The ethical dilemma of forensic therapy

Therapy and reporting to the judiciary - psychiatric professionals in prison have a conflict of loyalties. How do they deal with it?

The treatment of people for whom a therapeutic measure has been ordered by the court creates a conflict of loyalties for medical professionals. A study(*) supported by the SNSF reveals how they deal with this in practice.

Approximately one thousand people in Switzerland are receiving court-ordered psychiatric treatment (approx. figure for 2019). The total period for which these persons are deprived of their liberty ultimately depends on the success of the psychotherapy. The professionals assigned to this task - forensic psychiatrists, psychologists and nurses - thus serve two masters: on the one hand, they are supposed to provide the best possible therapy to those being treated; on the other hand, they must report to the judiciary on progress and assess whether release would pose a threat to society.

The Institute for Biomedical Ethics at the University of Basel has, for the first time, conducted a nationwide qualitative study of around 30 people working in this field and asked them about their dual role: where do they see themselves in the triangular relationship with the judiciary and the medical system and people under therapeutic measures? And what methods do they use to solve the ethical dilemma in their daily work? The study was conducted as part of an interdisciplinary SNSF project about ageing in prisons, led by the physician and theologian Bernice Elger.

Limited confidentiality

As the interviews show, the professionals are aware of the problem and most of them place themselves somewhere in the middle between the parties. All respondents also report similar approaches to solving the problem. But there are considerable cantonal differences in the organisation of the court-ordered therapies – for example in the placement of patients under therapeutic measures in prison or in a psychiatric clinic, as well as in the terms under which the psychiatrists and psychologists treating them are employed by the justice or health department.

"No one denies that transparency in communication between all parties involved is important," Elger said. This can be achieved, for example, by giving patients access to reports to the justice system. Or by clearly communicating from the outset which personal details may or may not be passed on to the justice system. A number of therapists find it particularly problematic that they can only assure these patients of limited confidentiality because they have to provide information to the justice system - they fear that this will impair the success of the therapy.

"So far, unfortunately, there are no binding guidelines in Switzerland for dealing with such ethical conflicts," says Elger, "The findings from the interviews may offer a basis for developing common guidelines." But it would remain a major challenge due to the lack of a common approach to treating people under therapeutic measures in Switzerland.

* H. Merkt et al.: Forensic mental health professionals’ perceptions of their dual loyalty conflict: findings from a qualitative study. BMC Medical Ethics (2021)External Link Icon