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The Politics of Psychiatric Evaluation: Towards a Critical Anthropology of Forensic Psychiatry

Samuel Lézé
Traduction de Lucy Garnier
Cet article est une traduction de :
Les Politiques de l'expertise psychiatrique. Enjeux, démarches et terrains

Résumé

In the legal context, psychiatric evaluations are subject to controversy, considered as either indispensable or flawed, and yet rarely studied in their own right. This article puts forward a political anthropology of mental healthcare that is attentive to social context (the problem of recidivism), professional logic (the evaluation of dangerousness) and liminal practices (at the limits of the correctional and the medical). It thus intends to delimit the methodological and theoretical stakes of a study of (i) the psychiatric creation of the expert witness report (ii) its legal use (iii) its consequences on psychiatric care in prison and beyond. What makes reports authoritative or, on the contrary, how are they contested? What are the political issues at stake? Thus, the complexity of the politics of psychiatric evaluations can be drawn out from delineated ethnographic fields; a complexity linked to the situation of these evaluations between, on the one hand, legal and psychiatric theories of personality and, on the other, how they are received and effectively applied by the legal system.

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Notes de l’auteur

The seminar “Critiques de la psychiatrie, psychiatrie critique” co-organized with Pedro Valente (at the ASM 13 centre Philippe Paumelle) focused on this theme this year, as did a workshop co-organized with Sandrine Bonneton (AFFEP and MSH Paris Nord) 15th February 2008: “Psychiatrie, quelle expertise? Regards croisés sur les figures contemporaines de la déviance”.

Texte intégral

Context

  • 1  Before becoming a legal notion, recidivism is a medical or clinical category referring to the reap (...)

1Since the end of the 19th Century, the question of recidivism has been something of an anomaly in criminology, revealing the failure of the prison system and constituting, in point of fact, a political scandal. How should we treat individuals considered responsible for their acts (and therefore not committed to correctional healthcare) who, having completed their full sentence, then continue to commit the same crime1? In order to explain and prevent this continual behaviour, the Italian positivist school developed the concept of dangerousness (or dangerous state) in order to qualify a particularly twisted individual, who is resistant to the law or even medical care (Gassin, 2007: 691-700). While the sentence punishes the past crime that established guilt, dangerousness requires an expert responsible for evaluating the risk of a future crime and a type of institution at the limits of the correctional and medical fields entrusted with the mission of reducing or neutralising this risk. At the end of the 20th Century and the beginning of the 21st, a string of highly mediatised affairs (e.g. Dupuy, Evrard, Schmidt) brought two new criminal figures to the forefront that now haunt current affairs: the “paedophile” and, to a lesser, albeit still significant, extent, the “mentally-ill offender”. In this context, recidivism is doubly intolerable as a societal problem not only due to the difficulty of finding a satisfactory technical solution but also, and above all, morally due to the nature of the crime and the status of the victim. The latter is also a new figure in the legal field, demanding the recognition of their status and legitimate compensation. This has led to modifications regarding both the legal mandate of forensic psychiatry and the interdependent relationships between these different figures.

  • 2  JO, 26 Février, p. 3266. On the legal front, see on the one hand, the comments made by Matsopoulo (...)
  • 3  The social criticism simply relayed or reformulated Robert Badinter’s (2008) objections.
  • 4  Magistrate presiding over a specific section of the Court of Appeals (the Court of Appeals is divi (...)

