There is a specialised governmental institution for forensic psychiatry in Lithuania – the National Forensic Psychiatry Service under the Ministry of Health (NFPS) which is established in 1992. NFPS is forensic expertise institution and belongs to National health system. All rights and duties of owner of NFPS are realised by Ministry of Health.
The main task of this Service is to provide forensic psychiatric assessments (expertise). NFPS has 6 outpatient forensic psychiatry departments for consultations and outpatient forensic psychiatric assessments (expertise) located in different parts of Lithuania and 1 inpatient forensic psychiatry department with 44 beds for inpatient forensic psychiatric assessments which usually last from 14 to 30 days and can reach up to 60 days in very rare cases. A specialised NFPS department for children and adolescents is dedicated for assessments of the mental health of minors. Specialised children and adolescents’ forensic psychiatrists and psychologists work in this department. The Central forensic psychiatry department is dedicated to handling the most complicated cases, involving malingering, and repeated forensic psychiatry assessments which are rare and make up around 1-2 percent of all assessments undertaken in a year.
Only certified forensic psychiatry experts (22) and forensic psychology experts (15) work in the NFPS. Two types of evaluations are made in NFPS: first – the pre-trial consultation and second – the forensic psychiatric assessment (expertise). When making consultations during pretrial investigations, only the data from the medical documentation of the accused person is assessed in order to decide if there are any signs of a serious mental illness and whether there are grounds for a full forensic psychiatric examination. About 2500 consultations are made each year. By making these consultations during the pretrial investigation we avoid performing full assessments where they are not prudent. Only accused person with a serious mental illness – psychosis, intellectual disability or dementia – is counted as having juridically significant mental disturbances. The accused person with primary diagnosis of personality disorders, depression, anxiety and other neurotic disturbances, also substance use disorders is regarded as having not juridically significant mental illness without need to be evaluated in full forensic psychiatric assessment (expertise). The second type of evaluation are court ordered forensic psychiatric assessments in criminal and civil cases. All forensic psychiatric assessments in Lithuania are conducted by certified forensic psychiatry and forensic psychology experts.
NFPS is acting as a methodological centre for forensic psychiatry and psychology. The NFPS carries out an ongoing quality control on the work of the forensic psychiatrists and psychologists, arranges professional development courses, and once a year holds an international conference ,,Actual questions on forensic psychiatry and forensic psychology”. NFPS also prepares the technical methodological documents on various topics of forensic psychiatry and psychology.
Depending on the expert’s work experience, the NFPS grants forensic psychiatry and psychology experts the following categories of expert: 3rd degree - after passing the expert examination; 2nd degree - after 5 years of work that has been considered of high quality; 1st (highest) degree - after 10 years of qualified, high quality work experience.
The NFPS is responsible for the training of forensic psychiatrists and psychologists - the training is done via an apprenticeship program. Only licensed psychiatrists after full training and psychologists that have completed studies in clinical psychology are admitted to the apprenticeship program. After the apprenticeship and a successful exam result, an additional Forensic Expert Certificate is then granted. An apprentice is employed at the NFPS and carries out assignments alongside an experienced expert. The apprenticeship usually lasts between 6 and 12 months, however it may be extended upon the apprentice’s request. At the end of the apprenticeship, the apprentice takes a Forensic Expert Exam, which is made up of two parts: special methodological forensic psychiatry/forensic psychology questions and basic knowledge of the relevant laws. The Exam is organised by the NFPS and includes a representative of the Academia. For the Exam, the apprentice provides examples (minimum of 5) of the assessments they have produced during their apprenticeship. Having passed the Exam, the forensic psychiatrist/psychologist gives an oath orally and in writing to the minister of Justice, after that their names are entered into the list of forensic experts, administered by the Ministry of Justice and available on the Ministry's website.
NFPS is also responsible for the continued confirmation of the qualifications of forensic psychiatrists and psychologists. Every 5 years certified forensic psychiatry and forensic psychology experts must provide examples and description of products (expertise) of their work which are then reviewed by a committee and a decision for the extension of the certificate is made.
