Forensic psychiatry: Where medicine and law meet

Female prisoners sewing clothes in Kajang Prison. Dr Sivakumar says that it is a misconception to think that female offenders are the same as male offenders. Photo: Filepic

“In psychiatry, the mind is a very complex concept. It takes time, it takes effort, and sometimes, we don’t always get the result that we want.”

He treats people, and at the same time, has to defend them in court.

He can cause people to be detained and put in hospitals, and take away their freedom for the greater good of society.

As a forensic psychiatrist, Dr Sivakumar Appan deals with the mentally ill and works with the legal system to keep such people who have committed crimes off the street and away from endangering themselves and others.

“A psychiatrist will come and interview you, and tell the court, yes, this person here is mentally ill; but not just that, his mental illness was directly related to the offence that was committed to the extent that he wasn’t aware of what he was doing. That’s one part of my job.

“Apart from that, forensic psychiatry deals with identifying mentally-ill people who are in the criminal justice process very early on.

“So, for example, if you get arrested and you get taken down to custody, before you get moved to prison, if it is found that you are mentally unwell, we would want to bring you into the hospital,” he says.

Numbers, not names

Dr Sivakumar is currently a consultant forensic psychiatrist with the National Health Service Greater Glasgow and Clyde’s Forensic Directorate in Scotland.

Before entering medical school, he had considered becoming a lawyer as he enjoyed debating during his school days.

The International Medical University alumni’s love for medicine and enjoyment of getting to go to court were what drove him to enter the field of forensic psychiatry.

“When I was doing my housemanship in Malacca, I found that I wasn’t spending a lot of time with my patients because I was just so busy.

“(There were) so many things to do, so many things to look after, and it was multiple floors from seven o’clock in the morning till 11 o’clock at night, and I was just running around doing things.

“People stopped becoming names, they just became bed numbers.

“At that point in time, I thought I wanted a career that would allow me to communicate with people, to interact with them on a meaningful, lengthy basis, rather than just a snapshot interaction where I fix them, then they go away.

“That’s when I thought about psychiatry,” he says.

Dr Sivakumar works at Rowanbank Clinic in Glasgow, a medium-security facility, which he describes as having very high fences and airport-type scanners.

Dr Sivakumar shares that forensic psychiatrists have to work in the alien environments of the prison and courtroom, where they have to play by other peoples rules. — IBRAHIM MOHTAR/The Star
Dr Sivakumar shares that forensic psychiatrists have to work in the alien environments of the prison and courtroom, where they have to play by other peoples rules. Photo: The Star/Ibrahim Mohtar

Patients there are the mentally ill from the prison service, who are a risk to both themselves and others.

He says: “It is different if you have committed a crime and you go to prison.

“If you are unwell, and you are a risk to yourself or other people, I can legally put you into hospital for a period of time.

“Even if you have not committed anything and you have not even done anything, but I deem you to be a risk to yourself or others, I can detain you in the hospital.

“This means stripping you of your freedom, and any movement you want to make out of the clinic has to go through the clinical team.”

Dr Sivakumar is also a visiting prison psychiatrist at Cornton Vale Prison, Scotland’s main women’s prison.

According to him, it is a misconception to think that female offenders are the same as male offenders, and the punishments for female offenders are usually of a lesser degree compared to their male counterparts.

Foreign domain

For Dr Sivakumar, working in a prison is a completely different experience from working in his clinic as he has to enter someone else’s domain.

“It is not my clinic. I’m not working in the hospital, I’m working in a prison – a prison that has security, prison officers, locked doors and big keys.

“It is not my universe, so I have to abide by their rules.

“They bring patients to come and see me, and I’m very much dependent on the prison services to allow me to do my job,” he says.

The same goes when he is in court voicing and defending his medical opinion against aggressive and experienced lawyers who are looking to get the best outcome for their clients.

Everything he presents in court is scrutinised and it is a lot of pressure in an environment that is alien to him.

“If I’m in my clinic, I’m very safe; I know exactly what goes on, I know what to do.

“But if you’re in the court, it is very different and I’m not in charge anymore.

“The sheriffs are in charge, the judges are in charge, and I have to play by their rules.

“It can be quite a stressful environment because you are being scrutinised by sometimes more than two lawyers, sometimes, three or four,” he says.

He adds: “I suppose psychiatry in particular, is not an objective field.

“I can’t do a blood test and tell you that you have depression; I can’t do a blood test and tell you that you have schizophrenia, and I can’t scan your brain.”

Despite the challenges in his job, he sees it as an opportunity to make the lives of his patients better.

The treatment process can take years, but seeing most of his patients now being able to contribute to society is very rewarding for Dr Sivakumar.

As one of the few Malaysian doctors in this sub-speciality of psychiatry, Dr Sivakumar urges fellow Malaysian doctors to consider the possibility of entering this field.

“It is a field that is exciting, challenging and you will push yourself as a person, as you will be involved in high-profile cases that will test you as a doctor.

“I do think that if you feel that if you have the ability to communicate well – and I think all doctors should have that ability – this is a field that is exciting.

“I know that there is a stigma attached to mental illness, but as time goes on, that is beginning to gradually improve,” he says.

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