2In this respect, the law n°2008-174 passed on the 25 February 2008 regarding rétention de sûreté (preventive detention after a prison sentence has been expunged) and the déclaration d’irresponsabilité pénale pour cause de trouble mental2(declarations of lack of criminal responsibility by reason of mental disorder) clearly delineate a global but unprecedented process fighting recidivism: a detailed response to the context of the affairs and the culmination of a series of reports that have, in general, tried to define the phenomenon and the means for solving the problem (Burgelin, 2005; Goujon et Gautier, 2005-2006; Garraud, 2005). Dangerousness is placed at the heart of the procedure in order to better distinguish between two exclusive aspects: the “criminological” (risk of committing an offence by reason of a personality disorder) and the “psychiatric” (acting on an impulse linked to a psychiatric disorder). Thus, the law puts forward two sections focusing upon the two deviant figures that pose a problem: the sexual offender and the mentally ill offender. The first section puts in place a system in which offenders can be placed, as a “last resort”, in a socio-medical-custodial facility of preventive detention. The second – little discussed in the social criticism which precipitated the vote on this law and concentrated on the theoretically indefinite duration of the deprivation of liberty3 – established that mentally ill offenders would appear beforea court to evaluate the material accountability of the facts regardless of their lack of criminal responsibility or their committal or placement in preventive detention. The role of psychiatric evaluation, at the heart of this law, is decisive. Given that the aim of the process is specifically to take into account the victims’ suffering, a representative of a national association for victim support is present on the regional “pluridisciplinary committee” (the composition of which is already defined by the law of 12th December 2005 on dealing with recidivism of criminal offences) responsible for assessing dangerousness (alongside a président de chambre à la cours d’appel4, the regional prefect, the interregional director of penitentiary institutions, a psychiatric expert witness, a psychology expert witness and a lawyer). This process is backed up by a second medical assessment carried out by two experts. This assessment takes place upon entry to the custodial facility, continues throughout the duration of internment, and occurs when release is being considered.

  • 5  Cf. particularly Nicolas Herpin (1973).
  • 6  Which is a way of revisiting and completing Robert Castel’s pioneering work in La gestion des risq (...)

3In order to understand this situation, it is not enough to expound upon the texts or criticize the security environment in question, as this is merely a way of acting in rather than upon the situation. On the contrary, it is necessary to launch empirical work looking at the logic of practice -  the concrete application of both psychiatric expertise and of the law5 - so as to render intelligible the scope of the changes in the social mandate of mental healthcare, of our moral vision of the intolerable and the general political configuration that can serve as a means of analysing processes that reach beyond national political agendas6. Identifying the specificity of an overall situation through fieldwork based on practice is the remit of an anthropological approach. The political anthropology of mental health, which constitutes, in this case, a very fitting angle of approach, consists more specifically in determining the political dimension of practices approached solely from the perspective of their technical or epistemic sides.

The Technical Paradoxes of Psychiatric Evaluations

4Within the “mosaic of forensics”, psychiatry holds a particularly sensitive place, facing many different and often contradictory criticisms: the omnipresence of the psychiatric evaluation coupled with the demographic lack of psychiatric expert witnesses; a power over judges’ decisions that raises fears of a psychologising of the justice system coupled with substantial fallibility regarding evaluations in general (Dietz, 1985):

“The expert does not benefit from the aura of scientific, objective and technical knowledge that comes, for example, with witness statements in ballistics or accountancy. On the contrary, the questions constantly raised by the evaluations of expert witnesses in forensic psychiatry show that such witnesses are, rather, the only ones seen as fallible by definition. Not credited with restricting themselves, as is required by expert witnesses in general, to simple questions of “fact”, the psychiatric experts figure, here, in a far more problematic relationship to the sentence itself, thus inevitably raising the question of the boundary between their expertise and that of the judge” (Thèry, 1992).

  • 7  Regarding the prison as an “asylum-like” care facility, cf. Goffman, 1968; Milly, 2001; Bessin, Le (...)
  • 8  This does not bring with it a lack of civil responsiblity, which entails the reparation of the con (...)

5This questioning becomes particularly acute in a context wherein the mediatisation of legal errors confronts the responsibility of the judge with that of the experts (e.g. the Outreau affair) while, in parallel, the number of mentally ill offenders in prisons7 seems, to many, to have never been so high since the 19th Century (Brahmy, 2005), as Not Guilty for Reasons of Insanity8 verdicts become less and less common (HAS, 2007:17). However, on all of these issues, it is very difficult, due to a lack of statistics, to establish the rate of these errors and the actual numbers in question.

