic practice should involve dealing only with people whose criminal responsibility is questionable[8]. Consequently, in Japan, offenders with schizophrenia are inevitably dominant in the FMH setting[9]. Since forensic psychiatrists in Japan devote most of their expertise and energy to the treatment of schizophrenic patients, they hardly deal with psychopathic patients who may be incarcerated in prison[10]. Additionally, Japanese forensic psychiatrists do not have a very strong sense of responsibility with regard to contributing to public safety.

This, however, does not imply that risk assessment is ignored in forensic practice in Japan. Considering the fact that approximately three percent of the inpatients of general psychiatric wards are secluded or physically restrained[11], psychiatrists in Japan frequently have to evaluate the risk of violent behaviors in psychiatric patients. However, it is doubtful that these assessments are based on structured professional judgment. In addition, masked medication may still be accepted in some contexts in Japan. By and large, it appears that Japanese psychiatrists tend to behave in a paternalistic manner with psychiatric patients.

In the United Kingdom, private hospitals are rapidly growing in the FMH sector[12]. Some private facilities deal with specialized or niche needs such as developmental disorders. In contrast, in Japan, the private sector has been dominant in providing psychiatric beds[11]. At present, the MTSA inpatient facilities are limited to the public sector. Nonetheless, further discussion is required to clarify the future role of the private sector in relation to FMH.

Forensic specialists from both countries paid attention to the prolongation of the term of hospitalization of MDOs. Similar to MSUs in the United Kingdom in terms of their capacity and human resources, Japanese inpatient facilities, in accordance with the MTSA in Japan[13], have more long-stay patients. However, this fact should be interpreted cautiously because some patients discharged from an MSU are transferred to a low secure unit, HSU, or prison. In contrast, Japanese legislation has no provision for discharged patients to be recalled to prison[10]; moreover, there are no facilities equivalent to HSUs in Japan.

In conclusion, this preliminary study revealed some substantial differences between the United Kingdom and Japan with regard to FMH systems as well as significant differences between the views of British and Japanese specialists in this academic area. Therefore, great caution should be exercised when analyzing evidence in different countries.

Additionally, to improve the management of MDOs, there are points that should be taken from both Japan and the United Kingdom. In Japan, the task of making structured clinical judgments for risk assessment and management should be shared broadly among psychiatric practitioners. In the United Kingdom, a consensus needs to be reached with regard to the dispute surrounding the treatability of personality disorders and psychopathy. Furthermore, in both countries, a more detailed dialogue between general psychiatrists and forensic psychiatrists is required in order to shed light on what exactly FMH practice should entail.

COMMENTS

Background

Forensic mental health is one of the focused regions in psychiatry. Japan has established a newly forensic mental health system since a decade ago. However, there are potentially several differences in the perspective of forensic mental health among countries, considering the various histories of each country.

Research frontiers

Treatment of psychopaths is a hot topic in forensic psychiatry. In many countries, several attempts have done to reduce the future risk of recidivism of psychopathic persons. But most of them were in failure. From the medical economic point of view, some countries are going to abandon the treatment of psychopaths.

Innovations and breakthroughs

This mini-study revealed the difference of ideas and perspectives toward forensic mental health in the United Kingdom and Japan. Several international comparisons are conducted previously. But there are no other examples to investigate the basic thoughts regarding this region, such as the treatment of psychopaths, social responsibility of forensic psychiatrists, and medical economics of forensic mental health.

Applications

The reader will deeply understand the difference between two countries on forensic mental health. It will provide readers a widened view and sensibility about the interpretation of the contents when readers read papers mentioning the situation in other countries.

Terminology

The Medical Treatment and Supervision Act was a legislation established in Japan in 2003, enforced in 2005, for improved care and treatment for offenders with mental disorders.

Peer-review

This is an interesting paper, with an important contribution to understanding neurobiology.