NFPS acts as the centre for the academic development of forensic psychiatry in Lithuania. NFPS has a wealth of records dating back to 1994. Our forensic psychiatry experts carry out data analysis on specific scientific and practice topics. On the basis of data analysis, lectures are prepared for yearly forensic psychiatry and forensic psychology conferences. Academic works are prepared and published in the Lithuanian Science Journal ‘Sveikatos mokslai’ (Health Sciences) as well. Over the past 10 years, the themes of publications cover topics such as: neonaticide, portraits of sexual offenders, evaluation of persons’ civil capability, evaluation of malingering, post-mortem psychiatric evaluations, evaluation of the level of mental health disturbances of victims and analysis of crimes against a person’s health and life. The NFPS acts as a training base for medical residents in psychiatry curricula from Vilnius and Kaunas Universities also.
The legal regulation of forensic psychiatry expertise
In Lithuania the regulation of all kinds of forensic expertise is defined in the special Forensic Expertise Law.
All forensic experts must work according to the Ethical Codex for Forensic Experts where the main principles of forensic expert work are declared. The adherence to these practices is monitored by the Council of the Forensic Experts’ Activity Coordination, which considers any complaints regarding an expert’s breach of ethics and has the power to impose penalties to an expert - from a warning, to a public warning (via official posting), to a removal from the List of Experts for repeated, gross offences of the Code of Ethics. Council of the Forensic Experts’ Activity Coordination approves strategical tasks and priorities for all expertise institutions in Lithuania and subordinated to the Ministry of Justice.
All forensic expertise institutions in Lithuania must work according to the principles of European Commission for the Efficiency and quality of Justice (CEPEJ) Recommendations 2014. Recommendations of the Council of Europe is taken on as fundamental. CEPEJ issued guidelines on the role of court appointed experts in judicial proceedings. The role of forensic experts in European Union countries is defined in paragraph 89 of the Recommendations - forensic experts must work according appropriate and correct procedure and in paragraph 17 – forensic experts according their special knowledges, education and experience musts present all the facts to the court that the judge according these facts could make the conclusions.
The tasks of forensic psychiatrists and forensic psychologists
The average annual number of forensic psychiatric assessments in the period of 2013-2022 was 2280, about each half in civil and in criminal cases respectively. After carrying out the forensic psychiatric evaluation, the forensic psychiatrist produces a Statement of the Expertise according to the requirements set in the Forensic Expertise Law. The conclusions of this forensic psychiatry assessment are provided to the court in written form as an Act of Forensic Psychiatry Assessment (Expertise). Additionally, the forensic psychiatrist can be invited to participate in a court hearing, to confirm their findings verbally.
- In criminal cases the main task of a forensic psychiatrist is to evaluate the mental health status of the offender at the moment of the crime. In the period of 2013-2022 in average about 28 percent of assessed offenders were found as irresponsible for the crime because of a serious mental illness (NGRI) according to the 17th Paragraph of the Penal Code of the Republic of Lithuania. A small part of assessed offenders – from 1 percent to 5 percent – each year was evaluated as having diminished responsibility according to the 18th Paragraph of the Penal Code of the Republic of Lithuania. In cases of persons with criminal irresponsibility a forensic psychiatrist must recommend the level of compulsory medical measures which must be applied by the court to the person with criminal irresponsibility.
- Another task for a forensic psychiatrist in criminal cases is to evaluate the mental health status of the victim of crime: to assess his/her capability to understand and resist the criminal actions, processual capability, also to assess the level of disturbance of mental health of the victim.
- In very rare criminal cases, the forensic psychiatrist must evaluate the mental health status of the witness.