  • 9  Cf. in particular the Burgelin report (2006).
  • 10 In the case of the psychiatrist, the consensus-conference regarding police custody in December 2004 (...)
  • 11 The articles D.16 and D.17 of the Code de procédure pénale make this mandatory in five cases, even (...)
  • 12  Does an examination of the subject reveal mental or psychological anomalies? If applicable, descri (...)
  • 13 It should be noted now that the pre-trial evaluation of criminal responsibility does not apply the (...)

6This disquiet regarding psychiatric evaluations is not new, but has never been subject to systematic examination. The most recent report on criminal expertise (Wednesday 11th July 2007) by the Fédération française de psychiatrie (FFP – French Federation of Psychiatry) which is the result of a public hearing by the Haute Autorité de Santé (HAS – Higher Authority for Healthcare) underscores the fact that “forensic psychiatry fulfils less and less the role of a filter that aims to identify the mentally ill in order to provide them with the necessary care, and no longer acts as a regulator in prison or hospital”. Could it be that the height of the debate on the law on recidivism (i.e. dangerousness9) of sexual offenders saw an unprecedented demand emerge, on behalf of the victims, for greater focus upon, and strengthening of, the judgment of murderous insanity? It is the scope of this redefinition that now makes a study of psychiatric evaluation and its usage at all stages of the judicial investigation necessary, beyond the strictly technical aspects in question. Distinctions can thus be made between evaluations in cases of garde à vue10(police custody for questioning), pre-trial evaluations (known as evaluations during investigations11), which should provide answers to seven standardized questions12) and sentencing evaluations or post-trial evaluations13.

  • 14  Particularly in the case of sexual offenders.

7Professional critiques (criminological, legal and psychiatric) of psychiatric evaluations (Bourcier and de Bonis, 1999; Landry, 2002; Danet and Saas, 2007; Schweitzer and Puig-Verges, 2006) thus converge with the small existing body of critical sociology (Hakeem, 1958) in denouncing the designation and judicialization of mental pathology. However, in the absence of sufficiently in-depth empirical studies on the logic of practice and the concrete work carried out by these professionals, the forensic psychiatrist becomes nothing more than a figure of psychiatric power serving social control (Foucault, 1999; Castel, 1991; McCallum, 2001). A moral verdict regarding the expert as yet another agent of domination (Szasz, 1958; Steadman, 1972) is combined with the epistemological verdict (the evaluation as solely a social construct). This approach closes off the empirical field rather than opening it up to investigation (Lézé, 2007). In so doing, within a certain “tradition” of the sociology of healthcare and deviancy that often considers the expert evaluation as a manifestation of power, and medicine, de jure, as an evaluation (Parsons, Freidson), the majority of studies have not taken into consideration the “sense of justice” supported by these kind of actors and have downplayed the difference between evaluation and treatment. In the same way, by focusing upon the expert evaluation and not on the way it is used legally, this research does not address the judge or lawyer’s “sense of psychology” in specific cases. While the question of treatment and punishment within the correctional world (Fernandez, Lézé, 2005; Fernandez, 2007) is sometimes addressed in its own right in sociology literature, the notion of the sociology of the critique of mental health professionals – which would allow the studies in critical sociology to be somewhat qualified – is only just beginning. Would it not be necessary, for example, to take into consideration the protests of certain psychiatrists regarding the mental health aspects of criminal reform? And what about the refusal of others to move the “diagnostic” evaluation towards an evaluation of “prognosis”14, shifting the question of responsibility to that of dangerousness (Aldige, 1995; Doron, 2006)? What could be said about those who call for a reform of “mental expert” training (Bouchard, 2002) either recognizing an equivalent space for psychologists, or seemingly attempting to better defend themselves against the threat posed by the indispensable “professionalization of the forensic expert” (David, 2004)? Is the mandate of the mental healthcare evaluation growing or, on the contrary, as the Lamanda (2008) report would seem to indicate, is its scope narrowing through the delegation of forensic evaluations to a new body of experts considered more professional in this domain?

