Alec Buchanan, PhD, MD

The management of the risk of harm to others is an essential aspect of psychiatric care. While psychiatric patient populations, as a whole, do not show substantially higher rates of violence than the general population, it is possible, as with the general population, to identify sub-groups who have a higher risk. This is usually done using information derived from a clinical interview and from the patient's background, including details of illness, drug use and past violence. Some of our research has been designed to measure the relative contributions of each of these to accurate predictions. At least when predictions are made over the long term, a history of violence seems to carry the greatest weight.

The next question that arises is to what extent psychiatric services are likely to be able to use these predictions to prevent violence. Here the most important factor seems to be the base rate of violence in the population (see Psychiatric Services 2008; 59, 184-190). At the base rates of violence seen in most psychiatric patient populations, the limits to predictive accuracy are such that most violent acts could only be prevented by admitting to hospital large numbers of people most of whom would not, in fact, have gone on to cause harm. Even then, many of those who would have acted violently would have been left in the community. Psychiatric services do not have the option of ignoring the risk of harm to others. But our research suggests that admission to hospital, whether compulsory or voluntary, should be based on a range of clinical considerations, not just violence risk.

Risk assessment and management in the context of out-patient psychiatric treatment is discussed along with other aspects of forensic psychiatric care in the second edition of Care of the Mentally Disordered Offender in the Community (A. Buchanan, L. Wootton eds., Oxford, 2017).

Psychiatric jurisprudence is the philosophy of law as it applies to the mentally disordered. It forms the theoretical basis for the clinical sub-specialty of forensic psychiatry. Mentally disordered people encounter the law in proceedings relating to hospital commitment, in criminal trials and in civil cases, including medical malpractice and negligence. A recurring question has been whether legal standards, such as those relating to competence to stand trial or make a will, should change according to what is at stake (see Journal of the American Academy of Psychiatry and the Law 2006; 34, 458-465). There are several possibilities and the answer may not be the same for criminal and civil cases. Other aspects of our research have concerned the "ultimate issue" question in criminal testimony and the use of psychiatric diagnoses in authorizing the detention of those convicted of sexual offenses.

Psychiatric jurisprudence is the subject of Psychiatric Aspects of Justification, Excuse and Mitigation (A. Buchanan, Jessica Kingsley, 2000). The preparation of psychiatric reports for courts is the subject of The Psychiatric Report (A. Buchanan, M. Norko, eds., Cambridge, 2011), which won the American Psychiatric Association's Guttmacher Award in 2013.