- In civil cases each year about 1100 forensic psychiatry assessments for the evaluation of civil capability of a person are made. From 2016 the institution of partial civil capability was established in the Civil Code of the Republic of Lithuania. In the period of 2016-2022, each year from 4 percent to 9 percent of evaluated persons are found as having full civil capability. On average about 15 percent of evaluated persons are found as having partial civil capability and about 77 percent from evaluated persons are found as having civil incapability. Repeated evaluation of a person’s civil capability level is to be carried out once every two years.
- A forensic psychiatrist also has a task to evaluate testamentary capacity in post-mortem forensic psychiatric assessments where the person's mental health status at the moment of making the will is assessed.
- In very rare cases, a forensic psychiatrist will have the task to evaluate the mental health status in which the person was before death by suicide.
- In civil cases the children's and adolescent’s forensic psychiatrist and forensic psychologist are making assessments in disputes of child custody situations.
- In both criminal and civil cases, the forensic psychiatrist must evaluate a person's capability to participate in the court dispute (fitness to stand trial or processual capability). It is defined in paragraph 38 of the Civil Process Code of the Republic of Lithuania. In the Criminal Code, the processual capability is not defined by a dedicated paragraph, but is instead defined in a Comment within the Criminal Code.
A forensic psychologist is working together with a forensic psychiatrist. The forensic psychologist has a task to evaluate the emotional status of an offender during the legally relevant period, to reveal the motivation behind their acts, to identify personality traits, determine intellectual abilities and to perform other psychological tests. In rare cases forensic psychologists have a task to identify psychological elements of the social maturity of a young adult, to determine a suicidal ideation in the pre-death period, to evaluate the status of psychological affect. A forensic psychologist has a task to conduct the risk assessment of violent behaviour of an offender using the HCR – 20 in cases where offenders are found not responsible for the crime because of mental illness (NGRI).
All forensic psychiatry assessments are ordered by courts. The results of assessments are provided to courts in written form. The results of a forensic psychiatric assessment the court evaluates as one part of the body of evidence, alongside with other data. However, in most cases, the courts pay heed to the results of forensic psychiatric examinations, especially in criminal cases, and use the results for guidance. In civil cases there are a lot of disagreements between the solicitors of the opposing parties during court disputes and the opinion of the forensic psychiatrist is not always taken into account by the court. One way or another, the final decision maker is always the court.
Compulsory medical measures for forensic psychiatry patients with irresponsibility or diminished responsibility
Compulsory measures of a medical type can be ordered by a court after the forensic psychiatric assessments of the offenders when they are found not responsible for the act of crime because of a serious mental illness (NGRI). The forensic psychiatrist has a task to recommend the type of compulsory measure to be taken – compulsory outpatient treatment or compulsory inpatient treatment in a specialised psychiatric hospital for forensic psychiatry patients.
In Lithuania, the certified forensic psychiatry experts are working in NFPS and carry out only pretrial consultations and forensic psychiatric assessments (expertise). They do not participate in compulsory treatment of forensic psychiatry patients. All compulsory treatment tasks for forensic psychiatry patients for both outpatient conditions and inpatient conditions are provided by general psychiatrists who have no specialisation and qualification in forensic psychiatry.
Compulsory outpatient treatment is provided by general psychiatrists in a local primary level Mental Health Care Centres. In Lithuania there are no specialised outpatient treatment centres for forensic psychiatry patients. In cases with higher risk of violent behaviour compulsory inpatient medical measures are recommended. In such cases the offenders are admitted to a specialised psychiatric hospital, which has three levels of security: low, medium and hight security wards.
In Lithuania from 2007 we have one specialised psychiatry hospital (Rokiškio psichiatrijos ligoninė) with 380 beds where forensic psychiatry patients are treated after the court ordered compulsory inpatient treatment. From 2007 onwards all forensic psychiatry inpatients are treated only in this specialized psychiatry hospital with specially trained personnel and a special security level. There are 15 hight security, 55 medium security and 310 low security beds in this specialised psychiatry hospital. Data from the specialised psychiatry hospital shows that the oldest forensic psychiatry patient was 76 and the youngest was 16 years old. About 80 percent of forensic psychiatry patients are men, 19 percent are women and 1 percent are adolescents. The average length of treatment of forensic psychiatry patients in this specialised psychiatry hospital is 800 days, the duration depends on the results of the treatment and can last from 2 to 5, in rare cases more years. In Lithuania the length of treatment of forensic psychiatry patients does not depend on the length of incarceration for their criminal acts carried out.