Psychiatric Evaluations: Logic of Practice and Political Stakes

  • 15  See also: Expertise et socialisation des savoirs. Actes des rencontres des 14-15 mars 1985, CRESAL (...)
  • 16 L'avènement d'organisation d'expertise (Benamouzig, Besançon, 2005).
  • 17  Dossier « Le juge et l'expert », Droit et Société, n° 2, 1986 and Dumoulin (1998).

8Calling upon expert witnesses means calling upon specialist knowledge that is considered liable to shed light upon a practical decision in a problematic situation (Trepos, 199615.). A distinction must be made between scientific evaluations (Roqueplo, 1997; Turner, 2001; Golan, 2004; Lascoumes, 2005) focusing on potentially controversial social issues (food safety and public health16) and clinical or judicial evaluations focusing on specific cases (individuals and states) involving medico-administrative or medico-judicial categories (degree of responsibility or dangerousness, medical knowledge and regulations) (Dodier, 2004). Although in the 1980s questions regarding the function of expert witness statements and the respective roles of the expert and the judge intensified17, “forensics is currently a blind spot in the social sciences” (Dumoulin, 2000). There is therefore a stark contrast between the prolific professional literature of the field and an obvious lack of empirical studies.

9The disquiet surrounding psychiatric evaluations comes under the remit of a traditional investigation in the sociology of professions and forensic sociology (Dubar, Tripier, 1998). From this perspective, the aim is to render the politics of psychiatric evaluation intelligible by carrying out a concrete analysis of the logic of practice of the actors in question and of the meaning that they give to their actions. This approach allows the description of the issues pertaining to this particular activity and of the function of the psychiatrist when they position themselves as an expert outside the medical context. Building on historical studies concerning the professionalization of forensics (Chavaud, 1999; Chavaud, Dumoulin, 2003) and the advent of forensic psychiatry in courts, it is possible to examine the way in which a particular professional sector (forensic psychiatrists) came into being and the tasks comprised by their work. It is necessary to go beyond simply noting the legitimacy of a status, through two complementary research angles in a perspective of the sociology of professions and work: How does one become a forensic psychiatrist? How does this sector deal with negotiating the boundaries of the medical and legal worlds? According to what principles is forensic psychiatry carried out and positioned? The aim of the study is thus to obtain a precise knowledge of the politics of psychiatric evaluations in France and the practical and professional issues at stake. More generally, the question is that of understanding the modalities of the legal use of psychiatric evaluations.

  • 18  At least at the time of publication, as research is currently being developed and the initial resu (...)
  • 19  This programme is situated within two research projects funded mainly by the Gip “Mission Recherch (...)

10As my aim here is essentially programmatic18, my contribution is organized around the presentation of two collective surveys19 from which two general aspects can be retained:

  • 20  This brings to mind the "école de Lyon” which attributes a therapeutic dimension to the situation (...)

11Studying the process of becoming - and being - an expert witness (Trépos, 1996: 9) allows the constitution of the expert witness report to be considered through a number of facets: different types of professional career paths; possibilities for branching out into other fields, along with the degree of predictability of such bifurcations; personal and professional motives; representations of the legal world; psychiatric theories employed; relationships with both those subject to trial and the judges; the registers of evaluation at work; etc. It is on this basis that the working conditions of the expert in action can be understood, from the routines acquired within certain specialities (forensic science, criminology, victimology, correctional psychiatry…) to the concrete organisation of the “series of tasks” (part-time work, ongoing collaboration with the justice system and the national healthcare system, occasional work, etc.) involving, or not, attempts to create room for manoeuvre within the specific constraints of the justice system. What kinds of justifications (epistemic, ethical, legal, etc.) are called upon in order to carry out this evaluation and/or restore the “treatment” dimension of the process20?

12The study of the way in which expert witness reports are used in court can be carried out in counterpoint by means of the ethnographic observation of a significant number of (criminal) trials and by going through a large corpus of cases that have called upon one or more expert reports. Psychiatrists’ “principles of justice” can be compared with the “principles of psychology” of the magistrates in their understanding of the personality of certain defendants. In some local initiatives, the pre-established balance between the expert and the magistrate, within the mechanisms of collaborative work, must be examined. By analyzing cases where expert witness report have presented a particular difficulty, the intention is to render intelligible the way in which a figure of deviant Otherness is constituted through the use of specialist knowledge. In these cases, and as some observations show, it is necessary to analyze how psychiatric and psychological legitimacy is produced, as this is never the work of the report alone but rather the way in which the latter is used in trial.

Conclusion

13The medicine of mental health entered the political sphere from the moment at which it became an official instrument for the administration of populations, whether particularly dangerous or not. In the legal framework, and within a given context, the politics of psychiatric evaluations cannot be reduced to simply the technical response of the fight against recidivism. When considered as a mere “means” – whether functional or dysfunctional – their political dimension is completely ignored, particularly by social criticism that tends to reduce psychiatric evaluations to mere instruments of power. Accordingly, it is perhaps necessary to “forget Foucault” for a time, along with the notion of an anonymous structuring power that shapes the field of deviancy, and to consider also the tactical (i.e. political) power at work embodied by the actual practice of the actors developing, acquiring and deploying it in specific and clearly defined action strategies, even if these tactics are more often than not invisible to the public eye (Kurtz, 2001: 25).

  • 21  See also Didier Fassin’s analysis of the politics of ethnopsychiatry (2000).

14A system of enunciative authority such as forensics implies invoking specialist knowledge outside its traditional sphere, with a view to conferring legitimacy and to providing answers to questions not directly linked to the professional field in question (Trépos, 1996: 57). The expert witness statement is produced in the expert’s name (and not in the name of the profession). In this way, through experts’ strategies for action, there is a need to consider the positions taken up regarding the political and moral questions raised by psychiatric and criminological dangerousness within society. Henceforth, the politics of the expert witness report can be considered as being located in the principles of evaluation or the strategies at the heart of the forensic psychiatrists’ logic of practice, seeking to link knowledge of disorders with the actual management of individuals or populations, and legitimizing or contesting a particular political order21. This is the dialectic that a political anthropology of the psychiatric evaluation intends to clarify so as to render intelligible the determining factors of the current security environment.

This text is a revised version of a paper given in the seminar of the Groupe Européen de Recherche sur les Normativités, “Prison, pénalité, modernité”, at the MSH Paris, Friday 21st March 2008. I would like to thank Gilles Chantraine for having invited me to lay out the initial directions of this new research programme. I am also grateful to the respondants (Caroline Protais, Delphine Moreau and Christophe Adam) and participants for their comments and encouragement.

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Notes

1  Before becoming a legal notion, recidivism is a medical or clinical category referring to the reappearance of an illness after it has been completely cured.

2  JO, 26 Février, p. 3266. On the legal front, see on the one hand, the comments made by Matsopoulo (2008) who considers the second section to be needless whilst criticizing the preventive measures as disguised sentences, and on the other hand, Pradel (2008) who heralds a “double revolution” in criminal law.

3  The social criticism simply relayed or reformulated Robert Badinter’s (2008) objections.

4  Magistrate presiding over a specific section of the Court of Appeals (the Court of Appeals is divided into "Chambres" given over to different specific legal areas).

5  Cf. particularly Nicolas Herpin (1973).

6  Which is a way of revisiting and completing Robert Castel’s pioneering work in La gestion des risques (1981).

7  Regarding the prison as an “asylum-like” care facility, cf. Goffman, 1968; Milly, 2001; Bessin, Lechien, 2000.

8  This does not bring with it a lack of civil responsiblity, which entails the reparation of the consequences of actions and the compensation of victims (article 489-2 of the Code civil).