In this specialised psychiatry hospital there are several rehabilitation programs being carried out: psychosocial rehabilitation, professional rehabilitation, work rehabilitation.
Evaluation of risk of violent behaviour of forensic psychiatry patient is conducted 1-2 times a year by a clinical psychologist and treating psychiatrist. Each 6 months the evaluation of mental health status of all forensic psychiatry patients must be made by the treating team. This requirement applies in all outpatient and all inpatient compulsory treatment cases. The results of such evaluation are sent to the court, which ordered the compulsory treatment with recommendations to continue, to change to higher or to lower level of compulsory measures or to discontinue compulsory treatment of forensic psychiatry patient. All changes of compulsory treatment measures are made consecutively. Only from treatment in the general security ward can a patient in compulsory treatment progress to outpatient treatment. All changers of compulsory treatment are made only by court. Compulsory treatment of forensic psychiatry patients is oriented to the alleviating symptoms of mental illness and also to minimise the risk of violent behaviour.
Compulsory medical measures of forensic psychiatry patients differ from involuntary treatment of other civil patients. Compulsory medical measures are ordered by courts for people who are found not culpable (NGRI) because of a serious mental illness for the crime, which they have committed, or not fitting to stand trial because of serious mental illness, which appeared after the criminal act. The civil committed patients are not considered as forensic psychiatry patients. Involuntary treatment for a civil patient is still ordered by a court, but it is realised in general psychiatry hospitals.
The strengths and weaknesses of Lithuanian forensic psychiatry
The strengths of Lithuanian forensic psychiatry are:
1. The existence of an organised Forensic Psychiatry institution – National Forensic Psychiatry Service, which has structural system - regional outpatient departments across the country, that are able to carry out expertise work for the public in that region, alongside with the existence of an inpatient expertise department. NFPS carries out the forensic psychiatrists' initial training, the further improvement of competences and the quality control of the expertise work carried out by them. NFPS also serves as methodological centre.
2. In Lithuania, all forensic psychiatry assessments (expertise) are carried out only by certified forensic psychiatrists and forensic psychiatrists - a fact that helps keep the quality of forensic assessments very high and the number of repeated assessments is very low - only around 1-2 percent from all expertise performed.
3. One more strength is the existence of a Forensic Expertise Law, which codifies Expert work of all areas.
4.The existence of the Forensic Expert Activity Coordination Council, which carries out the oversight of experts’ keeping to the principles of the Code of Ethics of Experts is another very important strength.
5. The strength is the fact that in Lithuania is a specialised psychiatry hospital (Rokiškio psichiatrijos ligoninė) dedicated purely for forensic psychiatry patients and these patients, from 2007 onwards, are no longer treated at general psychiatry hospitals.
6. Level of international collaboration among Baltic and Nordic forensic psychiatrists, as well with European Society for Forensic psychiatry, other international professional societies with regular scientific conferences and publications.
A weak point in Lithuania’s forensic psychiatry is the lack of specialised outpatient treatment centres for forensic psychiatry patients, thus this function falls on practitioners of general psychiatry, who often lack specialised knowledge and skills for engagement with difficult clients. Partly due to this shortcoming in the Lithuanian forensic psychiatry system, there is relatively high level of repeated offenses among the forensic psychiatry patients and readmission to specialised psychiatry hospital.
All the additional questions on forensic psychiatry in Lithuania please address to:
MD, psychiatrist, certified forensic psychiatry expert,
director of National Forensic Psychiatry Service of Lithuania