9  Cf. in particular the Burgelin report (2006).

10 In the case of the psychiatrist, the consensus-conference regarding police custody in December 2004 concluded: “the psychiatric examinations requested urgently, during a subject’s period of police custody, whether on the mode of requisitioning a psychiatristor not) 1) should be restricted to looking for possible psychiatric disorders requiring psychiatric care and contraindicating police custody; 2) This request must not replace the traditional pre-trial evaluation in its usual format; 3) As with all evaluations, it must not highlight personality traits that could then be used as an argument against a subject who denies the facts at the origin of the police custody”.

11 The articles D.16 and D.17 of the Code de procédure pénale make this mandatory in five cases, even in the absence of mental disorders: 1) the person in question is under the age of 25; 2) they are a repeat offender; 3) they are being prosecuted for intentional bodily harm, sexual crimes or arson; 4) in cases where the withdrawal of parental authority is a possibility; 5) before a decision regarding the remission of sentence. If the article 122-1 of the Code Pénal is taken at face value, the expert should find themselves facing a single simple question: does the defendant present with a mental disorder that prevents or alters their judgment and/or the control of their actions?

12  Does an examination of the subject reveal mental or psychological anomalies? If applicable, describe these and specify to what affection they are related. Is the subject in a dangerous state? Is the subject fit for criminal sentencing? Can the subject be cured or rehabilitated? At the time of events, was the subject suffering from a psychological or neuropsychological disorder that prevented or altered their judgment or impaired their control of their actions? Specify the possibility for a medical treatment injunction in the context of someone sentenced to social and legal supervision as defined by article 28 of the Loi n°98-468 of 17th June 1998. On the subject of the evolution of the questions asked of forensic psychiatrists since art. 64 of 1810, the Chaumié decree of 1905 and the new Code de procédure pénale of 1958, cf. Gourmillaux, 1981: 18.

13 It should be noted now that the pre-trial evaluation of criminal responsibility does not apply the same logic as the post-trial pre-release evaluation. One focuses upon an act in the past (retrospective imputability and indication, or not, of a judgment and sentence) whereas the other evaluates a future risk (potential dangerousness and indication, or not, of release or preventive measures) (Archer, 2006). 

14  Particularly in the case of sexual offenders.

15  See also: Expertise et socialisation des savoirs. Actes des rencontres des 14-15 mars 1985, CRESAL, UA CNRS 899, Saint-Étienne, 1985.

16 L'avènement d'organisation d'expertise (Benamouzig, Besançon, 2005).

17  Dossier « Le juge et l'expert », Droit et Société, n° 2, 1986 and Dumoulin (1998).

18  At least at the time of publication, as research is currently being developed and the initial results are being drawn up.

19  This programme is situated within two research projects funded mainly by the Gip “Mission Recherche Justice” and directed by Alban Bensa (Iris, EHESS) with Fabrice Fernandez, Antonelle Di trani and Olivier Doron. I do not expand, here, upon the survey funded by the INHES on the organization of psychiatric care in prison, directed by Thomas Le bianic (Cerco, Paris Dauphine) with Fabrice Fernandez and Guillaume Malochet.

20  This brings to mind the "école de Lyon” which attributes a therapeutic dimension to the situation of psychiatric evaluation.

21  See also Didier Fassin’s analysis of the politics of ethnopsychiatry (2000).

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Samuel Lézé, « The Politics of Psychiatric Evaluation: Towards a Critical Anthropology of Forensic Psychiatry », Champ pénal/Penal field [En ligne], Vol. V | 2008, mis en ligne le 07 avril 2011, consulté le 29 avril 2017. URL : http://champpenal.revues.org/8007 ; DOI : 10.4000/champpenal.8007

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Samuel Lézé

Maître de conférences en anthropologie des sciences à l’École normale supérieure de Lyon, membre du C2So, Centre Norbert Elias (UMR 8562, CNRS-EHESS).

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